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Full text of "A system of practical medicine"

COLUMBIA LIBRARIES Ol-l-si i c 

HEALTH SCIENCES STANDARD 



HX00052469 



Columtjia ^mbersiitp ^ 
intteCitpofi^etogorfe 

COLLEGE OF PHYSICIANS 
AND SURGEONS 




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http://www.archive.org/details/systemofpractica03loom 



LIST OF CONTRIBUTORS. 



CABOT, RICHARD C, M. D. ; 

COLEMAN, WARREN, M.D.; 

DOCK, GEORGE, M.D.; 

FINLEY, FREDERICK G., M. D. ; 

GRAHAM, J. E., M. D. ; 

HARE, H. A., M.D.; 

JAMES, WALTER B., M. D. ; 

JOHNSTON, WILLIAM W., M.D.; 

JONES, ALLEN A., M. D. ; 

KINNICUTT, FRANCIS P., M.D.; 

LAMBERT, ALEXANDER, M.D.; 

LAW, JAMES, F.R.C.V.S.; 

LOCKWOOD, GEORGE ROE, M. D. ; 

LYMAN, HENRY M., M.D.; 

McNUTT, W. F., M.D., M.R.C.S. Edin., etc. 

STARR, M. ALLEN, M. D. ; 

STEWART, JAMES, M. D. ; 

STOCKTON, CHARLES G., M.D. ; 

VAUGHAN, VICTOR C, Ph.D., M.D. 



SYSTEM 



PRACTICAL MEDICINE 



BY 



AMERICAN AUTHORS. 



EDITED BY 

ALFRED LEE LOOMIS, M. D., LL.D., 

Late Professor of Pathology and Practical Medicine in the New York University, 

AND 

WILLIAM GILMAN THOMPSON, M.D., 

Professor of Medicine in the New York University; Physician to the Presby- 
terian AND Bellevue Hospitals, New York. 

VOLUME III. 

DISEASES OF THE ALIMENTARY CANAL- DISEASES OF THE 
PERITONEUM -DISEASES OF THE LIVER AND GALL BLAD- 
DER-DISEASES OF THE SPLEEN -DISEASES OF 
THE PANCREAS -DISEASES OF THE THYROID 
GLAND - CHRONIC METAL-POISONING ; 
ALCOHOLISM ; MORPHINISM, ETC. 

ILLUSTRATED. 




LEA BROTHEES & CO., 

NEW YORK AND PHILADELPHIA. 

1898. 



Entered according to Act of Congress in the year 1898, by 

LEA BROTHERS & CO., 

in the OflBce of the Librarian of Congress, at Washington. All rights reserved. 



WESTCOTT & THOMSON, 
ELECTROTYPERS, PHILADA. 



PRESS OF 
WILLIAM J. DORNAN, PHILADA. 



LIST OF CONTRIBUTORS. 



EICHAED C. CABOT, M. D., 

Visiting Physician to the Channing Home, Boston, Mass. 

WAREEN COLEMAN, M. D., 

Instructor in Gross Pathology in the New York L'niversity, Medical Department ; 
Visiting Physician to the City Hospital, New York. 

GEOEGE DOCK, M. D., 

Professor of the Theory and Practice of Medicine and Pathology in the L'ni- 
versity of Michigan, Department of Medicine and Surgery, Ann Arbor, Mich. 

FEEDEEICK G. FINLEY, M.D., M. B. (Lond.), 

Associate Professor of Clinical Medicine and Assistant Professor of Medicine 
in the McGill University, Faculty of Medicine, Montreal. 

J. E. GEAHAM, M.D., M.E.C. P. (Lond.), 

Professor of Medicine and Clinical Medicine in the L^niversity of Toronto, Medi- 
cal Faculty, Toronto, Can. 

H. A. HAEE, M.D., 

Professor of Materia Medica and Therapeutics in the .Jefferson Medical College ; 
Physician to the Jeflerson Medical College Hospital, Philadelphia. 

WALTEE B. JAMES, M. D., 

Clinical Lecturer on ^Medicine in the College of Physicians and Surgeons ; Visit- 
ing Physician to the Presbyterian and Bellevue Hospitals, New York. 

WILLIAM W. JOHNSTON, M. D., 

Professor of the Theory and Practice of Medicine and Clinical Medicine in the 
Medical Department of Columbian University, "Washington, D. C. 

ALLEN A. JONES, M. D., 

Lecturer on Clinical Medicine in the Medical Department of the University of 
Buffalo, Buffalo, New York. 



6 LIST OF CONTRIBUTORS. 

FRANCIS P. KINNICUTT, A.M., M.D., 

Professor of Clinical Medicine in the College of Physicians and Surgeons ; Visiting 
Physician to St. Luke's and the Presbyterian Hospitals, New York. 

ALEXANDER LAMBERT, M.D., 

Visiting Physician to Bellevue Hospital ; Assistant Bacteriologist to the Health 
Department, New York. 

JAMES LAW, F. R. C. V. S., 

Professor of Veterinary Surgery in Coi-nell University, Ithaca, New York. 

GEORGE ROE LOCKWOOD, M.D., 

Professor of Principles and Practice of Medicine in the Woman' s Medical College 
of the New York Infirmary, New York. 

HENRY M. LYMAN, A. M., M. D., 

Professor of the Principles and Practice of Medicine in the Rush Medical 
College, Chicago. 

W. F. McNUTT, M.D., M. R. C.S. (Edin.), L.R.C.P. (Edin.), 

Professor of the Principles and Practice of Medicine in the University of Cali- 
fornia, Medical Department, San Francisco, California. 

M. ALLEN STARR, M. D., 

Professor of the Diseases of the Mind and Nervous System in the College of 
Physicians and Surgeons ; Consulting Neurologist to the Presbyterian Hospital, 
New York. 

JAMES STEWART, M. D., 

Professor of Medicine and Clinical Medicine in the McGill University, Faculty 
of Medicine, Montreal. 

CHARLES G. STOCKTON, M. D., 

Professor of the Principles and Practice of Medicine and Clinical Medicine in the 
Medical Department of the University of Buffalo, Buffalo, New York. 

VICTOR C. VAUGHAN, Ph.D., M.D., 

Professor of Hygiene and Physiological Chemistry and Dean of the Medical 
Faculty in the University of Michigan, Ann Arbor, Michigan. 



CONTENTS OF VOLUME III. 



DISEASES OF THE ALIMENTARY CANAL. 



PAGE 

DISEASES OF THE MOUTH, TONGUE, TONSILS, PHAEYNX, AND 

SALIVARY GLANDS 19 

By Richard C. Cabot, M. D. 



DISEASES OF THE (ESOPHAGUS 57 

By Allen A. Jones, M. D. 

DISEASES OF THE STOMACH 85 

By Charles G. Stockton, M. D., and Allen A. Jones, M. D. 

DISEASES OF THE INTESTINES 185 

By William W. Johnston, M, D. 

DISEASES OF THE INTESTINES (continued) 231 

By Henry M. Lyman, M. D. 

APPENDICITIS 277 

By W. F. McNutt, M. D., M. R. C. S. Edin., etc. 

INTESTINAL PAEASITES 315 

By George Dock, M. D. 

TRICHINOSIS 351 

By George Dock, M. D. 

FOOD-POISONING (BROMATOTOXISMUS) 359 

By Victor C. Vaughan, Ph. D., M. D. 

1 



8 COXTENTS. 

DISEASES OF THE PEEITONEUM. 

PAGE 

DISEASES OF THE PERITONEUM 389 

By H. a. Hare, M. D. 



DISEASES OF THE LIVER AND GALL BLADDER. 

DISEASES OF THE LIVER 409 

By J. E. Graham, M. D. 

DISEASES OF THE GALL BLADDER AND DUCTS 565 

By J. E. Graham, M.D. 



DISEASES OF THE SPLEEN. 

DISEASES OF THE SPLEEN 605 

By George Roe Lock wood, M. D. 



DISEASES OF THE PANCREAS. 

DISEASES OF THE PANCREAS 645 

By Charles G. Stockton, M. D. 



DISEASES OF THE THYROID GLAND. 

DISEASES OF THE THYROID OLAND (EXCEPTING CRETINISM 

AND MYXCEDEMA) 663 

By Francis P. Kinnicutt, M. D. 

CRETINISM ; MYXCEDEMA 693 

By M. Allen Starr, M. D. 



CONTENTS. 9 

CHROMIC METAL-POISONING; ALCOHOLISM; 
MORPHINISM. 

PAGE 

CHRONIC METAL-POISONING 715 

By Frederick G. Finley, M. D. 

ALCOHOLISM; MORPHINISM 729 

By James Stewart, M. D. 



INFECTIOUS DISEASES COMMON TO MAN AND 

ANIMALS. 



GLANDERS 741 

By James Law, F. R. C. V. S. 

ANTHRAX 753 

By James Law, F. R. C. V. S. 

RABIES 763 

By James Law, F. R. C. V. S. 

ACTINOMYCOSIS 775 

By James Law, F.R. C. V.S. 



MISCELLANEOUS SUBJECTS. 

PURPURA 787 

By George Roe Lockwood, M. D. 

BERI-BERI 805 

By James Stewart, M. D. 

HEMOPHILIA; FIL.\RIA SANGUINIS HOMINIS 809 

By Walter B. James, M. D. 

DIABETES; GLYCOSURIA 821 

By Warrex Coleman, M. D. 

INSOLATION 873 

By Alexander Lambert, M. D. 



DISEASES OF THE ALIMENTARY CANAL. 



DISEASES OF THE ALIMENTARY CANAL. 



DISEASES OF THE MOUTH, TONGUE, TON- 
SILS, PHARYNX, AND SALIVARY GLANDS. 

By RICHARD C. CABOT, M. D. 



DISEASES OP THE MOUTH. 

Stomatitis. 

introduction. 

The salivary glands during the first three or four months of life 
are very inactive, and the mouths of infants are therefore compara- 
tively dry. Even irritation fails to start any considerable flow of 
saliva. Hence the great likelihood of accumulation in the mouth of 
various irritating substances or organisms which in the adult Avould be 
washed away by the saliva. Even after the flow of saliva is estab- 
lished, it is less useful than it might be, since it escapes very largely 
from the lips, and does not carry down irritants to the stomach, where 
the gastric acids might destroy them. 

Again, the habit of carrying everything to the mouth, as young 
children do, adds to the sources of irritation of that cavity. 

Hence it is that we always think chiefly of children when the sub- 
ject of stomatitis is mentioned. 

Catarrhal Stomatitis. 

Etiology. — For the reasons given in the preceding section the dis- 
ease occurs chiefly in infancy. Surroundings are of influence only as 
they "prepare the soil" for the disease by lessening the general resist- 
ance of the system. 

We must consider three classes of factors in etiology : 

1. An irritant ; 

2. The condition of the tissues as aSected by the general 

condition ; 

3. Excretion by the saliva. 

1. Irritants may be divided into — ■ 
(a) Mechanical ; 
(6) Chemical and bacterial ; 
(c) Thermal. 

19 



20 DISEASES OF THE MOUTH. 

(«) Mechamcal IrritanU. — The pressure or friction of rubber nipples 
during sucking, rubbing the gums, especially during dentition, rough 
cleansing of the mouth, and local irritation from a sharp tooth or in 
adults from ill-fitting false teeth. 

(6) Chemical or bacterial irritants are brought into the mouth on the 
surface of articles given to children to chew during teething, especially 
when such articles are allowed to roll on the floor when not in use. 
Other things which the child puts into its mouth, with or without per- 
mission, may serve as irritants. 

Food given when fermenting, very acid food, or anything sticky, 
such as might remain and decompose in the mouth, may give rise to 
catarrhal stomatitis in infants. In older persons poor care of the teeth 
and the resulting caries start an inflammation around the carious tooth. 
This leads to sparing the parts in chewing, and this to the retention and 
fermentation of food, accumulation of tartar, and thus to greater inflam- 
mation in a vicious circle. 

Pus from a perialveolar abscess may start a local catarrhal stomatitis 
as it flows over the gum. 

The acrid fluids which pass through the mouth in persistent vomit- 
ing may set up this form of stomatitis. 

Abuse of tobacco by smoking and chewing is another not infrequent 
cause, and similarly red pepper or horseradish may irritate and inflame 
the mouth. 

(c) Thermal irritants, such as very hot tea, are not rare causes of 
sore mouth, especially in infants, who do not test the temperature of 
the tea before it is swallowed. 

The influence of a bad hare-lip or cleft-palate in starting a stomatitis 
may be mentioned here, whether cold is the chief factor or not. 

2. The soil on which these irritants are effective is prepared by any 
disease that lowers the general vitality. Such diseases are tuberculosis, 
syphilis, diphtheria, malaria, typhoid, the exanthemata, and chronic 
diarrhoeas in childhood. In adults wasting diseases and the rheumatic 
or gouty diathesis seem to predispose the patient particularly to this 
affection. 

Gastro-enteric disturbances and indigestion have been frequently 
mentioned as causes of stomatitis, but are probably to be thought of 
more properly as results or concomitants. Such causative influence as 
they exert is probably through the changes in the saliva next to be 
mentioned. It may be that all the diseases spoken of above act in pro- 
ducing stomatitis through diminishing the antimicrobic action of the 
saliva, or through 

3. The Excretion of Toxic or Irritating Substances by the 
Saliva. — Our definite knowledge of such a process is mostly confined 
to the action of mercury, the iodides, lead, phosphorus, and other inor- 
ganic substances, to be discussed more fully in the section upon Ulcera- 
tive Stomatitis (page 26). But there is good reason to believe that 
various organic substances are excreted by the saliva in disease, and 
thus cause stomatitis. 

Boucheron has found uric acid in the saliva, and it is probable that 
the toxins of various diseases may exert their influence here as well as 
upon the skin and kidneys. 



GATABBHAL STOMATITIS. 21 

We have no direct evidence that any special micro-organism is con- 
cerned in the production of catarrhal stomatitis. 

Finally, it should be mentioned that a rhinitis or pharyngitis extends 
very rarely to the buccal mucous membrane as stomatitis. 

Symptoms and Signs. — Except in the rarer local form of the dis- 
ease there is no favorite starting-place. The whole mouth shows changes 
which are in the earliest stages simple erythematous, merging later into 
the true catarrhal. This early erythema is to be distinguished from the 
physiological hypereemia of the mouths of infants during the first week 
of life, for, although this last may be so intense as to cause slight hemor- 
rhages, it does not go on to genuine catarrhal inflammation. It is also 
distinct from the passive hypersemia which gives the bluish tinge to 
the mouths of children with whooping cough, or any other disease in 
which the return of blood to the right heart is hindered. 

The mouth is red, hot, at first dry, but soon bathed in abundant 
saliva, and painful. Swelling of the mucosa of the lips and cheeks is 
present, and if there are any teeth their marks can be seen in the cheeks, 
lips, or tongue. 

In older children the gums around the incisor teeth are very puffy 
and painful. 

Occluded mucous glands show as minute beads above the surface, 
and rarely the occlusion leads to a retention-cyst. The vessels are so 
distended that a very slight injury starts bleeding, and slight abrasions 
of the macerated epithelium of the mucous membrane are common, but 
rarely involve the deeper layers. Small vesicles may form and burst, 
leaving shallow ulcers. The tongue is dry and coated white at first ; 
later its edges are cleaned off by the hyjDersecretion of saliva. The 
gums are smeared with mucus. In children there is usually an evening 
temperature of 101°-102° F., with morning remissions. Where continu- 
ous fever is present, as in the stomatitis accompanying typhoid or scar- 
let fever, the whole mouth, and particularly the tongue, becomes de- 
nuded of epithelium, dry, fissured, and bloodstained, and sordes collect 
on the teeth. 

The lymphatic glands are swollen, the amount of enlargement corre- 
sponding with the severity of the disease. 

In adults the complaints are mostly of soreness and salivation, a bad 
taste in the mouth, and disagreeable odor to the breath. There is little 
or no fever. Sometimes speech and chewing are painful. 

Infants are unwilling to nurse. " The little patient goes at the 
breast with a good will, evidently hungry ; takes one or two pulls, then 
suddenly lets go the nipple and begins to cry. By a little coaxing he 
will try again, but the same result follows, and finally the baby abso- 
lutely refuses to be put to the breast, preferring to remain hungry to 
suffering pain " (Forscheimer). The acid saliva flows from the mouth, 
and often starts an obstinate eczema. 

The acute form as seen in children is usually well in one to two 
weeks, the worst symptoms lasting only three or four days. The chronic 
form, seen in topers and inveterate smokers, is obstinate. 

Prognosis. — In adults the disease is an inconvenience only, but in 
infants, though usually of no great importance, the disease may even 
prove fatal by preventing the child from taking food at a time when its 



22 DISEASES OF THE MOUTH. 

vitality has been greatly reduced by other causes (malaria, the exan- 
themata, etc.). This is very rare. It should, however, be remembered 
that a catarrhal stomatitis may set up gastric and intestinal disturb- 
ances which are sometimes serious. One attack seems to predispose to 
another, and in badly nourished " marantic " children the disease may 
become chronic. 

Treatment. — The majority of cases are not treated and recover 
easily, but, as other and more severe forms of stomatitis may take root 
on the simple catarrhal mucous membrane, treatment has a certain 
importance. 

In adults the removal of the cause is the chief indication. In regard 
to infants, the mother should be impressed with the duty of habitually 
cleaning the mouth several times daily with absorbent cotton dipped in 
boiled water (lukewarm) and wrapped round the finger. This is the 
most important element both in prophylaxis and treatment ; but gentle- 
ness is essential, else more harm than good is done. The form of stoma- 
titis known as " Bednar's aphthae "is in all probability due to roughness 
in attempts to clean the mouth. In fever frequent washing of the 
mouth with cold water or sucking small pieces of ice are pleasant and 
helpful. 

Food should be given cold (except to children at the breast), and the 
water used for washing out the mouth should also be cold. Feeding 
should be kept up in spite of the resistance of the child, and if the child 
is badly nourished at the start and refuses to suck, a carefully modified 
milk should be given with a spoon or dropper for a few days. Lotions 
and the use of chlorate of potash are unnecessary. 

Ulcerations should be touched with mitigated stick nitrate of silver. 

Herpetic Stomatitis ("Aphthae;" "Canker"). 

Etiology. — Forscheimer has offered excellent evidence that the 
disease is a form of herpes occurring in the mouth, and differing from 
ordinary herpes only in such ways as are brought about by the differ- 
ence in situation. According to him, it is due to the elimination by the 
saliva of toxic products. Friedrich ^ produced by the injection of the 
toxins of the streptococcus and bacillus prodigiosus (Coley's) herpes 
facialis in 7 cases and "aphthae" in 2 cases. 

This does not necessarily exclude the a'ssociated influence of bac- 
teria, but most bacteriological investigations in connection with the 
disease have shown only pus-forming organisms. Looss - has repeatedly 
found what he calls a diplo-strejjtococcus in connection with the lesions, 
and Chaumier ^ considers it contagious and epidemic, the lesions being 
only a local manifestation of a general infection. He succeeded in pro- 
ducing the disease on the mouth and lips by inoculation of the arm 
with material from other cases. The 107 cases observed by this writer 
occurred in 21 families in groups of from 2 to 4 cases in a family, but 
this, of course, does not prove that it is contagious, as the same cause 
may have produced them all without direct transmission. Evidence 

1 Bed. klin. Wock, 1896, Nos. 49 and 50. 

^ Mediz. bericht d. Jenner's Kinderspital, Bern, 1896. 

* Nancy Congress, August, 1896. 



HERPETIC STOMATITIS. 23 

has been oflPered that foot-and-mouth disease in cattle is the same dis- 
ease as herpetic^ stomatitis, and, while this cannot be absolutely denied, 
it has been shown that the transmission does not take place through 
milk. It may occur independently, or in connection with any febrile 
disease or digestive disturbance. 

It occurs not infrequently in adults as well as in children, and may 
be very obstinate in neurasthenic conditions and during pregnancy and 
lactation. In children the debility often associated with the first den- 
tition may be the reason for the frequency of the disease at that period, 
the tissues being less resistant than normally. A catarrhal stomatitis 
usually accompanies it, and probably adds to the vulnerability of the 
mucous membrane. 

Pathology and Symptoms. — The spots or aphthae which charac- 
terize the disease form macules rapidly developing into vesicles, and ap- 
pearing as small, yellowish white, subepithelial spots singly or in groups 
in various parts of the mouth, but especially on the inner surface of the 
lips, on the side and under surface of the tongue, on the cheeks, and on 
the frsenum. Less frequently we find them on the gums or in the 
pharynx. Crops of herpes facialis may accompany the aphthae. 

Usually within twenty-four hours the epithelium is soaked off and 
a small shallow ulcer remains, the red areola persisting. Several spots 
may run together to form larger ulcerations. Microscopically, the 
white spots consist of fibrin and leucocytes in the superficial layers of 
the epithelium, which is thickened and opaque. After the ulcer has 
formed and the exudation washed away, we find in the ulcer various 
saprophytes, but usually no pathogenic organisms. 

Within a few days the epithelium is formed anew and no cicatrix is 
left, though the young epithelial cells are for a time opaque, so that a 
light spot marks the seat of the ulcer. 

Although the individual vesicle lasts but a few days, successive crops 
usually appear, so that the disease may run on for ten to fourteen days. 
A few of the vesicles may be absorbed without ever coming to the stage 
of ulceration. In some adults the process is chronic. 

The constittttional disturbance may be very slight or may be severe. 
The symptoms are the same as those described under Catarrhal Stoma- 
titis — pain, salivation, fever, loss of appetite. The breath is not foul, as 
in the severer forms of stomatitis. The disease appears to be usually 
self-limited, and a week is the average duration. 

Prognosis. — Except in children much reduced by other diseases the 
prognosis is absolutely good. The only harm done is that the child 
will not eat well, and loses some strength in consequence. Relapses 
are rare. In adults, as already mentioned, the disease may be obstinate 
and inconvenient. In one case observed by the writer a girl of twenty- 
three was subject to recurrent attacks of herpes facialis with herpetic 
stomatitis and crops of herpetic vesicles on the palms and soles of the 
feet. Each attack was accompanied by fever and coryza, and ran a self- 
limited course entirely unaffected by treatment, ending in about two weeks. 

Treatment. — In infants the only treatment necessary is to touch 
each ulcer with nitrate of silver. Washes and potassium chlorate are 
unnecessary. As to feeding, what has been said under Catarrhal 
Stomatitis is sufficient (page 22). 



24 DISEASES OF THE MOUTH. 

In adults our attention should l^e directed to improving the general 
health as far as possible. Rest, change of air, outdoor exercise, and 
tonics are indicated. Silver nitrate will heal the single " canker sore," 
but has no tendency to prevent its recurrence. 

The name of " Bednar\s aphthce " is associated with small, shallow 
ulcers occurring on the hard palate near the velum palati, and sometimes 
on the soft palate, due, as above indicated, to roughness in cleaning the 
mouth. They heal readily without treatment. Such lesions are rarely 
seen in this country. 

Mycotic Stomatitis (Thrush). 

Etiology. — Authorities differ as to whether the thrush fungus 
belongs to the class of yeast fungi or to that of moulds. It is probably 
not the oidium albicans, as has been long supposed. It is found in 
threads (mycelium) or spores, one or the other predominating according 
to the structure of the tissue in which it grows. 

The fungus has been found on various mucous membranes, respira- 
tory as well as alimentary, and in the genito-urinary tract as well as in 
the lungs, the brain, and in the bloodvessels. 

It has a preference for flat or squamous epithelium, such as that in 
the mouth and pharynx, but is by no means confined to these localities. 
(See page 25.) 

Rarely, the disease develops in the mouths of perfectly healthy chil- 
dren (Epstein ; Forscheimer), but usually it is found in those who are 
enfeebled by disease or neglect, and whose mouths are consequently in 
a condition of catarrhal stomatitis. Children are most liable to it during 
the first two or three weeks of life, but it may occur at any age, and is 
occasionally seen in wasting diseases of adults (diabetes, tuberculosis). 

The parasite may be carried by the nipple of the mother from child 
to child, or by the rubber nipples of feeding-bottles not properly 
cleaned, or by the fingers of the nurse. Hence epidemics formerly 
occurred in foundling hospitals, etc. 

Forscheimer points out that, owing to its method of growth in the 
tissues, it takes root best where it is least disturbed, — hence in subjects 
who move their tongues least, which helps to explain its frequency in 
very young children and cachectic diseases of adults. It will also be 
noted that these two classes of patients are alike in living chiefly on 
milk diet. 

Pathological Axatomy. — The disease usually appears on the tip 
of the tongue as white, raised, pearly dots on the mucous membrane. 
These grow rapidly and soon join to form large patches, and may spread 
to the cheeks, lips, pharynx and larynx, trachea, gullet, and even into 
the lungs and stomach. From their growth into the bloodvessels me- 
tastases may take place, as in the brain (Zenner) or in the kidney 
(Schmorl), but this is very rare. 

In the gullet the growth may be so luxuriant as to occlude the tube. 
Heller found thrush in the gullet of 17 out of 18 autopsies in which the 
gullet was examined, 7 times in the larynx, 4 times in the lung, and 
once in the stomach. 

The little white spots on the tongue with which the disease begins 



MYCOTIC STOMATITIS. 25 

can sometimes be scraped oflF without hurting the mucous membrane, 
and sometimes leave a bleeding surface if removed. These thrush 
jjatches are composed of buds and threads of the fungus, together with 
cast-oflP epithelial cells, bits of food, and fibrin. They very closely re- 
semble a bit of curdled milk, and may be mistaken for such. Accord- 
ing to the nature of the food or medicine taken the thrush patch may 
be gray, brown, or even black. 

The fungus begins its growth between the layers of epithelium in the 
form of spores without mycelium. As it develops it separates the 
strata of epithelium and grows upward and downward. The superficial 
layers are killed and cast off. Mycelium threads are developed abun- 
dantly in the direction of the connective tissue, and in a lesser degree on 
the free surface. 

It has been supposed until recently that the fungus rarely penetrates 
below the epithelium, but the studies of Heller ^ prove that this is not 
the case. His examination of 33 thrush growths in 25 autopsies showed 
that in only 12 per cent, was the growth confined to the epithelium, while 
in 88 per cent, it penetrated deeper. Of 18 cases with lesions in the 
gullet, 16 had penetrated to the connective tissue, 9 to the connective 
tissue and vessels, and 1 to the muscular layer. 

Around the fungus growth we find areas of necrosis and round cell 
infiltrations, but no pus. These evidences of irritation are usually of a 
very transitory nature, and soon disappear when the fungus is removed ; 
but Heller has found it in foci of broncho-pneumonia and in ulcerations 
of the gastric mucosa. 

Symptoms. — Although it is possible for a healthy child to become 
infected with thrush, the vast majority of cases occur in weakened and 
debilitated patients, and in such patients it may be difficult to distin- 
guish the symptoms due to the thrush from those of the underlying 
condition. In some cases there are no symptoms at all, and the patches 
are discovered accidentally. The local symptoms may be those of a 
mild catarrhal stomatitis, but the tissues round and under the membrane 
show little if any evidence of reaction against the parasite. Pain is 
present only when the deeper tissues are involved ; if the growth spreads 
to the tonsils, we may have a tonsillitis with swelling, pain on swallow- 
ing, and even absolute refusal of food. Sometimes ulcerations form at 
the point where a patch of thrush has dropped off, which may be filled 
up again with the parasitic growth or remain as obstinate, sometimes 
chronic, ulcers. 

In severe cases we may have fever, swelling of the glands at the 
angles of the jaw, and general constitutional disturbance. Rarely the 
growth in the gullet may be so abundant as to cause obstruction and 
prevent swallowing. The plug is sometimes expelled by vomiting. 
Gastro-intestinal disturbances are common in severe cases, probably 
owing to the large quantities of the parasites and its products which 
are swallowed. 

Eczema of the nates is a frequent complication. If not properly 
treated, the disease may last indefinitely. 

Prognosis. — The chief source of danger, aside from the rare occur- 
rence of obstruction of the gullet, is malnutrition. In patients not 

^Deutsch. Arch. f. klin. Med., 1896, vol. iv. p. 123. 



26 DISEASES OF THE MOUTH. 

much debilitated and promptly and properly treated, the disease is not a 
serious one. But where the vital forces are already much impaired by 
inherited or acquired disease, the hindrance to proper nutrition occa- 
sioned by thrush may prove a serious complication. 

In general, the aflPection is worse in very young children, and the 
extent of the growth is a measure of the severity of the disease. 

Treatment. — Prophylaxis is highly important. In hospitals or 
asylums, cases of thrush should be isolated. Cleanliness of the mouth, 
and especially of the mother's nipples and the nipples of nursing-bottles, 
will do much to prevent the occurrence or spreading of the disease. 
All feeding utensils should be boiled after each feeding. 

Aside from prophylaxis, the treatment is largely the patient, mechani- 
cal removal of the growth. This is best done with an alkaline solution 
(lime water, sodic bicarbonate 1 : 20). Dip a rag in this solution and 
wipe off all that can be seen of the growth. This should be done 
several times a day, as often as the spots form. A moderate amount of 
violence is necessary. It is unnecessary to use any other remedy, and 
the use of honey diould be scrupulously avoided. Ulcerations may be 
touched with nitrate of silver. Some cases are very stubborn and resist 
treatment for a long time. 

Constitutional treatment is important. In stubborn cases a change 
of air should be tried, and careful regulation and cautious changes of 
diet are sometimes of service. 

Grdsg,^ who has recently studied an epidemic among the newborn, 
which remained endemic with frequent relapses, thinks that the pro- 
phylactic cleansing of the mouth of newborn babies predisposes to 
thrush by removing the superficial epithelium and providing the fungus 
with its favorite soil. He finally controlled the disease and reduced the 
number of cases from 32 per cent, to 9 per cent, of the newborn chil- 
dren by wiping out the mouth once daily with 3 per cent, silver nitrate, 
as well as frequently removing the growth as above indicated. 

Ulcerative Stomatitis (Stomacace ; Putrid Sore Mouth). 

Etiology. — If mercurial stomatitis be taken as the type of this 
disease, the chief factor in etiology is evidently the eliminative function 
of the saliva. The importance of this view, which has already been 
alluded to, has been strongly emphasized by Forscheimer.^ Elimina- 
tion by the saliva of substances like mercury, iodine, lead, arsenic, anti- 
pyrine, and possibly bacterial products, produces a soil in which the 
ordinary bacteria of the mouth can set up a variety of pathological pro- 
cesses. 

A striking fact about the disease is that it occurs only where there 
are teeth, and affects chiefly the gums around the teeth. This is prob- 
ably due to the fact that the unknown irritant or organism which attacks 
the diseased mucous membrane accumulates best around, and especially 
between, the teeth. 

The disease has repeatedly occurred in endemics under conditions 
of bad hygiene, but is not contagious. No specific micro-organism has 
been found. It is most common in children between five and ten years 

^ Jahrb. d. Kinderheilk., 1896, p. 177. ^ Journal of Pcediairics, Jan., 1897. 



ULCERATIVE STOMATITIS. 27 

old, but rarely attacks those who are otherwise healthy. Measles, 
scarlet fever,^ malaria, typhoid, pneumonia, and whooping cough 
among acute diseases, and syphilis, tuberculosis, and rickets among 
chronic diseases are especially apt to be complicated with ulcerative 
stomatitis. 

Children who are neglected and whose mouths are not cared for are 
often attacked by it. The accumulation of tartar, and carious teeth, 
are thought to predispose to it, but are more likely to be due to the 
same cause that produces the stomatitis. 

Pathological Anatomy axd Symptoms, — The disease always 
begins at the free border of the gums, and thence extends in all direc- 
tions, but is usually confined to the gums and the parts immediately 
adjacent — viz. the borders of the tongue and the parts of the cheek 
opposite the teeth. The teeth on the lower jaw, and especially the 
incisors, are first affected. 

Swelling is the earliest symptom, and is first seen in the portion of 
the gums covering the anterior aspect of the teeth. The gums between 
the teeth and the posterior aspect of the gums are rarely affected, except 
in very severe cases. The swelling may be so great as nearly to cover 
the teeth. The cheek-pockets adjacent show indentations from the teeth. 

Injection of the swollen gums is so great that the overfilled vessels 
bleed at the slightest touch, and even from a movement of the jaw. 
Tenderness on pressure is usually marked. Detachment of the gums 
from the teeth soon follows, the cavity being filled with muco-purulent 
secretion. 

The stage of ulceration follows. A yellowish band or line of spots 
appears along that part of the gums first affected. This represents an 
epithelial necrosis, and covers an ulcerated surface bathed in sero-puru- 
lent fluid. If left to itself, the ulceration spreads until the whole tooth 
is denuded, falls out ; bone-necrosis follows, and small sequestra are sepa- 
rated from the stripping up of the periosteum of the alveolar process. 

The lesions extend downward into the tissues with great rapidity, 
but spread over the surface much more slowly. 

Infection of the cheeks, tongue, etc. takes place chiefly by direct 
contact and with lesions similar to those on the gums, but we some- 
times find ulcerations in the fold between the gum and cheek, with 
healthy tissue between them and the original lesions, as if the materies 
iniorhi had dropped down by gravity. 

The most striking symptoms are the horrible foulness of the breath 
and the salivation, which is profuse. The saliva is generally odorless. 
There is difficulty in chewing, swallowing, and speaking. 

In older children constitutional symptoms may be slight in spite of 
extensive ulceration ; sometimes they are severe. The appetite is poor 
and nutrition suffers. Pain in the mouth may be very severe, and in 
young children a great deal of sleep is lost. 

The lymphatic glands are usually swollen, and may remain so after 
the disease is cured. 

Prognosis and Course. — If proper treatment is begun before the 
disease has reached an advanced stage, the outlook is for a prompt and 
complete recovery within seven to ten days. Parely cases have been 
known to recover without treatment. When recovery begins the fetor 



28 DISEASES OF THE MOUTH. 

and salivation diminish, the pulpy yellow covering of the ulcer is thrown 
off, and new epithelium is formed over the seat of the ulcer. 

Rarely a milder but chronic form of the disease is seen, probably 
identical with what the dentists call shrinking of the gums, but this 
form finally recovers. 

When secondary to such diseases as syphilis or rickets, it may 
be im]50ssible to cure the stomatitis until the underlying disease is 
conquered. 

The possibility of a gangrenous stomatitis (" noma ") arising from 
ulcerative stomatitis must be recognized, though the occurrence is rare. 

Treatment. — Chlorate of potash is a wonderfully effective though 
somewhat dangerous remedy. It has decided toxic effects in overdose, 
and is very painful to swallow, owing to the ulcerations over which it 
must pass. On account of this pain it is best given internally, and local 
applications in powder or as mouth-wash are not as desirable. 

Rotch gives the following table of doses : 

Amount of Chlorate of Potassium which can Safely be Given in Twenty- 
four Hours. 

Age. 
Under 1 year 15 grains. 

1 to 2 years 20 " 

2 to 6 " 30 " 

6 to 8 " 40 " 

8 to 14 " 45 " 

Drowsiness, dark urine of small amoimt, and weakness of the heart 
should always be watched for when giving chlorate of potash, and should 
these symptoms appear the potash should at once be stopped. It i& 
best given in solution at short intervals through the twenty-four hours. 

In most cases so great an improvement in the lesions takes place 
within thirty-six to forty-eight hours that the pain from swallowing the 
potash ceases, and the other symptoms rapidly ameliorate. . 

Rapid recovery is often followed by relapse, and the slightest evi- 
dence of returning ulceration should be watched for. Should such 
occur the potash should be begun again at once. 

Where chlorate of potash does not rapidly affect the lesions nitrate 
of silver should be used in the usual way several times a week. Miku- 
licz advises the use of iodoform paste on the ulcerations and lays strips 
of iodoform gauze between the lower teeth and the cheeks. 

The general condition of the patient should be cared for in every 
possible way. The child should stay outdoors, weather permitting, a 
considerable part of each day. Food should be regularly administered 
despite any pain which it may cause, and the mouth should be washed 
out with sterile water after each feeding. It may be necessary to feed 
through a nose tube and by rectum if the child cannot be made to 
swallow. 

Gangrenous Stomatitis Noma (Oancrum Oris). 

Fortunately, this terrible disease is a rare one, and apparently, like 
hospital gangrene, it is growing rarer. It consists of a gangrene of the 



GANGRENOUS STOMATITIS. 29 

cheek beginning on the inner side near Steno's duct and spreading with 
great rapidity* 

Etiology. — No specific micro-organism has been isolated, and there 
is no satisfactory evidence of its infectious nature. It is not contagious. 
It is safe to say that the disease never occurs except in children whose 
vitality is reduced by previous illness. 

Measles has immediately preceded the gangrene in nearly one half 
the cases on record. Other diseases, such as typhoid, scarlet fever, 
pneumonia, and many more, are more rarely antecedent. 

Ulcerative stomatitis has repeatedly been observed to develop into 
noma. 

It is a disease of children. Of 413 cases collected by v. Bruns,^ 
only 11 occurred after the fifteenth year, and only 6 in young infants. 
Most cases occur between the third and seventh years. 

Pathological Anatomy and Symptoms. — Almost all cases begin 
in the same place — viz. on the inside of the cheek between the corner 
of the mouth and the opening of Steno's duct, opposite the first or 
second molar. A bluish red vesicle forms, which rapidly becomes 
black or greenish black. The cheek for some distance outside the 
lesion is swollen and brawny, with a waxy pallor which soon spreads 
over the whole side of the face. The process is one of typical moist 
gangrene, and advances with frightful rapidity. The gangrenous area 
soon begins to show on the outside of the cheek, and is surrounded by 
a red areola. 

Usually the earliest symptom which calls attention to the disease is 
the peculiar smell of gangrene. The flow of saliva and ichorous fluid 
is profuse and horribly fetid. 

If untreated, and often in spite of treatment, the disease spreads so 
as to perforate the cheek, and goes on to destroy the nose, the eye, the 
frontal bone, while in the mouth the bones are laid bare, the teeth fall 
out, and the soft palate and tonsils may be involved. The process may 
run down the neck and along the supraclavicular fossa and backward 
beyond the ear. 

Occasionally, as in a case seen by Forscheimer, the disease may sud- 
denly stop before it has progressed far, leaving a clean-cut hole in the 
cheek. In such cases the line of demarcation becomes broader and of 
a brighter red, the surrounding infiltration disappears, and the gan- 
grenous slough is separated by vigorous granulations ; bone sequestra 
are cast off, and cicatrization with enormous scars takes place. 

Relapses are rare. The total duration of fatal cases is usually from 
one to two weeks, perforation of the cheek often occurring within 
twenty-four hours. Acute cases are of short duration, and chronic 
cases rarely occur. 

Subjective symptoms are sometimes very slight, the child remaining 
bright and interested in play, and taking food well as long as swallow- 
ing is possible. Diarrhoea is, however, almost invariable, due to the 
swallowing of gangrenous products. Sooner or later fever and grave 
constitutional disturbances are developed, food is refused, and the child 
dies of exhaustion. The mind is often clear to the end and pain is 
rarely severe. Sometimes there is stupor or delirium. 

^ Handbuch des praktischen Chirurgie, Zweite Abtheilung, 1. Band. 



30 DISEASES OF THE TONGUE. 

Broncho-pneumonia, probably by inhalation of gangrenous matter, 
is a common complication. The lymph glands are greatly swollen, and 
albuminuria is the rule. Hemorrhages are rare. 

Diagnosis. — Anthrax is to be excluded by its etiology, its greater 
constitutional disturbance, and the recognition of the anthrax bacillus. 
A local ulceration produced by a decayed tooth may give a very foul 
odor and considerable infiltration of the cheek. The course of the case 
will soon decide the question, the appearance of true gangrene rapidly 
following where noma is present. 

Prognosis. — Very prompt and early surgical interference, with 
extensive extirpation of the infiltrated as well as the gangrenous parts, 
may save the patient. Without early and radical treatment almost all 
cases die, and after the disease has perforated the cheek treatment is 
usually ineffectual. The mortality is from 70-90 per cent. 

Treatment. — The gangrenous tissues being removed, an area of 
apparently healthy tissue around them should be burnt out with the 
Paquelin cautery. The wound should be carefully watched for the 
slightest sign of returning gangrene, and another operation done if 
necessary. 

The nutrition should be maintained at the highest possible level, and 
the child should be kept in the open air as much as possible. 



DISEASES OF THE TONGUE. 

Glossitis. 
1. Acute Glossitis. 

A RARE affection, usually due to the stings of insects, burns,, 
traumatism, or foot-and-mouth disease. The tongue has an enor- 
mous power of resistance to pathogenic bacteria, and abscess does not 
often occur. It is occasionally seen affecting the superficial part of 
the dorsum near the base, starting as furuncles do on the skin, and giv- 
ing rise to pain and increase in the size of the tongue. Deep abscesses 
are very rare, and occur chiefly as complications of a severe stomatitis or 
from wounds (fishbones, etc.), and occasionally in typhoid, erysipelas, 
variola, and anthrax. 

Pain, salivation, and enlargement of the tongue, with difficulty in 
speaking and swallowing, are the chief symptoms. The tongue often 
becomes too large for the mouth and protrudes. CEdema of the palate, 
pharynx, and glottis may occur and constitute a dangerous complication. 

Fluctuation is rarely to be obtained even where pus is present. 

Fever, anorexia, headache, and other signs of a general infection 
may be seen. 

In the DIAGNOSIS one must exclude the passing inflammatory exacer- 
bations which occur in diffuse hypertrophy or lymphangioma of the 
tongue. Syphilitic gummata sometimes are mistaken for abscesses, but 
the history and other evidence of syphilis, and the absence of pain and 
fever, usually put one on the right track. 

Treatment. — Scarification and the application of iodoform gauze 



LEUCOPLASIA BUGCALIS. 31 

are the most efficient remedies. Ice and cooling mouth-washes are 
rarely of use. 

2. Chronic Glossitis. 

Repeated attacks of acute inflammation may lead to a chronic 
enlargement of the tongue, with salivation and possibly ulceration of 
its edge from the pressure of the teeth. A similar state of things is 
occasionally seen in myxcedema and cretinism. Speaking and swallow- 
ing are difficult. 

The TREATMENT is that of the underlying disease. 

This condition is to be distinguished from congenital enlargement 
of the tongue or lymphangioma of the tongue, which is the most fre- 
quent cause of what is known as — 

Macroglossia. — Besides the lymphangioma of the tongue, the organ 
may be enlarged purely by muscular hyperplasia, even to three times 
its normal size, its shape and surface remaining normal. Occasionally 
only one half of the tongue is enlarged in such cases, and is then 
associated with hypertrophy of the whole corresponding half of the 
body. Another rare cause of muscular macroglossia is acromegalia. 

The so-called lobed or fissured tongue may be of such a size as to 
come under the head of macroglossia. It is a congenital condition. 

As above mentioned, an acute glossitis may supervene in any of these 
forms of enlargement of the tongue, especially the cavernous lymph- 
angiectatic form. 

The TREATMENT of all such affections is purely surgical. Wedge- 
shaped pieces can be removed until the tongue is reduced to a more 
manageable size. 

Geographical Tongue (Lingua Geographica, Mapped Tongue). 

A loss of epithelium in spots and patches, bounded by sinuous white 
outlines which appear and disappear with great rapidity and suggest 
the appearance of the boundaries and mountain-chains of a map. The 
patches are smooth and red, and the papillae at the borders of the de- 
nuded areas are white and prominent and catch the eye. The appear- 
ances vary almost from hour to hour, and the whole may temporarily 
disappear, and appear again within forty-eight hours. Occasionally 
similar outlines are seen on the cheeks and lips. 

The CAUSE of the affection is unknown, and it gives rise to no symp- 
tom unless the mind of the patient begins to dwell upon the process 
and fears of syphilis are entertained. It runs a chronic course and is 
not affected by treatment. 

It should be distinguished from the mucous patches of syphilis, which 
never wander about or change their shape with such rapidity. It is not 
at all uncommon at any age, but may go unnoticed for years or for life. 

Leucoplasia Buccalis (Ichthyosis, Keratosis, and Psoriasis of 
the Tongue ; Smoker's Tongue). 

A disease of the surface of the tongue of obscure etiology and chronic 
course, characterized by sharply circumscribed white patches of corni- 
fied epithelium heaped up so as to form flat raised patches. It is not 
confined to the tongue, and occurs occasionally on the lips and cheeks. 



32 DISEASES OF THE TONSILS. 

These accumulations of epithelium are accompanied by a round cell 
infiltration of the underlying mucosa. Occasionally the patches become 
detached at their edges or entirely, leaying deep cracks or small denuded 
surfaces. 

Sypliilis and smoking have been by some observers held responsible 
for the disease, but it occurs in many who have never had syphilis and 
is entirely unaffected by antisyphilitic treatment. While the disease 
hardly ever occurs in women and is repeatedly observed in excessive 
smokers, it is also found in men who have never smoked, and it is as- 
serted that it hardly ever occurs in women in countries where they 
smoke as much as men. 

As a rule, the symptoms are trifling, and tlie disease may be acci- 
dentally discoyered. Rarely jDain from deep cracks or slight trouble in 
speaking and chewing are complained of. It sometimes annoys patients 
with a vague sense of something unnatural in the mouth, and they 
half consciously make effort with the tongue or cheek to rub off the 
patches, and are so constantly reminded of the existence of the patches. 
Hypochondriacal fears of syphilis or cancer are not infrequent, and, in 
fact, the possibility cannot be denied that cancer may develop from such 
patches. This is the only point of view from which the disease is of 
importance. 

It should be distinguished from the mucous patches of syphilis and 
from the mapped tongue. The history of syphilis, the seat of the lesions, 
and the effects of antisyphilitic treatment enable us to exclude mucous 
patches, while the rapid changes in the looks of a mapped tongue and 
the white border round a denuded surface easily distinguish the latter 
from the buccal leucoplasia. 

As above mentioned, the disease runs a very chronic course. 

Treatment. — In view of the possibility of carcinoma and the tend- 
ency to hypochondriasis, it is best to treat every case surgically when 
the diagnosis is established. The patches should be curetted away and 
the subjacent mucosa cauterized. The danger of cancer is probably there- 
by averted and the basis for hypochondriasis somewhat weakened, though 
the tendency may still be very marked after the removal of the lesions. 



DISEASES OF THE TONSILS. 

Acute Follicular Tonsillitis. 

Synonyms. — Acute catarrhal angina ; Acute amygdalitis ; Croupous 
tonsillitis ; Lacunar tonsillitis. 

This is a disease with wdiich most people have had personal 
experience. 

Etiology. — («) The soil ; {h) bacteria. 

(a) The Soil. — Young adults are most often attacked. In children the 
chronic form of tonsillitis (with acute exacerbations from time to time) 
is the rule, and in the aged acute tonsillitis is impossible, because there 
are no tonsils to be inflamed, owing to the general atrophy of the lym- 
phoid tissue about the throats of old people. 

Sex is of no importance. 



ACUTE FOLLICULAR TONSILLITIS. 33 

Spring and Autumn are the times when we see most cases, whether 
this be due to conditions of temperature or to conditions of work and 
occupation, or to other causes. 

It seems as if one attack predisposed to another, the tonsils perhaps 
never becoming quite normal in the interval. 

Debility from any cause certainly predisposes to tonsillitis. We see 
many cases among medical students in the dissecting-room and among 
hospital internes. Overwork, loss of sleep, sexual excess, and the de- 
pression of the menstrual period act in the same Avay. During the past 
winter I have seen a number of cases occurring just at the menstrual 
period, and passing oif with the cessation of the flow. 

Epidemics certainly occur, and frequently several members of a 
household are attacked one after another. It is difficult to decide in 
such cases whether we are dealing with real contagion or whether the 
disease is endemic. 

The disease is often attributed to " catching cold." In my opinion 
it is rare for the temperature to play any important part in the causa- 
tion of a case. In a debilitated person a thorough chilling may still 
further lower the vital resistance of the tissues and allow bacteria to 
set up pathological processes in them, but in most instances the tem- 
perature would have had no eifect but for the existing debility. 

By extension the disease is said to be set up by a coryza, pharyngitis, 
or stomatitis, but this is not common. 

Rheumatism has been supposed by many writers to be often asso- 
ciated with acute follicular tonsillitis, as well as with quinsy and other 
affections of the tonsil. It has even been asserted that we may see 
endocarditis complicate cases of tonsillitis as it does cases of rheu- 
matism. 

Scarlet Fever, and less often the other exanthemata, are very apt to 
be complicated by an acute tonsillitis. 

(6) Bacteria. — Goodale has recently shown that in acute lacunar 
tonsillitis the number of bacteria normally present in the crypts is 
greatly increased, but that they frequently do not enter the tonsillar 
tissues, owing perhaps to the resistance they meet from the phagocytes 
of the glands. " The possibility is at once suggested that the inflam- 
mation of the tissues may be due to the absorption through the mucous 
membrane of irritating toxins formed in the crypts as in a test tube." 

Be this as it may, there is no reason to doubt that bacteria are asso- 
ciated with all cases of tonsillitis. As a rule, they are those varieties 
found ordinarily in healthy throats — i. e. the pyogenic cocci and the 
diplococcus lanceolatus. 

Vent,^ Jaccoud,^ and others have maintained that those cases in 
which the diplococcus lanceolatus is obtained in pure culture are apt to be 
characterized by a violent onset with chill and by a sharp defervescence, 
reminding one of croupous pneumonia. In such cases a membrane may 
or may not be present on the tonsils, but in most cases of membranous 
angina it is a streptococcus which is found. Some of these cases run 
the course of a very severe septicaemia, hence the term " septiccemic 
angina'^ has been applied to them. In this group probably belong 

^ Vent : Inaug. Dissert., Greifswald, 1895. 
^ Jaccoud : La Bulletin Med., Sept. 13, 1896. 
Vol. III.— 3 



34 DISEASES OF THE TONSILS. 

those cases described as " the white throat of the lake region " by Genf, 
and recently by Greene ^ and Tidey.^ 

Many of the pseudo-membranous anginas occurring on or about the 
fourth day in scarlet feyer are associated with the presence of the strep- 
tococcus. ' Thus Lemoine,^ in a study of 168 cases of angina, 112 of 
which complicated scarlet feyer, found the streptococcus in eyery case. 
In 142 out of 145 cases in which he took his cultures from the interior 
of the tonsil he found the streptococcus in' pure culture, while in 11 
out of 23 cases in which the cultures were taken from the surface of 
the tonsil other organisms were present besides the streptococcus (a 
staphylococcus, the diplococcus lanceolatus, or one of the colon bacil- 
lus group). 

Most cases of suspected diphtheria where the Klebs-L5ifler bacillus 
is not found show streptococci. The virulence of these organisms is 
often much greater than that of the streptococci found in healthy 
throats. 

Pathological Anatomy. — Three types may be distinguished : (a) 
The erythematous or catarrhal ; (b) The lacunar ; (c) The pseudo-mem- 
branous. 

(a) The main features of these types are usually found in all severe 
cases, though one or the other may predominate. If erythema pre- 
dominate, we see a more or less vivid reddening of the tonsils, pillars, 
soft palate, and uvula, all of which may or may not be swollen as well. 

(6) In most cases we find also several yellowish white spots on one or 
both tonsils, the spots corresponding to the orifices of the gland-crypts, 
which are plugged up by an accumulation of degenerated leucocytes, 
epithelium, and bacteria in a meshwork of fibrin. These cheesy plugs 
can be picked off or pressed out, and are not adherent to the subjacent 
parts. The exudations of contiguous lacunse may coalesce, and most of 
the tonsil may thus be covered, so that the appearances of diphtheria are 
strongly suggested ; but, as a rule, the deposits do not form a continous 
layer. The parenchyma of the tonsil is infiltrated with serum and 
leucocytes, increasing its bulk. 

The affection may be unilateral or bilateral. Very often first one 
tonsil and then the other goes through the process. 

In the severer cases the glands at the angle of the jaw are swollen. 

Occasionally the cheesy plugs, instead of being pushed out in a few 
days, are retained and become calcified. The chalky masses may later 
be expectorated — "timid persons may be badly frightened, believing 
them to be tubercles." Again, the follicles may become occluded and 
small abscesses result. 

(c) Pseudo-membranous tonsillitis is also known as necrotic tonsillitis, 
gangrenous tonsillitis, aphthous tonsillitis and diphtheroid sore throat. 
The two latter terms are misleading, and should not be used, since it 
has no connection with aphthae, and the most important fact about it is 
that it is not diphtheria. 

We have here a superficial necrosis which may or may not become 
gangrenous. A grayish white membrane, exactly like that of diph- 
theria, spreads over the tonsil and may involve the soft palate, uvula, 

1 N. T. Med. Rec, Feb. 15, 1896. _ ' Ibid., April 11, 1896. 

^ Annates de I'Institut Pasteur, 1896, vol. ix. No. 12. 



ACUTE FOLLICULAR TONSILLITIS. 35 

and even the pharynx. It is not detachable, or if detached leaves a 
bleeding surface. The process may extend quite deep into the structure 
of the mucous membrane. 

This form of sore throat is seen most often as a complication of 
scarlet fever, but is occasionally seen as a primary disease. The evolu- 
tion of the membrane takes four or five days, after which it is usually 
not reproduced. 

Bacteriologically, the important point is the absence of the Klebs- 
Loffler bacillus. Other bacilli closely resembling it are sometimes 
found in such throats, and to them the name of pseudo-diphtheritic 
bacilli has been attached. The term should never be used. Competent 
observers can distinguish the Klebs-Ldffler from all other bacilli, 
including this variety. It is true that the virulence of the Klebs- 
Lbffler bacillus varies widely in different cases, but this is true of many 
bacteria, and there is no reason for giving another name to the weakly- 
virulent races. 

The streptococcus is the organism most often found in necrotic ton- 
sillitis, either alone or in connection with a staphylococcus or the dip- 
lococcus lanceolatus. Occasionally one of the latter varieties is found 
in pure culture. In the severe septic cases the organs may show the 
changes common to many forms of septicsemia — granular degeneration 
of the heart, liver, and kidneys, metastatic processes in various organs, 
ulcerative endocarditis, and other lesions. 

Moure of Bordeaux makes out a separate disease called "herpetic 
tonsillitis," in which, after becoming red and swollen, the tonsils present 
a crop of herpetic vesicles, which are also to be found scattered over 
the neighboring parts of the throat. In from twelve to thirty-six hours 
the vesicles break, leaving little ulcers covered with whitish exudation. 
The majority of observers fiud these lesions in connection with other 
forms of tonsillitis, and do not recognize a separate affection. 

Symptoms and Signs. — 1. Symptoms and Signs of a General Infec- 
tion. — 1. In some cases constitutional symptoms are so slight that the 
patient is scarcely aware of any, but, as a rule, he experiences more or 
less lassitude and malaise, which in bad cases may amount to severe 
prostration and great fatigue on any muscular or mental effort. 

Headache, and pain and soreness " in the bones " or " all over," are 
the rule, and may be very severe, coming on suddenly and violently or 
gradually increasing for a day or two. Delirium has been observed, 
especially in children. 

The appetite is usually poor and the tongue coated ; vomiting some- 
times occurs, and there may be constipation or more rarely diarrhoea. 

Fever is almost invariably present, often reaching 102°, and not 
infrequently rising to 104 or 105° F,, especially in children. Chilly 
feelings at the time of the onset are the rule, and occasionally there 
is a genuine chill. 

The pulse is correspondingly elevated, and the respiration is often 
rapid even where cough and affections of the lung are entirely absent. 
This is especially apt to be the case in young children. At the height 
of the fever an apex systolic murmur is not uncommon, but is no indi- 
cation of endocarditis. 

There is no characteristic type of fever. Onset and defervescence 



36 DISEASES OF THE TONSILS. 

may be alike abrupt or one or both may be gradual. As a rule, the 
fever is continuous with moderate morning remissions and evening 
exacerbations. From three to six days is the average duration. If the 
disease crosses over to the other tonsil, the whole course may be re- 
peated. The fever is usually over before the local lesions are gone, and 
in children it may last but twenty-four hours or even less. 

The urine is that of fever — high color and specific gravity, with now 
and then a trace of albumin and a few hyaline or granular casts. 

The spleen is occasionally enlarged. 

Leucocytosis is always present in marked cases, and may run as high 
as in diphtheria or pneumonia. 

The above symptoms and signs of a general infective process are, 
as a rule, much more marked than the extent of the local process would 
lead us to expect. This is especially true in young children, in whom 
throat lesions may be found only in the course of routine physical exam- 
ination. 

As in grippe, patients are amazed to find themselves feeling so sick 
with so little to show for it. 

2. Local Symptoms and Signs. — Tickling, burning, or " scratchy " 
feelings in the throat are usually the earliest. Pain is present on swal- 
lowing or occasionally on speaking, but not, as a rule, when the parts 
are at rest, except in very severe cases. Salivation is not infrequent. 
The voice is often altered, and may have a nasal twang or be muffled. 

Movements of the head and neck are often painful, even when the 
cervical lymph glands are not involved, and there may be stiff neck or 
actual torticollis. Sometimes the pain on swallowing shoots to the ear 
without there being any involvement of the Eustachian tube or middle 
ear, but these parts are occasionally involved by extension. 

Cough is not usually troublesome unless pharyngitis is also present, 
and in many cases there is none at all. 

Examination shows usually redness and swelling of one or both 
tonsils, with one or more yellowish-white spots on them, varying 
from the size of a large pinhead to that of a split pea. These can be 
easily stripped off or poked out, leaving an intact mucous membrane 
beneath. 

These are the appearances in the great majority of cases, and it is in 
these cases that clinical observations can usually anticipate the results 
of the bacteriological examination (which should be made in every 
case), and distinguish the disease from diphtheria. Where a wide- 
spread membrane is present the bacteriological examination alone can 
decide whether it is or is not diphtheritic. Still, it remains true that 
the vast majority of membranous throats are diphtheritic, and the vast 
majority of those showing only spots at the orifices of the tonsillar 
crypts are not diphtheritic, the bacteriological test remaining the ulti- 
mate one for diagnosis. 

The exudate of tonsillitis is usually patchy, with sound tissue inter- 
vening, seldom extends beyond the tonsils, can be stripped off, leaving 
an intact surface beneath, and does not give the impression of necrosis. 
Diphtheritic lesions, usually not patchy, do extend beyond the tonsil 
and cannot be stripped from the surface, since they represent a necrosis 
of its superficial layers. 



ACUTE FOLLICULAR TONSILLITIS. 37 

The breath may be foul, but the strong gangrenous odor often 
noticed in diphtheria is not present. 

Herpetic vesicles are occasionally seen on the tonsils, with or mthout 
other lesions. They may occur in crops. 

The appearances of pseudo-membranous tonsillitis have already been 
described (Vol. I. pp. 708-710). They are identical with those of 
diphtheria, and the extreme fetor of the breath and adeno-phlegmon 
of the neck are as frequent as in the latter disease. 

In scarlet fever membranous angina may occur near the beginning 
of the disease or in convalescence. The latter (according to Moure) are 
almost always diphtheritic, the others rarely so. 

Course and Prognosis. — After forty-eight hours the worst symp- 
toms are usually over. The forms due to the diplococcus lanceolatus 
are said to be very abrupt in onset and termination, and Moure 
holds similar views in regard to the " herpetic tonsillitis " described by 
him. 

Except in the fulminating septicsemic forms, which are rarely seen, 
the prognosis as to life is entirely good. Some of the pseudo-membran- 
ous throats seen in scarlet fever do serious mischief by extension to the 
nose, ear, or larynx. 

Bassford asserts that after " rheumatic tonsillitis " we may see an 
endocarditis develop. Hague-Brown in an analysis of 345 cases found 
that 8 had endocardial lesions ending in valvular disease, and 3 had 
pericarditis. Gougenheim records a case of membranous angina due to 
streptococcus in which purulent pericarditis, empyema, and suppura- 
tion in the sterno-clavicular joints occurred and caused death from gen- 
eral septicaemia. Suppurative tonsillitis is "not very uncommon as a 
complication, especially in those who have had previous suppurative 
attacks. Osier regards paralysis, local or general, following " tonsil- 
litis " as indicating that the diagnosis was wrong and the case really 
one of diphtheria. Moure, Bosworth, and Striirapell, on the other 
hand, consider that paralyses similar to those following diphtheria have 
occurred after genuine non-diphtheritic angina. Personally I have 
never seen such. 

Nephritis is very rarely if ever a complication. 

Treatment. — Until diphtheria is positively excluded patients should 
be isolated. After that it is unnecessary. The disease is self-limited, 
and cannot be aborted or much shortened by any means known to us.^ 
In the great majority of ordinary lacunar cases no local treatment is 
necessary. If fever is present, the patient had better go to bed. A 
laxative should be given in case of constipation, not otherwise. The 
headache, soreness, and general discomfort are often greatly relieved by 
phenacetin, which can be given in doses of 10 grains combined with 2 
grains each of caffeine and sodic bicarbonate. Such a powder may be 
given to an adult two or three times in twenty-four hours for the first 
day or two, if needed, and will serve to keep the temperature moderate 
and allay the discomforts of high fever, as well as the pain and muscu- 
lar soreness. Quinine has no action unless given in doses sufficient to 

^ A possible exception to this statement is the use of Marmorek's antistreptococcus 
serum, which in the hands of Dubois (Bull. Med. du Nord, April 10, 1896) is said to have 
caused marked improvement, local and general, in 4 cases of scarlatinal angina. 



38 DISEASES OF THE TONSILS. 

reduce temperature, and there is no reason for giving iron. My expe- 
rience with the salicylates has not been encouraging. 

The diet is to be suited to the digestive power, and, other things 
being equal, it is better for the patient to eat as nearly as possible what 
he is used to. If the appetite is gone, considerable nourishment can be 
'got in in the guise of cold drinks, to which patients always take kindly. 
Milk, egg-nog, albumin water, and ice cream are usually acceptable, and 
should be given every four hours if no other food is taken. The tem- 
perature not infrequently goes down a degree or more after a meal, and 
the patient is proportionally more comfortable. 

As a rule, patients sleep enough in the course of the twenty-four 
hours, making up by day-time naps for any wakefulness at night. 
Trional gr. x to xv acts well in case insomnia is present, and relieves 
moderate pain. 

Local treatment is not effective in most cases, but patients who 
expect gargles and poultices to the neck should not usually be disap- 
pointed. In gargles heat is the main thing. Any hot, non-irritating 
liquid gives temporary relief, and nothing is better in my experience 
than milk used as hot as it can be borne and swallowed after gargling. 
Especially at night such a gargle may give enough relief to enable the 
patient to get to sleep. The mouth should be rinsed with cold water 
before and after each feeding — a procedure which makes the meal much 
more likely to be well borne. 

In the pseudo-membranous forms of tonsillitis an eflfort should be 
made to prevent the spread of the membrane to the nose, ear, or larynx 
by the use of a twenty-five volume solution of peroxide of hydrogen 
as a spray or on a cotton swab. 

In the septicaemic cases the treatment is that of any form of 
septicaemia. 

Acute Ulcerative Tonsillitis. 

In follicular tonsillitis there is little or no genuine ulceration. 
Moure ^ has recently reported 9 cases of a very rare affection of the 
tonsils which he calls by the above title. The general appearance of 
the disease is very closely similar to that of tertiary tonsillar syphilis. 
It occurs mostly in young adults. The onset is insidious. There is 
usually no fever or other constitutional symptoms, pain on swallowing 
being the chief complaint. Examination of the throat shows on one or 
both tonsils a considerable loss of substance, punched out, with sharp 
red edges, and often a cheesy deposit at the bottom. There is no 
SAvelling and no involvement of the cervical lymph-glands. There may 
be two or three such ulcerations on each tonsil, with no tendency to 
coalesce. 

If the exudate covering the floor of the ulcer be removed, we find 
a granulating surface beneath. It has the appearance of a spot which 
has been cauterized several days previously. The ulceration may be 
as large as a dime or even larger ; it is always rather deep, and may 
extend to the floor of the tonsillar space. " The lesion is absolutely 
benign and ephemeral and runs its course in a few days." 

^ Centralb. filr Laryngologie, etc., Feb. 1897. 



SUPPURATIVE TONSILLITIS. 39. 

Diagnosis. — (a) Lupus of the tonsil is distinguished by its longer 
course. (6) CJiancre of the tonsil causes swelling of the whole tonsil 
and cervical adenitis, and lasts often for several weeks, (c) Gumma 
of the tonsil bears a very close resemblance to the disease which we are 
considering, but usually occurs toward the edge of the tonsil and ex- 
tends rapidly to the pillars of the fauces, the soft palate, pharynx, or 
tongue, while acute ulcerative tonsillitis does not spread. The infiltrated 
edges, the chronic course, and the history of syphilis usually suffice to 
distinguish the gummatous ulcer from ulcerative tonsillitis. 

Treatmeis'T. — The sloughs should be carefully removed and the 
following gargle used every four hours : 



Boracis, 




Potassii bromidi, 


ad. 3j ; 


Glycerini, 


^j I. 


Aquam, 


ad iviij 



Smoking should be forbidden, and the debility which is often present 
treated in the ordinary ways. 

Suppurative Tonsillitis. 

Synonyms : Quinsy ; Tonsillar abscess ; Peritonsillar abscess ; 
Parenchymatous tonsillitis ; Phlegmon of the tonsil. 

Although it has been strenuously insisted by Bosworth that all cases 
start in the peritonsillar tissue and only incidentally perforate the 
tonsil, the great majority of writers make no such distinction, since 
they find usually some involvement both of the tonsil and of the tis- 
sues which surround it. Clinically, the distinction is not important. 

Etiology. — Males between twenty and forty are most frequently 
attacked, and cases are more numerous in early spring and late autumn 
than at other times of the year. 

The disease seems to occur in certain families with particular 
frequency, and affects especially the poorer classes. One attack predis- 
poses to another. 

Most writers agree in regarding the disease as connected in some 
way with rheumatism, though MacKenzie attributed but little import- 
ance to the admittedly frequent association of the two diseases. 

Persons whose tonsils are chronically enlarged are apparently more 
apt to suffer from quinsy, especially in cases where subacute attacks of 
superficial inflammation are of frequent occurrence. 

Attacks are occasionally preceded by exposure to cold, by one of the 
exanthemata, or by a follicular form of tonsillitis, the common factor in 
these predisposing causes being the debility which they all tend to pro- 
duce, and which renders the patient more susceptible to the action of 
bacteria and their products. 

Probably the micro-organisms active in the disease are those nor- 
mally present in the gland crypts — namely, the pyogenic cocci and the 
pneumococcus, whose effects are ordinarily warded off by the action of 
phagocytes or other protective agencies of the tissues. Owing to a 
weakening of these protective powers by the predisposing causes of the 



40 DISEASES OF THE TONSILS. 

disease, inflammation is set up by one or more of the organisms above 
mentioned. 

Pathological Anatomy. — One or both tonsils becomes much 
enlarged and hypersemic. In the early stages the organ is hard to the 
touch, but softens if pus appears. 

The throat may be almost occluded by the tumefied tonsils. The 
salivary and buccal secretions are increased, the cervical glands enlarged, 
and the jaw may be fixed so that the patient is hardly able to open the 
mouth. 

The uvula and soft palate are displaced by the swollen tonsil and 
are usually oedematous. The abscess often points midway between the 
upper edge of the tonsil and the base of the uvula. Sometimes the pus 
burrows down the side of the pharynx, and may reach as far as the 
orifice of the oesophagus. Of 133 cases seen by Bosworth/ 115 pointed 
in the soft palate, 11 in the posterior pillar of the fauces, 2 in the ton- 
sil itself, and 2 in the pharynx. Very rarely the pus may make its 
way down into the tissues of the neck or even into the mediastinum or 
pleural cavity. 

Microscopically, the tissues of the tonsil show hypersemia and cellular 
infiltration, as in any other abscess. 

Symptoms. — The local discomfort is usually very great and the con- 
dition of the patient pitiable. 

The pain is generally very severe, and is not confined to the tonsil, 
but extends to the ear, to the floor of the mouth, and to the angle of 
the- jaw. It is deep-seated, gnawing and boring, or sometimes neuralgic 
and lancinating. It persists even when the parts are absolutely at rest, 
but is aggravated by any movement, such as swallowing, speaking, open- 
ing the jaws, or even moving the head and neck. The mouth can rarely 
be opened more than half an inch without great pain. 

The salivary secretion is greatly increased and may be fetid, and, 
owing to the pain and difficulty in swallowing, the patient usually lets 
the saliva escape from the mouth. 

The voice is much altered ; it is thick, muffled, and nasal, and ar- 
ticulation causes much pain. Sometimes the Eustachian tube is pressed 
upon and the patient complains of deafness or noises in the ear. 

Nasal breathing is usually obstructed, and smell and taste may be 
abolished. 

" The accumulation of thick and tenacious mucus in the fauces be- 
comes the source of so much annoyance that the patient makes frequent 
efforts to clear the passages by an attempt at hawking, which is quite 
characteristic in that the sodden condition of the muscles renders the 
effort somewhat futile." Torticollis is not infrequent, and contraction 
of the masseters may be so great as to render examination and treatment 
difficult. 

Constitutional symptoms are also very marked, and the prostration 
may be early and severe. The temperature is often 104° or 105° F. 
and the pulse correspondingly elevated. A well-marked chill is often 
seen at the outset, and chilly sensations are the rule where chill is 
absent. 

Headache, pains in the back and " bones," malaise, and anorexia are 

1 New York Med. Rec, Oct. 4, 1884. 



SUPPURATIVE TONSILLITIS. 41 

very commonly met with. Constipation is the rule. Sleep is impossible 
without opiates. 

When both tonsils are involved we have an aggravation of all the 
symptoms, and not infrequently serious disturbance in breathing. 

The COUESE of cases if untreated varies a great deal. The exuda- 
tion may be absorbed and the symptoms disappear within a few days, 
without there being at any time unmistakable evidence of pus. More 
commonly fluctuation can be made out in from two to four days, and 
rupture takes place somewhere between the fifth and tenth day, accord- 
ing to the time of the appearance of pus and the character of the tissues 
involved. Abscesses which point in the soft palate break sooner than 
those which extend into the posterior pillar or the wall of the j^harynx. 

As soon as the pus is evacuated the local and general symptoms 
rapidly ameliorate, and in a few days the patient is well. The amount 
of pus discharged is usually small. 

If the inflammation has been intense, the process may take a little 
longer, the pus being discharged intermittently. 

Occasionally the burrowing pus opens a bloodvessel. The resulting 
hemorrhage may be very serious, but is fortunately of rare occurrence. 
The tonsillar, ascending pharyngeal, or internal carotid are the arteries 
which may be involved. The majority of the reported cases have ter- 
minated fatally. Prompt ligation of the common carotid has saved 
several recent cases. Burgess reports a case ^ in which, after various 
hsemostatics had proved useless, the bleeding finally stopped of itself, 
the patient being greatly exhausted. 

Diagnosis. — In the earliest days of the attack diagnosis may be 
impossible. After twenty-four hours deep fluctuation may often be 
obtained. The local pain is usually much greater and the swelling more 
considerable than in other forms of tonsillitis. 

Fibrous tumors of the fauces are of very rare occurrence, but may 
occasionally be mistaken for a quinsy. 

Prognosis. — A properly treated tonsillar abscess is almost never a 
danger to life, but causes a great deal of suffering while it lasts. Cases 
in which the pus is allowed to burrow and is not evacuated may prove 
fatal — (a) by breaking into the air passages at night ; (6) by giving rise 
to a general septicaemia ; (c) by obstruction of the fauces with or with- 
out oedema of the glottis ; (d) by erosion of a large artery. 

Early incision of the abscess will prevent, in practically every case, 
the occurrence of these complications. 

The patient is usually somewhat prostrated by loss of sleep, inability 
to take food, and by pain, but the course of a well-treated case is seldom 
over ten days from start to finish. 

Attacks are very apt to recur in the spring and fall, — especially in 
those whose tonsils are chronically enlarged. 

Treatment. — Sometimes the products of inflammation are absorbed 
without drainage, natural or artificial. During the earliest stages of the 
disease an effort should be made to promote absorption by the following 
measures : 

{o) Free catharsis by mercurials or salines. 

(6) Early scarification of the swollen tonsil. 

1 Lancet, 1896, p. 105. 



42 DISEASES OF THE TONSILS. 

(c) The use of aconite and of the salicylates (drop doses of the 
tincture of aconite every hour till the lips and fingers tingle ; 10 
grains of sodic salicylate every two hours till toxic symptoms appear). 
The fever may be reduced by phenacetin or lactophenin, gr. v every 
fowr hours till the thermometer indicates 100° F. or less. 

Local applications, such as ice or cocaine, are usually of little bene- 
fit ; poultices to the neck are liked by some patients. While waiting 
for the formation of pus we frequently find the use of morphine indis- 
pensable for the control of pain. Bosworth recommends that the 
patient should rub dry cooking-soda into the tonsil at short intervals. 

As soon as the presence of pus is ascertained a curved bistoury 
should be plunged into the most fluctuant point, and the incision car- 
ried from above downward for at least one half an inch, parallel to 
the anterior pillar of the fauces. The bistoury should be guarded with 
adhesive plaster up to about three quarters of an inch from the point. 
If pus does not flow at once, a probe should be inserted and pushed in 
various directions in search of pus. The flow is often sluggish at best. 

After the evacuation of the pus it is important to keep the opening 
patent until the wound has healed from the bottom, since pus may be 
penned in by a superficial healing, and in this way an abscess may 
re-form. 

It is often almost impossible for the patient to take food, but he 
should always be urged to do so, cold liquids and ice-cream being best 
borne. It may be necessary to cocainize the parts before a meal. 

Hypertrophy of the Tonsils (Chronic Tonsillitis). 

As a rule, hypertrophy of the faucial tonsils forms part of a general 
overgrowth of the adenoid tissue of the upper respiratory passages, 
including the naso-pharynx and pharynx, and in treating of the con- 
ditions in the faucial tonsils it is impossible to avoid some repetition of 
matter covered by the section on the Diseases of the Naso-pharynx. 

Etiology. — Occasionally the condition is congenital, and in the 
great majority of instances we seem forced to assume that congenital 
influences (of a nature wholly unknown) strongly predispose certain 
children to an overgrowth of adenoid tissue about the faucial ring. It 
is essentially a disease of childhood, though it may persist in rare cases 
into adult life. By some writers it is considered as akin to the scrofu- 
lous or tubercular taint, but there is but little evidence to support such 
a view. 

In most cases the tonsils begin to enlarge at about the age of three 
or four. It is doubtful whether the occurrence of one or more of the 
exanthemata or of repeated attacks of " sore throat " are to be considered 
as etiological factors. It is probably truer to consider the recurrent 
acute attacks as results rather than causes of the hypertrophy. 

Bad hygiene does not seem to bear any relation to the disease, which 
is as frequent in good hygienic conditions as in bad. 

Benham has recently reported a case in which chronically enlarged 
tonsils became very much smaller during an attack of pneumonia, but 
regained their former size by the end of convalescence.^ 
^ Benham : Lancet, 1896, p. 68. 



HTPERTEOPHY OF THE TONSILS. 43 

Pathological, Anatomy. — The lymphoid elements are chiefly 
involved, witliout much development of the trabeculse in most cases. 
Where the condition persists into adult life the tonsil is firmer, owing 
to the great hypertrophy of the stroma, but in early life this is usually 
absent. 

The tonsils bulge out in irregular lumps and may almost touch each 
other. The crypts are always deep, and the closed follicles greatly 
increased in volume. In the deep crypts masses of mucus, desquamated 
epithelium, and leucocytes collect and degenerate. Occasionally the 
tonsil is adherent on one or both sides to the pillars of the fauces, but, 
as a rule, the tonsil maintains its individuality and is attached only by 
its base. 

There is usually a notable thickening of the lining of the crypts and 
an enlargement of the bloodvessels. 

In the hard tonsils seen in adults occasionally the proliferation of 
the connective tissue practically obliterates the crypts, and compresses 
the vessels so that the blood supply is considerably diminished. The 
surface of such a tonsil is much smoother and somewhat paler than in 
the common form seen in children. 

Symptoms. — Many symptoms once attributed to hypertrophied 
faucial tonsils are now considered to be due largely or entirely to the 
encroachment of adenoid growths on the naso-pharynx. 

The enlarged faucial tonsils act as foreign bodies and mechanically 
interfere with the function of the parts if the enlargement is very great, 
but we are often surprised to see how little trouble they give unless 
acutely inflamed. Patients breathe, swallow, and talk through a hole 
that looks very small, without being aware that anything is wrong. 

Breathing is sometimes slightly interfered with at night, and the 
frequent occurrence of nightmare in children with large tonsils may 
perhaps be thus explained. 

The voice is altered in cases where the tonsils interfere with the 
functions of the uvula and soft palate, its tone being sometimes com- 
pared to that of a person trying to talk with a full mouth. 

Swallowing is rarely interfered with, except during acute inflamma- 
tions of the enlarged organs. 

Mouth-breathing is the rule even when the naso-pharynx is clear. 
The throat gets dry, and cough may be set up in this way. Stuttering 
and habit-chorea are said to be dependent on mouth-breathing in certain 
cases. 

Quinlan ^ and others have noted deafness due to enlarged faucial 
tonsils, and cured by their excision. As a rule, this symptom is due to 
naso-pharyngeal growths, and it is not easy to explain the connection 
of the faucial tonsil with the ear. 

Torticollis is occasionally caused by tonsillar enlargement, and cured 
by removal of the growths. 

It has been already mentioned that in the deep and dilated crypts 
of hypertrophied tonsils decomposition of secretions and cells goes on. 
The products of this decomposition are exuded on to the surface of the 
organs, and over them the air and food ingested must pass. Fetor of 
the breath is thus brought about. Whether, as Bosworth suggests, the 

^ New York Eye and Ear Infirmary Reports, 1896. 



44 DISEASES OF THE TONSILS. 

general health is impaired by pollution of the air and food in this way 
may be doubted, since a considerable proportion of children with big 
tonsils are as well as their neighbors, and such troubles as they are 
subject to can easily be explained in other ways. 

Where more serious symptoms, such as mental dulness or misshapen 
thorax, are present the naso-pharyngeal growths are almost always the 
chief factor in the trouble. 

Children with enlarged tonsils are very liable to " colds," to attacks 
of tonsillitis, and sometimes to wheezing or " croupy " attacks at night. 

Diagnosis. — The faucial tonsils are easily seen if enlarged. When 
a contraction of the velum palati takes place they approach each other 
more nearly. The size of the mass to be seen in the mouth depends a 
good deal on whether or not the tonsils are incarcerated — i. e. adherent 
to the pillars of the pharynx. A free tonsil always looks larger than 
an incarcerated one, other things being equal. Occasionally they are 
pedunculated and hang down the throat, so that they may irritate the 
epiglottis. 

Cheesy masses or concretions distending and projecting from the 
follicles are occasionally seen. They may be imprisoned behind the 
anterior pillar, and brought to light only by turning the tonsil back- 
ward and using a probe. 

Malignant disease of the tonsil may develop so insidiously as to sug- 
gest only a simple hypertrophy. Such cases are usually unilateral and 
develop in persons past middle life. 

Prognosis. — Enlarged tonsils almost invariably begin to disappear 
at puberty, and by the twentieth year are gone. This fact, together 
with the absence of any danger to life, has led some to consider treat- 
ment unnecessary. But our prognosis in untreated cases must take 
account of the fact that before the twentieth year the patient may be 
permanently injured by the presence of obstructions in the upper air- 
passages. Further, there is reason to believe that infections may take 
place more easily through the crypts of enlarged tonsils, and dijDhtheria 
occurring in a child with such trouble runs a severer course. The 
physician's chief concern with the prognosis of hypertrophied tonsils 
is to change it by his treatment. 

Treatment. — Removal of the hypertrophied organ is the essential 
thing. In the vast majority of cases this is best done with some form 
of tonsillotome. This instrument does not necessitate the use of an 
anaesthetic, and does its work with great quickness. It is in principle 
a guillotine loop, which is fitted around the tonsil and amputates it by 
a single quick cut. There are various kinds of tonsillotome, each having 
its advocates, but the general principle is the same. 

The patient is held in a sitting position, and if there are any signs 
of refractiveness the hands should be secured and the mouth prevented 
from shutting by a gag or pad of towel placed between the teeth. A 
good light is important. 

The instrument is then fitted around the tonsil as near as possible to 
its base. The spatula which has hitherto held down the tongue is now 
dropped, and the left hand pressed against the shaft of the tonsillotome, 
so as to work it into place at the base of the tonsil. A quick contrac- 
tion of the fingers of the right hand cuts through the tonsil. The 



MYCOSIS OF THE TONSILS. 45 

patient's head is then brought forward, so that he can spit out the blood 
and tissue. > 

The tonsillotome can be used as a tongue-depressor in refractory 
cases where the left hand is not at liberty to manage a spatula. The 
operation is terrifying to children, but not very painful. 

If the whole tonsil is not removed by this procedure, what remains 
may be taken off with the cold wire snare. 

With the soft tonsils of childhood, to which the above method is 
best adapted, hemorrhage is rarely severe. The bleeding, which is at 
first profuse, usually ceases within half a minute. Almost all the 
serious hemorrhages reported after tonsillotomy have occurred in adults. 

With adults hemorrhage is frequently serious, and not to be con- 
trolled by ordinary haemostatics or styptics, — torsion, pressure, or liga- 
tion of the common carotid being usually the only available remedies. 
Hemorrhage may, however, be avoided in almost all cases by using the 
cold wire polypus-snare instead of the tonsillotome, and in all adult 
cases this should be used, especially in hard tonsils where the vessels 
are too stiif to retract. 

In some cases the tonsil has to be dissected out from its bed of 
adhesions with a bistoury. It is usually best to give an ansesthetic in 
such cases, since experience shows that without anaesthesia it is hard to 
get out the whole tonsil, and if any considerable portion is left the 
trouble may recur. 

The throat is not usually much sore twenty-four hours after the 
operation, but an exudation is sometimes seen on the raw surface, and 
this may be accompanied by all the symptoms of an ordinary acute 
tonsillitis. In the membrane seen in such cases the Klebs-Loffler 
bacillus is sometimes found. Lichtwitz examined 27 such cases, and 
found the Klebs-Loflfler bacillus in 11 cases, twice in pure culture. 
There were no symptoms to speak of in these cases, and the patients 
rajDidly recovered without antitoxin or other treatment. 

Moure states that such complications can be prevented by using 
washes of lemon juice or boric acid for some days before the operation, 
and carefully disinfecting the mouth just before operating, and by 
declining to operate on inflamed tonsils. 

Mycosis of the Tonsils. 

This may be due («) to the leptothrix buccalis, (6) to thrush. 

(a) Leptothrix Buccalis. — Since this organism is present in the 
mouths of most healthy persons, the question of chief interest is as to 
the conditions which lead to the deposit of masses of its growth on the 
tonsils and fauces. The patients are sometimes in the best of health, 
usually in early adult life. No plausible account of the etiology of 
the disease has yet been given. 

Symptoms. — The disease is a rare one, and gives rise usually to so 
little disturbance that its existence may be discovered only by accident. 
No inflammation is excited, and the most that is complained of is feel- 
ing of stiffiiess or a pasty feeling in the throat. There is no fever, and 
usually no cough. 

The fungus develops best in the crypts of the tonsils, and spreads 



46 DISEASES OF THE TONSILS. 

thence over the surface of the organ about the mouths of the crypts. 
It may occur on the Ungual tonsil, and occasionally is seen on the 
tongue, soft palate, or pharynx. 

Yellowish white, hairy bundles or masses project from the surface, 
to which, they are firmly adherent. Moure states that they have a 
horny consistency, but in this connection the statement of Kelly,^ that 
keratosis is often mistaken for mycosis, should be borne in mind. 

The microscopic examination of the masses, which should never be 
omitted, serves to differentiate the trouble from the cheesy plugs of 
follicular tonsillitis and from thrush. The absence of all inflammatory 
change makes tonsillitis impossible. 

It may follow or accompany diphtheria, and in case any true mem- 
brane is present the cultural test should never be omitted, even when 
the leptothrix has been demonstrated under the microscope. 

The disease, once established, is sometimes obstinate, slowly extend- 
ing to the adjacent parts and sometimes crossing from one tonsil to the 
other. Ragged surfaces like those of the lingual and faucial tonsils 
seem to favor its growth. 

The disease is purely local and entirely harmless. 

Treatment. — The destruction of the fungus in loco is the indication. 
This may be done by the curette or galvano-cauterv, or less effectively 
with chromic acid or silver-nitrate stick. Much patience may be 
required and recurrences are possible. 

(6) Thrush of the tonsil presents no features differing from thrush 
of other parts of the mouth (see p. 24). Its occurrence on the ton- 
sils has been lately described by Moumer^ and by Sendziak.^ The 
case described by Sendziak occurred after diphtheria and persisted on 
the tonsils for tw^o months, having invaded the rest of the mouth for 
only a fortnight. 

Diseases of the Lingual Tonsil. 

The collection of closed follicles at the base of the tongue, which has 
recently attracted notice under the name of the lingual tonsil, is subject 
to most if not all of the diseases by which the faucial and pharyngeal 
tonsils are affected. 

1. Acute Inflammation. 

The chief element in a sore throat is sometimes found to be the lin- 
gual tonsil. As a rule, the other tonsils are more or less involved, but 
the appearances, sensations, and results of treatment may point to the 
lingual tonsil as the principal offender. 

Symptoms. — The general symptoms are those already described 
under Follicular Tonsillitis (p. 35), but the pain is referred to the 
region of the hyoid bone, and the patient may be conscious of a lump 
at the base of the tongue, and of pain on sw^allowang, which is on the 
middle line and not at the side as in ordinary tonsillitis. The pain 
sometimes radiates to the ear. Cough is frequent, and aggravates the 
pain. 

1 Glasgow Med. Journ., Aug. -Oct., 1896. ^ q^^^ ,„g^_ ^g Nantes, Oct. 12, 1896. 
"* Archil- fill' Laryngol. u. Bhinol., 1896, Bd. iv. 



DISEASES OF THE UVULA. 47 

Examination shows either simple redness and swelling or discrete 
yellowish spots, as in follicular inflammation of the faucial tonsil. 

Occasionally an abscess forms in or about the lingual tonsil. The 
tongue is then greatly swollen, and cough or swallowing is exquisitely 
painful. CEdema of the glottis is a possible complication. 

Teeatmext. — Xon-suppurative cases are to be treated with local 
applications of boroglyceride or morphine and tannin. Sodic salicylate 
is given by many physicians. Abscesses should be opened as soon as 
the presence of pus is ascertained. Moure reports a case where an 
abscess of the lingual tonsil ran a very slow course with frequent 
exacerbations. 

2. Hypertrophy. 

Etiology. — The same (mostly unknown) conditions which result 
in the hypertrophy of adenoid tissue elsewhere in the throat presum- 
ably determine hypertrophy in the lingual tonsil. The exception to 
this statement is the fact that the latter organ is usually affected in 
adult life rather than in childhood. It is seen more often in females, 
especially of the neurotic type, perhaps owing to their great proneness 
to become conscious of relatively slight disturbances. 

Pathology. — Increase in the size of the lymph follicles of the part 
goes on in a way analogous to that occurring on the other tonsils. 

Symptoms. — Considerable increase in the size of the follicles may be 
present without any symptoms. It is chiefly when the growths touch 
the epiglottis that they are felt. The patient is rarely able to give us 
any symptoms more localizing than cough and tickling in the throat, 
and the diagnosis is made, if at all, in the course of thorough examina- 
tion of the fauces in search for a cause for the irritation. Occasionally 
a sense of fulness is experienced in the median line at the base of the 
tongue. 

There is often a tendency to " empty swallowing." Very rarely 
the epiglottis may be hindered in its motions by the pressure of masses 
of the growth. 

Examination with the laryngeal mirror shows " the glosso-epiglottic 
fossae more or less completely filled with a mammillated, somewhat 
cone-shaped mass of a pale pinkish color." 

Treatment, — Temporary relief can be obtained by the use of local 
apphcations of acetic acid, nitrate of silver, or astringents, but the chief 
indication is the removal of the hypertrophied follicles. This is best 
accomplished A\dth the cold wire snare, the use of which is preceded by 
cocainizing the parts. Soothing lozenges should be used for a day or 
two after the operation. 

Diseases of the Uvula. 

1. CEdema of the Uvula. 

Etiology. — Persons whose uvula is broad and pendulous are more 
susceptible. Attacks are occasionally associated with quinsy or pha- 
ryngitis, but most cases occur without involvement of the surrounding 



48 DISEASES OF THE PHARYNX. 

tissues. Caustics and irritants swallowed or applied to the fauces with 
therapeutic intent are occasional causes. 

Symptoms. — Pain on swallowing, the sense of a lump in the throat, 
and cough are the common symptoms. If the enlargement is very 
great, we may have dyspnoea. 

Examination shows a red swollen uvula whose tip is grayish and 
semitranslucent from serous infiltration. 

Treatment. — Punctures wdth a sharp bistoury should be made in 
various parts of the uvula, especially on the lower and posterior por- 
tions. These usually give immediate relief. If they do not, the organ 
may be snipped off. 

2. Elongated Uvula. 

A congenital condition by reason of which the uvula touches the 
base of the tongue or the epiglottis. 

Instead of the usual three eighths of an inch the organ may be from 
three fourths to one and a half inches long. 

Symptoms. — In some persons there is no discomfort from this con- 
dition. In those whose throats are more sensitive it may cause tickling, 
hawking, and cough. In neurotic patients it may start a spasm of the 
glottis. The symptoms are worse when the patient lies down. 

Treatment, — The organ should be cut down to its normal length — 
three eighths of an inch. The tip of the uvula is held with a pair of 
forceps, and the superfluous portion cut off with scissors. Occasionally 
considerable bleeding follows, but this is chiefly in cases where the 
whole uvula has been removed, which should never be done. Should 
hemorrhage occur, the use of haemostatic forceps followed by ligature 
will control it. 

Soothing lozenges and the avoidance of irritating food for twenty- 
four hours should be advised. 



DISEASES OF THE PHARYNX. 

1. Acute Pharyngitis. 

The pharynx is practically never acutely diseased except in associ- 
ation with more or less inflammation of the soft palate and tonsils. We 
shall not consider here the affections of the pharynx which occur in the 
exanthemata and syphilis, but only the so-called primary pharyngitis. 

Etiology. — " Taking cold," whatever that means, is undoubtedly 
the origin of many cases of pharyngitis. It is necessar}' to add, how- 
ever, that one may " take cold " from lack of sleep, from confinement 
in bad air (as in the dissecting-room), and from any form of overwork, 
as well as from direct exposure to low temperature. 

Connection between the diseases of the pharynx and those of the 
stomach has been insisted on by various writers. French ' in an investi- 

^ Trans, of the Amer. Laryng. Assoc, May, 1896. 



ACUTE PHARYNGITIS. 49 

gation of 50 cases of pharyngitis in medical students found a clean 
tongue in only 1 case, and definite stomach trouble in 47 ; 14 were 
constipated. Further, in the study of 23 cases of dyspepsia in women 
(one half of whom were neurotic) the pharynx were more or less 
inflamed in every one. 

Smoking, alcohol, and highly seasoned food act on the pharynx only 
when the stomach is also affected. Of the 50 medical students exam- 
ined by French, the 33 smokers had no worse throat than the 17 non- 
smokers. 

Nam! obstruction is frequently a causal factor. Nasal respiration 
being cut off, the inspired air is not warmed, moistened, nor disinfected 
as it is normally in its passage through the nasal cavities. 

The extension of a coryza sometimes starts an acute pharyngitis, and 
the effects of iodide of potash should not be forgotten. Rheumatism 
and gout are often mentioned as causes, but their influence is doubtful. 

Little is known of the bacteriology of acute pharyngitis, but from 
the constant presence of bacteria in the throat it is natural to suppose 
that their pathogenic activities are a factor, together with the above 
predisposing causes. 

The disease seems to be sometimes epidemic or endemic, and con- 
tagion is often suggested by the occurrence of several cases in a house- 
hold in rapid succession. 

The disease is not more common in infancy, as has been claimed. 

Symptoms. — The constitutional symptoms are rarely marked, offer- 
ing a decided contrast to tonsillitis in this respect. Occasionally there 
is a degree or two of fever. 

There is usually a " scratchy " feeling in the throat and si desire to 
swallow frequently. There is no pain on swallowing unless the tonsils 
are involved. The tickling of the throat starts a dry cough, especially 
on going from a warm to a colder temperature, or vice versa. 

The pharynx is reddened and if the naso-pharynx is involved streaks 
of grayish white secretion are to be seen. 

Attacks usually pass off in from three to six days, and do not usually 
keep the patient from his ordinary occupation. It is to be remembered, 
however, that a red pharynx is sometimes the first stage of diphtheria 
or other severe infection. 

Treatment. — It is doubtful whether any known treatment affects 
the course of the disease, but in certain persons the use of lozenges or 
gargles seems to give relief. Inhalations of steam are grateful in some 
cases. Gargles should always be given hot. The time-honored chlorate 
of potash is probably as good as any, but no gargle whose taste is unpleas- 
ant (e. g. listerine) should be used, as it may provoke nausea. Hot milk 
is a soothing gargle, and used just before going to bed may help the 
patient to sleep. It is not necessary to keep patients in the house 
unless fever is present, but the less exertion of mind or body that is 
made (beyond the needs of ordinary exercise of both) the easier it is to 
"throw off" the disease. 

Where the stomach or the nose is at the bottom of the trouble treat- 
ment should be directed chiefly to these organs. 

Fever, if present, should be reduced by the use of quinine or phen- 
acetin. The diet should be what the patient is used to, provided no 

Vol. III.— 4 



50 DISEASES OF THE PHARYNX. 

gastric symptoms are present, and provided his ordinary diet is not 
obviously bad. 

Many mothers expect to have their children's necks poulticed in 
cases of pharyngitis, and it is not well to disappoint such an 
expectafton. 

Chronic Follicular Pharyngitis (Chronic Granular Pharyn- 
gitis). 

This is a process entirely analogous to the chronic hypertrophy of 
adenoid tissues elsewhere in the throat. 

Etiology. — The disease usually begins in childhood, but does not, 
as a rule, give rise to symptoms at that time, its manifestations being 
usually masked by those of the hypertrophied tonsils. 

The condition persists into adult life in some cases, and then causes 
considerable annoyance. 

The original cause of the hypertrophy of the pharyngeal lymph 
follicles is presumably the same as that of the tonsils (see p. 42). It 
is complained of more frequently by women, but the number of cases 
is probably the same in both sexes. 

There is no reason to suppose that this disease is directly the result 
of attacks of acute pharyngitis, but the latter often occurs as an ex- 
acerbation. 

Most writers consider an excessive use of the voice as a causative 
factor. 

Pathological Anatomy. — The mucous membrane is relaxed, the 
venules are dilated, and roundish bodies from 2 to 4 millimetres in diam- 
eter project above the surface. These elevated knobs correspond to the 
lymph follicles of the pharynx. All the structures of the membrane 
are more or less thickened, but the chief change is in the follicles. 

In childhood the follicles are soft, but as time goes on they get 
smaller and harder. They may be scattered throughout the pharynx 
or grouped chiefly about its sides and behind the pillars of the fauces. 
There is no considerable secretion unless the naso-pharynx is involved. 
Rarely the follicles contain cheesy plugs. 

Symptoms. — Dull pain in the throat, especially on speaking or swal- 
lowing, is often complained of. Hoarseness, which is often complained 
of, is due to complicating laryngeal troubles. Dry cough is the rule. 
The patient often gets used to these symptoms, and does not mind them, 
except as they prevent his speaking or singing. Hawking is not present 
unless the naso-pharynx is involved. Tickling in the throat leads to a 
frequent "hem," especially in neurotic individuals, in whom all the 
symptoms are more marked. 

Examination shows in most cases bright red masses about the size 
of bird shot standing out against the paler tint of the pharyngeal 
mucous niembrane. Rarely the whole pharynx is of the same color, 
and diagnosis is then more difficult. As before stated, there is no in- 
creased secretion, and the uvula is not elongated unless there is a com- 
plicating naso-pharyngeal catarrh. 

Prognosis. — The disease is chronic and stubborn, but not in any 
way serious. As years go on the follicles shrink up, but the process is 



RETROPHARYNGEAL ABSCESSES. 51 

a very slow one, and patients are usually troubled for years unless the 
enlarged follicles are removed. 

Treatment. — The hypertrophied follicles can be removed by actual 
or galvano-cautery. Several sittings are usually needed, and the throat 
is decidedly sore after each treatment. 

Obvious faults in hygiene should be corrected and the general condi- 
tion attended to. 

Pharyngitis Sicca (Atrophic Pharyngitis). 

Etiology. — Without previous or associated atrophy of the turbi- 
nated bodies atrophic pharyngitis rarely if ever occurs. Partly by 
extension, partly as a result of the desiccation made possible by the 
cessation of nasal function, the atrophic condition of the pharynx fol- 
lows that of the nose. 

Symptoms. — The patient is usually aware of the dryness of his 
throat, which is sometimes so great as to make swallowing difficult. 
Much hawking sometimes takes place in the effort to free the throat 
from the crusts and scales which form there and cause irritation. Not 
infrequently the Eustachian tubes are involved and deafness results. 

The pharynx and naso-pharynx appear dilated and roomy. The 
mucous membrane is so dry as to appear as if glazed, with opaque 
patches here and there. Crusts are often seen similar to those formed 
in the nose, and there may be deposits of thick greenish secretion. The 
mucous membrane moves but little, owing to the atrophy of the muscular 
layer, and is usually very pale. 

Prognosis. — To public speakers or singers such a disease is a 
serious obstacle ; it has no tendency to heal, and may resist all 
treatment. 

Treatment. — Moure advises vibratory massage applied to the 
mucous membrane of the nose, naso-pharynx, and pharynx. This, he 
thinks, tends to favor secretion and awaken the vitality of the mucous 
membrane. The naso-pharynx should be frequently cleaned, and direct 
application of menthol 1 : 15 or benzoated glycerin made. General 
treatment, such as a course of baths at some well-known bath cure, 
may be of service. 

Retropharyngeal Abscesses. 

These may be classified as — (a) Acute or idiopathic ; (h) Chronic 
^' cold " or tubercular. 

Etiology. — (a) Idiopathic Form. — This is by far the most com- 
mon, making up about 90 per cent, of all cases. It is almost invariably 
a disease of early infancy. Thus of 77 cases seen by Koplik,^ 55 were 
in infants under twelve months, and 65 in those under eighteen months. 
The children affected are usually in good health. Sex has no influence. 

In all probability it is an abscess of pharyngeal lymphatics or 
lymph follicles in which an infection has become localized, as in 
quinsy. The atrophy of these follicles in later life explains the rarity 
of the disease after childhood. It may follow one of the exanthemata 

1 New York Med. Journal, April 4, 1896. 



52 DISEASES OF THE PHARYNX. 

or be due to traumatism. Moreau ^ and Koplik - think that the infec- 
tive agent may gain entrance through the tonsil and be carried thence 
through the lymphatics to lodge in the pharynx. In his cases strepto- 
cocci were always found, except where the disease was due to vertebral 
tuberciHosis. 

Pathological Anatomy. — According to the localization of the 
infective agent we have naso-pharyngeal, bucco-pharyngeal, latero- 
pharyngeal, or inferior pharyngeal abscess. The first of these is the 
more common situation. The presence of the median septum ot the 
pharynx checks the tendency to lateral extension in this direction in 
most cases, and causes the pus to work up, down, or into the neck, 
unless it breaks into the mouth. The pus is usually fetid, perhaps from 
the close relation to the oesophagus. Various organisms have been 
found other than the streptococcus mentioned by Koplik. Staphylo- 
cocci, the diplococcus lanceolatus, and the colon bacillus are occasion- 
ally cultivated from the abscess. 

In children the development of the abscess is usually slow and 
gradual, as is so frequently the case with abscesses of adenoid tissue. 
The rare cases which occur in adults develop faster owing to the 
fact that here the adenoid tissue is largely atrophied and the abscess 
forms in the cellular tissue, like any other phlegmon. 

Symptoms. — When one first hears the cry or cough of an infant 
suffering from this disease, it is hard to believe it human. It sounds 
much more like the bark of a puppy or the cry of a large bird (" a^i de 
canard/' JReigenier). The diagnosis can sometimes be made without 
seeing the patient, simply from the sound of the voice. 

The parents are frequently not aware that the throat is the seat of 
the trouble. Slight fever, cough, and refusal of the breast are noticed, 
the latter due to the pain or impossibility of swallowing. Later 
dyspnoea and cyanosis become prominent, the inspiration having some- 
times a peculiar crowing quality. 

In adults the onset is not so insidious, and attention is at once 
attracted to the throat. Pain aggravated by swallowing, fever, chills, 
and later dyspnoea are the prominent symptoms. 

Examination. — In children the pus forms so gradually that there is 
hardly any inflammatory reaction in the surrounding tissues. But, 
provided our attention is once directed to the pharynx, the presence of 
a unilateral bulging can usually be made out, which palpation or prob- 
ing shows to have the consistency of a pus sac. 

In adults the tumor is fiery "red and very hot to the touch. Occa- 
sionally the process may have already extended into the neck when the 
patient comes under observation. 

Diagnosis. — In children retropharyngeal abscess may be mistaken 
for "croup " or oedema of the glottis ; thorough physical examination is 
the only method of avoiding such an error, since the symptoms may 
exhibit nothing characteristic. In adults aneurysm and solid tumors 
are to be excluded. 

Prognosis. — In the adult the course is the same as that of a quinsy. 
In children its duration is from two to four weeks. If not due to 
vertebral tuberculosis, it is not dangerous to life, provided the diagnosis 

^ These de Paris, 1896. '^ Loe. cit. 



NEUROSES OF THE PHARYNX. 53 

is made in time. Bat death may result from oedema of the glottis, 
from direct pressure, suifocation, from erosion of a bloodvessel, from 
rupture into the trachea or gullet, or from inanition, exhaustion, and 
septicsemia. 

Occasionally death occurs very suddenly and without the presence 
of any of the above complications. In such cases death may be due 
to pressure on the great nerves or ganglia of the neck. 

Teeatment. — As soon as the diagnosis is made we should try to 
evacuate the pus. If no pus has yet formed, scarification may be useful. 
The lowest point of fluctuation should be opened, and as soon as the pus 
appears the child should be held head downward to avoid its inhaling 
the contents of the abscess. 

Some writers advise opening the abscess through the neck in all cases, 
but the majority are agreed in reserving this method for cases in which 
the pus shows no tendency to point in the mouth. Where the pus is 
burrowing very deeply or very much to one side, or where a contraction 
of the masseters prevents the jaws from opening, the incision may have 
to be made through the neck. 

In opening an abscess through the mouth the knife should be guarded 
with adhesive plaster up to within half an inch of the point. 

(6) Abscess from Vertebral Caries. — Here the course is much 
more chronic, and the pus is apt to burrow along the vertebral column : 
the symptoms are those of the underlying disease plus a certain amount 
of pain and bulging in the pharynx. The prognosis is very grave, as 
the abscess is merely a symptom of a (usually) widespread tuberculosis. 

The abscess should not be opened unless the imminence of acute 
complications or suffocation seems to demand it. 

Acute Infectious Phlegmon op the Pharynx. 

This rare disease was first described by Senator. Its etiology is 
unknown. 

A virulent inflammation starts usually at one side of the pharynx, 
and rapidly infiltrates the deeper tissues of the neck, with a marked 
tendency to spread doivnward, so that it may reach the pleura or medi- 
astinum. The neck is much swollen, brawny, and very tender exter- 
nally, and the lymphatic glands show similar changes. Pain, dyspnoea, 
and dysphagia are marked. 

The couESE is very rapid, and the general symptoms those of a 
severe acute septicaemia — high fever, weak, rapid pulse, anorexia, deli- 
rium, albuminuria, splenic enlargement, and great prostration. Meta- 
static processes in the joints and a scarlatiniform eruption may occur. 

The DIAGNOSIS rests on the rapid extension of the local signs and 
the rapid aggravation of the constitutional manifestations. 

It is almost invariably a fatal disease, and the treatment must be 
wholly palliative and symptomatic. 

Neuroses of the Pharynx. 

1. Parsesthesiae. — Any sensation in the resting pharynx is patho- 
logical. In cases of insanity, hysteria, and from '' reflex " irritations 
a great variety of abnormal sensations are referred to the pharynx. 



54 DISEASES OF THE SALIVARY GLANDS. 

(a) Solvations of Constrictio7i or of a Foreign Body (Globus Hys- 
tericus). — This may be due to a spasmodic contraction similar to those 
which sometimes occur in the oesophagus, but in most cases there is 
probably no muscular spasm. 

(6) Sensations of Heat, Cold, or Irritation in the Absence of Appre- 
ciable Cause for Such. — Of course the diagnosis of a neurosis of this 
nature is made possible only by the exclusion, through rigid scrutiny of 
the parts, of all local organic causes for the sensations — e. g. enlarged 
lingual tonsils, distended tonsillar crypts, etc. 

2. Anaesthesia, partial or complete, and resulting in choking because 
the parts do not contract at the proper moment. 

3. Hypersesthesia with too great or premature contraction, causing 
dysphagia. 

4. Nervous or functional paralyses, with trouble in speech or in 
swallowing. 

5. Spasm. — (a) Choreic ; (6) Excited by attempts at examination or 
other causes. 

6. Secretory and Vaso-motor disturbances : (a) Hypersecretion ; 
(6) Urticaria ; (c) Angio -neurotic CEdema. 

The COURSE, PROGNOSIS, and treatment of these affections are 
those of the neurotic or hysterical disposition underlying them. Local 
treatment is valuable, if at all, only as a means of suggestion, and the 
chief aim should be to reform or convert the temperamental condition. 



DISEASES OP THE SALIVARY GLANDS. 

Leaving out mumps or epidemic parotitis, an account of which is 
given under the Infectious Diseases on p. 725 of Vol. I., we have only 
three affections of the salivary glands : 

1. Secondary Parotitis. 

2. Ptyalism or Salivation. 

3. Xerostomia or Dry Mouth. 

1. Secondary Parotitis (Symptomatic Parotitis; Parotid 

Bubo). 

If we exclude tuberculosis, mumps, malignant disease, and retention 
cysts, secondary parotitis is almost the only organic disease of a salivary 
gland of which we have any knowledge, salivation and dry mouth be- 
longing rather to the functional or secretory disturbances. 

The larger number of cases are seen as a complication of typhoid 
fever, but the parotid may be inflamed in the course of typhus, septic 
diseases, phthisis, pneumonia, and other fevers. 

Stephen Paget called attention to the occurrence of parotitis in con- 
nection with injuries or diseases of the abdominal or pelvic viscera. 
Over one half of the 101 cases collected by him occurred in pelvic 
troubles — sometimes physiological events such as menstruation or preg- 
nancy. Blows on the testis or the insertion of a pessary has been fol- 
lowed by parotitis. Pepper saw a case complicating gastric ulcer. 



PTYALISM. 55 

Fagge observed it in two cases of cancerous obstruction of the intestine, 
Gowers in peripheral neuritis with facial paralysis. 

The connection with genital affections is all the more interesting 
because of the occasional occurrence of orchitis or epididymitis follow- 
ing mumps. The exact nature of the connection is unknown in both 
cases. 

The cases occurring in the course of infectious diseases may be ex- 
plained either as metastases taking place by the blood current, or as 
infection from the mouth by extension up the salivary ducts. 

The gland is usually swollen to a greater extent than in mumps, but 
the aifection is usually unilateral. In Paget's cases about 60 per cent. 
sujDpurated ; the remainder resolved without coming to pus formation. 
The symptoms are usually overshadowed by those of the underlying 
disease. 

The pus points either behind the ramus of the jaw or burrows into 
the external auditory meatus or down into the neck or into the ptery- 
goid region. 

Osier considers that the occurrence of parotitis in the course of a 
fever is of unfavorable prognostic significance. 

Treatment. — An attempt may be made by the use of ice, leeches, 
iodine, or mercury ointment to favor resolution and prevent pus forma- 
tion. As soon as pus is known to be present it should be evacuated. A 
small deep incision and a drainage tube will secure the necessary drain- 
age without the need of a large scar. Flaxseed poultices give great 
relief. 

2. Ptyalism (Salivation). 

The normal amount of saliva secreted by an adult in the course of 
twenty-four hours is from two to three pints. Under pathological con- 
ditions the quantity may be as much as 5 quarts in twenty-four hours, 
the saliva being viscid and glairy, and varying in specific gravity from 
that of Avater to as high as 1059. It contains but little sulphocyanide 
of potassium and less ptyalin. This condition is known as ptyalism or 
salivation. 

The condition is now much less common than it used to be, owing to 
a better understanding of the use of mercury. 

ETiOLoaY. — The secretion is somewhat increased by the taking of 
food and in children by dentition. While these variations are not to be 
ranked as pathological, it is difficult to draw any distinct line between 
physiological responses to the stimulation or reflex irritation of food, or 
teeth, and the varieties of " reflex" salivation next to be enumerated. 

We recognize the following varieties : 

1. Those cases occurring during a part or the whole of pregnancy. 

2. Cases due to drugs, such as pilocarpine, mercury, potassium 
iodide, jaborandi, muscarine, tobacco ; or to metals, such as gold, silver, 
copper, arsenic, and lead. 

3. Cases associated with lesions of the pons and medulla. 

4. Cases associated with infective diseases, such as rabies and small- 
pox. 

5. Cases associated with psychic disturbance — insanity, hysteria, the 
perception of certain tastes. 



56 DISEASES OF THE SALIVARY GLANDS 

6. Bohn describes cases in children in which the salivation occurred 
only in the daytime, ceasing at night ; the cause was unknown. 

Course and Treatment. — Cases due to mercurial poisoning last 
often from one to three weeks. The patient gets thin ; the bowels are 
frequently constipated, and the amount of urine small. 

In the course of pregnancy, as mentioned above, the trouble may be 
a very persistent one, ceasing only with the birth of the child. 

Effective treatment is ordinarily confined to the treatment of the 
underlying cause. Astringent solutions — alum, gallic acid — or the tinc- 
ture of myrrh may be used as mouth washes. The use of atropine, gr. 
gljj- repeated every four hours until the throat becomes dry, sometimes 
affords relief. 

Prophylaxis during the administration of mercurials will prevent the 
occurrence of many cases. The patient should be directed to brush the 
teeth several times daily and to rinse the mouth with tincture of myrrh 
night and morning. Any tenderness of the teeth on striking them 
smartly together, any soreness of the gums or unusual odor to the 
breath, should be the signal for withdrawing the mercury until all such 
symptoms have passed away. Mercurials (e. g. calomel) given to a pa- 
tient with renal disease appear especially prone to cause salivation, so 
that under such conditions the physician should be as careful as possible 
in his prophylactic measures. 

3. Xerostomia (Dry Mouth). 

Jonathan Hutchinson was the first accurately to describe this con- 
dition, occurring mostly in neurotic women and characterized by deficient 
secretion of saliva. 

It may come on after a fright or in the course of hysteria or hypo- 
chondriasis. Freqiiently the mode of onset is entirely obscure. 

A somewhat similar condition is often seen in diabetes owing to the 
great loss of "water by the kidneys, in mouth-breathers, in aged persons, 
and in febrile diseases. It is physiological in early infancy. 

The mucous membrane of the mouth becomes dry, glazed, and of 
the color of raw beef. Speaking, swallowing, and chewing are difficult. 
The tongue may be deeply fissured. 

The patient gets temporary relief by moistening the parts with water 
or oil. Sometimes the use of pilocarpine and more often the galvanic 
current is of service. 

I have seen a diabetic patient who got relief from dryness of the 
mouth and throat by eating small pieces of oatmeal cracker. 



DISEASES OF THE (ESOPHAGUS. 

By ALLEN A. JONES, M. D. 



SPASM OF THE (ESOPHAGUS. 

Synonyms. — QCsophagismus ; Spasmodic dysphagia ; Angina con- 
vulsiva ; Spasmodic stricture of the (.esophagus. 

The part plaj^ed by the oesophagus in the act of swallowing is reflex 
in nature, its action being similar to intestinal peristalsis. The gan- 
glionic plexuses of the cesophagus are connected with the medulla ob- 
longata by fibres of the vagus, and they also inosculate with the termi- 
nal sensory nerve fibres in the mucous membrane. The function of the 
ganglionic nerves is manifestly motor, while the influence exerted by 
the vagus is inhibitory, as shown by the fact that section of the pneu- 
mogastric causes continuous contraction of the oesophagus. 

During the act of swallowing the terminal sensory nerve filaments 
in the mucous membrane of the oesophagus are stimulated by contact 
with food, and they convey the stimulus to the ganglionic plexuses, 
thus producing peristaltic contraction. It is supposed that the medulla 
oblongata is in a quiescent or non-inhibitory state during the passage 
of food through the oesophagus, and therefore active peristalsis is al- 
lowed. In health the balance between inhibition and action is nicely 
maintained, but in neuroses spasm of the cesophagus may be caused by 
reflex irritation from other organs, by lesions involving the roots or 
branches of the vagus nerve and medulla oblongata, or by psychic influ- 
ences, as in hysteria. 

Etiology. — Spasmodic stenosis of the oesophagus occurs in females 
more frequently than in males, and particularly in women who are of 
a neurotic temperament. It occurs in connection with organic diseases 
of the cesophagus, such as ulceration, and is then called symptomatic 
spasm. It may be caused reflexly by disease of organs adjacent to the 
cesophagus, as, for instance, the nose, pharynx, larynx, trachea, heart, 
lungs, the cervical vertebrae, the stomach and intestines, or by disease 
■of distant organs — the uterus, ovaries, or external genitals. It has 
been known to result from hypertrophy of lymphoid tissue at the base 
of the tongue, from chronic follicular tonsillitis, and from accumulation 
of cerumen in the external auditory meatus. Diseases of the rectum 
sometimes cause it, and it is occasionally excited by sciatica. It may 
be the result of toxaemia, as in gout, rheumatism, or uraemia. It is 
sometimes observed in pregnancy, and is occasionally a symptom of 
hydrophobia or tetanus. The most important factor in the etiology of 
the affection is the neurotic condition in neurasthenia, hysteria, or the 
psychoses. Globus hystericus has been wrongly considered a form of 

57 



58 DISEASES OF THE (ESOPHAGUS. 

oesophagismus. There may be temporary spasm associated with globus 
hystericus, but dysphagia, as a rule, is lacking. 

Symptoms. — The cardinal symptoms of this affection are dysphagia, 
regurgitation, and more or less substernal pain or discomfort. The 
dysphagki lasts longer in some cases than in others, depending upon the 
duration of the spasm. The upper part of the oesophagus is a common 
seat of the contraction, and when so located regurgitation takes place 
very soon after an attempt at swallowing. If, however, the contraction 
is lower in the oesophagus, the food is not usually regurgitated until 
some length of time after being swallowed, the tolerance of the oesoph- 
agus above the stricture and its distensibility having much to do with 
the time allowed before the food is expelled. Complete stenosis of the 
oesophagus is rarely present, and therefore fluids are swallowed with 
some degree of ease. Sometimes, however, they are regurgitated, and, 
strangely, an occasional instance is seen in which solids are swallowed 
without much difficulty, while fluids are rejected. 

The onset of the dysphagia is usually sudden. It may follow a fit 
of anger, a fright, or some circumstance affecting the nervous system in 
a forcible manner. Its duration varies in different cases ; it may last 
only a few minutes or for several weeks. The intermittent form of the 
disease is, however, the more common — spasm occurring at any meal 
without warning. The dread of its occurrence rather increases the lia- 
bility to its onset. Some cases have frequent short attacks for many 
years, while it has been known to occur during the whole lifetime of an 
individual. Patients troubled with the intermittent form of the affec- 
tion do not suffer much from lack of food, but those who have many 
days of continued spasmodic stricture lose ^^'eight and strength, and 
their nutrition may even be very seriously affected. 

In many cases the aliment is stayed for a few minutes only, and 
finally the contraction yields. During its retention at the point of 
stricture a sensation of severe pain may be felt, or, if not actual pain, a 
dull, sickening ache precedes the passage of the food through the nar- 
rowed portion of the tube. Persistent spasm may result in considerable 
dilatation of the oesophagus, and food may be regurgitated after remain- 
ing some hours or a day in the oesophagus. There is usually a good 
deal of oesophageal flatus accompanying the regurgitation, and the food 
returns mixed wdtli ropy mucus. 

Symptoms of a spasmodic nature in other organs may accompany 
oesophagismus, as, for instance, bronchial asthma, hiccough, pharyngeal 
muscular spasm, while vaso-motor phenomena, cardiac palpitation, or 
syncope may occur. The affection sometimes ends as suddenly and as 
unexpectedly as it begins. 

Diagnosis. — The affection should be differentiated from organic 
stricture, benign or malignant, dilatation of the oesophagus, pressure, 
stenosis of the oesophagus, and impacted foreign bodies. Chief stress is 
to be laid upon the intermittent character of the spasm, the association 
of other nervous phenomena, the existence of a sufficient cause for the 
contraction, the sex and age of the patient, the sudden onset, the fickle- 
ness of its behavior, and, in the majority of cases, the well sustained 
nutrition of the patient. In conjunction with these the passage of the 
sound is of the greatest utility in diagnosis, as in most cases it passes 



SPASM OF THE (ESOPHAGUS. 59 

beyond the stricture with little or only moderate difficulty, and it glides 
along into the^ stomach without the slightest resistance if the patient be 
anaesthetized. In some cases the passage of a flexible stomach tube is 
difficult or impossible, but if a stiff" bougie is used it may be passed 
with comparative ease. Organic strictures of large calibre may also 
admit a stiff bougie, or even allow a stomach tube to pass; so it is 
necessary to anaesthetize the patient in order to arrive at a more definite 
conclusion. 

In differentiating betAveen oesophagismus and impacted foreign body 
the Rontgen ray may be of decided value (see " Foreign Bodies," p. 78). 

Prognosis. — The prognosis is usually favorable, but should be some- 
what guarded if the affection has persisted for a long period or if the 
patient shows evidence of a greatly disturbed nervous system. As is the 
case with many of the neuroses, oesophagism may obstinately persist or 
recur for a long time despite the most thorough management. When 
the affection is a reflex from serious disease of neighboring parts, the 
outlook is accordingly discouraging. 

Treatment. — The cause of the spasm should first be sought for and 
removed if possible. In case it is not discovered, the condition should 
be treated by antispasmodics, among the most effectual being asafoetida, 
valerian, and potassium bromide. Asafoetida should be given in from two 
to four ounce doses of the emulsion bv the rectum, the dose being; re- 
peated according to the indications. Sometimes this alone is sufficient 
to overcome the spasm. If it is not successful, a half drachm or drachm 
dose of chloral hydrate dissolved in four ounces of camphor water may 
be given as an enema ; this may be repeated if necessary. If licjuids 
are not regurgitated, these remedies may be administered by the mouth. 
Much value has been ascribed to potassium bromide as a drug that al- 
lays the sensibility of the mucous membrane of the pharynx and oesoph- 
agus, especially the former, but it must be given in doses of a drachm, 
or even more, in order to be particularly effectual, and in these doses is 
very depressing. 

In some cases moral treatment alone suffices to effect a cure. Such a 
case is mentioned by P. Hanshalter of Xancy.^ The patient was a girl 
twelve years of age Avho manifested oesophagism soon after a fit of anger 
and mortification occasioned by being jeered at by a boy who discovered 
her Avhile bathing in a river. She was unable to swallow anything save 
raw carrots and green fruits until the physician announced that at a 
certain time he would cure her. Preparations were made, the child was 
suspended for a few minutes by a suspension apparatus, and the phy- 
sician impressively said that she was cured. She immediately ate and 
drank a meal that had been brought in while she was suspended, and 
thereafter was cured. 

In this connection much may be accomplished by requiring the pa- 
tient to eat in the presence of the physician or a stranger, who may 
make assurances that no harm will befall her from the passage of food 
into the larynx. Considerable stress has been laid upon the systematic 
passage of an oesophageal bougie or a stomach tube. If the tube is used, 
gavage may be practised regularly, and the nutrition of the patient thus 
maintained. 

^ Quoted in Sajous' Annual, 1892. 



60 DISEASES OF THE (ESOPHAGUS. 

The passage of the bougie sometimes effects relaxation of the spasm, 
and it may not be necessary to resort to its farther use. The intra- 
oesophageal application of the continuous current has been employed, 
and also advised against. The chief objection to its use is that it may 
cause syncope by its effect upon the pneumogastric, but if used in the 
strength of from five to fifteen milliamperes it will do no harm and may 
have a good effect. The continuous current may also be applied upon 
the skin along the tract of the vagus nerves, but should be employed in 
mild strength. Counter-irritation may be applied along the course of 
the pneumogastric nerves, or the Paquelin cautery may be used along 
the cervical and dorsal spine. 

In chronic cases hydrotherapy, medical gymnastics, fresh air, change 
of scene, and all measures for the purpose of restoring tone to the ner- 
vous system are called for. Aside from the remedies above mentioned, 
camphor, sumbul, hyoscyamus, and conium may be used as antispas- 
modics. Morphine should be resorted to only in extreme cases. As 
tonics, phosphorus, zinc phosphide or oxide, arsenic, and quinine may 
be used. 



NEUROSES OF THE (ESOPHAGUS. 

Paralysis of the (Esophagus. 

Syxoxyms. — Paralytic dysphagia ; Atonic dysphagia. 

Etiology. — Paralysis of the oesophagus may be due to (a) organic 
disease of the nerve centres or of the nerves governing motion of the 
oesophagus ; (6) functional nerve disturbances ; (c) diseases of the 
muscular fibres ; {d) adhesions. 

Dysphagia may result from paralysis of the pharyngeal muscles, 
whose function is to open the oesophagus. The organic lesions of the 
nerves or nerve centres that may cause oesophageal paralysis are atrophy 
of a nerve trunk occurring independently of or following a neuritis ; 
pressure upon the nerve from hemorrhage, or from an abscess or tumor 
•of contiguous parts. Any of these may involve the nerve centre or the 
nerve trunk. Among the common causes of paralysis in this situation 
may be classed the toxaemias arising from diphtheria, lead, or syphilis. 
Functional nerve disturbance may be dependent upon anaemia and mal- 
nutrition following fever or other debilitating disease. 

^Muscular atrophy may result from toxaemia or myositis resulting in 
<?onnective-tissue proliferation between the muscular fibres. Paralysis 
that can hardly be called functional is present in dilatation of the 
oesophagus or adhesions of the organ to neighboring structures. Some- 
times it results from a sudden shock to the nervous system, and it may 
be due to hysteria. 

Sy:mptoms. — As ]3aralysis may be local, the symptoms vary with 
different locations. If it is situated high up at the first part of the 
oesophagus, food is rejected immediately after an attempt at swallowing 
is made. In these cases there is some danger of food particles gaining 
entrance to the larynx, causing suffocation. If the paralysis is acute. 



NEUROSES OF THE (ESOPHAGUS. 61 

the symptoms are sudden in onset, while if it manifests itself slowly, 
the symptonls accordingly supervene with some irregularity and delay. 
If the paralysis is located in the lower part of the oesophagus, a con- 
siderable quantity of food may be swallowed and collect above the 
cardia, being rejected some time after the meal and in large quantities. 
Patients naturally differ in the tolerance shown to food. Sometimes 
the dysphagia caused by paralysis is so great that very little food enters 
tlie stomach, though it usually passes slowly down the oesophagus, being 
pushed downward by that which is above. Things may be washed 
down quite easily sometimes, though usually a considerable period is 
required before either fluid or solid substances will enter the stomach. 
There is usually no pain in this affection, unless it be caused by pressure 
from a large collection of food in the oesophagus. 

Pathological Axatomy. — The morbid changes are usually those 
found in the disease of which oesophageal paralysis is merely one 
symptom — viz. bulbar paralysis, general paresis, or cerebro-spinal dis- 
seminated sclerosis. Occasionally oesophageal paralysis is associated 
with paralysis of the larynx, soft palate, or tongue. 

Diagnosis. — It is imjjortant to differentiate between paralysis and 
stenosis of the oesophagus, and that may be done by auscultation and 
by the use of the oesophageal sound. When fluids are swallowed the 
deglutition murmur is heard to be loud and rumbling, so as to be heard 
sometimes at a distance from the patient; but it is best to use the 
stethoscope, as the point at which the sound ceases indicates the location 
at which stasis occurs ; this point is usually midway between the upper 
and lower portions of the oesophagus. The sound enters the stomach 
without obstruction, the ease with which it passes being sometimes 
significant. A stiff bougie may be moved freely and widely in the 
paralyzed area. J. Solis-Cohen speaks of the food as being rejected 
in the form of an inverted cone, the bolus being subjected to compres- 
sion only at its upper part. The history of the case and the presence 
of causative conditions give material aid in the diagnosis. 

Prognosis. — The prognosis depends upon the cause. It is neces- 
sarily grave if it is due to serious intracranial or spinal cord disease ; it 
is most favorable when dependent upon hysteria. The prognosis should 
be reserved in some cases until the results of treatment have been 
observed. 

Treatmext. — If the disease is caused by syphilitic gumma of the 
brain or syphilitic peripheral nerve disease, potassium iodide should be 
given in increasing doses. A good plan is to commence with five minims 
of a saturated solution of the drug, given in infusion of quassia before 
meals or with essence of pepsin after meals, the dose being increased 
one drop a day until thirty or more drops are taken three times a day. 
If lead-poisoning is present, potassium iodide should be given in ten 
grain doses three times a day, and magnesium sulphate administered in 
half ounce or ounce doses in concentrated solution each morning. If 
necessary, magnesium sulphate may be used as an enema. Nux vomica, 
ignatia, or strychnine are especially indicated, the advantage of strych- 
nine being that it may be given by the subcutaneous method. In some 
cases it is necessary to use the stomach tube for feeding purposes, and 
gavage may be continued as long as it seems indicated. 



62 DISEASES OF THE (ESOPHAGUS. 

Duchenne cautioned against the use of electricity in the oesophagus, 
owing to the danger of over-stimulation of the pneumogastric and 
resulting fatal syncope. We have, however, seen strong currents of 
electricity used in the oesophagus without any untoward effects, and the 
intra-oesophageal application of a gentle fa radio current is certainly 
strongly indicated in paralysis of the organ. It should be used tenta- 
tively, and discontinued at once upon the appearance of untoward 
symptoms. J. Solis-Cohen attaches much importance to Duchenne's 
caution against the use of electricity, while Fitz advises the use of the 
continuous and interrupted currents by means of the oesophagal elec- 
trode when either of them is indicated. 

Hyperesthesia of the CEsophagus. 

Hypersesthesia of the oesophagus is sometimes present in hysteria, 
neurasthenia, and hypochondriasis. It is an underlying factor in the 
causation of oesophageal spasm in some cases, and may be manifested 
either by special predisposition to such spasm or by unnatural sensa- 
tions of soreness, burning, prickling, or distress upon swallowing solids 
or liquids. When symptoms of oesophageal par£esthesia are present, 
organic diseases such as ulcer or oesophagitis should be eliminated if 
possible. CEsophagoscopy may materially assist in the diagnosis. 
Clinically we find cases in which unnatural sensations — a common one 
being that known as globus hystericus — are referred to the region of 
the oesophagus, and may be due to hypersesthesia of that structure. 

Zenker and von Ziemssen consider hypersesthesia of the oesophageal 
mucous membrane as a particular cause of oesophagismus in many cases, 
and mention the analogous conditions of over-sensitiveness and spasm 
of the pharynx and larynx ; also the favorable effect of potassium bro- 
mide in these affections. As this condition is purely functional, there 
are no morbid changes to be considered. 

Diagnosis. — In many cases, of course, the diagnosis is largely hypo- 
thetical, though from a clinical standpoint we are not infrequently jus- 
tified in concluding that hypersesthesia is present. 

Teeatment. — The treatment should be directed toward the correc- 
tion of the accompanying nervous disorder. Of the drugs that have 
been found useful in our hands, asafoetida, valerian, camphor, and po- 
tassium bromide claim first mention, and of these asafoetida seems the 
most valuable and reliable. The emulsum asafoetidse is the form in 
w4iich the drug seems most effectual. It should be given in large 
doses, not less than half an ounce, four times a day ; its unpleasant 
odor is not an insurmountable difficulty to its administration in many 
cases, although it is frequently not prescribed when it should be, purely 
from that consideration. In a case of hypersesthesia and irregular mild 
oesophagismus now under the writer's care asafoetida is very effectual. 
This is the case of a young woman who is chlorotic and is also taking 
iron and arsenic. 

Anesthesia op the (Esophagus. 

Ansesthesia of the oesophagus may be present in cases of slight dys- 
phagia or sluggish peristalsis of the oesophagus without manifest organic 



ORGANIC STRICTURE OF THE (ESOPHAGUS. 63 

lesion. Patients not infrequently complain that their food goes down 
too slowly, and they therefore readily form the habit of washing it 
•down with copious draughts of water, tea, or coflPee, In these cases 
sometimes a highly spiced bolus of food is swallowed with more ease 
and despatch than a less stimulating bolus. It is possible that anses- 
thesia of the oesophageal mucous membrane may be an underlying factor 
in the causation of paralysis in rare cases. 

Treatment. — When for clinical reasons this condition seems present, 
the treatment should consist in the use of strychnine or nux vomica 
with the intra-cesophageal application of the faradic current and appro- 
priate general treatment. 



ORGANIC STRICTURE OF THE (ESOPHAGUS. 

Synonyms. — QEsophageal stenosis ; Obstruction of the oesophagus. 

Etiology. — Stricture is caused by changes in the wall of the oesoph- 
agus interfering with its natural distention or narrowing its lumen. 
It most commonly results from cicatricial formation during the healing 
process of a wound, ulcer, or any loss of substance from burns or other- 
wise, and also from benign or malignant tumors occurring in the 
oesophageal wall. 

Next to carcinoma, the most common cause of stricture of the oesoph^- 
agus is cicatricial obliteration due to the swallowing of caustic or 
corrosive fluids, which happens not infrequently either from accident 
or intention. Sulphuric acid, strong ammonia, carbolic acid, or other 
caustics may be swallowed. Very frequently, however, death results 
from the taking of these substances, but sometimes they are taken in 
insufficient quantity to produce death, yet in sufficient quantity to cause 
destruction of a portion of the mucous membrane of the oesophagus. 

Cicatricial stricture occurs most frequently about on a level with the 
cricoid cartilage, and next in frequency near the cardiac orifice ; it may, 
however, be located anywhere along the oesophagus or involve its whole 
length. The calibre of the stricture varies according to the depth of 
destruction of the oesophageal wall. If the mucous membrane alone is 
destroyed, a layer of connective tissue is formed which is tolerably 
smooth, though it may project into the lumen of the tube at different 
points. These projections may even have a papillomatous appearance. 
If the muscular layer is destroyed, a thick, hard cicatrix results, which 
by progressive contraction more and more diminishes the calibre of the 
tube, which may indeed be entirely obliterated. It is apparent that, 
as is the case in stricture of the urethra, its calibre varies between wide 
limits. 

The stricture may be angular in form, new connective tissue pro- 
liferation being evenly distributed throughout the whole circumference 
of the tube, or it may be more dense upon one side than upon the other, 
as is especially the case in the cicatrix of a small ulcer. This cicatrix 
may project somewhat into the lumen of the oesophagus. Strictures 
may be single or multiple ; when multiple their calibre may be of 
different size. 



64 DISEASES OF THE (ESOPHAGUS. 

Besides the destruction of tissue resulting from the swallowing of 
caustics, ulceration may occur as the result of too hot a bolus of food or 
sharp bones or other foreign bodies passing into the oesophagus. In 
rare cases stricture has followed smallpox as the result of cicatrization 
of the eruption in the cesophagus. Instances have been recorded in 
which round ulcer of the oesophagus in its cicatrizing stage resulted in 
stricture. It is thought that round ulcer in this situation is caused by 
digestion of a localized area of the oesophageal mucous membrane by 
the gastric juice, a small quantity of which remains in the oesophagus 
after vomiting. This hypothesis is probably incorrect, as round ulcer 
in this situation is as likely a result of trophic disturbance as when it is 
situated in the stomach or duodenum. Syphilis is also a cause of ulcer 
of the oesophagus, as has been attested by numerous observers, and cica- 
trization following tubercular ulcer is also a cause of stricture. Benign 
and malignant tumors involving the mucous membrane and the deeper 
structures of the Avail of the oesophagus, as well as abscess in that situa- 
tion, usually cause obstruction. Stenosis may also result from pressure 
of tumors, enlarged organs, or a variety of diseases involving adjacent 
structures. Enlarged bronchial and cervical glands, such as sometimes 
occur in Hodgkin's disease, may cause pressure stenosis. An over-dis- 
tended diverticulum of the oesophagus or an enlarged thyroid may have 
the same effect. Perhaps only the lateral portions of the thyroid may 
enlarge, and cause pressure upon the oesophagus without noticeable in- 
crease in the size of the gland in its middle. The enlargement of the 
thyroid may result from simple hyperplasia or from malignant disease. 
Sometimes abscess in tuberculosis of the vertebrae and tumors and exos- 
toses in this situation, or even extensive lordosis, may be responsible for 
the disease. Eichhorst mentions that it has been observed as the result 
of dislocation of the hyoid bone and clavicle, also from excessive length 
of the styloid process and ossification of the stylo-hyoid ligaments and 
thickening of the cricoid cartilage. Cancer of the lungs or pleurae, re- 
traction of the apex of the lung, pericarditis with effusion, hypertrophy 
of the heart, aneurysm of the aorta, subclavian or carotid arteries, 
mediastinal tumors or abscess, may be the cause of the condition. 

In its etiology must be included the impaction of foreign bodies, a 
variety of which may be swallowed. Those, however, most liable to 
remain impacted in the cesophagus are either so large that their passage 
is an impossibility, or because they are very irregular in shape, with 
jagged corners and edges, such as a dental plate, or because they are 
sharp-pointed and therefore liable to lodge in the mucous membrane. 
Sometimes large pieces of bone lodge in the oesophagus and demand 
operative procedure for their removal. Finally, stenosis or atresia may 
be congenital in origin, although but few cases are upon record. Everard 
Holmes, Cassan, and Zenker have reported cases, and Grandou cites 
that of a newborn infant that took the nipple an hour after birth, but 
was noticed to become congested and purple each time it nursed. Upon 
abandoning the breast it immediately vomited the milk it had taken. 
Efforts at feeding were ineffectual, and gavage was also a failure. Death 
occurred on the sixth day, and in front of the trachea the oesophagus 
was entirely replaced by a firm band or cord an inch long which was 
adherent in front to the trachea. Beyond this the cesophagus appeared 



OROANIC STRICTURE OF THE (ESOPHAGUS. 65 

normal. An opening was found connecting the inferior portion of the 
oesophagus with the trachea. Stenosis occurs more commonly in males 
than in females, the benign cicatricial form occurring in the young and 
middle-aged most frequently, while that caused by malignant disease 
is observed later in life. 

Symptoms. — The symptoms usually manifest themselves slowly, the 
most important being gradually increasing dysphagia. Difficulty in 
swallowing solids is first experienced, especially when they are insuf- 
ficiently masticated or a large bolus is attempted. The stricture may be 
such that the food passes it slowly, and in that case there is no inter- 
ference with nutrition until considerable time has elapsed, during which 
the calibre of the stricture grows smaller. In some cases dysphagia 
rapidly increases. Compensatory hypertrophy of the muscular layer 
above the stricture may take place to such a degree that even though its 
calibre be small all the food may be forced through if sufficient time is 
allowed. When solid food may no longer be swallowed, semisolid or 
fluid still passes with some ease. Finally, the stenosis may become so 
complete that even liquids are regurgitated. With organic stricture 
more or less spasm is sometimes associated, and periods of pronounced 
dysphagia alternate with periods of comparatively easy swallowing. 
This fact is occasionally quite confusing in the diagnosis, organic steno- 
sis not infrequently being mistaken for oesophagismus. 

As dilatation of the oesophagus above the stricture usually occurs, 
many mouthfuls of food may be swallowed, and regurgitation take place 
only after the oesophagus is more or less distended with food. Pain is 
an inconstant symptom : in some cases it is present, while in others it 
is absent. Occasionally it is quite severe, and is usually aggravated by 
eating, since the pressure, fulness, and distress are almost always present 
when the food collects above the stricture, and these sensations are re- 
lieved after free regurgitation has occurred. The regurgitated contents 
consist of food mixed with an abundance of tenacious, ropy mucus, 
the food being merely water-soaked, not digested. The reaction 
varies with the reaction of the ingesta. If the starches are well 
masticated, ptyalin digestion continues in the oesophagus. Evidences 
of the digestion of nitrogenous substances are entirely absent unless 
predigested foods have been taken. If the stenosis be due to car- 
cinoma, there may be blood or blood cells, or fragments of the neo- 
plasm which upon microscopic examination show the presence of cell 
nests. The strength and weight of the patient are gradually re- 
duced and anaemia is progressive ; the skin is dry and harsh ; great 
thirst is frequently present ; finally emaciation becomes extreme and 
the patient may die of gradual exhaustion. In some cases, however, 
rupture of the oesophagus may take place, or asphyxia may result from 
the inhalation of regurgitated material. 

If the stenosis be due to malignant disease, ulceration may tempo- 
rarily enlarge the lumen of the stricture, and swallowing may be for a 
time successful, to be followed, however, by a reciirrence of the dys- 
phagia. If the stricture be due to carcinoma or to pressure upon the 
oesophagus, dysphonia or aphonia may be caused by interference with 
the recurrent laryngeal nerve, and dyspnoea may be due to the same 
cause or to compression of the trachea. On auscultation upon the back 

Vol. III.— 5 



66 DISEASES OF THE (ESOPHAGUS. 

at the left of the spine on a level with the eighth dorsal vertebra, or 
anteriorly on a level with, and to the left of, the ensiform cartilage, the 
deglutition murmur may be heard to occur later than seven seconds, 
the time it usually follows swallowing in health, or in the case of com- 
plete stenosis may be altogether absent. A loud gurgling sound is 
sometimes heard at the seat of the stricture even though there is an 
absence of a hissing sound, indicating the passage of the liquids into the 
stomach. In some cases, however, auscultation affords little informa- 
tion. 

Diagnosis. — Sometimes the diagnosis is extremely easy, although 
in some cases it is difficult and is only to be determined by extended 
observation of the case. The slow onset, the history of syphilis or 
tuberculosis, or of the swallowing of caustics are significant points. 
There may be enlargement of the supraclavicular or other lymph nodes, 
while secondary carcinomata may be discovered, thus suggesting malig- 
nant stricture. The age and sex are to be considered ; dysphagia, pain, 
and pressure symptoms are important points. The use of the sound 
gives most valuable information. A stiff, hollow, fenestrated oesopha- 
geal tube or olive-tipped bougie may be used, the latter indicating the 
location, size, extent, and consistence of the stricture, as well as the 
number if there be more than one. Caution should be exercised in 
using the bougie not to injure or rupture the oesophagus, and if there 
is reason to suspect pressure from an aneurysm, sounds should not be 
employed at all. Care should also be taken not to introduce the sound 
into the larynx, an accident which may occur if the stricture is located 
in the upper part of the oesophagus. Sometimes it is necessary to anaes- 
thetize the patient before passing a sound. 

Marie devised a sound with a compressible olive-pointed tip and a 
manometer upon its proximal extremity. When the sound reached the 
stenosis the color-fluid in the manometer rose, owing to compression of 
the tip, and fell again after the obstruction was passed. By this means 
he measured the length of the stricture, and also obtained some idea as 
to the variations in the different parts of its calibre. 

The stricture may be located by oesophagoscopy, which was first 
practised by Mikulicz, and has since been employed by Eosenheim and 
others. The .-c-rays may also prove serviceable in diagnosis, as a neo- 
plasm may give a distinct shadow or the dilated portion of the oesopha- 
gus above the stricture may thus be detected if it is filled with bismuth 
mixture. 

Prognosis. — The prognosis is unfavorable in most cases. With 
benign stenosis the patient may live for years, provided obstruction be 
not complete, and in these cases surgical treatment may prolong life. 

Treatment. — So long as semifluid or liquid foods may be swal- 
lowed and thus maintain a fair degree of health and strength, there is 
no particular occasion for interference with the stricture. As soon, 
however, as the patient is starving an endeavor to enlarge the calibre 
of the stricture should be made. This may be done by slow dilatation, 
using graduated sounds or bougies, while if possible gavage should be 
employed to ensure nourishment to the patient. Gradual dilatation 
may be supplemented by electrolysis, which has proved successful in 
some instances. Continuous dilatation may be practised by leaving the 



CARCINOMA OF THE (ESOPHAGUS. 67 

oesophageal tube in place. Intubation of the oesophagus is a valuable 
method of tifeatment in cases in which the stricture is located in its 
first portion. George W. Gay of Boston considers it superior to gas- 
trostomy. The ordinary length of oesophageal tubes is about eight 
inches, and they are of diiFerent calibres. A tube may be worn for sev- 
eral weeks even in a case of malignant disease. If it is impossible to di- 
late a stricture either by the rapid or gradual method or to introduce an 
oesophageal tube, the only remaining measures are surgical. CEsoph- 
agostomy, gastrostomy, or oesophagotomy are operations demanded by 
threatened starvation. Supporting remedies, such as strychnine, quinine, 
and rectal feeding, should be employed. Finally, morphine should be 
used when the case is hopeless and our main purpose is to encourage 
euthanasia. 



OAROINOMA OF THE (ESOPHAGUS. 

Etiology. — Carcinoma of the oesophagus is more frequent in males 
than in females, about three-fourths of the cases occurring in the former. 
It occurs most commonly between the ages of forty and sixty, although 
it may be present earlier or later in life. Rebitzer says the average 
age is fifty-eight years, and Butlin says it occurs upon an average in 
females ten years younger than in males. It is usually primary, but 
may be secondary. Zenker and von Ziemssen found in 5079 autopsies 
primary carcinoma 13 times, or 0.25 per cent., while the secondary form 
was present in 6 cases, or 0.11 per cent. 

Irritation of the oesophagus, whether acute or of long standing, is 
considered by some to predispose to the development of carcinoma. As 
carcinoma sometimes has its starting point in a cicatrix of an old 
gastric ulcer, so it may spring from the seat of an ulcer in the oesopha- 
gus. Alcoholism and wounds of the mucous membrane caused by 
foreign bodies may determine the development of carcinoma. The 
most common site is in the lower third of the oesophagus, though 
Mackenzie considers the upper third as the part most frequently 
involved. It is also located at the point where the oesophagus crosses 
the left bronchus. These three points — viz. in the vicinity of the 
cricoid cartilage, opposite the left bronchus, and at the diaphragm — are 
probably subject to more irritation during swallowing than are other 
parts of the tube. The cases seen by the writer have been almost all 
situated in the lower third. It may occur at any point or involve the 
whole oesophagus. 

Carcinoma is the most common disease and the most important 
neoplasm affecting the oesophagus. The primary form is the squamous 
epithelium type, similar to that observed so commonly in the lip. It 
occurs isolated or in widespread infiltrations, the disease beginning in 
the mucous membrane, extending to the muscular coat, and from thence 
to adjacent tissues and organs, causing more or less inflammation of 
these parts. The mucous membrane becomes greatly thickened and 
its surface is rough and lobulated, projecting into the lumen of the 
oesophagus. The muscular coat becomes infiltrated and thickened, 



68 DISEASES OF THE (ESOPHAGUS. 

which, with proliferation and infiltration of the surrounding tissue, 
causes rigidity of the oesophagus and diminution of its calibre. Usually 
there is only one growth, from one to three inches in length, although 
in some cases it is of much greater extent. 

Ulceration of the oesophageal surface readily occurs, and this pro- 
cess leads to perforation into organs that are involved in the cancerous 
growth, which may extend to the trachea, bronchi, lungs, and pleurae, or 
to the heart or aorta, pericardium or peritoneum, pharynx, and stomach. 
The vertebrae may be involved or the growth may extend into the 
spinal canal between the vertebrae. The bronchial, tracheal, and medi- 
astinal lymph nodes are commonly secondarily involved, while the 
cervical lymph nodes usually escape, although the supraclavicular, 
especially the left, is said to be frequently enlarged in the presence of 
intrathoracic malignant growths. The disease may spread by dissem- 
ination through the lymph channels, or metastasis may take place and 
thus the liver most frequently, and the lungs next in frequency, may 
be secondarily diseased. 

Petri holds that when the cancer is situated at or near the cardia its 
elements may be transmitted directly to the liver through the inferior 
oesophageal veins which empty into the portal. Metastases have been 
found in the kidneys, suprarenal capsules, pancreas, bones, and brain. 
Perforation most frequently happens in the trachea, bronchi, and lungs, 
although it may take place into the pericardium, pleurae, peritoneum, or 
mediastinum, or into the heart or great bloodvessels. Ewald described a 
case in 1895 in which perforation occurred into the aorta in a man sixty 
years of age, who suddenly developed hematemesis and died. Vimot and 
others have also reported cases of death from ulcerative perforation of 
the aorta. The growth may also perforate the carotid, the subclavian, 
or pulmonary arteries. The pneumogastric nerves or the recurrent 
laryngeal may be involved in the neoplasm, and thus dysphonia or 
aphonia arise. 

The oesophagus is usually dilated above the growth, at first its 
musculature being hypertrophied but later thinned and atrophied ; 
below the growth it is collapsed. 

Symptoms. — The symptoms usually make themselves manifest 
slowly. Pain may be present early, or it may be absent throughout 
the entire course of the disease. Dysphagia is at first experienced only 
when solid foot is eaten ; later semisolid and liquid foods are regurgi- 
tated, though a small quantity may pass into the stomach. There is no 
hard-and-fast rule that applies to all cases in reference to the onset and 
severity of the symptoms, as these may last in one for nearly two years, 
while another may succumb in six or eight months. Gradually or 
steadily increasing dysphagia with regurgitation of part of the food 
at first, and later of all the ingesta, pain or substernal pressure and 
distress, thirst, anorexia, loss of weight and strength, either a coated 
or clean, attenuated, glazed, dry, red tongue, foul breath, persistent con- 
stipation, progressive anaemia, weak pulse, nervous phenomena, cachexia, 
— these and other symptoms are present as the case may be, and are 
significant of serious trouble. 

Involvement of the recurrent laryngeal nerve may cause, besides 
dysphonia or aphonia, aggravated cough or dyspnoea. If the neoplasm 



CARCINOMA OF THE CESOPHAGUS. 69 

is situated in the upper part of the oesophagus, it may be visible either 
with an ordinary laryngoscopic mirror or with the oesophagoscope, or 
it may be accessible to the finger in this region. If it extends to the 
pharynx, it may be visible through the mouth. The regurgitated con- 
tents may contain fragments of cancer, which readily become detached 
owing to the ulcerative process, and which usually contain the so-called 
" pearly " globules or cell nests. In addition to the food, there may 
also be pus and blood, and usually these are mixed with an abundance 
of ropy mucus. The regurgitated food may have remained many hours 
in the oesophagus above the stricture, but is found entirely undigested. 
It is neutral or slightly acid in reaction, showing especially an absence 
of hydrochloric acid and an absence of the end products of albuminoid 
digestion. Starch digestion may occur from continued action of the 
ptyalin, provided mastication is thorough, though it has been found 
that the saliva in malignant and wasting diseases is markedly deficient 
in ptyalin. In only one condition of the stomach is the food returned 
so wholly undigested as it is from a stenosed, dilated oesophagus. This 
is the condition termed by Einhorn " achylia gastrica," and described 
by the writer as " gastric anacidity." Upon careful examination, how- 
ever, the gastric contents in cases presenting all the clinical manifesta- 
tions of achylia may reveal traces of pepsin and rennet or the rennet 
zymogen, which is not the case with the contents of the oesophagus. 
If predigested food has been taken, due allowance should be made in 
the examination. The attempt to pass the stomach tube is usually 
ineffectual, though it may sometimes be pushed through the stricture in 
cases of total inability to swallow. The growth in these cases is prob- 
ably soft and villous, with pendulous masses projecting into the lumen 
of the stricture, and the stomach tube doubtless pushes them aside, 
whereas upon deglutition they are simply wedged more firmly into the 
narrowed portion of the oesophagus. Bougies may be passed or stenosis 
may be sufficiently complete to prevent their entrance. The deglutition 
murmurs may be greatly delayed beyond the normal six or seven sec- 
onds, or they may be absent, depending upon the degree of stenosis. 
Loud gurgling sounds may be heard above the stricture. According 
to Gaucher, compression of the recurrent laryngeal nerve may in rare 
instances cause suffocative attacks early in the disease before dysphagia 
occurs. 

Diagnosis. — Cancer of the oesophagus is not usually suspected until 
more or less stenosis is manifest. It is chiefly important to differentiate 
between malignant and benign stenosis. The age and sex of the patient 
and the history should be taken into account. In cancer pressure 
symptoms are more common, especially if it is situated at the bifur- 
cation of the trachea or in the vicinity of the cricoid, and cachexia is 
earlier and more marked than in benign stricture. If the disease be 
advanced, the examination of the blood may show a grave anaemia, with 
a moderate leucocytosis in the event of ulceration of the neoplasm. 
Glandular enlargement, especially the supraclavicular, with the dis- 
covery of carcinoma in other regions, will serve as valuable diagnostic 
points. If fragments of cancer are found in the regurgitated matter, 
the diagnosis will be confirmed. 

Prognosis — The prognosis is extremely unfavorable. In a patient 



70 DISEASES OF THE (ESOPHAGUS. 

not too far advanced in years who still has considerable reserve vitality 
life may be prolonged and made tolerable by gastrostomy or by oesoph- 
ageal intubation. Symonds of London uses a tube about six inches 
long made of gum elastic and woven silk. It tapers from a small lower 
end to a funnel-shaped upper extremity. The lower end has an eye 
through which liquid food escapes into the stomach. A silk cord is 
attached to the upper end of the tube and is drawn out through the 
mouth. The tube is inserted by means of a whalebone rod. 

Strictures usually dilate under this treatment, and the tube may re- 
main in position without being removed for several weeks, though it is 
frequently necessary to remove it for cleansing purposes. With a tube 
in place swallowing is sometimes possible until shortly before death, 
and life is prolonged because the element of starvation is obviated. 
S. J. Mixter of Boston has used this treatment satisfactorily in several 
cases, and considers it very valuable, and Solis-Cohen also endorses it. 
Intubation is manifestly applicable to both malignant and benign stric- 
tures of the oesophagus, and it is to be recommended because in some 
cases after withdrawal of the tube swallowing may be performed with 
comparative ease for a considerable period. In some instances it is 
impossible to introduce the tube from above, it being then necessary to 
perform gastrotomy and insert the tube from the stomach. 

Moravitsky treated a case of carcinoma of the oesophagus with car- 
mine in daily doses of ten grains for a period of five months. Improve- 
ment occurred, but finally the carmine lost its effect, and pyoktanin in 
solution was substituted with very satisfactory results. One case, how- 
ever, does not necessarily prove the value of these remedies. Some- 
times the patient may be nourished by gavage when the dysphagia is so 
marked that starvation is imminent. ISTutritive enemata should be 
resorted to when insufficient food is taken into the stomach. Bracing 
and tonic remedies, especially strychnine, should be used in suitable 
doses to assist in maintaining the strength of the patient. General 
hygienic management should of course be carried out in the best possi- 
ble way in each case. If necessary, gastrostomy should be performed 
with a view of prolonging life. 

Other Tumors of the (Esophagus. — Sarcoma of the oesophagus is a 
rare aifection. It has been found in the very young, and is more liable 
to occur before the age of forty than is carcinoma. Lympho-sarcoma 
of the oesopahgus has been found at the age of four years. Benign 
tumors, fibromata, myomata, myxomata, lipomata, lymphomata, and 
cysts, all of which are extremely rare, occur in the oesophagus. Some- 
times fibromata appear as polypi having long pendulous attachments. 
Cases of polypi have been recorded in which occlusion of the oesopha- 
gus resulted. Sometimes adenoma is found, and may have a polypoid 
appearance. The symptoms of sarcoma are much the same as those of 
carcinoma, while the clinical history of benign tumors of the oesopha- 
gus is usually that of more or less occlusion of the tube. Small myx- 
omata may exist without causing much obstruction, and the same is 
true of small retention cysts. 



DILATATION OF THE (ESOPHAGUS. 71 



BILATATION OF THE CESOPHAGUS. 

Etiology. — Dilatation of the oesophagus may be diffuse (cylindrical) 
or sacculated (diverticulum). Only a small portion of the organ may be 
dilated, or the whole tube may be enlarged in all directions or in a 
fusiform manner. Dilatation has been found commencing at the cricoid 
cartilage and ending at, or a few centimetres above, the cardia. Some- 
times dilatation is so great that the diameter of the oesophagus is four 
or more inches, and its capacity accordingly increased. The organ is also 
lengthened, and in rare cases it has been found almost twice its normal 
length and tortuous in shape. The disease is classed as primary and 
secondary. 

Primary dilatation is in rare instances a congenital affection, owing to 
an insufficient muscular coat, but occurring in later life it is said to re- 
sult from injury to the chest, from the ingestion of large amounts of 
liquid, and from chronic catarrhal oesophagitis, in which affection the 
mucous membrane of the oesophagus may be nodular or ulcerated. 
Fatty degeneration of the muscular coat and chronic interstitial inflam- 
mation of the deeper coats have been found. The affection is one of 
early life, giving rise to dysphagia and regurgitation. Patients may or 
may not be conscious of the lodgement of food in the oesophagus, but 
usually a sense of distress, fulness, or pain is felt when sufficient food 
has been ingested to cause pressure. Food may be washed down with 
large quantities of liquid, and various positions of the body may "be as- 
sumed to assist deglutition ; a sense of suffocation and palpitation some- 
times results from the pressure of a large collection of food distending 
the oesophagus. Such a collection may remain many hours before be- 
ing regurgitated, and while in the oesophagus may undergo fermentation 
or putrefaction, causing extremely foul breath. When regurgitated the 
food is entirely undigested with the exception of a change that starches 
may have undergone from the action of ptyalin. The disease may last 
many years, and, though recovery may occur, the prognosis is doubtful. 
It may be necessary to feed by means of the stomach tube for a protracted 
period. 

Secondary dilatation of the oesophagus results from obstruction some- 
where along the course of the organ. Such obstruction may result from 
impaction of a foreign body, from cicatricial or malignant stenosis, the 
presence of an occluding benign tumor, syphilitic gumma, or pressure 
from without. Carcinoma and cicatricial stenosis are the most common 
causes of secondary dilatation. The muscular coat of the oesophagus- 
above the constriction at first hypertrophies, but later grows thin, its 
fibres stretch and atrophy, and as dilatation progresses peristaltic power 
gradually diminishes until it is entirely abolished. Below the obstruc- 
tion the oesophagus is collapsed. The mucous membrane above the 
stricture is in a condition of chronic catarrhal inflammation, and as the 
inflammatory process extends to the deeper structures the wall is often 
considerably thickened — a condition not inconsistent wdth extreme dila- 
tation. 

The SYMPTOMS of this affection are those of stenosis of the oesopha- 
gus coupled with the symptoms peculiar to its cause. 



72 DISEASES OF THE (ESOPHAGUS. 

The PKOGNOSis necessarily depends upon the cause. If dilatation 
results from malignaut disease, the outlook is hopeless ; whereas, on the 
other hand, if a benign tumor or impacted foreign body is removable, 
the prognosis is favorable. 

TEEArMENT. — If this disease can be diagnosed, early feeding should 
be practised through the stomach tube quite persistently, though a 
small quantity should be masticated and swallowed by the patient. The 
object of this is to prevent or delay stenosis by the frequent jiassage of 
the stomach tube, which will maintain the calibre of the oesophagus, and 
also to prevent an accumulation of food in the dilating portion. The 
small quantity of easily deglutible food eaten by the patient is amply 
sufficient to give the muscular layer of the oesophageal wall enough labor 
to prevent its atrophy. As dilatation is almost always secondary to ob- 
struction, the most eifectual treatment consists in its removal when pos- 
sible ; if it is not practicable, the oesophagus should be intubated or 
gastrostomy should be performed. The ingesta should be most nutriti- 
ous, and strychnine should be given in large doses. 



DIVERTICULUM OF THE CESOPHAGUS. 

Definition. — A circumscribed saccular dilatation or pouch of the 
oesophagus. 

Two forms — (1) the pulsion (pressure) and (2) the traction diverti- 
cula — are described. 

1. Pulsion Diverticulum. — Etiology. — Congenital defects, such as 
misplacement of the vitelline duct or a faulty development of the bron- 
chial clefts, have been thought possible causes. It is, however, rarely 
found in the newborn or in the young, but is a disease of advanced life, 
the fortieth year or later. It is more common in men than in women, 
and almost always occurs at the junction of the pharynx with tlie oesopha- 
gus. It occurs at the posterior part of the oesophagus in the median line 
or only slightly to one side of it, a situation in which the muscular coat 
is ■weakest and the lumen narroAvest. In most cases the diverticulum 
has no muscular layer, though in some instances a few muscular fibres 
may be seen, and the condition consists of a protrusion of the mucous 
membrane between the separated muscular fibres, thus resembling a 
hernia. Zenker and von Ziemssen state that the initial cause of the 
weakening of the oesophagus is, in the majority of cases, the lodgement 
of a foreign body Avhich presses upon and separates the muscular fibres, 
between Avhich the mucous membrane is forced gradually farther and 
farther by repeated acts of swallowing. A small foreign body like a 
kernel of corn if lodged a few days and then rejected is sufficient to 
start the trouble. The muscular layer may also be weakened by ulcer- 
ation or trauma. 

Pathological Anatomy. — The diverticulum is always single, 
arises from the posterior and upper portion of the oesophagus, and is 
usually pear-shaped. It may be very small or several inches (four to 
six) in length. It presses upon the oesophagus, pushing it forward and 



DIVERTICULUM OF THE (ESOPHAGUS. 73 

making it difficult for food or a sound to pass into the stomach. The 
mucous membrane of the pouch is in a condition of chronic catarrhal 
inflammation. 

Symptoms. — In some cases symptoms are absent for many years, 
but usually dysphagia is pronounced and persistent, growing progres- 
sively worse. The sac fills with food and may appear as a tumor in the 
neck. Manipulation sometimes empties it and the swelling disappears. 
The pouch when full may press upon the oesophagus below and cause 
complete pressure stenosis, and if large enough the diverticulum may, 
by pressure upon the heart, trachea, bronchi, or recurrent laryngeal 
nerve, cause palpitation, dyspnoea, or suffocation. The food is usu- 
ally not regurgitated until several hours have elapsed after its inges- 
tion, unless at any meal the pouch becomes over-distended. If the 
diverticulum interferes seriously with nutrition, the patient manifests 
symptoms of inanition, and finally dies from exhaustion if no com- 
plication carries him off. There will manifestly be added to the local 
symptoms those of a depraved general nutrition and starvation. 

Diagnosis. — In place of the normal deglutition murmur there may 
be heard gurgling, rumbling sounds in the diverticulum when fiiuid is 
swallowed. If an attempt is made to pass the stomach tube, it usually 
enters the pouch and its contents may be withdrawn. After it is empty 
a sound may be left in it, while one or two extra sounds may be passed 
successfully into the oesophagus. Emptying the diverticulum sometimes 
gives relief, and food more easily enters the stomach. The tip of the 
sound may be felt at the bottom of the diverticulum. The arrays 
may prove useful by photographing a diverticulum distended with 
bismuth mixture. 

Prognosis. — The disease may last for many years notwithstanding 
marked dysphagia. Patients learn by many little manipulations to 
swallow sufficient food upon which to subsist, though it is often neces- 
sary to perform gastrostomy and nourish by that means. Walter 
Whitehead in 1882 performed gastrostomy upon a woman who had 
suffered from dysphagia for eight years. She was nourished by the 
gastric fistula, and then again commenced to swallow her food, but 
gradually failed and died a few years later. A diverticulum three 
inches in depth Avas found. 

Treatment. — From a medical standpoint tonics and careful con- 
servation of the vital forces -are indicated. Brilliant results have been 
achieved by surgeons in the removal of diverticula. Kocher of Berne 
reported two cases of successful removal and complete cure. Von 
Bergmann successfully removed a diverticulum of probable congenital 
origin in the case of a woman aged thirty-eight years. In some cases 
a stomach tube may be introduced without much difficulty and the 
patient nourished by gavage. Intubation of the oesophagus as prac- 
tised by Butlin and Mixter for stricture should be tried if the divertic- 
ulum is not too high up. 

2. Traction Diverticulum. — Traction diverticula are caused by adhe- 
sions forming between the oesophagus and neighboring bronchial or tra- 
cheal lymph nodes, or inflammatory processes in the mediastinum may 
result in adhesions. As the adhesions retract the wall of the oesophagus 
is drawn outward, and funnel-shaped depressions from one half to three 



74 DISEASES OF THE (ESOPHAGUS. 

quarters of an inch in depth are formed in the oesophagus. The peri- 
adenitis is commonly the result of tubercular disease extending from 
the lung, though it may depend upon inhalation lobular pneumonia or 
caries of the sternum, vertebrae, or ribs. Traction may also result from 
pleurisy or pericarditis. 

Symptoms. — There is usually no interference with deglutition, 
owing to the small size of the diverticulum. Perforation is the chief 
danger, and it may be caused by retained food giving rise to ulceration 
into a bronchus, thus exciting pulmonary gangrene or grave pneumonia. 
Pleuritis, pericarditis, suppurative or gangrenous mediastinitis may also 
result from perforation. 

ACUTE (ESOPHAGITIS. 

Definition. — Acute inflammation of the oesophagus. 

Etiology. — QEsophagitis is a rare disease ; at least, it is very infre- 
quently recognized clinically. Mild catarrhal oesophagitis occurs as an 
idiopathic affection from exposure to cold and damp. Frequent use of 
very hot and very cold drinks is said to cause it, and alcohol, tobacco, 
and highly irritating spices, such as mustard, sometimes excite it. Irri- 
tating drugs also induce it, especially if they are retained in the oesoph- 
agus for a length of time owing, let us say, to temporary spasmodic 
stricture of the organ. CEsophagitis may occur secondarily by extension 
of the inflammation from the stomach or pharynx. It may arise in 
the course of the eruptive fevers or be caused by peri-oesophageal 
inflammation. 

The most common causes are the swallowing of corrosive substances 
and injuries from foreign bodies, which frequently excite phlegmonous 
oesophagitis — a condition that is also due to spinal caries, abscess of the 
mediastinum, suppuration of tracheal and bronchial lymph nodes, and 
smallpox. 

Pathological Anatomy. — The inflammatory process may be gen- 
eral or localized, occurring most frequently in the lower portion of the 
oesophagus. In the catarrhal form there are desquamation of the epi- 
thelium and swelling of the mucous follicles, which are filled with 
mucus or muco-purulent material and appear as small gray elevations. 
Ulceration may occur in small or large areas, and by extension into the 
deeper structures cause suppuration and sloughing of portions of the 
mucous membrane, or an intramural abscess may develop. Gangrene 
sometimes occurs. The eruption of variola upon the mucous membrane 
of the oesophagus assumes the form of pustular inflammation ; the pus- 
tules may, as in the skin, be discrete or confluent. 

Phlegmonous oesophagitis, according to the findings of Zenker and 
von Ziemssen, begins as a submucous purulent infiltration which finally 
destroys all the constituents of the areolar tissue, and later may rupture 
through the mucous membrane and cause destruction of extensive areas. 
Cicatrization following destructive processes of this nature may event- 
ually narrow the lumen of the oesophagus or even cause marked ste- 
nosis. Hemorrhage sometimes results from ulcerative processes. 

Symptoms. — The chief symptom is painful deglutition, which may 
last a few days or many weeks. In a case of the writer's the pain 



CHRONIC (ESOPHAGITIS. 75 

caused by swallowing was accompanied by intense burning in the oesoph- 
agus, which lasted several hours after the ingestion of food. The burn- 
ing pain was so distressing that the patient was rapidly losing ^veight 
and strength when she presented herself for treatment, owing to the 
fact that she subsisted upon a very small amount of semisolid and fluid 
food. Regurgitation of the food sometimes occurs before it reaches the 
stomach. In the purulent forms of the disease there is an elevated 
temperature, with, perhaps, slight or quite pronounced chills. Blood, 
pus, mucus, or shreds of tissue may be regurgitated in cases with 
suppurative or gangrenous processes. Thirst is often a prominent 
symptom. 

Diagnosis. — It is sometimes very difficult to differentiate between 
, the milder and severer grades of the affection, but the diagnosis of 
oesophagitis may be made from the cliief symptoms — deglutition pain 
and regurgitation, with, perhaps, spasm of the muscular fibres of the 
oesophagus. Inspection of the pharynx in a second case of the writer's 
showed marked follicular pharyngitis, and it is not improbable that the 
oesophagitis was closely related to the pharyngitis. By means of the 
oesophagoscope inflammatory processes of different varieties might be 
detected, but the instrument is not in general use. The passage of the 
sound meets ^vith no obstruction unless tumefaction be very great or the 
swelling of an abscess encroaches upon the lumen of the gullet. Other 
diseases of the oesophagus should be differentiated if possible. 

Prognosis. — The outlook in the catarrhal form is favorable, but in 
the suppurative varieties the prognosis is grave, owing to the liability 
of perforation, gangrene, or subsequent stricture. 

Treatment. — Fluid diet should be insisted upon until all acute 
symptoms subside. Sometimes even liquids are regurgitated, and then 
nutritive enemata should be given. If it is possible to ascertain the 
cause, it should receive attention. In case the oesophagus is burned by 
very hot ingesta, cracked ice may be sucked, and sodium bicarbonate 
should be placed dry upon the tongue and swallowed slowly. Soda 
gives distinct relief if used in this manner, a few" grains being allowed 
at a time. Bismuth subnitrate suspended in mucilage of tragacanth is 
another soothing and healing remedy, or the diy bismuth may be placed 
upon the tongue and swallowed without water, in order that it may 
spread over the oesophageal mucous membrane. 

If burning pain is intense, relief may be afforded by adding a quar- 
ter or a half grain of cocaine muriate to the soda or bismuth. In case 
of phlegmonous inflammation rest in bed should be ordered, supporting 
measures adopted, anodyne and mild antiseptic emollient solutions ad- 
ministered, and surgical measures instituted if perforation occurs. As 
recovery takes place solid food ought not to be allowed too early. 



CHRONIC (ESOPHAGITIS. 

Etiology. — Repeated attacks of acute or subacute oesophagitis may 
lead to chronic inflammation. It is apt to result from the constant use 
of very hot and irritating drinks. Abuse of alcohol is said to induce it. 



76 DISEASES OF THE (ESOPHAGUS. 

Passive congestion of the oesophagus, as in chronic pulmonary and car- 
diac affections, is likely to cause it. Sometimes chronic oesophagitis 
succeeds the injury caused by a foreign body "vvhich remains lodged in 
the oesophagus for a considei'able length of time, or it may be set up 
bv extension of inflammatory processes in contiguous structures. It ac- 
companies carcinoma, benign stenosis, tubercular and syphilitic lesions. 

Pathological, Anatomy. — Klebs and Zenker and von Ziemssen 
insist that inflammations of the mucosa of the oesophagus differ very 
materially from inflammations of the mucous membrane of the stomach. 
There is rarely found abundant mucus, such as occurs in the stomach. 
Proliferation of connective tissue leads to thickening of the mucous 
membrane — even, in rare instances, causing polypoid growths. The 
muscularis sometimes becomes hypertrophied, and when this is asso- • 
ciated with marked hyperplasia of the submucous tissues the lumen of 
the oesophagus may be encroached upon, and if it is situated near the 
cardia stenosis and dilatation may follow. 

Symptoms. — Chronic oesophagitis may exist without causing symp- 
toms, though sensations of deep substernal soreness and rawness may 
not infrequently be complained of. The passage of the food, especially 
rough ingesta, may cause a sense of soreness, or actual dysphagia may 
be present at times. It is likely that the inflammation undergoes 
repeated exacerbations, and that the symptoms are then more marked, 
but subside again as soon as the temporary increased congestion passes 
aAvay. There may be symptoms of stenosis added to those above 
mentioned. 

Diagnosis. — The diagnosis is necessarily presumptive in some cases ; 
in others the symptoms are sufficiently pronounced and definite to afford 
diagnostic data. GEsophagoscopy might detect the true state of affairs. 

Prognosis. — The prognosis is favorable in mild forms of catarrhal 
oesophagitis, and it assumes gravity only in cases with deeper inflamma- 
tory involvement causing stricture. 

Treatment. — The cause should be treated if it is possible to ascer- 
tain it. The diet should be bland and non-irritating. Alcohol should 
be interdicted, excepting it be taken highly diluted, and then only when 
it is indicated from a medical standpoint. When burning follows the 
ingestion of food it may be greatly relieved by the administration of 
small quantities of bismuth, with a drop or two of chloroform, sus- 
pended in mucilage of tragacanth. A favorite formula of the writer's 
is as follows : 

I^. Bismuthi subnitratis, Sij ', 

Chloroformi, gtt. xx ; 

Mucilaginis tragacanthidis, 
Aquse menthse piperitse, da. q. s. ad siv. 
Sig. Teaspoonful undiluted as often as needed to relieve burning. 

This prescription answers well in the acute form of oesophagitis. 
Astringents should be applied to the mucous membrane of the oesoph- 
agus by means of a soft sponge or absorbent cotton securely attached to 
an applicator. Argentic nitrate is the best, and should be used in the 
strength of eight grains to the ounce. Argonin, alum, tannin, hydras- 



FOREIGN BODIES IN THE (ESOPHAGUS. 77 

tis, iron, or other astringent may be employed. The stomach tube or 
oesophageal soHud should be passed occasionally in order to prevent the 
formation of a stricture. 



MEMBRANOUS CESOPHAGITIS. 

Teue croupous membranes are sometimes formed in the oesophagus. 
They are usually found in patches scattered over the mucous membrane, 
especially in the upper portion of the organ, but they may occur in lon- 
gitudinal strips or spread over a considerable area. Several instances 
of exfoliation of the epithelial layer of the oesophagus have been re- 
ported. Birch-Hirschfeld, Reichmann, Fitz, Rosenberg, and others 
have contributed illustrative cases of great interest. Reichmann's 
case was that of a man thirty-three years old who had sudden occlu- 
sion of the oesophagus, vomited a thick membrane a few days afterward, 
and later passed a similar formation per rectum. The membrane was 
a cast of the oesophagus, and was composed of a number of layers of 
squamous epithelium. This, then, is difPerent from either a fibrinous 
or mucous cast, which latter so commonly occurs in so-called membran- 
ous colitis. Fibrinous oesophagitis may be caused by extension of the 
disease from the pharynx. It occurs sometimes in pulmonary tuber- 
culosis, typhoid fever, the exanthematous fevers, jwremia, nephritis, 
and pneumonia. Ulceration and hemorrhage occasionally happen at 
the site of these croupous deposits. The writer recently saw a case 
with Dr. J. C. Brown of Southport, Pa., in which the mucous mem- 
brane, submucous tissues, and part of the muscular layer of the oesopha- 
gus, together with the mucous membrane of the cardia and a portion 
of the stomach, were vomited as a complete cast ten days after the 
swallowino; of a corrosive. 



FOREIGN BODIES IN THE (ESOPHAGUS. 

FoEEiGX bodies frecjuently lodge in the oesophagus. They are often 
swallowed by accident, though they are commonly intentionally swal- 
lowed, especially by the insane. They may be classed into those that 
are smooth and regular in shape and lodge only because of their large 
size ; those that are rough and jagged, and very liable to catch in the 
mucous membrane ; and, finally, those that are sharp-j)ointed and likely 
to penetrate the wall of the oesophagus. This, of course, is merely a 
suggestive classification. Among the foreign bodies most frequently 
lodged in the oesophagus are coins, dental plates, pins, needles, and 
fishbones. The insane not infrec|uently swallow a great varietv of 
sharp articles, such as stones, tacks, nails, hairpins, screws, and occa- 
sionally knives, forks, and spoons. Jackstones and toothbrushes have 
been found in the oesophagus. Large pieces of beef, mutton, or chicken 
bones are sometimes accidentally swallowed. 



78 DISEASES OF THE (ESOPHAGUS. 

Foreign bodies may be ejected by the patient or pass down into the 
stomach, where they may remain or move onward and be expelled per 
rectum. Gould and Pyle in their interesting book, Anomalies and 
Curiosities of Medicine, cite Evans' case of a girl who swallowed a gold 
plate wkh four artificial teeth, and two years afterward vomited them 
after violent retching. Another case is cited in the same work, of a 
young man who swallowed a coin that lodged and remained in the 
middle portion of the oesophagus for ten months, causing great pain. It 
then passed into the stomach, and after thirty-five years had not been 
passed by the rectum. It will thus be seen that bodies may remain for 
a protracted period in the oesophagus or stomach without causing death. 
On the other hand, the gravest results often follow their retention in 
the oesophagus. In the first place, obstruction results, and may even 
prevent the passage of liquids into the stomach ; therefore strength and 
weight are soon lost. More serious still is the likelihood of perforation 
into the trachea, bronchus, lungs, pleura, mediastinum, or large vessels. 
Fatal pneumonia, pulmonary abscess, or gangrene may thus result or 
empyema may be caused. Sudden fatal hemorrhage has resulted from 
perforation into the aorta. Gould and Pyle mention that Poulet col- 
lected 31 cases of perforation into the neighboring bloodvessels ; into 
the aorta, 17; carotids, 4; vena cava, 2; inferior thyroid artery, right 
coronary vein, demi-azygos vein, right subclavicular (abnormal) artery, 
and the oesophageal artery, each 1. Cases of perforation into the 
innominate artery are also recorded. In many cases of perforation into 
the bloodvessels the foreign body is either a sharp-pointed bone or some- 
thing that easily penetrates the tissues. Sharp foreign bodies frequently 
migrate through the tissues and appear beneath the skin at some remote 
portion of the trunk or extremities. Needles and pins have been found, 
years after they were swallowed, in the side between the ribs, in the 
neck, behind the ear, in the abdominal parietes, and elsewhere. The 
literature contains many interesting reports of such cases. The results 
of migration may or may not be harmless. Foreign bodies have re- 
cently been photographed in the oesophagus by the a;-rays with marked 
success, being thus definitely located. 

Teeatmext. — American and foreign surgeons agree that foreign 
bodies should not be allowed to remain impacted any longer than can 
be avoided, owing to the danger of ulceration, abscess formation, and 
serious results. Certain medical means may be tried before surgical 
methods are resorted to. The patient should drink a glass of milk, 
and be given an emetic forty minutes thereafter. The milk goes down 
in a fluid state, forms large curds in the stomach, which when vomited 
carry a small body, such as a fishbone, before them. Successful removal 
of some foreign bodies may be accomplished by directing the patient to 
swallow a tangled mass of thread, which is left in the oesophagus for 
some time and then withdrawn, with perhaps, the article in its meshes. 
Fishbones and coins have been removed in this manner. It is proper 
to push the body gently toward the stomach in case it is known to be 
smooth and unlikely to lacerate the oesophagus, but if gentle efforts do 
not succeed in moving it, no force should be applied. 

An attempt should be made to extract the foreign body with forceps, 
especially if it is lodged in the upper part of the oesophagus. Yon 



PERFORATION AND RUPTURE OF THE (ESOPHAGUS. 79 

Haeker ^ reports a case in which he removed a fragment of bone by the 
aid of electria light ; the oesophagoscope guided him in locating the 
bone and removing its jagged corners, so that it was easily extracted 
with forceps. The winter has seen a coin successfully removed from 
the upper part of the oesophagus by holdiug the patient, a boy, head 
downward and vigorously slapping the back between the shoulders. 
The boy ran excitedly down stairs to his father, who was a physician, 
and after a few slaps the coin dropped out. Had more than a few 
seconds elapsed, probably the treatment would have failed. 

CEsophagotomy, gastrotomy, or gastrostomy should be resorted to 
early, as the gravity of the case increases with the length of time a 
foreign body remains impacted. 

(For further discussion upon these operations the reader is referred 
to many valuable surgical reports and to works on surger}\) 



PERFORATION AND RUPTURE OF THE (ESOPHAGUS. 

Rupture of the (Esophagus is an accident that is liable to occur in 
dilatation, diverticulum, ulceration from an impacted foreign body, 
abscess in the Avail of the oesophagus or in the peri oesophageal tissues, 
and from injury. Sometimes it occurs spontaneously without apparent 
cause, and the condition described as oesophagomalacia has been found 
in such cases. It is a rare condition, the majority of cases occurring 
in men, some of whom habitually use alcohol to excess. Rupture may 
occur from over-distention of the oesophagus, especially when it is 
dilated, and when a diverticulum ruptures it is usually owing to ulcera- 
tion, with, perhaps, over-distention from a collection of food or gas in 
the sac. It sometimes happens upon great exertion or a violent jar, as 
over-straining in lifting or jumping, or falling from a considerable 
height. Morley^ reports the case of a middle-aged German who was 
seized with pain in the stomach and hematemesis upon jumping from 
his wagon. He was an alcoholic and died on the second day. On post- 
mortem a linear rupture of the oesophagus was found at its cardiac 
extremity. G. R. Turner'^ mentions the case of an apparently healthy 
woman in which rupture of the oesophagus occurred from vomiting, the 
patient dying within ■ twenty-four hours. At autopsy a left-sided 
pneumo-thorax was found with collapse of the lung. 

RujJture is also apt to occur from the action of corrosive substances 
upon the wall of the oesophagus, and cpiite frequently it is caused by 
carcinomatous ulceration ; indeed, any morbid process leading to more 
or less solution of continuity in the wall or marked thinning and weak- 
ening of the wall may lead to rupture. 

Zenker and von Ziemssen classify rupture of the oesophagus as pri- 
mary and secondary — primary occurring from diseases of the oesophagus 
itself, and the secondary occurring from diseases of the bronchial and 
tracheal lymph nodes, caries of the vertebrae, ulceration of the trachea, 

^ Wkrier Min. Woch., Oct. SI, 1889. ^ X^orthwesteru Lancet, April 1, 1892. 

^ London Med. Soc, Jan. 11, 1897. 



80 DISEASES OF THE (ESOPHAGUS. 

abscess or gangrene of the lung, aneurysm of the aorta, empyema, and 
mediastinal abscess. 

Perforation may occur in any part of the oesophagus, but is more fre- 
quent in the intra-thoracic than in the cervical portion, the anterior wall 
near the bifurcation of the trachea being a favorite point. The size of 
the perforation varies greatly according to the underlying disease and 
the violence causing it ; the opening may be only large enough to admit 
a small probe or it may be one inch or more in diameter. Linear per- 
forations usually result from peri-oesophageal disease. 

SYj\rPTo:MS. — The immediate symptoms of rupture are sudden great 
pain felt beneath the shoulder-blades or beneath the sternum, with 
symptoms of shock. The temperature in some cases is elevated ; in 
others it is subnormal ; nausea and vomiting frequently occur, occasion- 
ally hematemesis being immediate and copious ; and bloody stools may 
be observed. If rupture occurs into the pleural cavity, there may be 
signs of pleural effusion or pneumo-thorax, as pyo-pneumo-thorax is 
quickly developed. If it occurs into the pericardium, pyo-pneumo-peri- 
cardium results ; if into one of the bronchi, symptoms of purulent tra- 
cheitis, bronchitis, lobular pneumonia, pulmonary abscess, or gangrene 
may quickly manifest themselves ; if into the aorta, sndden fatal hem- 
orrhage follows ; if into the mediastinum, abscess or gangrene occurs. 

Sometimes protective adhesions are formed about the oesophagus, and 
perforation may burrow along through these adhesions and appear in 
the neck, giving rise to subcutaneous emphysema — a condition which, 
however, occurs in rupture without peri-oesophageal adhesions. 

Diagnosis. — The diagnosis is sometimes extremely difficult, while in 
some cases it is made with comparative ease. 

Prognosis. — The prognosis is extremely grave, death usually occur- 
ring immediately or in a few days. 

Treatment. — The medical treatment is symptomatic, stimulants 
and morphine being indicated. No food or liquid of any kind should be 
allowed by the mouth, but nutritive enemata should be employed. In 
some cases surgical measures promptly resorted to might perhaps save 
or prolong life. 



ULCER OP THE CESOPHAQUS. 

Ulcer of the oesophagus occurs sometimes in acute oesophagitis, es- 
pecially when the inflammation is caused by chemical irritants, and also 
in chronic oesophagitis of the follicular type. It may occur in smallpox 
as a local manifestation of the disease. Foreign bodies injuring the 
mucosa freqnently lead to ulceration. It may be tubercular or syphil- 
itic, and is a frequent accompaniment of malignant disease of the oesoph- 
agus. Involvement of the oesophageal mucous membrane from suppu- 
rative processes in adjacent parts may also cause it. 

Peptic ulcer of the oesophagus is occasionally seen. Guiteras ^ reports 
the case of a woman, aged forty-four, in whom numerous ulcers were 

1 Int. Med. Magazine, Nov., 1894. 



HEMORRHAGE OF THE (ESOPHAGUS. 81 

found post-mortem. Most of these ulcers were small, varying in size 
from a pinhead to a pea, while opposite the bifurcation of the trachea 
two large perforating nlcers were found. Microscopic examination 
showed anaemia of the tissues, absence of extensive areas of involve- 
ment, and the presence of large numbers of plasma cells in the layers 
of the oesophagus. The edges of one ulcer show^ecl little evidence of in- 
flammatory reaction ; the muscular coat showed no evidence of degene- 
ration. Guiteras concludes from a study of the case that " the absence 
of hyperplasias, of thickening, of congestion, and of the clean-cut edges 
of the more recent ulcers would exclude the view that they were the 
result of catarrhal inflammation." The ulcers had the anatomical feat- 
ures of peptic nlcers, and Guiteras considered them due to hysterical 
ischsemia and the habit of merycismus which was practised by the pa- 
tient. 

Dr. Herbert U. Williams of Buffalo has kindly furnished the writer 
with a report of a case of oesophageal ulcer, probably peptic, upon which 
he performed the autopsy. The case was that of a well-formed male 
child, three days old, who had suffered from profuse hemorrhages from 
the rectum, and it was remarked that the blood had the appearance of 
being arterial. There was also vomiting of blood. Further clinical 
history could not be obtained. The autopsy was made t^venty-four 
honrs after death. The case was supposed to be one of haemophilia. 
Examination of the mucous and serous surfaces of the skin showed no 
petechia ; in fact, there were no hemorrhages except that from the ali- 
mentary tract, and all the organs appeared normal, except that there 
were uric acid infarcts of the kidneys. The umbilicus and the um- 
bilical vein appeared normal"; they were examined with reference to 
possible infection ; for the same reason the liver was examined for bac- 
teria by attempts at cultures and by smear preparations with negative 
results. The stomach and intestines were filled with dark blood clots. 
The only lesion found in the alimentary tract was a shallow ulcer in the 
posterior wall of the oesophagus just above the stomach. It was oval 
in shape, one-half to seven-eighths of an inch long ; no bacteria could 
be discovered in sections of this ulcer. In the centre it passed down to 
the muscular coat ; over the greater part of it the mucosa and muscu- 
laris mucosa were wanting ; the adjacent tissues were infiltrated with 
blood. 

The causation of peptic ulcer of the oesophagus is probably the same 
as that of peptic ulcer of the stomach and duodenum. Anaemia of a 
localized area of mucous membrane is not sufficient reason for its occur- 
rence. It is probably the result of a tropho-neurosis resembling herpes 
in this respect. 



HEMORRHAGE OF THE (ESOPHAGUS. 

Hemorrhage is more likely to occur in advanced age. In some 
cases of cirrhosis of the liver and thrombosis of the portal vein a vari- 
cose condition of the veins of the oesophagus is present ; and profuse, 
sometimes fatal, hemorrhage not infrecpiently happens. Small and 

Vol. III.— 6 



82 DISEASES OF THE (ESOPHAGUS. 

repeated hemorrhages may, however, occur in any stage of cirrhosis, 
sometimes being the earliest manifestations of the disease. When 
hemorrhage is caused by rupture of varicose veins, the blood is usually 
regurgitated, not vomited. Profuse and rapidly fatal hemorrhage fol- 
lows the rupture of an aneurysm into the oesophagus or a perforation 
of the oesophagus into the aorta or other large vessels. Hemorrhages 
of diiferent degrees may also occur from erosion or ulceration of the 
oesophageal mucous membrane. Rupture and perforation are sometimes 
accompanied by profuse hemorrhage from the wall of the oesophagus. 
It occurs also in carcinoma and from the presence of sharp foreign 
bodies. 



TUBERCULOSIS OF THE (ESOPHAGUS. 

TUBEECULAE lesions rarely occur in the oesophagus. They may 
result from extension of the disease from the bronchial lymph nodes, 
the larynx, vertebrae, or pharynx. Pepper and Edsall reported a case 
of " tuberculous occlusion of the oesophagus, with partial cancerous in- 
filtration," ^ in which probably a local tuberculosis of the oesophagus 
occurred, and cancer arose from the chronic irritation. Such cases are 
very rare. 



SYPHILIS OF THE CESOPHAGUS. 

Syphilitic lesions of the oesophagus may result from extension of 
ulcerative processes in the pharynx. Ulceration or gummata may be 
found. Syphilitic ulcers not infrequently cause cicatricial stenosis of 
the oesophagus, and indicate the use of iodide of potassium in large and 
continued dosage. 



PARASITIC DISEASE OF THE CESOPHAGUS. 

Yegetable parasites rarely lodge upon the oesophageal mucous 
membrane. Thrush {synonyms : Oidium albicans ; Sprue ; CEsophago- 
mycosis oidica) may extend from the mouth to the oesophagus, occur- 
ring most commonly in children, being associated sometimes wath 
measles, scarlet fever, smallpox, and pulmonary tuberculosis. _ Zenker 
and von Ziemssen found it in adults most frequently in connection with 
phthisis and typhus fever; it occurs also in pyaemia and puerperal 
fever. 

Oidium albicans may appear as small or large patches on the mucous 
membrane. Occasionally the fungus proliferates so exuberantly that it 
causes obstruction. Eichhorst mentions that AVagner noticed that the 
^ American Journal of the Medical Sciences, July, 1897. 



CONGENITAL DEFECTS AND MALFORMATIONS. 83 

fungus penetrates the layers of epithelium and causes atrophy of the 
cells. It may^also enter the mucosa and bloodvessels. Sometimes the 
disease gives rise to no symptoms, though dysphagia or aphagia may be 
present. 

A peculiar complication of sprue of the oesophagus was found by 
Zenker to be metastasis of the disease in the brain. The fungus spores 
may be conveyed to the brain by the bloodvessels and develop in the 
brain substance, as thrush does not occur in the circulation. 

The TEEATMENT consists in swabbing the oesophagus frequently 
with a soft sponge or cotton saturated with a solution of borax. If 
obstruction occurs, it should be overcome by bougies, sounds, or a stiff 
stomach tube. 

Of animal parasites, the only one that invades the oesophagus is the 
trichina, which may be found in great numbers in the muscular coat of 
the oesophagus, and may thereby cause dysphagia and perhaps some 
pain. 



CONGENITAL DEFECTS AND MALFORMATIONS. 

Amoxg the congenital defects of the oesophagus tracheo-oesophageal 
fistula deserves mention. Pulsion diverticula are sometimes congenital 
in origin ; occasionally cysts of congenital origin are found near or 
attached to the oesophagus. 

According to the suggestion of Fitz, some fault in the development 
of Meckel's diverticulum may account for duplication pulsion diver- 
ticulum and cysts of the oesophagus. The most common abnormality 
is atresia of the oesophagus, a condition in which it ends in a pouch a 
short distance below the glottis. From this point, down as far as the 
bifurcation of the trachea, there exists a fibrous cord in which a few 
muscular fibres are sometimes found ; then the lower portion of the 
oesophagus is attached to the posterior wall of the trachea. 



DISEASES OF THE STOMACH. 

By CHARLES G. STOCKTON, M. D., and ALLEN A. JONES, M. D. 



GENERAL EXAMINATION OF THE PATIENT, INCLUD- 
ING- EXAMINATION OP THE STOMACH. 

Examination of the Patient. 

Tpie application of modern methods to the study of diseases of the 
stomach is yet too recent for us to expect a perfect agreement as to the 
pathology of these affections. Some misconceptions may be explained 
by the tendency that has existed of referring the symptoms of so-called 
dyspepsia to definite lesions of the gastric mucosa. Of course the 
stomach, like other organs, is liable to morbid anatomical changes as 
the result of well-known diseases, but such changes are present less 
frequently than is commonly supposed, and when loss of substance 
actually occurs there is no part of the economy in which repair goes 
on so rapidly as in the gastric mucous membrane. The frequency with 
which symptoms are referred to the stomach rests upon the remarkable 
sympathy that exists between that organ and other parts of the econ- 
omy. In the majority of cases in which complaint is made of the 
stomach it is not that organ which is at fault, but rather it is the man 
who is sick and the stomach is merely sounding the alarm. The close 
relationship existing between gastric symptoms and diseased states of 
other parts of the body makes it important for a thorough general 
examination to be made before concluding that there is present a gastric 
disease. The physical examination of the stomach and the chemical 
examination of its contents should be left until the last. 

The family history is occasionally of importance, as in the instance 
of cancer or neurotic tendencies, but it is usually necessary to study 
carefully the patient's personal history. This should include an inves- 
tigation of his past and present occupation, his habits as to exercising, 
sleeping, eating, drinking, and smoking, variations in weight, and pre- 
vious or accompanying illnesses. 

As to occupation, it may be learned that the patient was used to 
active out-of-door life, and experienced trouble with digestion only after 
taking up a sedentary, in-door occupation, or it may be found that a 
man having soft muscles and a weak heart suffered from stomach trouble 
after abruptly resorting to vigorous exercise either in athletics or in 
labor. There are some special avocations that often give rise to diges- 
tive disorders ; such, for instance, are those that require a stooping 
posture with pressure upon the epigastrium, or overtaxing the eyes, or 
exposure to the influence of lead or other poisons. 

85 



86 BISEASES OF THE STOMACH. 

As to habits, it should he ascertained if there is a just proportion in 
the lionrs spent in exercise, sleep, and recreation. The meals may be 
too close together, too far apart, or violent exercise may be undertaken 
without sufficient rest after eating ; too much liquid may be taken with 
meals, or digestion may be disturbed by too much coffee, tea, or alcohol. 
Certain individuals uniformly suffer from indigestion when using 
tobacco in any form. Acute febrile diseases, syphilis, gout, influenza, 
etc. often leave the digestive apparatus in a state of depression, and 
when aufemia, jaundice, ursmia, and toxaemias of various kinds are 
present, a disordered digestion is to be expected. 

In studying the present condition of the patient attention should be 
given to liis bearing and attitude. The preoccupied and dejected man- 
ner observed in those sufiering from continued gastric flatulency, the 
restless, discomposed behavior, the stooped posture and half-surprised 
expression often seen in the victims of gastralgia, the emaciated, weak, 
and cachectic appearance frequently accompanying chronic food stag- 
nation, are good examples. A sallow, earthy-colored skin, showing 
improper secretion ; a dry, harsh sldn with too rapid loss of epithelium, 
showing poor nutrition ; a skin showing cedema, poor capillary circula- 
tion, lividity, or acne ; certain forms of eczema, excess of pigment, or 
syphilides, — may afford important information as to the digestion, inas- 
much as some of these may be the results, and others accompaniments, 
of gastric disturbance. Any of the obstructive diseases of the lungs, 
as emphysema, interstitial pneumonia, or pulmonary conditions from 
which blood changes might result — as, for instance, tuberculosis and 
certain forms of bronchitis — must be considered. The patient's method 
of breathing, whether abdominal or thoracic, whether hurried or re- 
tarded, his ability to expand the chest, and the strength of the respira- 
tory muscles, should be noted. The heart is frequently disttirbed from 
sympathy with functional disorders of the stomach, as is shown by 
intermittency or great frequency of the pulse. The question of blood 
pressure is important, and should be studied with relation to the vigor 
of the heart and the vascular tension. Frequently digestion is dis- 
turbed from low blood pressure arising from a feeble heart, when no 
a]3parent structural disease of that organ can be discovered, A common 
cause of functional and structural disease of the stomach is found in 
the venous stasis resulting from chronic valvular disease of the heart 
or from pulmonary or hepatic obstruction. 

In examination of the kidneys it is not enough to exclude the various 
forms of nephritis, but the amount and character of urinary solids ex- 
creted in twenty-four hours should be ascertained, so that the functional 
activity of the kidneys may be known. Inquiry should be made as to 
the presence of renal insufficiency, hyperlithuria, indicanuria, phosphat- 
nria, cystinuria, glycosuria, peptonuria, albumintiria, and the micro- 
scopic revelations. An alkaline state of the tirine is expected after a 
full meal, but such alkalinity does not occur in the absence of the se- 
cretion of HC'l. Xothnagel holds that this is so uniformly true that it 
may be considered a criterion of the presence of such secretion. Alka- 
linit}^ following meals is therefore rarely seen in cases of carcinoma 
ventriculi. The chlorides are diminished when the amount of food 
taken is small, and a corresponding diminution of urea is also observed. 



EXAMINATION OF THE PATIENT. 87 

Laudenheimer found the chlorides diminished in carcinoma without a 
proportionate ^lecrease in the elimination of urea. Rommelaere showed 
that the urea is greatly diminished in cases of carcinoma — an observa- 
tion that has been abundantly confirmed. This fact seems grounded 
upon the lowered nutrition present in malignant disease, and is known 
to obtain in other cachectic states. Nothnagel calls attention to the 
fact that while both chlorides and urea are diminished in benign dis- 
eases of the stomach in which nutrition is greatly lowered, the chlorides 
are disproportionately low in cancer of the stomach. Indicanuria is a 
common condition when putrefactive changes are present in the intes- 
tinal contents — a state of affairs favored by faulty gastric digestion. 
Simon states that indicanuria is almost constantly present when free 
HCl is absent from the gastric contents. While this is true in a pro- 
portion of cases, the exceptions are so numerous, as we have many times 
demonstrated, that the rule is rendered worthless. 

Functional and organic disease of the liver should be considered in 
connection with the condition of the intestinal tube. Many cases of 
gastric disease have their inception in csecal or other forms of intestinal 
stasis, sometimes arising from functional inactivity, but often from 
compression or narrowing of the intestine from displacement of the 
duodenum, the caecum, the hepatic or sigmoid flexures, or the trans- 
verse section of the colon. A dilated or otherwise weakened descend- 
ing colon or rectum, an ulcerated, catarrhal, hemorrhoidal, or fissured 
rectum, may result in intestinal stasis or may disturb the stomach from 
reflex irritation. 

The dejections must be studied as to their frequency, regularity, 
quantity, and character. With some individuals insufficiency in evacua- 
tions exists unknown to themselves, for the reason that there are daily 
stools, although the amount is too small, and fsecal accumulation results. 
A moderate accumulation is sufficient to excite hepatic and gastric dis- 
orders, particularly in those patients having disturbed secretions, and 
consequently putrefactive changes in the intestinal tract. 

Diarrhoea may be an important symptom of gastric disease, and 
arises from too rapid peristalsis, disturbed secretion, or offensive fer- 
mentation. It may also aiford evidence of intestinal catarrh or ulcera- 
tion that often bear a relation to the gastric disorders. The color, form, 
and consistency of the stools should be noted, and they should be exam- 
ined as to the presence of undigested foods. When there is an absence 
of diarrhoea, and when pancreatic disease can be excluded, the presence 
of undigested shreds of muscle-fibre and fragments of starchy food may 
be set clown as depending upon faulty gastric digestion. A lienteric 
diarrhoea following meals generally has its origin in a gastro-intestinal 
neurosis. Clay-colored or very dark stools, melsena, and stools very 
offensive in odor should attract attention. 

The blood should be examined if there is evidence of anaemia. This 
condition frec|uently exists without a proportionate pallor of the mucous 
membranes, and its presence is suggested more by the quality of the 
pulse and the condition of the skin than by the color of the lips and 
gums. While anemia is frequently a result, it is also often the cause, 
of digestive failure. For this reason the blood should be studied, not 
alone to determine the presence or absence of chlorosis nor to enumerate 



88 DISEASES OF THE STOMACH. 

the red blood cells, but the number of white blood cells should be ascer- 
tained, and the variety of both red and white corpuscles should be 
carefully studied in every case in which a diagnosis is doubtful. (See 
Vol. II. pp. 639-6-43.) Inflammatory conditions may thus be differ- 
entiated from neuroses, and sometimes the causes of cachectic states 
may be ascertained. 

In malignant disease marked changes in the blood are common, 
although these changes are inconspicuous in the beginning of the affec- 
tion. After the appearance of the cachexia the quality of the blood 
depreciates as to its specific gravity, hsemaglobin, and the number and 
shape of the cells. In advanced carcinoma there is found a severe 
secondary anaemia, marked poikilocytosis, and a multinuclear leucocy- 
tosis, all of which changes may be observed in other cachectic condi- 
tions. Nothnagel in commenting on this work draws attention to the 
fact that the deterioration of the blood depends largely upon the motor 
activity of the stomach, and in any case in which the anaemia has been 
very marked, improvement in general health following gastro-enteros- 
tomy, is accompanied by a corresponding improvement in the blood 
state ; which goes to prove that the changes in the blood are not 
changes special to carcinoma, but are rather the result of interference 
with assimilation. 

Pohl observed that there was a physiological leucocytosis accom- 
panying digestion, and Schneyer found in 18 cases of carcinoma of the 
stomach that this physiological leucocytosis disappeared, while in all 
cases of ulcer examined, save one, this transient leucocytosis occurred, 
although a condition of marasmus was present. It might be expected 
that the alkalinity of the blood would be increased in cases of gastric 
anacidity, but, according to the limited investigations of Noorden in 
this direction, only an inappreciable difference in the alkalinity of the 
blood Avas observed in the cases of anacidity and hyperacidity. 

It is well known that functional gastric disorders are often due to 
classified disturbances or diseases of the nervous system ; structural 
disease of the stomach may have the same origin. In neurasthenia 
comfortable digestion is rarely present, and the condition called "brain- 
fag " and another known as " brain-irritation " have, quite uniformly, 
their attending disordered gastric states. Reflex irritation is so com- 
monly the source of functional disturbance of the stomach that certain 
regions in Avhich the reflexes usually arise — for instance, the genito- 
urinary apparatus — should receive careful scrutiny. We are indebted 
to Gould for recognizing and studying the effects of eye-strain upon the 
digestive organs, and can testify as to the frequency with which this is 
an etioloffic factor in stomach diseases. 



The Physical Examination of the Stomach. 

We now have many resources for making a physical examina- 
tion of the stomach. The abdomen should be inspected, with the 
patient placed first in the upright and then in the horizontal position. 
Meteorism and peristaltic movements of the stomach and intestine 
should be looked for, the importance of which was pointed out by 
Kussmaul, and the contour of the abdomen, including the comparison 



THE PHYSICAL EXAMINATION OF THE STOMACH. 89 

of the two sides, should be noted. Palpation of the abdomen while 
the muscles ^f the part are thoroughly relaxed, not only over the 
stomach, but over the other abdominal viscera, should be practised. 
Chapowsky recommends that palpation be made with the patient in a 
full warm bath, and hence with muscles more completely relaxed ; then 
by the skilful use of the hand the physician may describe the lower 
border of the liver, sometimes including the gall-bladder, the spleen, 
the stomach, the large and small intestines, the appendix, and not infre- 
quently the kidneys. 

The gastric succussion or splashing sounds are developed by two 
methods, the digital and total. The former is practised by requiring 
the patient to thoroughly relax the abdomen, and then rapidly tap- 
ping upon the part with the fingei'-tips over a line from the umbilicus 
upward and outward to the border of the left ribs. The latter method 
is practised by making sudden pressure alternately, Jfirst over the region 
occupied by the fundus of the stomach, and then over the neighborhood 
of the umbilicus, using both hands. Or the patient may succeed in 
developing the splashing sound by abruptly relaxing and contracting 
the abdominal muscles. For its successful demonstration there must 
be retained in the stomach a certain amount of gas and fluid. For 
this reason the appearance of the sign after long fasting is particularly 
significant of food stagnation. 

Following palpation, percussion should be made as a means of 
confirming the impression already gained, and also of determining 
the amount of gas and fluid in the stomach and intestine, besides 
discovering the presence of accumulations of faecal matter, abdominal 
growths, displacements or enlargements of organs, or the accumulation 
of fluid within the peritoneal cavity. To locate the upper border of 
the stomach the percussion should be made from above downward ; 
to locate the lower border, from below upward or from the left flank 
toward the stomach area. When these procedures are unsatisfactory 
assistance may be had by distending the stomach with air by means 
of a rubber bulb connected to the stomach tube, or by causing the 
patient to drink a solution containing thirty grains of sodium bicar- 
bonate, followed immediately by fifteen grains of tartaric acid in 
solution. The procedure may be repeated until a proper degree of 
gastric distention is obtained. As a further assistance the transverse 
colon may be distended with water as suggested by Simon. Or when 
the stomach contains considerable fluid, the colon may be distended with 
gas generated by the method above described (von Ziemssen), or by 
allowing gas to escape into the rectum through a tube connected with 
an inverted Seltzer bottle. Auscultation may be successfully employed 
either alone or conjointly with palpation, or percussion may be made 
while the stethoscope is placed below the free border of the ribs on a 
line with the left nipple. The deglutition murmurs can be heard, and, 
as a rule, the lower border of the stomach can be located by requesting 
the patient to suddenly retract and then expand the abdominal parietes, 
thereby producing splashing sounds which are quite audible to the 
unaided ear, and which enable one to locate the boundaries of the 
stomach quite accurately by stethoscopy, provided there is enough fluid 
and gas within the stomach. 



90 DISEASES OF THE STOMACH. 

The size of the organ is sometimes sought by estimating the quan- 
tity of the fluid withdrawn through the tube when the stomach has 
previously been filled. This measure is not free from dangers, and 
is in other ways unsatisfactory. Another plan is to introduce a deli- 
cate rubber bag attached to the end of a stomach tube. The bag is 
then inflated with air as much as possible without causing discomfort 
to the patient ; the capacity of the stomach is ascertained by estima- 
ting the amount of fluid that the air displaces when it is made to 
escape into a properly arranged flask. The size, shape, and position 
of the stomach may be learned by the use of Einhorn's gastro-diaphane, 
and the same instrument may be useful in detecting deformities of the 
stomach and growths in the anterior gastric wall. Turck of Chicago 
has invented an instrument, the gyromele, consisting of a metallic flex- 
ible sound having attached to its distal extremity a bulb or sponge. As 
the sound revolves in its sheath the moving extremity can be felt 
through the abdominal wall, and thus the lower border of the stomach 
may be determined. The inventor claims that the bacteria of the 
stomach may be studied by examining the material that adheres to the 
sponge. The rubber bag, contrived by Schreiber, already referred to, 
may be connected with a manometer, as practised by Purgecz, and thus 
not only the capacity of, but the ])ressure within, the stomach, and, to 
some extent, the motions of the stomach, may he studied. 

The Stomach Tube. — The most common instrument employed in 
the diagnosis of stomach diseases is the soft rubber stomach tube of 
Faucher, an improvement on the rigid tube used by Leube. Ordi- 
narily, in adult patients it should be about five feet long and about 
half an inch in diameter. There should be two oblong openings, about 
half an inch in length, at the distal extremity, the first being one half 
inch, and the second one and a quarter inches, from the rounded end. 
The calibre of the tube should be as large as possible compatible with 
proper rigidity. When too flexible there is difficulty in introducing it, 
and it is also likely to collapse either by pressure or suction during the 
process of aspiration. When it is too rigid there is danger of injuring 
the soft parts unless used with caution. When of proper rigidity a 
stomach tube of the size described will support without bending twelve 
inches of its own weight if held in the erect position. Such tubes are 
sometimes divided, for convenience in cleansing or in storage, into two 
equal parts, and they may be connected when used by glass tubing or a 
suitable steel clamp. The braided silk tubes are too rigid for most pur- 
poses. Larger tubes are rarely necessary if a proper test meal is em- 
ployed. When called upon to empty a stomach in emergency cases it 
is best to have a tube with the largest calibre possible. In order to 
empty the stomach satisfactorily it is found necessary to introduce the 
tube twenty-two inches beyond the teeth. In short individuals twenty 
inches may suffice ; in the very tall twenty-four inches may be required. 
In persons of medium stature, if more than twenty-two inches is neces- 
sary to remove the gastric contents, it may be assumed that in propor- 
tion to the increased length of the tube the stomach is displaced or 
enlarged. AA^e have found that in a person five feet and ten inches in 
height the light of the gastro-diaphane appears below the border of the 
ribs at a point just to the right of the left nipple line when introduced 



THE PHYSICAL EXAMINATION OF THE STOMACH 91 

twenty-two inches from the teeth. Such proficiency is acquired in the 
use of the stdmach tube that other instruments are generally unneces- 
sary for the estimation of the size of the stomach. Ebstein first showed 
that the stomach tube was equally useful in the very young. For 
infants under one year of age a No, 12 soft rubber catheter should be 
selected for purposes of aspiration of the stomach, and should be passed 
from six to eight inches beyond the lips.- Where there exists narrow- 
ing in the oesophagus or at the cardia conically shaped tubes or coni- 
cally shaped sounds of various sizes may be employed. The whalebone 
sound, to the extremity of which one of the various sized oblong bulbs 
is attached, may be employed in place of the rubber instrument. The 
double-current tube, although still in use, is now practically obsolete. 
It is sometimes employed in connection with Schreiber's rubber bag. 

Many rules have been given for introducing the stomach tube, but 
those most expert in its use will not be able to make the practice unob- 
jectionable to the patient ; nevertheless, it is most unusual to find a 
patient who cannot be made to take the tube without serious difficulty. 
The patient should sit in a rather high straight-backed chair. A 
rubber cloth should be thrown on the lap and a rather heavy towel 
pinned around the neck to protect the clothing. It is best to avoid 
explanations or discussions. Require the patient to protrude the tongue, 
and then, having dipped the tube in cold water, slip it back dextrously 
against the posterior pharyngeal wall, and then steadily and rather 
quickly push it onward until it has passed the sphincter-like contraction 
of the oesophagus in the region of the cricoid cartilage. Do not allow 
the patient to elevate the chin, but if a somewhat violent choking ensues, 
sternly command him to draw a long breath, and meantime complete 
the introduction of the tube to the desired point. The tube may be 
held a little to one side, thus avoiding some of the epiglottic irritation. 
The patient should steady the tube by holding it, the hand resting 
against the chin. He should be told not to swallow the saliva, but 
allow it to drip from the lips. 

If the patient becomes excited, calmness may be restored by requir- 
ing him to take deep and regular inspirations and to concentrate his 
mind upon breathing. The stomach contents may now be removed 
readily by the so-called expression method of Ewald, provided the 
proper test meal has been taken. The pressure is brought to bear upon 
the stomach by contraction of the abdominal walls, as in coughing or 
straining as if at stool. If the contents fail to flow out through the 
tube, it may be concluded either that the stomach is empty or that the 
tube has been too far or not far enough introduced. If too far, by 
bending upward the openings into the tube are raised above the level 
of the stomach contents. Having procured the nndiluted specimen for 
examination, lavage of the stomach should be practised, as information 
may be gained bv noting the number of flushings recpiired before the 
water comes away clear as when introduced. The amount and charac- 
ter of the mucus present should be carefully observed. From one to 
three pints of water should be allowed to flow in at a time, and as it 
siphons out an estimate should be made of the quantity that returns, so 
that no unexpected accumulation, hence no improper gastric distention, 
shall occur. 



92 DISEASES OF THE STOMACH. 

Having emptied the stomach, the patient should be required to turn 
his head to one side ; the tube should be carried a little to the opposite 
side and withdrawn by one steady sweep of the arm. AYhcn but a 
small quantity of the stomach contents is required for examination, and 
when th(i employment of the stomach tube is not feasible, Einhorn's 
stomach bucket may be used. This instrument consists of a hollow 
perforated oval body the size of a cherry, to wdiich a cord is attached. 
The bucket is swallowed by the patient, the deglutition made easier by 
drinking a little water. Having remained in the stomach for a short 
period, the bucket is withdrawn by means of the cord, the patient at the 
same time being instructed to swallow. 

Examination of the Stomach Contents. 

The contents of the stomach should be examined macroscopically, 
chemically, and microscopically. The macroscopic examination 
embraces the following : 

1. Amount. — The quantity withdrawn through the tube or vomited 
depends upon the amount of food taken, the accumulation of food, and 
the time elapsing between the examination and the last meal. One 
hour after a test breakfast consisting of a dry roll and 300 c.c. of water, 
between 25 c.c. and 55 c.c. of contents should be withdrawn undiluted 
by Ewald's expression method. This apj)lies to healthy conditions, as 
Boas as shown. Therefore, if a larger quantity is withdrawn, some 
defect of gastric motion or absorption may be suspected. If as large 
a quanity as 500 c.c. or 1000 c.c. of dark, offensive matter wells up 
through the tube, gastrectasia with pyloric stenosis may be suspected. 
A very small quantity found in the stomach or an empty stomach 
within two or three hours after a test meal of scraped beef, bread, and 
water is evidence either of a very hurried gastric peristalsis or a 
relaxed pylorus. 

2. Consistency. — The consistency of the contents depends upon 
the amount of fluid and the character of the solid ingesta, as well as 
upon the absorption and motor power of the stomach. 

3. Color. — This depends upon the color of the food eaten ; as, for 
instance, red or blue berries impart their color to the contents. Blood 
may also stain the contents red or dark. Bile usually imparts a 
greenish-yellow hue. The color may be changed by different fermen- 
tations. 

4. Odoe. — The odor should be noticed. There may be none 
appreciable, while, on the other hand, the volatile acids, acetic and 
butyric, may impart their respective odors. Hydrochloric and lactic 
acids are not volatile, and are therefore inodorous. The copious, dark, 
frothy material Avithdrawn from a dilated stomach usually has a foul, 
yeasty, sickening smell that is almost characteristic. Drugs such as 
valerian, asafoetida, ethers, and camphor may be detected by their odors. 
Certain foods, such as onions, cauliflower, and oranges, impart their 
respective odors to the contents. 

5. Mucus. — Vomited contents usually contain a considerable quan- 
tity of thick, ropy, tenacious mucus which comes from the throat and 
oesophagus. Mucus from the stomach is not, as a rule, so abundant 



EXAMINATION OF THE STOMACH CONTENTS. 93 

nor so tenacious and clear. Ordinarily it is present in a flocculent form, 
although sometimes it is present in a stringy condition, holding food 
particles in its meshes. It is not pigmented unless derived from the 
buccal, pharyngeal, or respiratory mucous membrane, in which case it 
has been swallowed. Sometimes it is blood-streaked, and in such cases 
it may have been swallowed or it may have come from the gastric 
mucosa. Not infrequently the stomach is the recipient of sputa which 
appear in the contents as frothy, isolated masses. Chemically, mucin 
may be separated by washing the mucus with cold water, which is then 
poured off and treated with a few drops of liquor potassse, in a solu- 
tion of which mucin is soluble, but from which it is precipitated by 
acetic acid even though the acid be in excess. 

6. Blood. — A large quantity of bright arterial blood may be vomited 
or washed from the stomach, or it may be present in small quantities 
only, but still bright red and streaking the mucus or slightly staining 
the wash- water. Blood may be present in clots not entirely disor- 
ganized, or in the form commonly termed " coffee-grounds," in which 
the red cells have undergone disintegration. Red wine gives the stom- 
ach contents a blood color, and in cases of gastrectasia the stagnant 
contents often look like " coffee-grounds." Bile pigment may cause a 
brownish black color, and some preparations of iron will impart a blood- 
like color to the gastric contents. Tea leaves or blackened fragments 
of spinach or lettuce may simulate changed blood elements. It should 
be remembered that blood from the oesophagus, throat, mouth, nose, or 
lungs may be swallowed and afterward vomited or withdrawn by means, 
of the stomach tube ; so the presence of blood in the gastric contents 
is not positive proof of gastrorrhagia. The detection of blood in the 
gastric contents may be accomplished by the aid of the microscope,, 
which reveals the red blood-corpuscles, provided they are not broken 
up, or its presence may be shown by the guaiacum test : To a small 
quantity of the stomach contents in a test tube one to four drops of 
tincture of guaiacum are added, and ozonic ether is floated on the sur- 
face ; at the point of contact a blue color is seen if blood is present. 
When the red blood-corpuscles are disorganized and the haemoglobin is. 
transformed into insoluble hsematin, the diagnosis may be made by 
Teichmann's test for hsemin crystals. Hsematin in combination with 
hydrochloric acid forms microscopic, brown, rhombic crystals. Place 
some of the black sediment upon a microscope slide and add to it a 
crystal of sodium chloride and one or two drops of glacial acetic acid ; 
cover and heat to a point below boiling, and in a short time, if blood 
coloring matter is present, crystals of hydrochlorate of hsemin may be 
seen through the microscope. If the patient has not taken iron, that 
substance may be searched for. Its presence may be demonstrated by 
the Prussian blue test. Some of the dark sediment is put in a porce- 
lain capsule, a little potassium chlorate is added and also a few dropa 
of hydrochloric acid. Heat is then applied, and a few drops of a 5 
per cent, solution of potassium ferrocyanide are added ; in the presence 
of blood Prussian blue is developed. 

7. Pus is sometimes present in the stomach contents. It may come 
from the rupture of an abscess into the stomach, or it may gain access 
to the stomach from the oesophagus, pharynx, nose, lungs, or mouths 



94 DISEASES OF THE STOMACH. 

Commonly it is present in tlie form of muco-pus from nasal and post- 
nasal catarrh or muco-purulent expectoration. In rare cases of phleg- 
monous gastritis pus is present. If in large amounts, it may be detected 
by the naked eye, but if in minute quantities, the microscope will reveal 
pus cells. 

8. Detached portions of mucous membrane should be searched 
for. They are sometimes discovered in the wash-water in gastric ero- 
sions ; they may come from the ragged edge of an ulcer, or pieces may 
be torn away by suction into a sharp-edged fenestrum of the tube. 
Small fragments from a carcinoma may be found and should be pre- 
served for microscopic examination. 

9. Food. — The food should be closely inspected to determine whether 
or not it has been acted upon by the gastric juice and saliva. If it has 
undergone digestion, the solid elements will be well milled and in a 
state of disintegration. The fragments of meat will be much softened 
and present a gelatinous appearance on the outside. Bread should be 
separated into fine particles, and other starchy food should be broken 
up and in partial solution. Coagulated egg albumin frequently resists 
the action of the gastric juice a long time. Sometimes the food is with- 
drawn from the stomach practically in the same condition as when it 
Avas swallowed ; it is simply water-soaked and undigested. The com- 
minution of the food dej^ends upon the size of the morsels as well as 
upon the time spent in mastication. Thus we may with accuracy de- 
termine the table and masticatory habits of the patient. 

Chemical Analysis. — Acidity. — It is necessary first to ascertain 
whether or not the stomach contents are acid, and for this purpose blue 
litmus paper may be employed. The normal acidity turns litmus very 
red, and the redness persists after the paper dries. If the change is 
only slight, the acidity is probably subnormal, as litmus is changed by 
the combined as well as the free acids ; this, however, will be deter- 
mined by testing the total acidity. The next step consists in testing 
for free acids, and first for free hydrochloric acid. 

Hydrochloric acid was first discovered in the gastric contents by 
Prout in 1824, and Schmidt afterward confirmed his observation, and 
also ascertained that free as well as combined hydrochloric acid was 
present. "With few exceptions since that time observers have agreed 
that this is the essential acid of the stomach. It is secreted by the 
gastric glands, and under normal conditions its secretion is caused by 
direct excitation, as, for instance, from the presence of food or from 
other irritation. Soon after food enters the stomach hydrochloric acid 
is poured out, and it first neutralizes the alkalinity of the stomach con- 
tents. Then it combines with the soluble proteids until they are satu- 
rated, after which it appears free in the proportion of 0.14 to 0.24 per 
cent. Leube says that thirty pounds of gastric juice are produced 
daily in a healthy adult stomach. This secretion contains 0.2 per cent, 
of hydrochloric acid. Chittenden says that four and a half litres of 
0.2 per cent, hydrochloric acid are required for the digestion of a hun- 
dred grammes of proteids, and still no free acid appears. 

A number of reagents are used to detect free hydrochloric acid, but 
some of them react in the presence of organic acids, and are consequently 
misleading in their results; therefore the reagents that indicate the 



EXAMINATION OF THE STOMACH CONTENTS. 95 

presence of hydrocliloric acid only will be first considered. Of these 
Giinzburg's reagent is one of the most valuable. It has been widely 
used, and is probably the best known test for free hydrochloric acid. 
In 1887, Giinzburg announced its character and usefulness, and in the 
same year Ewald published his first recommendation of it. Its chief 
merits are, first, that it yields its characteristic reaction to free hydro- 
chloric acid and to no other free or combined acid found in the stomach ; 
second, its reaction is not interfered with by the presence of other 
acids, acid salts, proteids, carbohydrates, nor fats ; third, the reaction 
occurs though free hydrochloric acid be present in as small an amount 
as 0.05 per mille (1 in 20,000). The following is the proper solution : 

Phloroglucin, 2.0 (gr. xxx) ; 

Vanillin, 1.0(gr. xv); 

Alcohol, absolute, 30.0 (f^j). 

When freshly made this solution has a light yellow color, which is stable 
for a long time if kept in a dark brown or black bottle ; it slowly 
changes to a reddish brown on prolonged exposure to light. It has a 
pleasant odor of vanilla. In the presence of free hydrochloric acid a 
bright red color is struck upon evaporation by heat, this change depend- 
ing upon the presence of vanillin. If concentrated hydrochloric acid 
is added to a drop of the reagent, rose red crystals are at once formed, 
but with the proportion of hydrochloric acid in the stomach contents 
this never occurs, it being necessary to evaporate the mixture to dry- 
ness over a water bath or flame. The test is very quickly applied, re- 
quiring only a few minutes to determine the presence or absence of the 
acid. Filtration of the contents is not necessary, it sufficing to fill a por- 
celain capsule with them and then empty it, allowing the liquid portion 
adhering to the surface of the capsule to remain. Three or four drops 
of the reagent are then poured into the capsule and mixed thoroughly 
with the residual contents by slight tipping and agitation. The capsule 
is then held over the flame from a Bunsen burner and its contents 
slowly evaporated. If hydrochloric acid is present, a bright red color 
appears at the edges of the mixture, and this deepens and spreads down 
to the centre. Care should be exercised against applying too great heat, 
else the contents will turn brown or black, being burned instead of simply 
evaporated to dryness. The intensity of the red color varies accord- 
ing to the amount of free hydrochloric acid present ; it may be a faint 
reddish tinge, only perceptible upon complete evaporation in case the acid 
is present in minute quantity, or it may be a brilliant red^ coming 
quickly upon the application of heat and spreading in deep red waves 
over the whole surface of the capsule. Its behavior in this regard 
affords some information as to the amount of free hydrochloric acid 
present, but, of course, only a rough estimate. Although not necessary 
to obtain the reaction, it is always desirable for nicety of technique to 
filter the contents and use about equal parts of the filtrate and the 
reagent — four or five drops of each. 

In 1888, Boas announced resorcin a good reagent for the detection 
of hydrochloric acid. The following solution is used : 



96 DISEASES OF THE STOMACH. 

Resorcini resublimati, 5.0 (gr. Ixxv) ; 

Sacchari albi, 3.0 (gr. xlv) ; 

Spiritus diluti, 100.0 (f'siiiss). 

A few drops of this are added to an equal amount of filtered gastric 
contents in a porcelain capsule and slowly evaporated to dryness over 
a flame. In the presence of as small a quantity as 0.05 per mille of 
HCl a red color appears. This is a valuable test, as it is reliable and 
the reaction does not occur to organic acids nor is it interfered with bv 
any substance found in the stomach. In case phloroglucin and vanillin 
cannot be readily obtained, the resorcin solution may be quickly made, 
and serves as well as Gunzburg's reagent, besides being much cheaper. 
Julius Friedenwald concludes that Boas' reagent is preferable to Giinz- 
burg's, being more stable, quite as reliable, and more easily obtained. 

When hydrochloric acid is added to a solution of ferric acetate and 
potassium sulphocyanide a brownish red color is produced, owing to the 
formation of sulphocyanide. This is Mohr's test, and in detail consists 
of the addition of 0.5 c.c. of a neutral solution of acetate of iron to 2 
c.c. of a 10 per cent, solution of sulphocyanide of potassium, and dilut- 
ing the mixture with water to 20 c.c. A few drops of this reagent are 
placed in a porcelain capsule and spread thinly over its surface ; then, 
drop by drop, the filtered stomach contents should be allowed to flow 
down the side of the capsule. At the junction between the two liquids 
a " peach red " color is seen if hydrochloric acid is present. Or some 
of the reagent may be put into a test tube and the filtrate floated upon 
its surface, when the brownish red color will be seen between the 
liquids. 

We have used tropseolin 00 as a test for free acids and acid salts, 
but have not relied upon it as a test for free hydrochloric acid. It is 
a yellow aniline dye, making an orange-colored solution with dilute 
alcohol. This is changed to a pinkish red or dark brown on the addi- 
tion of free mineral acids unless they are present in concentration. 
Acid salts are said to change it to a straw yellow, but usually no color 
change is perceptible other than would occur from dilution. 

A new test for the detection and quantitative estimation of free 
hydrochloric acid Avas recommended by Topfer in 1894. Julius Frie- 
denwald published the results of his use of this reagent in the Medical 
Record, Apr. 6, 1895. Dimethylamidoazobenzol is the substance used, 
a 0.5 per cent, alcoholic solution being employed. It is a light, brown 
powder of a somewhat aromatic odor, and its solution is reddish brown. 
To a few cubic centimetres of gastric filtrate, in a test-tube, porcelain 
capsule, or beaker, from one to four drops of the reagent are added, 
when a rose red color is produced if hydrochloric acid is present. The 
test is very delicate, and will answer in the presence of only 0.004 per 
cent, of the acid. Friedenwald considers it more sensitive than either 
Gunzburg's or Boas' reagents, and almost as delicate as Leo's calcium 
carbonate test for the quantitative estimation of free hydrochloric acid. 
Dimethylamidoazobenzol reacts to HCl only when the latter is in ?i free 
state ; its reaction is not interfered with by the presence of albuminous 
compounds, acid salts, peptone, sodium chloride, grape-sugar, or starch. 
It does not give any reaction to organic acids except when they are 



EXAMINATION OF THE STOMACH CONTENTS. 97 

present in a concentration of from 0.5 to 0.8 per cent., according as to 
whether or aot albumin or peptone is present in the mixture, it being 
found that their presence renders necessary a higher concentration of 
the organic acids in order to give a reaction. We find Topfer's reagent 
delicate, reliable, and admirably suited for quick quantitative and 
qualitative work. Einhorn finds that Topfer's reagent turns red in 
the presence of 0.1 per cent, of lactic acid, but considers it useful for 
quantitative work, after HCl has been shown to be present by Giinz- 
burg's reagent. 

The Detection of Free Acids. — For the determination of the pres- 
ence or absence of free acids several reagents are used. Litmus 
should not be employed for this purpose, as it is changed by combined 
acids. 

Congo Med. — This may be used in solution, or strij)s of filter paper 
may be dipped into a saturated aqueous solution of the dye and allowed 
to dry. Free hydrochloric acid turns it blue, and organic acids change 
it to a violet when the respective acids are used separately and in pure 
solution. The difference in color is not, however, sufficiently well 
marked when applied to the gastric contents to enable us to determine 
positively whether the color change is due to hydrochloric or to organic 
acid. No reaction is noticed in the presence of combined acid. It is 
therefore merely a reliable test for free acid. 

Benzo-Purpurin 6. B. — A saturated solution of benzo-purpurin 6. B. 
in water is dark red in color. Strips of filter paper may be dipped 
into it and allowed to dry. If a paper is then dipped into the gastric 
contents, the color changes to brownish black, indicating the presence 
of free acid. 

Methyl Violet. — This dye has a reddish violet color in weak aqueous 
solution, which is changed to a light blue on the addition of a gastric 
filtrate containing free acid. 

Testing Total Acidity. — In estimating the total acidity of the stom- 
ach contents phenolphthalein is an admirable indicator. It is made 
from phthalic acid and phenol, is a buff colored powder, making in 
alcohol a slightly opalescent solution, which remains unchanged in color 
in acid or neutral media, but assumes a carmine when in an alkaline 
medium. To 10 c.c. of thoroughly mixed, imfiltered stomach contents 
one or two drops of a 5 or 10 per cent, alcoholic solution of phenol- 
phthalein are added. Then from a burette a decinormal sodium hydrate 
solution is slowly added until the contents turn a pink color, at which 
indication the flow from the burette is checked. Agitation of the vessel 
containing the stomach contents should be made as the soda solution 
drops from the burette, in order to ensure thorough mixture. The 
nuraber of cubic centimetres of soda solution recpiired to neutralize 
10 c.c. of stomach contents is then ascertained, and the result is ex- 
pressed as percentage. Under normal conditions one hour after an 
Ewald test breakfast consisting of a roll and a glass of water from 4 to 
6.5 c.c. should be required to neutralize 10 c.c. of the contents, and this 
may be expressed as an acidity of from 40 to 65 per cent. Thus, for 
example, if 5 c.c. of soda solution are added to the contents, and at 
that point they assume a pink hue which does not disappear upon shak- 
ing, the result should be expressed as 50 per cent, total acidity. Deci- 

VoL. III.— 7 



98 DISEASES OF THE STOMACH. 

normal sodium hydrate solution is made by dissolving four grammes in 
one litre of distilled water. 

Topfer adopts another method of testing total acidity, which is as 
follows : Put 10 c.c. of stomach contents in a beaker, add three or four 
drops of ihe 1 per cent, aqueous solution of sodium alizarin sulphonate, 
and then add decinormal sodium hydrate solution until a violet tint 
appears corresponding in depth to that produced by the addition of 4 
drops of alizarin solution to 5 c.c. of 1 per cent, solution of sodium 
carbonate. 

Determination of the Total Amount of Free Hydrochloric Acid. — 
Mintz's method for the quantitative determination of free hydrochloric 
acid is based upon the estimate that the limit of Giinzburg's reaction 
is 0.03646 per mille HCl (1 c.c. decinormal soda solution to 100). He 
has also demonstrated that when decinormal sodium hydrate solution 
is added to albuminous mixtures like stomach contents, the alkali first 
combines with the free hydrochloric acid. The test is conducted as 
follows : To 10 c.c. of gastric filtrate in a beaker decinormal soda solu- 
tion is slowly added from a burette ; at frequent intervals the titration 
is checked and the contents examined with Giinzburg's reagent to ascer- 
tain whether or not all the free hydrochloric acid has been neutralized. 
Finally, the phloroglucin-vanillin reaction no longer occurs, and at that 
point the calculation is made. For instance, if after 3.4 c.c. of soda 
solution have been added Giinzburg's reaction is faint but positive, 
while after 3.5 c.c. have been added the reaction does not occur, the 
reading 3.4 c.c. is calculated as the limit of the reaction. If 3.4 c.c. 
neutralize the hydrochloric acid in 10 c.c. of gastric contents, it is plain 
that 34 c.c. will neutralize the free hydrochloric acid in 100 c.c. ; there- 
fore by multiplying 0.003646 by 34 the percentage of free hydrochloric 
acid is found to be 0.12. 

Mintz's method is laborious and consumes more time than T5pfer's, 
which is accomplished with greater despatch than any quantitative test 
for HCl known to us. Two or three drops of Topfer's solution of 
dimethylamidoazobenzol are added to 10 c.c. of gastric contents in a 
beaker, and decinormal soda solution is allowed to flow in drop by drop 
until the red color entirely disappears and a yellow color takes its place. 
The number of cubic centimetres of soda solution required to neutral- 
ize the free hydrochloric acid in 100 c.c. of stomach contents is used 
to multiply 0.00365, and the result expresses the percentage of hydro- 
chloric acid. For example, let us take an instance from our record 
books : 4 c.c. of soda solution were required to dissipate the red color 
of the contents subjected to examination ; then 0.00365 was multiplied 
by 40, the result equalled 0.14 per cent, free hydrochloric acid, the 
lower normal limit. 

Calcium carbonate is not decomposed by acid salts, but forms a 
neutral solution of calcium chloride with free hydrochloric acid, and 
upon this fact is based Leo's quantitative test for HCl. The stomach 
contents are first extracted with ether to remove the lactic and fatty 
acids, and then a small quantity of the contents is mixed with some 
chemically pure calcium carbonate and the reaction tested with blue 
litmus paper. A strip of litmus that has previously been dipped in the 
gastric contents is used as a standard. Compare the two papers. If 



EXAMINATION OF THE STOMACH CONTENTS. 99 

the litmus no longer reddens after the calcium carbonate has been added, 
then the acidit;^ depends upon free hydrochloric acid ; if the litmus is 
reddened the same as the control paper, the acidity is due entirely to 
acid salts. When it is ascertained that the acidity is due entirely to 
free hydrochloric acid, the amount may be very easily determined by 
titration in the manner already described. 

Estimation of Free and Combined Hydrochloric Acid. — Sjoqvist's 
method is based upon the fact that barium carbonate combines with the 
chlorine of the bound hydrochloric acid of the stomach contents, form- 
ing barium chloride. The organic acids form barium carbonate. The 
former is soluble in hot water, the latter insoluble. Accordingly, the 
barium chloride is dissolved and precipitated again by adding soda ; 
after it is collected it is once more converted into barium chloride by 
the addition of hydrochloric acid ; the mixture is evaporated to dry- 
ness, and the residue is dissolved in water and titrated Avith silver 
nitrate with addition of potassium bichromate. 0.001 c.c. of sodium 
chloride is represented by 1 c.c. of NOgAg solution, and the calcula- 
tion is made according to the formula : x -.t = 36.5 : 58.5 ; t = number 
of cubic centimetres of silver solution employed. Thus, 10 c.c. of the 
gastric filtrate are placed in a platinum capsule and 0.5 gramme of 
barium carbonate added ; the mixture is then reduced to ash. After 
cooling, the residue is dissolved in 50 c.c. of boiling water and filtered. 
The barium chloride is then precipitated as barium carbonate by the 
addition of several drops of concentrated soda solution. Filtration is 
again practised ; the precipitate is washed, dissolved in water, and 
titrated with NOyAg solution, the estimate being made according to the 
formula given above. If phosphates or chlorides are present in excess, 
they may interfere with the accuracy of the test. 

For the employment of Luttke's method two solutions are required : 

1. Decinormal solution of argentic nitrate, 16.997 grammes of 
NOgAg, C. P., in 900 c.c. of 25 per cent. NO3H ; 50 c.c. of liquor ferri 
persulphatis (B. P.) are added, and the mixture diluted to 1000 c.c. with 
water. 

2. Decinormal solution of ammonium sulphocyanite containing 7.6 
grammes to the litre. Upon mixing 10 c.c. of each solution a reddish 
color should appear. The first step consists in the determination of the 
total chlorine, and second of the chlorides. To 10 c.c. of the gastric 
contents 20 c.c. of the silver solution are added; the mixture is diluted 
with water to 100 c.c. and filtered. The precipitate on the filter con- 
tains the chlorine with silver, while the filtrate represents the excess 
of silver solution used. Ammonium sulphocyanite solution is now 
added to 50 c.c. of the filtrate until a red color appears. Now 
multiply by 2 the number of c.c. used, and that will equal the number 
of c.c. of silver solution used in excess. The amount of chlorine com- 
bined with silver is then estimated. 

Ten c.c. of gastric contents are evaporated to dryness in a platinum 
capsule ; the residue is ignited and the chlorides are extracted by grind- 
ing the ash with 100 c.c. of hot water. Filter and add 10 c.c. of silver 
solution to the filtrate. The excess of silver used and the amount of 
chlorine may be estimated as in the former process. Subtract the chlo- 
rines in the form of chlorides from the total chlorine, and the resulting 



100 DISEASES OF THE STOMACH. 

number, multiplied by 0.0365, gives the hydrochloric acid in 100 c.c. 
of stomach contents. 

The Heyner-Seeman llethod. — Ten c.c. of gastric filtrate is neutral- 
ized with decinormal sodium hydrate solution (e. g. 6 c.c.) ; it is reduced 
to ash and the ash dissolved in water, filtered, and the same quantity 
of decinormal hydrochloric acid solution (each c.c. contains 0.00365 
gramme HCl) as was used of the soda solution (/. e. 6 c.c.) is added to 
the filtrate. Phenophthalein is added, and the mixture is titrated 
with decinormal soda solution ; if 2 c.c. should be required for neutral- 
ization, 20 multiplied by 0.00365 equals combined HCL 0.073. 

A very complicated method has been devised by Hayem and Winter 
in which three separated determinations are made : first, the total 
amount of chlorine ; second, the total chlorine less that which is volat- 
ilized upon heating at 100 c.c. ; third, the chlorides combined with 
mineral bases. 

LaetiG Acid. — Lactic acid is formed in the stomach by fermentation 
or it is taken preformed in the ingesta. Sarcolactic acid is preformed 
in animal flesh, and therefore is not the result of lactic acid fermentation 
in the stomach. Upon an ordinary diet including many products of the 
bakery lactic acid is frequently present in the stomach during the first 
thirty or forty minutes after a mixed meal or Ewald's test breakfast. 
If a mixed meal contains a large quantity of starch and milk-foods, 
lactic acid usually prevails longer than forty minutes. When free 
hydrochloric acid appears, lactic acid usually disappears, although the 
two acids may be present together ; indeed, sometimes lactic acid is 
found three or four hours after a meal. 

Ewald and Boas stated that lactic acid was a normal constituent of 
the gastric contents during early digestion, but Martins and Luttke 
denied that, and demonstrated its absence from the stomach at all times 
during normal digestion. They found at five-minute intervals after a 
test breakfast that the total acidity and the amount of hydrochloric 
acid were precisely the same, and by this indirect method lactic acid 
was excluded. 

Boas reinvestigated the whole matter, and discovered that the reason 
lactic acid was found during the early part of digestion on ordinary diet 
was owing to the fact that it was introduced preformed into the stomach. 
Uffelmann's reagent Avas discarded as a test, owing to its reaction Avith 
other substances not infrequently taken into the stomach — as, for in- 
stance, glucose, phosphates, and tartrates — and also because it is a eom- 
paratiA'e color test and diiferent shades of yelloAV give rise to confusion. 
Boas therefore adopted a ncAV test for the detection of lactic acid, by 
means of Avhich the lactic acid is decomposed into aldehyde and formic 
acid, and the former is detected as iodoform in an alkaline iodine solu- 
tion. By this test Boas determined that products of the bakery contain 
an appreciable amount of lactic acid preformed, and therefore he gave 
a test meal in Avhich none Avas discoverable. This consists of a gruel 
made Avith a tablespoonful of oatmeal flour to a litre of AA^ater and 
flavored AA'ith a little salt. FriedeuAvald says Boas uses Knorr's 
" Hafermehl " on account of its pleasant taste. 

Using this test meal, Boas found that lactic acid is not a normal 
constituent of the stomach contents at any stage of digestion. It is 



EXAMINATION OF THE STOMACH CONTENTS. 101 

absent at all periods, both early and late. Furthermore, he found that 
even in the absence of free hydrochloric acid, with food stagnation, with 
benign pyloric stenosis, gastrectasia, chronic catarrhal gastritis, and 
other morbid conditions, lactic acid was very rarely present. In gas- 
tric carcinoma, however, it was present in large quantities, and in this 
disease alone it was demonstrable. This subject will be further con- 
sidered in the chapter on Carcinoma of the Stomach (page 150). 

Uffelmann's Test. — Ten c.c. of a 4 per cent, solution of carbolic acid 
are mixed with 20 c.c. of distilled water, and a few drops of liquor ferri 
chloridi are added ; this makes an amethyst blue solution. The gastric 
filtrate is added to this in a porcelain capsule or upon some other white 
surface, and if lactic acid is present a distinct canary yellow is devel- 
oped. The reaction depends upon the presence of the iron, as dilute 
solutions (almost colorless) of neutral ferric chloride turn canary yellow 
on the addition of lactic acid ; the carbolic acid is used to intensify the 
color change. Uffelmann's reagent responds to a 0.05 per mille (1 in 
20,000) solution of lactic acid. Ewald points out that lactates, phos- 
phates, sugar, and alcohol also give a yellow color, and the test is, there- 
fore, not free from sources of error. In order to ensure accuracy the 
gastric filtrate should be extracted with ether by shaking 5 or 10 c.c. 
with ether, pouring it ofP into a beaker, and evaporating to dryness over 
a water bath. Several portions of ether should be used, and the con- 
tents shaken separately with each in order to be sure of extracting suf- 
ficient lactic acid to give a good reaction. The residue is then dissolved 
in a little water and Uffelmann's test applied. It should be borne in 
mind that all color reactions to this test other than distinct canary 
yellow are not indicative of lactic acid ; e. g. the yellow color of the 
stomach contents imparts a yellow color to the blue solution, and excess 
of butyric acid changes it to a brownish yellow, but neither of these is 
a canary yellow. 

Manges mentions Leo's test for lactic acid as being a good one. It 
consists in driving oif the volatile acids (acetic and fatty acids) by boil- 
ing the stomach contents until litmus paper held in the vapor no longer 
turns red. The water lost by evaporation is then replaced, the contents 
cooled and extracted with ether, the residue redissolved and tested for 
lactic acid with Uffelmann's reagent. 

Boas' Method. — This is qualitative and quantitative. The qualita- 
tive estimation is as follows : The gastric filtrate is first tested for free 
acids, and if they are found present an excess of barium carbonate is 
added. Ten c.c. of the filtrate is then evaporated to the consistency of 
syrup, a few drops of phosphoric acid are added, and the carbon diox- 
ide is removed by boiling for a few moments. It is now allowed to 
cool, and extracted two or three times with 50 c.c. of ether (absolutely 
free from alcohol), digested half an hour, the layer of the ether poured 
off, evaporated, and the residue dissolved in 45 c.c. of water ; this may 
be filtered if necessary. This is poured into a flask and treated with 
5 c.c. of concentrated SO^Ha and a little manganese dioxide. A glass 
tube leads from this flask into a chamber containing an alkaline iodine 
solution which is made by mixing equal parts of decinormal iodine 
solution and decinormal sodium hydrate solution. Heat is applied to 
the flask, and as the mixture boils the iodine solution grows smoky and 



102 DISEASES OF THE STOMACH. 

the odor of iodoform is detected — i. e. if lactic acid is present in the 
gastric filtrate. 

For the quantitative estimation the following reagents are necessary : 
(a) Jq- N.lodine solution ; (6) J^ N. sodium arsenite solution ; (e) hydro- 
chloric acid of a specific gravity 1.018; (d) 56 grammes of potassium 
hydrate to 1000 c.c. of water; (c) solution of starch paste freshly made. 

The watery solution of the ethereal residue of the gastric filtrate, 
with the sulphuric acid and the manganese dioxide, is now carefully 
distilled until four fifths of the contents of the flask have passed over 
into 20 c.c. of water. Alkaline iodine solution is now made by mixing 
equal parts {e. g. 10 c.c.) of decinormal iodine solution and the KOH 
solution above mentioned, and 10 c.c. of this are added to the distillate : 
20 c.c. of the hydrochloric acid solution are then added, and sodium 
bicarbonate in excess is next added. The decinormal sodium arsenite 
solution is now added, and then decinormal iodine solution by titra- 
tion until a permanent blue color appears. Now, it is desired to find 
the amount of iodine used in forming iodoform, and this is determined 
by subtracting the number of cubic centimetres of alkaline iodine solu- 
tion employed, and by multiplying the result by .003388 the amount 
of lactic acid is determined ; 1 c.c. of decinormal iodine solution equals 
.003388 of lactic acid. For instance : 10 c.c. of yV normal iodine solu- 
tion is first used, and 6 c.c. of -^ normal sodium arsenite solution are 
added : 0.4 c.c. of iodine are required to titrate back. 10 c.c. + 0.4 = 
10.4 c.c. iodine solution used ; 10.4 c.c. — 6 c.c. = 4.4 c.c. X .003388 = 
.0149 for 10 c.c, or 0.149 per cent. 

AeetiG and Butyric Acids. — These acids are volatile and are detected 
by distillation. As the gastric filtrate is evaporated the fumes arising 
smell of either acetic or butyric acid if one or the other is present, but 
if both are present the odor test is unsatisfactory. 50 c.c. of the gas- 
tric filtrate are slowly distilled in a retort connected with a condenser 
leading into a receiving flask. When three fourths or four fifths have 
passed over the remainder is diluted again to 50 c.c, and distilled until 
three fourths have passed over. In the flask there is now a solution 
of the volatile acids. Acetic acid is more readily soluble than butyric 
acid, and the latter is often seen in small oily droplets on the surface 
of the liquid. Acetic acid strikes a blood-red color on the addition of 
a solution of ferric perchloride. If a small amount of alcohol and a 
couple of drops of sulphuric acid are added to a few cubic centimetres 
of the distillate, acetic ether is formed upon the application of heat for 
a short time. Butyric acid may be recognized by its odor of rancid 
butter, which is intensified by evaporation of a portion of the distillate. 
The addition of sulphuric acid and alcohol in the manner described 
gives rise to the formation of butyric ether, which has a characteristic 
pine-apple smell. Butyric acid also changes Uflfelmann's lactic acid 
reagent a brownish yellow. 

A quantitative estimation of the volatile acids may be made as fol- 
lows : 10 c.c. are neutralized by decinormal sodium hydrate solution, 
using phenolphthalein as an indicator. If 3 c.c of soda solution are 
required for neutralization, the result may be reckoned: 100 c.c. of 
decinormal soda solution correspond to 0.32 gramme of acetic acid ; 
therefore, 1 c.c. = .0032 gramme and 3 c.c. = .009 gramme. Now, 



EXAMINATION OF THE STOMACH CONTENTS. 103 

if the whole distillate amounts to 60 c.c, the acetic acid equals .064 
gramme, which represents the quantity in the original 50 c.c. of the 
gastric jfiltrate ; if 50 c.c. = .064, 100 c.c. = .128 gramme per cent. 
The volatile acidity is here reckoned as due to acetic acid, which suffices 
for practical purposes. 

The Dig-estion of Albumin. — This is accomplished by pepsin and 
hydrochloric acid. Neither of these acts alone to digest albumin. Pep- 
sin may act in the presence of acid other than hydrochloric, but not as 
perfectly nor as rapidly. The process of albumin digestion is called 
proteolysis. As soon as food enters the stomach pepsin and hydro- 
chloric acid are secreted ; the albumin first combines with the acid to 
form syntonin, which is further changed into the proteoses by the com- 
bined action of pepsin and hydrochloric acid. 

A number of products are formed midway between syntonin and 
peptone. This constitutes a process of hydrolysis and cleavage which 
is well represented by the following scheme : 

Native Proteid.^ 



Syntonin. 



Protoproteoses. Heteroproteoses. 

(dysproteoses). 



Deuteroproteoses. Deuteroproteoses. 



Peptone. Peptone. 

Normally, these proteoses are formed in the presence of gastric 
digestion. Each one is a distinct chemical body, having its own definite 
proportion of carbon, hydrogen, nitrogen, sulphur, and oxygen, the per- 
centage of these elements diifering in the proteoses of different forms 
of albumin — blood, fibrin, paraglobulin, egg albumin, caseine, myosin, 
elastin, gelatin, etc.^ 

It is not sufficient, therefore, to speak of propeptone as representing 
all these forms midway between the native proteid and peptone in pro- 
teolysis. If these substances are found in the stomach contents, they 
affi9rd evidence of pepsin-hydrochloric acid digestion, and it is therefore 
important that we should know how to detect and separate them. 
Syntonin is precipitated from the gastric filtrate by neutralization, and 
after precipitation is complete it should be filtered out. If proteoses 
are then present, the addition of nitric acid, drop by drop, to the neu- 
tralized fluid will result in a white precipitate which is dissolved on 
heating, but reappears on cooling. Or, instead of using the acid, we 
may add crystal of rock salt to saturation, and this usually results in 
precipitation. If the primary proteoses are absent, no precipitation 
will occur by either of the above methods employed alone, but if rock 

^ E,. H. Chittenden's Cartwright Lectures on Digestive Proteolysis. 
^ Kuhne and Chittenden. See Chittenden's Cartwright Lectures. 



104 DISEASES OF THE STOMACH. 

salt is used to saturation of the neutralized fluid, and then the acid is 
added, a precipitate will be thrown down which will consist of a part 
of tlie deutero-proteose present in the fluid. Protoproteose is soluble 
in plain water, but heteroproteose is only soluble in alcohol, acid, and 
salt solutions. Proteoses are not coagulated by heat nor by alcohol, 
they are, however, precipitated by alcohol as well as by potassium 
ferrocyanide, acetic acid, picric acid, cupric sulphate, plumbic acetate, 
metaphosphoric acid, and ammonium sulphate. 

In order to* determine whetlier peptone is present it is necessary, 
first, to precipitate the proteoses completely by the addition of ammo- 
nium sulphate, and then to separate them by filtration. Ammonium 
sulphate is best used for this purpose, because peptone is not affected 
in the slightest degree by that reagent in any medium. In precipita- 
tion of the proteoses there is one body that it is difficult to get rid of 
before applying the test for peptone, and that is deuteroproteose, all 
traces of which may be precipitated only by boiling for a long time 
with ammonium sulphate added to saturation. If the clear filtrate is 
now free from primary and mid-products of digestion, peptone is de- 
tected by adding an excess of potassium hydroxide and a few drops of 
dilute cupric sulphate. This gives rise to a pure red color, the reaction 
being strong or weak in proportion to the amount of peptone present. 
The method of precipitating the peptone is too complicated for in- 
sertion here, and belongs rather to the work carried on in a well- 
equipped physiological laboratory.^ When separated, peptone is a 
yellowish hygroscopic powder of bitter taste. For ordinary clinical 
purposes the biuret test is a good one to discover the presence or 
absence of the proteoses and peptone in the gastric filtrate. 

The addition of cupric sulphate to an alkaline solution of albumoses 
and peptone gives a purple red color. This is called the biuret reaction. 
For the sake of dispatch, especially in office practice, this reaction is 
obtained most satisfactorily by the addition of Fehling's solution, drop 
by drop, to one third or one half of a test tube of gastric filtrate held 
up to the light. 

These substances found in the gastric filtrate afford a knowledge as 
to the digestive power of the stomach. But little peptone is found 
ordinarily after a test meal ; proteoses, however, are usually present in 
considerable quantities. The reasons that peptone is found only in 
small quantities may be that the proteoses or peptone are absorbed as 
fast as they are formed. A certain amount of proteose resists further 
action and does not go on to the formation of peptone. 

When we speak of the absorption of proteoses and peptone, it should 
be remembered that they probably undergo some further change during 
absorption before they reach the blood current, because they act as 
poisons when introduced directly into the blood. It is interesting to 
note that the toxins formed by bacteria are proteose-like substances 
bearing a resemblance to the peptones and proteoses formed by pepsin 
proteolysis. 

Determination of Digestive Activity by the Gastric Filtrate. — When 
food is withdrawn from the stomach after it has been subjected to the 
action of the gastric juice for an hour or longer and the biuret reaction 

^ See E. H. Chittenden : Cartwright Lectures, 1894. 



EXAMINATION OF THE STOMACH CONTENTS. 105 

is obtained, and free hydrochloric acid found together with properly 
disintegrated food elements, there is sufficient warrant for believing that 
the gastric juice has been active. These findings contrast strongly, for 
instance, with those obtaining in "achylia gastrica" (p. 116), a condition 
in which there is a total absence of hydrochloric acid, digestion is held 
in abeyance, and the food is washed from the stomach in a water-soaked 
and undigested state, none of the products of proteolysis being present. 
It seems hardly necessary to use the incubator in estimating the diges- 
tive activity of the gastric juice when the stomach itself is the natural 
and most valuable test oven we can employ. If, however, it is desired 
to investigate the digestive activity of the gastric juice outside the 
stomach, then thin slices of white of egg may be added to four test 
tubes, the first containing simply the gastric filtrate ; the second two 
drops of hydrochloric acid, c. p., with 2.5 c.c. of the stomach contents 
the third containing the filtrate and 0.2 of pepsin added to it ; while to 
the fourth tube both hydrochloric acid and pepsin are added. All the 
test tubes are then placed in an incubator and kept at a temperature of 
100° F. They should be examined at intervals, and it will then be 
seen whether the filtrate alone is or is not sufficient to digest the egg 
albumin, whether the hydrochloric acid added to the second tube was 
needed or not, or whether the pepsin increased the activity in the third 
tube, etc. 

For clinical work such investigation is unnecessary as much more 
valuable information is obtained by allowing the stomach to act as 
best it will on certain foods, and then by withdrawing the contents and 
subjecting them to analysis we arrive at a very reliable estimate of the 
digestive power of the stomach. 

Rennet Ferment or the Milk-curdling Ferment, and Rennet Zymogen. — 
Besides pepsin and its enzyme the rennet ferment is formed in the 
stomach. It has the property of coagulating milk, but its proenzyme 
has no action itself upon milk. If, however, hydrochloric acid or 
calcium chloride is added to the filtrate containing the rennet zymogen, 
it is converted into a ferment and curdles the milk. 

The rennet ferment may be detected in the gastric filtrate by the 
following simple method : First carefully neutralize 10 c.c. with deci- 
normal sodium hydrate solution and add 10 c.c. of neutral milk; the 
mixture should then be placed in an incubator at 38° C. In from ten 
to fifteen minutes a casein coagulum is formed if the rennet ferment is 
present, and this coagulum is unbroken and floating in the clear whey. 

In other words, the coagulation is not flocculent in character. The 
rennet zymogen is detected by first making shghtly alkaline 10 c.c. of 
gastric filtrate, and then adding to that 2 c.c. of 1 per cent, solution 
calcium chloride. Ten c.c. of neutral milk are added and the mixture 
-is placed in an incubator. If the zymogen is present, a casein coagulum 
will be formed in from five to fifteen minutes. 

The quantitative examination of rennet ferment is made by diluting 
the neutralized gastric filtrate w ith distilled water in separate portions 
up to yL yL, ^, 2V, sV? etc. Five c.c. of each dilution are placed in 
separate beakers, an equal quantity of neutral milk being added. The 
mixtures are then placed in a chamber at a temperature of 38° C. If 
a casein cake is formed in the beaker containing dilution oV, and not in 



106 DISEASES OF THE STOMACH. 

the beaker with dihition -^, it is evident that the rennet ferment is no 
longer active beyond the ^V dilution. It is not present, therefore, in 
sufficient j][uantities to be active in a dilution of 1 to 40, which is the 
normal limit. 

The rennet zymogen is present in much larger quantities, and may 
be active in dilution of j-I-q. A portion of the gastric filtrate is made 
slightly alkaline, and separate quantities are diluted, ^, Jg-, J^, J^, J^, 
sV? tVj 4T> oV) ^^c- Five c.c. of the separate dilutions are placed in a 
number of beakers, and to each is added 1 c.c. of 1 per cent, solution 
of calcium chloride and 5 c.c. of milk. The point at which the 
zymogen fails to act is thus determined. 

The quantitative estimation of both the ferment and the zymogen 
has of late assumed considerable importance in gastric chemistry, owing 
to the fact that in certain organic diseases of the stomach they are 
greatly diminished or the ferment is absent altogether, while in func- 
tional and mild disturbances the relative amounts of these important 
gastric constituents are rarely disturbed. Julius Friedenwald ^ after a 
careful study of this matter concludes that the milk-curdling ferment 
may be present in dilutions up to the -^, and its zymogen up to yA-y 
under normal conditions. The ferment is usually greatly diminished 
in chronic gastritis, being lowered from ^^ to ; while the zymogen is 
reduced as low as -^ to ^. In carcinoma the milk-curdling ferment is 
reduced to ^ to i, and the zymogen to -^ to -^. In but few diseases 
of the stomach besides these is the rennet zymogen so markedly 
lowered. Indeed, it is present in plentiful cjuantities in secondary 
hypersemic conditions of the stomach and the gastric neuroses, with or 
without the presence of free hydrochloric acid. 

Starch Dig-estion. — Ptyalin, the salivary ferment, acts upon the 
starchy constituents of the food, changing them into grape sugar, and 
it also changes cane sugar into invert sugar. The action of ptyalin 
commences in the mouth during mastication, as may be demonstrated 
bv thorouffhlv chewino- for some minutes whole wheat or rice or some 
form of starch, which when first put into the mouth has not the slight- 
est sweet taste, but a decidedly sweet taste is soon noticeable owing to 
the formation of sugar. Salivary action continues in the stomach until 
hydrochloric acid is present up to .01 per cent. This acid seems to 
exert the earliest and the most marked inhibitory effect upon the action 
of the ptyalin. Other acids must be present in the stomach in greater 
concentration before its action is checked. Lactic acid up 0.1 to 0.2 
per cent, and butyric acid up to 0.4 per cent, is needed to produce a 
like effect. The digestion of amylaceous substances in the stomach 
lessens gradually after the beginning of gastric secretion, until it finally 
ceases, pro\nded the stomach is sufficiently acid. 

The mid-products of starch digestion are dextrin and maltose, there 
being two varieties of dextrin, erythrodextrin and achroodextrin. If 
undigested starch is present in the gastric filtrate, its presence may be 
detected by the addition of Lugol's solution (which is composed of 
iodine 1 part, potassium iodide 2 parts, aquas destillatse 200 parts), a deep 
blue or brownish blue color being produced. Achroodextrin, maltose, 

^ Julius Friedenwald : " The Quantitative Estimation of the Kennet Zymogen, its 
Technical Value in Certain Diseases of tlie Stomach," Med, News, June 22, 1895. 



EXAMINATION OF THE STOMACH CONTENTS. 107 

and dextrose do not yield any reaction to iodine, but in the presence of 
erythrodextrin a faint purple is seen. In the normal stomach one hour 
after the Ewald test meal we usually find sufficient undigested starch 
in solution in the gastric filtrate to giye rise to a faint bluish or brown- 
ish-blue discoloration upon the addition of a drop or two of Lugol's 
solution. In cases of suj^eracidity, on the other hand, this same shade 
is deepened and very pronounced, owing to the increased amount of 
undigested starch in solution. In cases of subacidity, if a large amount 
of undigested starch appears in the filtrate, it may be due to deficient 
mastication or to a poor quality or too small quantity of saliva. 

Motor Activity of the Stomach. — In order to determine whether 
or not the motion of the stomach is sufficient several methods may be 
employed. One of these is the salol test, which originated with Ewald 
in 1887, and which consists in the administration of one gramme of 
salol during the period of digestion ; it is best given in capsules. Salol 
is a compound of phenol and salicylic acid. It maintains its identity 
in an acid medium, but it is not stable in an alkaline medium, being 
here decomposed into salicylic and carbolic acids. It is therefore in- 
soluble in an acid stomach, but being soluble in the intestine it liberates 
the salicylic acid, which is absorbed and eliminated in the urine as sali- 
cyluric acid, in which fluid it is detected by a \'iolet color which is pro- 
duced on adding liquor ferri chloridi. Small traces of it in the urine 
may be extracted with ether after the urine is acidulated with hydro- 
chloric acid, and the ether extract may then be tested. 

Ewald gives a method by which the merest traces of salicyluric acid 
may be discovered in the urine. A small quantity of urine is dropped 
upon a piece of filter paper, and a drop of 10 per cent, solution of the 
chloride of iron is let fall upon the moistened spot. A violet color 
appears at the edge of the drop if only a very small quantity of the 
salicyluric acid is present. Ewald found that in a great majority of 
cases salicyluric acid appeared in the urine in from sixty to seventy -five 
minates after taking the salol, and disappeared at the end of twenty- 
four hours in healthy indi\4duals. In cases of motor inactivity of the 
stomach it may last forty-eight hours or longer, the condition of the 
bowels appearing to exert no influence upon it. 

This method has been severely criticised. The objection is raised 
that too many processes, mechanical, absorptive, and excretory, have to 
be allowed for in the estimation. The salol is to be expelled from the 
stomach, decomposed in the intestine, the salicylic acid absorbed, carried 
by the blood, perhaps by the lymphatic current, through the liver and 
lungs to the kidneys, by which organs it has to be excreted, and must 
then pass through the entire length of the urinary tract. 

It must then be presupposed that all these functions are performed 
in a normal manner. We have always objected to this test chiefly 
for the reason urged by Sydney Martin, viz. — that a small amount 
of salol may pass through the pylorus with the fluids of the gastric 
contents, but that the mechanical power of the stomach is not thus 
tested, because the knowledge that is particularly desirable is in what 
period the stomach can empty itself of a mixed meal. Most of the 
salol may remain in the stomach, yet the test may yield its reaction, but 
give us no information as to the emptying power of the stomach. 



108 DISEASES OF THE STOMACH. 

A. L. Benedict/ having used this test very frequently and having 
been struck by what he terms the monotonous results obtained by its 
use, after studying its action in 16 cases and iinding that the salicyluric 
acid reaction occurred anywhere from half an hour to three hours in 
subacidity of the stomach, says that " the conclusion seems justified 
that the appearance of salicylic acid after the administration of salol 
merely means that the latter has been absorbed somewhere, and that no 
practical deduction can be drawn, unless possibly from the occurrence 
of a very marked delay, but this delay does not often occur in the very 
cases in which we would most expect it." In answer to the argument 
that salol might be absorbed from the stomach and produce the charac- 
teristic urinary reaction, Ewald ligatured the pylorus of a dog and then 
gave the animal some salol. No salicyluric acid could be detected in 
the urine up to three hours, at wdiich time the dog died. The result 
of this experiment is adduced as proof that salol is not absorbed by the 
stomach. 

Kleniperer in 1887 attempted to estimate the motor activity of the 
stomach by first washing out the organ and then pouring 100 c.c. of 
pure olive oil into it. Two hours afterward the oil Avhich remained in 
the stomach was removed and measured. Seventy to 80 per cent, of 
oil should be expelled into the duodenum by a healthy stomach. This 
method has not been widely used in this country. 

Max Einhorn ^ has devised a novel and ingenious instrument for 
measuring the motor activity of the stomach. This instrument he calls 
the gastrograph. The apparatus comprises a ball, a few electric cells, 
and a ticker. The ball consists of two hollow metallic hemispheres, 
one within the other, but perfectly insulated. The inner ball is fur- 
nished wdth spikes radiating in all directions, but not touching the 
inner surface of the outer hemisphere. Another small platinum ball 
lies within the outer hemisphere, rolling about from spike to spike, 
thus serving to close the current as it rests against a spike and lies upon 
the inside of the outer hemisphere. The least motion of the apparatus 
is sufficient to dislodge this small platinum ball, and it Avill roll from 
one spike to another, thereby interrupting the electrical current and 
setting the ticker in motion. If the apparatus is considerably agitated, 
the small platinum ball will be kept rolling, thus making numerous 
interruptions and causing numerous ticks to be recorded. By means 
of this very ingenious instrument Einhorn has investigated gastric 
motion under physiologic and pathologic conditions, and the findings 
seem to show that mechanical activity of the stomach in health is a 
factor of considerable importance — the stomach maintaining an almost 
constant motion while it contains food, the number of motions for three 
minutes averaging from 4 to 41, while in a fasting stomach they are 
considerably fewer. Under pathologic conditions one class of cases cor- 
responds to the normal ; another shows increased motion, the number 
of ticks in these cases being very numerous ; and the third shows 
almost no motion whatever. The least motion occurred in gastro-suc- 
corrhea and in chronic gastritis Avith dilatation ; while the most marked 

1 A. L. Benedict: " Salol Test for Gastric Atony," Med. News, Feb. 9, 1895. 
^ Einhorn : " The Gastrograph : A New Means of Determining the Mechanical 
Action of the Stomach," New York Med. Journ., Sept. 15, 1894. 



EXAMINATION OF THE STOMACH CONTENTS. 109 

activity was noticed in a case with pyloric stenosis and dilatation of 
the stomach. 

These methods above referred to are all valuable, but for clinical 
purposes it is quite sufficient to determine the motor power of the 
stomach by the amount of food remaining in the stomach three, four, 
or perhaps seven, hours after a mixed meal has been eaten. Ordinarily, 
a healthy stomach should empty its contents into the duodenum within 
five hours, unless a large amount of food in rather coarse form has 
been eaten. Three hours and a half or four hours after a breakfast 
consisting of Hamburg steak, dry bread, and water not more than ten 
grammes of solids remain in cases of good motor activity. 

Absorption. — ^ Absorption is under the influence of the nervous 
system. Sometimes fluids are very slowly or not at all absorbed by the 
gastric mucosa ; and when water is drank in considerable quantities, it 
is present several hours afterward when the tube is passed. This is 
more common in those cases in which dilatation exists, with or without 
pyloric stenosis. In some cases salts, alcohol, and many substances in 
solution are undoubtedly absorbed rapidly from the stomach, in other 
cases absorption of these is largely abolished. 

A convenient and ready test of the absorptive powers of the stomach 
is made by giving about three grains of potassium iodide in a gelatin 
capsule, the outside of which has been carefully wiped oflP. Strips of 
filter paper which have been previously dipped in starch paste and dried 
are then used every few minutes to test the patient's saliva, and when 
iodine is eliminated in the saliva the starched paper will be turned 
brown or a brownish blue. Under normal conditions iodine appears in 
the saliva in from ten to fifteen minutes, whereas in conditions of slow 
absorption its appearance may be delayed for more than an hour. The 
solubility of the gelatin should be determined by a control case. 

Microscopic Examination of the Stomach Contents. — j^umerous 
bacteria are found in the stomach contents. Hydrochloric acid if 
present in the free state somewhat retards the development and activity 
of bacteria, although it does not destroy them all. There are bacteria 
that may pass through the stomach unharmed, as, for instance, the 
staphylococcus aureus and the micrococcus tetragenes. This is probably 
true of the typhoid bacillus. The bacillus pyocyaneus, the bacillus 
lactis aerogenes, bacillus mycoides, and many others have been found 
in the stomach contents. Some of them peptonize and some coagulate 
the casein of milk. Micro-organisms causing acid fermentations are 
very commonly present, especially when there is an absence of free 
hydrochloric acid. The most prevalent of these is the bacillus acidi 
lactici. It is an aerobe and forms lactic acid, especially in the presence 
of sugar and dextrin. The bacillus butyricus is an aerobe, and gives 
rise to the formation of butyric acid in the presence of starch, dextrin, 
or cane sugar ; it also changes lactic acid into butyric acid. Sarcina 
ventriculi may be found in the stomach contents, especially in the 
stagnating contents of gastrectasia. In appearance the sarcinse resemble 
the form of cotton bales ; they are not easily cultivated, and they 
probably give rise to the formation of some acid Avhich is incidental to 
their growth. 

Yeast spores may be found especially in the contents of dilated 



110 DISEASES OF THE STOMACH. 

stomachs, and become active in the presence of gUicose and maltose, 
the fermentation resulting in the formation of minute quantities of 
alcohol and perhaps considerable quantities of acetic and carbonic acids. 
Putrefaction may occur in the stomach when there is prolonged 
stagnation of the proteid foods, and putrefactive micro-organisms are 
then found in the gastric contents. Some of their products are very 
poisonous, especially the aromatic substances, ptomaines, and albumoses 
to which they give rise. Some of the symptoms of gastrectasis, as, for 
instance vertigo, nausea, and numbness of the extremities, may be due 
to the absorption of these noxious products. 



GASTRIC NEUROSES. 

Gastric Ixxeryatiox.— The stomach is supplied by the pneumo- 
gastric nerves, the right passing along the oesophagus, on its posterior, 
and the left along its anterior, surface. They form the anterior and 
posterior gastric plexuses, two thirds of the posterior going to the 
abdominal organs. As they pass along the oesophagus they send small 
filaments into its structure, thereby forming plexuses which reach the 
stomach. The terminal filaments of the pneumogastrics form numerous 
anastomoses with the abdominal sympathetic nerves, with branches of 
which the stomach is richly supplied. From the coeliac plexus the 
sympathetics branch to form secondary plexuses — viz. the coronary, the 
hepatic, and the inferior coronary, which accompany, respectively, the 
left coronary, the right coronary, and the right gastro-epiploic arteries. 
The ganglionic suj^ply is present in the form of Auerbach's plexus 
myentericus and Meisner's plexus submucosus. This complex nerve 
supply in the stomach presides over secretion, motion, absorption, and 
sensation, and brings the stomach into intimate and sympathetic rela- 
tionship with the rest of the body. 

Etiology of Gastric Neuroses. — Age. — Functional gastric dis- 
orders occur most commonly in young adults. They may, however, 
occur at any age, being frequently seen at or near the menopause. 

Sex. — The neuroses unquestionably manifest themselves more fre- 
quently in women than in men, but the number of men suffering from 
gastric neuroses has in our experience rather increased in the past few 
years. 

Nativity. — In this country the Jewish people seem especially pre- 
disposed to nervous disturbances of the stomach. Americans have for 
a number of years and ■with increasing frequency shown numerous de- 
partures from the normal gastric conditions. The stomach is one of 
the first organs to feel the effects of the wear and tear of life in this 
country. 

Occupation. — Long hours, close application, with poor or artificial 
light, in improperly ventilated offices, are often causes of nervous dis- 
turbance. Monotony either in student or business life wearies the 
nervous system. Seamstresses and others, working steadily in a stoop- 
ing posture, without fresh air or exercise, not infrequently develop 
stomach trouble. Any occupation requiring constant nervous strain 



GASTRIC NEUROSES. Ill 

and excitement almost invariably interferes with gastric as well as with 
general innervation. Occupations requiring incessant talking or shout- 
ing, particularly w^hen accompanied by physical activity or mental 
strain — as, for instance, auctioneering and schoolteaching — are prone 
to induce these affections. Mental strain, unusual and monotonous use 
of the special senses, simultaneously with physical strain, and unhy- 
gienic surroundings are the underlying harmful factors in occupations. 

Mode of Living. — The struggle for social pre-eminence leads a large 
class of people into taxing social engagements, resulting in loss of sleep 
and composure, and neglect of healthful recreation. At the same time, 
these people are subjected to the exigencies of business or domestic 
strain, and are harassed by financial limitations ; brain irritation and 
functional disturbances are the invariable results. Nerve tire follows 
in the wake of the social whirl, and stomachs suffering with exhausted 
innervation are made the recipients of a variety of delicious but dan- 
gerously in\dting refreshments. Sufficient sleep and nerve rest are 
necessary for good innervation of the stomach. In those who have 
habitually followed an active out-of-door life and have recently adopted 
a sedentary existence, and who continue the habits acquired during the 
former more active life, the stomach becomes overtaxed and neuroses 
present themselves. 

Reflex Causes of Gastric Distuebaxces. — One of the most 
prolific causes of functional gastric disturbances is eye-strain, and almost 
any neurosis may be induced by it. Gastric hypersesthesia accompanied 
by hyperchlorhvdria, to be followed later by more or less angesthesia 
and achlorhydria, seems to bear a definite relationship to astigmatism 
of high degree. Without attempting to refer the condition to any spe- 
cial form of eye-strain, we have, nevertheless, been impressed with the 
frequency of the association of astigmatism and muscular imbalance 
with painful sensory conditions of the stomach, especially taking the 
form of distress and pain, accompanied by belching after meals — with 
a good appetite, but voluntary starvation through dread of pain induced 
by eating. These cases sufi'er for years, and are made rather worse 
than better by restricted diet. 

Pelvic disease in women is also a fruitful source of reflex gastric 
disturbance. The correction of uterine displacement, especially retro- 
version, and ovarian disorders sometimes results in the disappearance 
or alleviation of the gastric affection. Other sources of reflex disturb- 
ance are occasionally to be found in abnormal conditions of the nose 
and throat, genito-urinary tract, rectiun, and other parts. Floating 
kidney and enteroptosis are well known causes of gastric symptoms, 
some of w^hich may be referred to disturbance of innervation. 

Finally, gastric disturbances are extremely common in neurasthenia 
and hysteria. It is sometimes difficult to draw a sharp distinction 
between these conditions, but for clinical purposes it suffices to recognize 
the fact that the gastric condition is simply a part of the symptom 
complex, and that treatment, if it is to be successful, should be directed 
to the general nervous system, although sometimes much may be 
accomplished by local treatment "of the stomach. 

Acute and chronic toxeemias not infrequently give rise to functional 
disturbance. Influenza is a good example of the acute form, although 



112 DISEASES OF THE STOMACH. 

other infections diseases in this way give rise to gastric disorders. The 
chronic forms may be illustrated by the dyscrasias of so-called lithsemia, 
gout, chronic nephritis, or renal insufficiency independent of organic 
disease (?f the kidneys, rheumatism, and diabetes. Some cases of 
stomach trouble may be traced to masturbation and to sexual excesses. 
Overtaxing the stomach is another common cause, and often results 
from hurried and bountiful eating when the nervous system is already 
tired. The heavy, indigestible lunches indulged in during business 
hours are responsible for many rebellions on the part of the stomach. 

The gastric neuroses may be divided into those seemingly due to 
irritation or stimulation of the nerves of the stomach and those due to 
depression. 

The neuroses are considered under four headings — viz : those of 
secretion, sensation, motion, and absorption. 

Disturbances of Secretion. 
hypeechloehydeia. 

When free hydrochloric acid is present in the stomach during diges- 
tion in quantities over .24 per cent., the condition is called hyperchlor- 
hydria, which should not be confounded with supersecretion (Reich- 
mann's disease), a term referring to the continuous secretion of gastric 
juice without the presence of food; nor should it be confused with 
superacidity, a condition in which the total acidity is raised above 
normal, but which acidity may be due to organic acids Avith or without 
free hydrochloric acid. 

Jaworski found hvperchlorhydria in 115 of 121 cases of supersecre- 
tion ; Ewald found it in only 45 of more than 1000 patients. Some 
observers take the ground that so-called supersecretion occurs in the 
majority of healthy stomachs. Martins found from ,4 per cent, to 
.5 per cent, free hydrochloric acid in 8 cases thirteen hours after the 
last meal, and he holds that constant secretion of hydrochloric acid is 
not an abnormal occurrence. In many cases we have found free hydro- 
chloric acid present in the empty stomach, but in all there were either 
symptoms of gastric irritation or hvperchlorhydria was present during 
digestion, Hayem believes that in hvperchlorhydria there frequently 
exists a mucous gastritis — a position that seems inconsistent with our 
fixed views of pathology, as it has been determined that inflamma- 
tion of an organ depresses rather than increases its functional activity. 
In this connection it is interesting to note that Einhorn has found 
during life a proliferation of the secretory glands of the stomach asso- 
ciated with hyperchlorhydria — a condition that might be ex|)ected where 
there is excessive functional activity. 

Symptoms. — While food is present in considerable quantities, the 
symptoms are not prominent, but usually appear from two to four hours 
after meals, and consist of gnawing or burning pain with eructation. 
Sometimes these sensations in the epigastrium are accompanied by sore- 
ness that is aggravated bv forcible voluntarv contraction of the abdom- 
inal muscles and tenderness upon pressure, occasionally sharply localized 
in the epigastrium a little to the right, of the median line, as in ulcer. 
In some cases the gastric distress comes on during the night. Xausea 



DISTURBANCES OF SECRETION. 113 

is not a constant accompaniment of the pain, but in some cases it occurs 
and persists until vomiting is induced. The patients complain that the 
matter vomited sets the teeth on edge ; it usually consists of a very 
sour fluid, often having a greenish tint, with perhaps a few food frag- 
ments present, and relief sometimes follows the vomiting. Many of 
these patients learn to relieve themselves by drinking copiously of hot 
water and then exciting vomiting. Sodium bicarbonate is a favorite 
household remedy, and patients not infrequently give a history of hav- 
ing taken pounds of it during their suifering. Food generally gives 
temporary relief, especially nitrogenous foods and milk, while starches, 
fruits, acids, and highly seasoned articles of diet as a rule aggravate the 
symptoms. 

Diagnosis. — If in hyperchlorhydria the stomach contents should 
be examined after a test meal, it will be found to contain more than the 
proper percentage of free HCl. In one hour after Ewald's test break- 
fast the total acidity is usually between 60 and 70 per cent. ; later the 
total acidity increases, and free hydrochloric acid rises above the 
normal point. Repeated experiences lead us to conclude that even in 
the absence of the latter event, with an excessive total acidity not 
dependent upon organic acids, hyperchlorhydria should be suspected. 
In the presence of meat or egg-albumin more hydrochloric acid is com- 
bined, and thereafter does not appear free in as high percentage, nor is 
the total acidity so high — a fact affording valuable suggestions as to 
treatment. 

The biuret reaction is usually present, and starch digestion is sus- 
pended. The exclusion of gastric ulcer in these cases is not always 
easy. The secretory condition is that which usually obtains in ulcer, 
and if the pain is paroxysmal and very severe, the case should be 
treated as if ulcer were present. The pain in ulcer, how*ever, is usually 
aggravated by food, whereas in hyperchlorhydria comfort is restored for 
a short time after eating. The neurotic state may be present in either 
affection, but the strictly localized pain and tenderness, and the gas- 
trorrhagia of ulcer are important differential points. 

Treatment. — If the pain is severe and persistent, an absolute milk 
diet for a few days is advisable. Six or eight ounces of milk may be 
given every two or three hours, about two quarts being taken during 
the day. Sometimes hot milk is better borne than cold, and it should 
be drank slowly. Often this absolute change in diet alone is sufficient 
to give relief. AVhen the case shows improvement the dietary may be 
enlarged, and all forms of fresh meats, preferably beef and mutton, are 
allowable ; but meat and milk should not be taken at the same meal. 
Although less satisfactory, fowl and varieties of fish not too oily may 
be eaten occasionally. Salt meats should be excluded, as it is desirable 
to restrict the ingestion of sodium chloride. Starches should be given, 
at first solely in the form of stale bread, toasted at times to avoid 
monotony, zwieback, and the crust of rolls ; these should be thoroughly 
masticated and not washed down with fluids. Eggs are usually well 
borne, and should be taken raw or very soft boiled ^ or soft poached. A 
very good plan for the day as regards diet is the following : 

^ A pint bowl filled with boiling water should be set upon a table; in this place an 
unbroken egg of medium size, and allow it to stand for ten minutes, when the white and 

Vol. III.— 8 



114 DISEASES OF THE STOMACH. 

BreaJcfast. — Soft boiled or " coddled " eggs, stale bread, or stale rolls 
warmed over, weak tea or coifee with cream and a moderate amount of 
suofar. In the middle of the forenoon a glass of hot milk should be 
sipped. • 

Luncheon. — Tliis should be light, consisting of stale bread or zwie- 
back, weak tea, and a pint of hot milk. Effervescing table waters 
should be avoided. In the middle of the afternoon a glass of milk may 
be taken. 

Dinner. — This meal should be abundant and slowly eaten. A period 
of rest should precede the meal and relaxation should follow it. Porter- 
house steak, roast beef, or mutton roasted or boiled, stale bread, and a 
small cup of coffee if desired. After dinner water should be drank 
freely. Between ten and eleven o'clock at night a glass of hot milk 
should be taken. This programme may be modified as the patient 
improves. For instance, a raw egg may be substituted for the milk 
between meals ; broiled bacon may be added to the eggs for break- 
fast, and baked potatoes, spinach, and other boiled salad, or greens 
may be added to the dinner. Condiments and zests are objectionable. 
Another, and in some cases the best, plan of diet is the " Hamburger " 
steak without herbs, or the so-called " meat balls," of which a proper 
amount should be taken every three hours and followed by large 
draughts of hot water. We have seen patients who did best when 
restricted to uncooked eggs given every hour or two for several days. 

Alkalies and sedative remedies are indicated, and a very valuable 
combination that we have used for many years, and call the " gastric 
sedative," is prescribed as follows : 

I^. Cerii oxalatis, oij ; 

Bismuthi subcarbonatis, Siv ; 

Magnesii carbonatis levis, Ej- — M. 

Sig. Even teaspoonful stirred in water in the middle of the fore- 
noon, middle of the afternoon, and at bedtime. 

This combination serves admirably to neutralize the excess of acid and 
soothe the irritated and perhaps congested gastric mucosa. Sometimes 
it acts as a cathartic, which is desirable, but if its action in that way is 
too pronounced, creta prseparata may be added or substituted for the 
magnesium. On the other hand, if three doses a day are not sufficient 
to afford relief, particularly when the bowels are not loose, it may be 
given every two or three hours. If gastric flatulency is pronounced, 
two to four drachms of charcoal may be added to the prescription. 
Sodium bicarbonate in half-drachm or one-drachm doses in hot water 
very often gives relief by lowering the acidity, but its effect is evanes- 
cent and its continued use is undesirable in this affection. The potas- 
sium salts, especially the bicarbonate, the tartrate, and the citrate, in 
sufficient dosage and in solution with eucalyptol water or chloroform 
water, sometimes serve very well as direct alkalies. In some cases 
great benefit attends the administration of ichthyol : from two to five 
minims enclosed in capsules should be given every three to four hours. 

the yolk will be slightly but equally cooked through, and the undesirable solid coagula- 
tion of the white is avoided. 



DISTURBANCES OF SECRETION. 115 

Atropine sulphate has been recommended to diminish the secretion of 
hydrochloric acid, and we have used it with good effect, although it 
sometimes interferes with salivary secretion to such an extent as to 
render it undesirable. Hydrocyanic acid, chloroform, cocaine hydro- 
chlorate, spirits of ether, camphor water, and a number of other drugs 
may be used occasionally, but are comparatively ineffectual. In case 
the stomach contains a large quantity of very acid contents consisting 
of gastric juice and food or of gastric juice alone, as in supersecretion, 
lavage gives the quickest temporary relief. The water used for lavage 
should be as hot as tolerable, but not hotter than the hand will comfort- 
ably bear. After the stomach is washed clean it is a good plan to intro- 
duce through the stomach tube and allow to remain in the stomach 
from two to four ounces of slippery elm water, linseed tea, or other 
mucilaginous fluid holding bismuth subcarbonate in suspension. Some- 
times the menthol spray is useful in hyperchlorhydria. The local effect 
of menthol and its oily vehicle diminishes the secretory activity of the 
peptic glands. 

The treatment of the condition underlying the neurotic state is ex- 
tremely important, and is necessary for a complete cure. It involves 
the removal, if possible, of the cause, or at least some modification of 
it should be effected. This matter will be considered with the general 
treatment of neuroses, 

HYPOCHLOEHYDEIA. 

Hypochlorhydria signifies a condition in which free hydrochloric 
acid is present in quantities below .14 per cent, at a time w^hen it ought 
to be present in normal amount. 

Etiology. — Causes depressing the secretory nerves induce this 
condition. We have not yet learned why from apparently like causes 
gastric secretion is stimulated in one person and reduced in another. 
At first this disturbance irregularly manifests itself; in other words, 
one day hydrochloric acid may be found in normal quantities, while the 
next day it is present only in traces or not at all, and if the neurosis 
persists upon every examination of the stomach free hydrochloric acid 
will be found absent, and this may go on until achylia gastrica is 
gradually established. 

Achlorhydria signifies the absence of hydrochloric acid, and is 
simply a further step in the secretory change which commences as 
hypochlorhydria. 

Symptoms. — This is a condition that may be present for years with- 
out giving rise to symptoms ; in many cases we have found it present 
when relief was sought for headache, lassitude, nervousness, diarrhoea, 
or some other remote symptoms. Gastric symptoms are sometimes 
prominent, and they usually consist of a feeling of weight, distress, 
and fulness in the region of the stomach, with eructation soon after 
meals ; nausea and vomiting may occur. 

DiAO:?sOSis. — This condition is differentiated from chronic catarrhal 
gastritis by the presence of a sufficient quantity of pepsin and the lab 
ferment. In catarrhal gastritis lavage shows that the stomach contains 
-an excess of ropy mucus, holding food fragments in its meshes. Car- 



116 DISEASES OF THE STOMACH. 

cinoma may be excluded bv the absence of a manifest tumor, dilatation, 
food stagnation, emaciation, and by the history and gastric chemistry. 
Lactic acid may be present but only in small amount, and that, as a 
rule, depending upon preformed lactic acid in the ingesta. The stomach 
contents may appear well digested, and when combined hydrochloric 
acid is present the proteoses are abundant. Little or no free hydro- 
chloric acid is present; acetic and butyric acid fermentations occur 
irregularly, being most marked when the patient is fatigued and Avhen 
gastric motion is thereby depressed ; indicanuria is frequently present. 

Teeatment. — Nitrogenous foods should not be used as freely as in 
hyperchlorhydria ; some clinicians decidedly limit the use of albumin- 
oids in this condition, but these foods may be allowed once daily. 

Starches may be taken liberally, provided they are properly cooked, 
the best forms of such food being stale bread, zwieback, toast, crust of 
rolls, and mealy baked potatoes ; soggy, half-cooked starchy foods 
should not be eaten ; cooked, succulent vegetables are admissible in 
some cases. Plenty of salt may be eaten ; condiments may also be 
used quite freely ; ginger-ale serves as a useful beverage. The intra- 
gastric application of the interrupted current stimulates and tones the 
secretory nerves, exciting the secretion of hydrochloric acid ; the con- 
tinuous current is also indicated, especially in cases of gastralgia and 
irregular secretion. Einhorn and the wa-iter have shoAvn that either of 
these electrical currents applied by the direct method excites hydro- 
chloric acid secretion, and such secretion may be excited when it fails 
to appear from the stimulation of food or the mere presence of the 
stomach tube. Frequently these cases present hyperlithuria, and alka- 
lies exhibited before meals are followed by some relief and also by a 
diminution of the indicanuria. 

Hydrochloric acid after meals is an excellent remedy in some of 
these cases, but does not seem to give the signal relief that is often 
noticed in cases of subacute or chronic catarrhal gastritis. If, however, 
fermentation is present, hydrochloric acid diminishes flatulency and 
restores gastric comfort. iSTux vomica before meals is one of the best 
remedies at our command in this affection, probably owing to its tonic 
effects upon depressed innervation ; occasionally this drug alone gives 
comfort and restores hydrochloric acid secretion. For further treat- 
ment of this condition see the general treatment of the neuroses. 

ACHYLIA GASTEICA. 

Definition. — We adopt the term achylia gastrica, as applied by 
Einhorn, to designate a condition of the stomach in w^hich no gastric 
juice is secreted and therefore no proteolysis occurs. We have else- 
where described the condition under the caption " Gastric Anacidity." 
Ewald refers to it as resulting from anadenia venti'iculi, or atrophy of 
the gastric glands. 

Etiology. — Although it may manifest itself as a strictly nervous 
disturbance of the secretory function, unquestionably most cases of this 
affection are associated wdth atrophy of the gastric glands. Consider- 
able discussion has arisen as to the nature of this atrophy, and most 
writers have attributed the degeneration to some form of chronic gas- 



DISTURBANCES OF SECRETION. 117 

tritis. The prolonged studv of cases leads us to the conclusion that 
some other factor is at work besides inflammation — first, because chronic 
gastritis continuing for years rarely leads to complete suppression of 
gastric secretion ; and second, because we have studied cases of achylia 
gastrica, in some instances observing the development from a transient 
state into a condition in which secretion was persistently absent, with- 
out any evidence of gastritis. In fact, we believe that this peculiar 
disease begins as a functional disorder, and that from continued disease 
there occurs atrophy of the gastric tubules in which morbid process 
inflammation plays no part. In the absence of gastric secretion and 
in the presence of degenerating glands it is natural and easy for inflam- 
matory changes to supervene, and in a proportion of cases this actually 
occurs. The most remarkable feature is that gastritis does not occur 
more frequently. The most important etiologic factors would seem, 
then, to reside in the causes of functional disturbance, and of these one 
stands out more prominently than all others, that cause being an aggra- 
vated eye-strain. This fact particularly applies to that group of cases 
in which a too active gastro-intestinal peristalsis is associated with the 
suppression of secretion resulting in a chronic lienteric diarrhcea. We 
have elsewhere described a grouj) of 12 cases in all of which marked 
asymmetrical astigmatism or anisometropia was present, and in those 
cases seen early, before atrophy was believed to have commenced, 
marked benefit resulted from correction of the ocular error, and in some 
cases a complete cure was obtained without other treatment. Since 
reporting these cases a still larger number have been studied, and the 
factor of eye-strain has been invariably present. The affection is most 
insidious in its development, has periods of qtiiescence followed by 
active progress, and often is unaccompanied by gastric symptoms. 
Ultimately, however, these occur, but are generally the result of motor 
disturbance ; that is to say, there is greatly increased or decreased 
gastric motility. 

Pathological Axatomy. — Based, on a clinical study, it is pre- 
sumed that no anatomical changes are to be found in the early history 
of this affection. Subsequently there appears atrophy of the gastric 
tubules following absence of functional activity. There are reasons to 
suppose that this does not occur uniformly throughout the gastric mu- 
cosa, but that some areas remain practically intact, while others have 
advanced in degeneration. Some observations recently made by Ein- 
horn confirm this \aew. He made sections from fragments of the mit- 
cous membrane found present in the water withdrawn during lavage, and 
from examination of these found that some showed a perfectly normal 
glandular structure, while others showed complete atrophy of the tu- 
bules. In one case a disappearance of the glands was demonstrated, and 
afterward there was found a fragment showing normal, undegenerated 
structure. When inflammatory changes occur, they are believed to con- 
form to the ordinary picture of chronic catarrhal gastritis hereafter 
described. 

Sy:mptoms. — In some cases no gastric symptoms are present, and it 
is only by direct examination of the stomach that the condition is dis- 
covered. In other cases gastric flatulency is pronounced, and a sense 
of weight, fulness, and distress may be felt after meals. The appetite 



118 DISEASES OF THE STOMACH. 

is usually good, or may be exaggerated, unless the condition is associated 
with gastralgia, during an attack of which there is usually anorexia. 
Gastralgia is not an infrequent accompaniment of this affection, and 
there are 'also often present other manifestations of a neurotic character, 
such as hiccough, vomiting, hyperaesthesia, and insomnia. It will be 
observed that the symptoms are those denoting functional disorder, and 
very rarely, almost never in early cases, are they characteristic of in- 
flammatory conditions of the mucosa. The symptoms referable to the 
stomach seem to bear a definite relation to its propulsive power, as it 
may be noted that distress, nausea, and vomiting supervene when food 
retention is prolonged. Constipation may be present, but is not as com- 
mon as diarrhaa, which latter symptom often assumes some prominence, 
occurring, as it does, in a lienteric form after meals. In some of our 
cases diarrhoea was the most marked symptom. The remote manifesta- 
tions of this affection are of considerable interest and importance, in- 
cluding, in some instances, profound anseraia with a cachectic appearance, 
and in others a painful condition of the joints, accompanied by rough- 
ening of the synovial surfaces, proliferation of the sero-fibrous struc- 
tures, synovial effusion, swelling, stiffiiess, and disability. In one of our 
cases the hip-, elbow-, and shoulder-joints were extremely painful, so 
much so that the patient had been kept awake many nights, and 
there was extensive muscular atrophy, the patient being unable to raise 
his arm or leg. He was greatly emaciatecl ; food remained twelve or 
more hours in the stomach ; diarrhoea existed to the extent of from four 
to eight movements a day ; the blood was much reduced ; walking was 
performed in a slow, shuffling manner with the body bent forward, and 
was very distressing ; the pulse was feeble, and death seemed immi- 
nent. Steady improvement took place, however, under lavage, intra- 
gastric faradization, and large doses of hydrochloric acid, pepsin, and 
strychnine. At the present writing the man is w^orking a market garden 
and is fairly well, though gastric digestion has not reappeared and it is 
still necessary to continue the medicines. 

Diagnosis. — The gastric contents after the Ewald test breakfast is 
usually either neutral or has a very low acidity, from 2 to 5 ; the food 
is little changed, being simply water-soaked ; free and combined HCl is 
absent ; lactic acid may be present in traces ; fermentation acids are 
absent ; no syntonin is found ; no proteoses nor peptones are present ; 
therefore the biuret reaction is negative; rennet ferment and rennet 
zymogen are absent ; starch digestion proceeds, provided the albuminoid 
covering of the granules is sufficiently broken or digested to allow sali- 
vary action. The absence of bound HCl is shown by the large amount 
of the acid that it is necessary to add to the contents, filtered or unfiltered, 
before it appears free. The absence of pepsin is shown by the total lack 
of digestive action of the filtrate after the addition of a suitable quan- 
tity of HCl. Eennet ferment and zymogen are proved to be absent by 
the failure of the filtrate when properly treated with calcium chloride 
to coagulate milk. 

In order to determine whether or not total absence of secretion ex- 
ists the method of Javorski may be employed. It is carried out in the 
following manner : 200 c.c. of decinormal HCl are introduced in the 
morning into the empty stomach, previously cleaned, and in half an 



DISTURBANCES OF SECRETION. 119 

hour it is withdrawn. The acidity of its filtrate is ascertained by deci- 
normal sodium hydrate solution, and a small piece of egg albumin is 
used to test its digestive activity. If no digestion occurs, it is evident 
that no pepsin is present, and it is therefore apparent that its proenzyme 
was not formed in the stomach, probably because of complete atrophy 
of the tubules, else the HCl solution would have liberated it. In some 
cases of achylia gastrica the employment of this method shows a small 
degree of latent secretory activity. 

Prognosis. — This condition may exist for years without failure of 
nutrition, provided the motor power of the stomach remains sufficient 
and intestinal digestion compensates for the lack of gastric function. 
Even when ansemia, loss of flesh and strength, diarrhoea, or the joint 
affection before mentioned become manifest, health may occasionally be 
restored by appropriate treatment. In the majority of cases improve- 
ment, but not cure, may be expected. There are instances of such 
marked deterioration of the general health that, though temporary im- 
provement may be brought about, vitality ultimately fails, and death 
from exhaustion or some intercurrent affection may supervene. In some 
instances of death from pernicious ansemia, atrophy of the gastric mu- 
cosa, having been found present, has been considered causative of the 
disease (Flint, Henry and Osier, Ewald, Kinnicutt, and others). It 
may be said in reference to this matter that we have found pronounced 
secondary an&emias in some of our cases, but in none has the blood 
shown the pernicious type except in those associated with malignant 
disease, and recent post-mortems in those dying of pernicious ansemia 
have shown no atrophy of the gastric mucous membrane, while in 
others in which atrophy was discovered pernicious ansemia had not 
existed. 

Treatment. — The main objects of treatment are — first, to re-estab- 
lish gastric secretion if possible ; second, to stimulate the propulsive 
power of the stomach if it is deficient ; third, to quiet excessive gastro- 
intestinal peristalsis when present ; and fourth, to combat the results 
of the disease, the chief of which are the ansemia and, in a proportion 
of cases, joint affection. 

As a preliminary means the eyes should be carefully corrected. 
Next attention should be directed to the local treatment of the stomach. 
The establishment of gastric secretion and the stimulation of the motor 
function are both subserved by lavage with intragastric faradization and 
the administration of nux vomica. Lavage should not be practised too 
frequently, and may be discontinued when the motor power improves. 
Lowenthal recommends the use of a 0.6 per cent, solution of sodium 
chloride at a temperature of 104° F. for lavage in these cases, and we 
also use a weak solution of Carlsbad salts. Electricity may be employed 
with advantage three times a week, or even more frequently, without 
the withdrawal of the gastric contents, so that the patient shall not be 
robbed of nutriment. The faradic current should be used for five or 
ten minutes at each sitting, one pole being in the stomach, into which 
about 150 c.c. of a weak saline solution is introduced before treatment, 
and the other pole placed upon the epigastrium or upon the dorsal 
spine. The galvanic current may also be used with advantage with 
the positive electrode inside the stomach and the negative upon the 



120 



DISEASES OF THE STOMACH. 



spine or epigastrium. The continuous current is especially advised 
when gastralgia is present. 

To assist gastric digestion from fifteen to thirty drops of dilute 
hydrochloi-Tc acid or the equivalent of the stronger acid should be ad- 
ministered after meals in repeated doses, sometimes combined with 



Fig. 1. 




Stockton's gastric electrode : d, stomach-tutie ; a, rubber tubing ; c, first steel tube ; 6, second 
steel tube, coupled ; e, electrode in situ, forming a plug to tirst steel tube (manufactured by 
George Tiemann & Co.). 

pepsin. The antiseptic influence of HCl in these cases may be of some 
importance, although there is a notable absence of fermentative changes, 
even when motility is impaired, such as occur in gastrectasia Avith 
pyloric stenosis or in many cases of catarrhal gastritis with atony in 
which the secretory function is fairly active, though hypochlorhydria 
may exist. Large doses of HCl are administered before meals in this 
aflFection by some clinicians. 

Other digestants, such as papain, extract of pancreas, taka-diastase 
and extract of malt, may be used. Excessive peristalsis with which diar- 
rhoea is associated is usually diminished or controlled by lavage with hot 
water and the administration of HCl. If these measures are insufficient, 
colon-flushing with hot boric acid solution or a solution of tannic acid 
one grain to the ounce may prove effectual, or bismuth subgallate may 
be given by the mouth. The fluid extract of coto bark in doses of ten 
or fifteen drops, or the fluid extract of guarana in half dram or dram 
doses, often gives satisfactory results. One-minim doses of Fowler's 
solution in an ounce of camphor water just before meals is often suc- 
cessful, and if the condition is urgent five drops of the tincture of opium 
may be added. Absolute rest in bed for a few days may be occasionally 
advisable. Anaemia usually improves without special medication, par- 
ticularly when the patient lives out of doors a good deal and has the 
advantages accruing from sunlight, exercise, and hydrotherapy ; but in 
some instances, notably in those with diarrhoea, tr. ferri chloridi, in 
fifteen- or twenty-minim doses, or a like amount of a solution of 
liquor ferri nitratis, serves a good purpose, owing perhaps, in a meas- 
ure, to the astringent properties. Arsenic is also a valuable drug in 
this connection. 



NEUBOSES OF THE ST02IACH. 121 

The joi^t aiFection is generally benefited by the treatment of the 
stomach, but sometimes it is advisable to use the galvanic electrical 
current upon the joints and the interrupted current for the weak and 
atrophied muscles. The static spray and sparks also give marked re- 
lief in some cases. These measures, with massage and hydrotherapy, 
are occasionally followed by distinct improvement, though too often 
the affection remains intractable to treatment. 

Einhorn advises that the diet should consist largely of starchy foods 
— if practicable thoroughly dextrinized, finely divided, and thoroughly 
masticated, so that the cellulose covering of the starch granule may be 
broken, thus assisting the action of the ptyalin. We advise albuminoids 
at one meal of the day, as they mil be digested in the small intestine. 
In the absence of catarrhal gastritis condiments may be taken, and salt 
should be freely used. The succulent fruits, oranges, grape-fruit, and 
lemons, are permitted at the meal when meats are taken. Rich pud- 
dings and pastries should be interdicted, while plain puddings, such as 
rice, sago, tapioca, and corn starch, may be allowed. ]\Iilk, perhaps 
peptonized, eggs, tender meats, stale bread, zwieback, salt and fresh 
fish, mealy baked or properly boiled potatoes and other vegetables, 
excluding those having too much cellulose, may be allowed. As bever- 
ages carbonated waters, lime-juice, acid phosphate, ginger ale, tea, coifee, 
and cocoa may be taken. Rhine wine, claret. Burgundy, sherry, and 
other wines should not be allowed, as they inhibit starch digestion in 
the stomach (Chittenden and Mendel). If the motor jjower of the 
stomach is unimpaired and if no diarrhoea is present, there is no need 
for prescribing a strict diet, as a wide mixed diet may be well cared for 
by intestinal digestion. 



NEUROSES OF THE STOMACH. 

Sensoey Neuroses. 

Hyperaesthesia. — Definitiojst. — An over-sensitive and unstable 
condition of the sensory innervation of the stomach. 

Etiology. — Hysteria and neurasthenia are often accompanied by 
gastric hypersesthesia, the latter being a part of the general disturbance 
of the nervous equilibrium, while idiosyncrasy is the causative factor in 
some cases. It may accompany or follow acute diseases like influenza, 
or be initiated by nervous shock or strain ; indeed, almost any of the 
causes of gastric neuroses may operate to induce this condition. 

Symptoms. — These may vary from the most trifling discomfort after 
meals to severe pain or almost continuous distress. The irritability of 
the stomach may render it intolerant of food or water even in small 
quantities. It is difficult to separate hypersesthesia and consider it as 
an entity, for the reason that it may play a part in any of the irritative 
disturbances. A very common illustration of this affection is observed 
in cases of pronounced neurasthenia in women, persisting for many 
years, and allowing not a mouthful of food to enter the stomach with- 



122 DISEASES OF THE STOMACH. 

out exciting so much distress that these patients bitterly complain that 
they never would eat were it not a positive necessity. All medicines 
are objected to because they cause distress, even tablet triturates of 
sugar of milk being complained of. 

Diagnosis. — This is made only by excluding organic disease of the 
stomach and adjacent organs, and, as far as possible, other functional 
disturbances. 

Treatment. — The general principles governing the treatment of 
the neuroses should be borne in mind. The special indications include 
the use of the galvanic current, the positive pole within the stomach, 
two or three times a week for five or ten minutes at each sitting, pre- 
ceded by a hot stomach douche, while cerium oxalate, ichthyol, menthol, 
cocaine, hydrocyanic acid, chloroform, carbolic acid, chloral hydrate, or 
other local sedatives may be administered, ofttimes with benefit, by 
means of the spray. The diet should be nutritious, but not stimulating. 

Gastralg-ia. — The term gastralgia, unqualified, signifies pain in the 
stomach. Essential gastralgia or neuro-gastralgia designates extremely 
severe paroxysmal pain in the stomach not resulting from organic 
disease. This occurs especially in neurasthenic and hysterical indi- 
viduals. It may appear at almost any age, but is most common in 
adult females. E. W. Saunders of St. Louis observed 4 cases of gas- 
tralgia in children three, four, and five years old which were entirely 
cured by operation for adherent prepuce. Sometimes it occurs in men 
as well as in women of phlegmatic rather than nervous temperament, 
and in whom one would not suspect neurasthenia. Toxaemias, such as 
lithsemia or syphilis, may cause neuralgia of the stomach, as they so 
frequently cause neuralgia in other parts of the body. Given the pre- 
disposing nervous and constitutional conditions, the paroxysms are often 
excited by overtaxing the stomach with irritating food, or by mental 
strain, grief, worry, sexual excess, menstruation, excessive fatigue, or 
any circumstance liable to disturb nervous equilibrium. In some cases 
it is difficult to say what the exciting cause really is, and especially is 
this true in those having periodical paroxysms resembling attacks of 
migraine. We have observed a case in a business man who has for a 
number of years had repeated attacks of gastralgia while attending to 
business, but has never had an attack while away from home. 

Symptoms. — The pain is usually paroxysmal, beginning and ending 
suddenly in most cases ; it is variously described as gnawing, tearing, 
burning, cutting, or boring, and is located in the epigastrium. It may 
radiate to either side, downward, upward, or through to the back. Its 
duration may be from a few minutes to many hours or even days. In 
some cases it occurs with tolerable regularity, while in others its recur- 
rence is notably irregular. It may come once a year or every few days. 
It seems to bear but slight, if any, relation to the ingestion of food,, 
excepting in those cases in which it is excited by overtaxing a tired 
stomach with an abundance of food that is irritating. Often it super- 
venes in the night ; in some of our cases paroxysms almost invariably 
appeared between two and four o'clock in the morning. Other symp- 
toms, such as vomiting, salivation, belching, or hiccough, often accompany 
gastralgia. When vomiting occurs it is usually after pain has been 
present for some hours, and the emptying of the stomach sometimes 



NEUROSES OF THE STOMACH. 123 

affords relief. Often the expression denotes excitement and anxiety ; 
the body may be bathed in perspiration, while the extremities are cold, 
the hands shake, the voice is tremulous, and the patient tosses about 
with moans and cries ; the pulse is tense and frequent, or sometimes 
infrequent ; the urine is pale and copious during the attack, while later 
it is scanty, high colored, and hyperlithic. Following the attack there 
are often depression, headache, and weak circulation. 

Diagnosis. — Other painful conditions are likely to be mistaken for 
gastralgia. One of these is gastric ulcer, which may be recognized by 
localized tenderness and pain, made worse by eating and by hsemateme- 
sis. Carcinoma may be excluded by the age, history, gastric chemistry, 
tumor, and cachexia belonging to this affection. The pain is often 
attributed to biliary colic, which may be excluded by the absence of 
jaundice and the absence of calculi in the stools. Besides, the pain in 
gastralgia is much more easily controlled by anodynes than is that of 
biliary colic. The referred pain of renal colic may also be mistaken 
for essential gastralgia. Intercostal neuralgia may be recognized by 
the presence of Valleix's points. Angina pectoris is excluded by the 
history and by the fact that the pain does not radiate down the left arm. 
There may be no arterial change and no heart murmur during the attack. 
The gastric crises of locomotor ataxia may also be excluded by the 
absence of other symptoms of tabes dorsalis. Sometimes, however, in 
latent locomotor ataxia paroxysms of gastralgia may be the only mani- 
festation of the disease. Severe gastric pain sometimes occurs in dissem- 
inated sclerosis, spinal curvature, chronic spinal meningitis, etc. ; there- 
fore the nervous system should always be examined. 

Pancreatitis, subphrenic abscess, appendicitis, floating kidney, or 
perinephritic abscess may give rise to pain simulating gastralgia. 

Treatment. — The paroxysm of gastralgia is often controlled by 
lavage with water at a temperature of 105° F., or the galvanic current 
may be applied, the positive pole being used internally and the negative 
over the epigastrium or the dorsal spine. The sitting should last from 
five to ten minutes, and the strength of the current should be from five 
to twenty milliamperes. After the lavage is finished and the stomach is 
clean, from thirty to sixty grains of bismuth subcarbonate or subnitrate, 
suspended in about four ounces of mucilage of tragacanth, acacia, or 
althaea, may be introduced into the stomach or menthol spray may be 
used internally. In case no stomach tube is at hand an emetic may be 
given, preferably one tenth of a grain of apomorphine hypodermically. 
Sometimes drinking copiously of hot water relieves the pain. The 
Scotch douche, consisting of the alternate application of hot and cold 
water to the epigastrium, occasionally eases the patient. In some cases 
the cold spinal douche, a full warm bath, or heat applied to the epi- 
gastrium may give relief. Eubefacients, such as mustard, applied along 
the dorsal spine and to the epigastrium, and dry cupping are of some use. 
Vibration applied either by the fingers of a skilful masseur or by the 
machine vibrator has been used with some success. Internally, the sed- 
ative combination of cerium oxalate, bismuth subcarbonate, and light 
magnesium carbonate, or cocaine, dilute hydrocyanic acid, menthol, spir- 
itus etheris comp., or chloroform may be given. If the stomach is dis- 
tended with gas, asafoetida, spirits of lavender, charcoal, oil of rosemary, 



124 DISEASES OF THE STOMACH. 

or oil of gaultheria may be administered. Sometimes drugs having a 
central action, such as quinine in a dose of ten or fifteen grains, or anti- 
pyrin, acetanilid, phenacetin, hyoscyamus, cannabis indica, or chloral 
hydrate, may ease or check the pain. Opium and its derivatives are 
most eifectual, but should not be used unless absolutely necessary, owing 
to the danger of the easily formed opium habit ; if necessary, morphine 
should be given subcutaneously, only by the physician. The vaso-dila- 
tors, such as nitro-glycerin, aromatic spirits of ammonia, amyl nitrite, 
or brandy, may cut short the attack. Chloroform or a mixture of oxy- 
gen and nitrous oxide may be inhaled until the pain ceases. Atropine, 
2^ of a grain, with hyoscj^amin sulphate or hyoscin hydrobromate, yro 
of a grain, may be given hypodermically. This combination is often 
of extraordinary value in controlling this as well as other severe neur- 
algias. Sometimes an enema of hot water or of the emulsion of asa- 
foetida relieves the pain. If we are able to locate the point of reflex 
irritation — as, for instance, the uterus — soothing applications there 
applied may result in stopping the gastralgia. The treatment of the 
nervous conditions underlying the gastralgia is considered under the 
General Treatment of the Gastric Neuroses (p. 134). 

Nausea. — The nausea here referred to is a neurosis due to external 
causes, such as grief or intense worry, or to reflex causes, such as abnor- 
mal conditions of the eyes, nose, pharynx, or tonsils ; it may be the 
result of the pelvic reflex (pregnancy), and is a common symptom in 
neurasthenia and hysteria, being present sometimes for days wdthout 
intermission, although perhaps not accompanied by vomitiug. The 
stomach contents may be normal or some secretory disturbance may 
be associated with the nausea. That which seems to be w^iolly ner- 
vous nausea may depend upon gastro-intestinal toxaemia or lithsemia. 

Treatment. — The treatment depends upon the cause. If the sym]> 
toms of neurasthenia are pronounced, valerianates, bromides, nitro- 
glycerin, and diffusible stimulants may give relief. If the heart is 
strong, the administration of acetanilid, antipyrin, or phenacetin is occa- 
sionally followed by a subsidence of the nausea. If the urine is hyper- 
lithic, alkalies exhibited before meals often cause a disappearance of the 
symptom in a few days. If constipation exists, calomel should be given, 
and may be followed by aloes, podophyllin, or salines. If there is low 
blood pressure and cerebral anaemia, digitalis and nux vomica and the 
cold spinal douche are followed by good results. Local gastric sedatives 
sometimes give relief, but are not as effectual as they are in inflamma- 
tory conditions of the stomach. Chloroform, cocaine, bismuth, cerium 
oxalate, hydrocyanic acid, or carbolic acid should be tried. Lavage 
with hot water usually gives temporary and, sometimes, permanent re- 
lief. 

Anorexia. — This term signifies total lack of appetite, although it is 
used to denote various degrees of diminished appetite. Hunger is the 
expression not only of a state of the stomach, but of the ultimate cells 
of the body. The stomach may be empty for days, and still anorexia 
persist. Loss of appetite may be due to nervous depression or to over- 
stimulation of the stomach. It usually accompanies nausea, and may 
persist after nausea ceases. It is a very common symptom of neuras- 
thenia and hysteria, and may coexist with good digestion. It may be 



NEUBOSES OF THE STOMACH. 125 

temporary ox continue for weeks or months, often coming and going 
irregularly. Occasionally it is associated with a disgust for food. Un- 
savory dishes, poor cooking, uninviting food may excite anorexia in a 
sensitive person, although there is a distinction between the lack of a 
desire for food and a dislike for certain dishes. The condition may per- 
sist until the patient loses flesh and strength, and in rare instances great 
emaciation results. We observed one case of traumatic neurosis in 
which death resulted from voluntary starvation, and no other cause of 
death was found post-mortem. It is not uncommon to meet patients 
who say they never experience hunger, but force themselves to eat, and, 
as these persons are well nourished, there is reason for thinking there is 
a good deal of exaggeration in their reports. Temporary anorexia may 
be caused by mental excitement or depression. 

Treatment. — In the treatment of this affection abundance of fresh 
air, sunlight, and out-of-door exercise, Avith exhilarating games, are very 
useful, their influence upon the nervous system being perhaps the chief 
factor in restoring appetite. Nux vomica and arsenic are the most val- 
uable drugs, although quassia, cinchona, gentian, condurango, chirata, 
orexin, valerianate of zinc, phosphide of zinc, or asafcetida may be tried. 
If gastric hyhersesthesia exists, sedatives, such as bromide of strontium, 
bismuth, cerium oxalate, or hydrocyanic acid, should be used. 

Hyperorexia. — The term bulimia is used synonymously with hy- 
perorexia, but a distinction may be drawn by saying that the former 
signifies a voracious appetite which is not appeased by anything but 
enormous quantities of food, if, indeed, it is satisfied at all (polyphagia), 
whereas the latter may be applied to a more moderate increase of the 
appetite. There is no criterion by which to govern every man's appe- 
tite, as each individual is a law unto himself in that respect. Some are 
satisfied and well nourished by small amounts of food, while some are 
never in good condition even though they possess large appetites and 
eat enormously. Marked hunger sometimes accompanies hyperchlor- 
hydria, the patient feeling a gnawing desire for food two hours after 
a hearty meal ; or it may appear without any apparent disturbance of 
the stomach whatever, being simply a manifestation of neurasthenia, 
hysteria, idiocy, or insanity. 

Instances of acute bulimia are on record in which enormous quanti- 
ties of food and drink were devoured in a short time, as in some inter- 
esting cases cited by Ewald. We have seen gluttons, including chil- 
dren, gorge themselves until they were obliged to vomit, and still they 
returned to eating. 

The most common form of hyperorexia is that in which the patient 
eats frequently between meals. Some individuals carry food in their 
pockets and take frequent mouthfuls during the day. Some crave food 
in the night, and make a practice of either having a supply at the bed- 
side or of getting up and cooking some savory dish between midnight 
and early morning — a matter that is exaggerated by habit. In order 
to establish a diagnosis of nervous hyperorexia, diabetes mellitus, an- 
aemia, pregnancy, intestinal parasites, insanity, or gross disease of the 
nervous system should be excluded. 

Mild and temporary increase of the appetite may be present in con- 
valescence from acute illness, long, profuse hemorrhage, or profuse 



126 DISEASES OF THE STOMACH. 

diarrhoea. Disorders of the appetite probably have their origin in the 
central nervons system, although in some instances they may be traced 
to peripheral irritation. The existence of a hunger-centre in the 
medulla lu*s been assumed, and is not improbable. 

The TREATMENT should be addressed to the general nervous state, 
and at the same time the patient's will power should be exerted, as the 
condition may be partly habit and can be controlled by mental influence. 
Peripheral irritation should be removed if possible. It may be neces- 
sary in some instances to give opium or morphine, but these " two-edged 
swords " should be used cautiously, as neurotics are ever prone to fall 
from one habit into another. 

Parorexia. — Parorexia signifies a desire for unusual articles of food, 
or for substances that cannot be called food, as slate-pencils and chalk. 
In rare instances this condition becomes a true psychosis in which the 
subjects eat disgusting and filthy substances with apparent relish. 

Idiosyncrasies. — The untoward effects of certain articles of diet as- 
sume most interesting and perplexing phases, causing phenomena that 
may be local or remote. Some individuals cannot eat beefsteak, others 
cannot eat oysters wdthout gastric discomfort, while potatoes, milk, eggs, 
parsnips, the different fruits, and many other ordinary articles of diet may 
each induce some form of stomach disturbance, such as pain, flatulency, 
nausea, vomiting, or diarrhoea, one or two things being usually singled 
out as offenders, while everything else agrees. The remote efl'ects 
include pruritus, erythema, urticaria, cancrum oris, herpes labialis, 
angioneurotic oedema, asthma or hay fever, and other similar disturb- 
ances which may follow the ingestion of shellfish, pork, cheese, celery, 
strawberries, or other foods that are not disturbing to the great majority 
of mankind. These peculiarities on the part of certain individuals 
cannot all be explained by assuming that the gastric nerves are hyper- 
iesthetic and therefore convey reflexes readily. The phenomena may 
be due to the absorption of certain principles in these foods which are 
to these individuals toxic and act through the blood upon the vaso- 
motor and trophic nerves of distant parts. 

Motor Neuroses. 

Eructation. — Gastric flatulency with belching is one of the most 
common of the neuroses. When the stomach fills wdth gas and does 
not allow its escape the condition is termed pneumatosis. Nervous 
belching frequently accompanies neurasthenia and hysteria. We have 
seen it continue uninterruptedly for forty-eight hours in the case of a 
lady whose horses ran away, throwing her from lier carriage, causing 
fracture of the tibia near the ankle." The belching was finally con- 
trolled by mistura asafoetidse cum opio. Eructation is sometimes asso- 
ciated with relaxation of the cardia, and, even though the cardia has 
good tone, it relaxes to intragastric pressure before the pylorus does, 
owing to its being the weaker sphincter. The origin and composition 
of the gas is doubtful. In some organic diseases of the stomach fer- 
mentation results, and eructations then consist of hydrogen, nitrogen, 
.and carbon dioxide. In the condition under consideration, however, 



MOTOR NEUROSES. 127 

the gas is probably chiefly composed of air that has been swallowed, 
although it may be mixed with gases from the blood and intestine. 
Woods Hutchinson advances the suggestive hypothesis that in some 
forms of gastric flatulency we have an instance of a reversion to the 
respiratory function of the stomach. Federn announces that if a 
healthy individual in the dorsal decubitus practises deep inspiration 
without swallowing, the amount of air found in the stomach is per- 
ceptibly increased. In some cases belching proceeds from the oesoph- 
agus. We frequently fail to find the stomach distended with gas in 
nervous patients complaining of bloating and belching. The act of 
belching may take place in nervous persons without gas being raised. 
Gastric Aveight, fulness, distress, or pain may be complained of by those 
who are subject to eructation, and there is almost universal testimony 
that relief follows belching. Cardiac palpitation, fulness in the head, 
vertigo, blurring of the vision, and a feeling of suffocation are symp- 
toms occasionally present with pneumatosis, which . disappear or are 
very much diminished by free eructation. 

Treatment. — Local gastric sedatives seem to check flatulency some- 
times by quieting excessive or irregular peristalsis. Bismuth subcar- 
bonate or subnitrate may be used alone or in combination with alkalies. 
Very finely powdered hardwood charcoal, as suggested by Leared, given 
in teaspoonful doses in wafer papers, afibrds temporary relief in almost 
•all cases. The charcoal should be reignited in an iron capsule, bottled 
while hot, and kept carefully stoppered. Aqua chloroformi, if given 
freely, may exert some control. Emulsum asafoetidee is one of the best 
remedies for nervous belching that we have at our command ; it should 
be given in half-ounce doses three or four times a day. Its disagree- 
able odor is the chief objection to its use, but such decided relief is 
experienced that patients are soon willing to take it. The aromatic 
oils of rue, cinnamon, cloves, peppermint, rosemary, and valerian are 
sometimes useful, as also are capsicum and gentian. In deficient secre- 
tion hydrochloric acid should be given, as it prevents flatulency by its 
•eflect upon gastric motility as well as upon the chemical change of the 
food. If constipation coexists, rhubarb with senna or aloes should be 
employed. Lavage and gastric faradization should be resorted to if 
other means fail. 

Regurg-itation ; Psrrosis; Heart-burn. — This is a condition in which 
the food rises involuntarily from the stomach into the oesophagus or 
mouth. It is a frequent symptom of organic disease of the stomach, 
such as catarrhal gastritis, and as a transient symptom is commonly 
seen when a healthy stomach is irritated by an improper meal. As a 
distinct neurosis, unaccompanied by any structural change, it is seen in 
neurasthenic and hysterical patients, being perhaps associated with, and 
somewhat dependent upon, gastric hypersesthesia, with probable relaxa- 
tion of the cardia. It occurs more commonly in women than in men, 
and usually follows the ingestion of food. Patients complain of the 
intense acidity of the regurgitated food, which, however, upon examin- 
ation, is found to be that of normal stomach contents. Eegurgitation 
frequently results in healthy individuals from accidental fermentation, 
but in those suffering from this neurosis the symptom occurs when the 
stomach contents is normal, although it is undoubtedly increased when 



128 DISEASES OF THE STOMACH. 

fermentative changes coexist. As a rule, when a small amount of food 
is regurgitated the nutrition of the patient is not appreciably impaired ; 
on the other hand, food may be raised so frequently and persistently, 
and may be so copiously ejected, that ^yeigllt and strength are quite 
rapidly lost, and the condition may eyen induce extreme ^yeakness and 
emaciation. Sometimes regurgitation is largely a habit, and the patient 
becomes convinced that no meal will remain in his stomach ; further- 
more, abnormal sensory states are developed and a feeling of comfort 
follows the expulsion of food. In some hysterical cases the food is 
expelled from the oesophagus before it reaches the stomach, almost 
immediately after it is swallowed. In the diagnosis it is important to 
exclude the functional disturbance known as merycismus or rumination 
as well as oesophageal stricture, carcinoma, or benign stricture at the 
cardia, and gastrectasia with pyloric stenosis ; these all being conditions 
interfering with the onward passage of the food. 

Treatment. — In addition to the general treatment of the neuroses, 
regurgitation calls for a few special measures. Local sedatives often 
diminish the intragastric irritation, thereby lessening excessive gastric 
peristalsis and the subsequent relaxation of the cardia. Bismuth sub- 
nitrate or subcarbonate may be given suspended in mucilage of traga- 
canth. A pleasant preparation is oifered by making a mucilage of 
tragacanth with chloroform or cherry-laurel Ayater and thoroughly 
mixing the bismuth with it, making an emulsion of the consistency of 
cream, which may be given in teaspoonful doses immediately before 
eating. Owing to the hypersesthesia of the gastric mucosa in this con- 
dition, the acidity of the stomach, even though it be normal, should 
be somewhat lessened by the administration of alkalies. Strychnine 
imparts tone to the muscular fibres of the cardia, and is sometimes 
effectual for the relief of this condition. 

The intragastric use of the interrupted current through Einhorn's 
electrode is sometimes beneficial. It may be applied from five to eight 

Fig. 2. 




Einhoru's deglutible gastric electrode. 

minutes two or three times a week, or every day for a short period if 
the case demands urgent measures. 

Merycismiis ; Rumination. — This is a rare affection in which the 
food is voluntarily raised from the stomach into the mouth, when it 
is remasticated and again swallowed. It is literally " chewing the 
cud," and is in all probability a distinct neurosis, occurring in both 



MOTOR NEUROSES. . 129 

sexes and at any age, except, perhaps, infancy. Rumination may exist 
during most of a lifetime, while, on the other hand, it may be of short 
duration. In some cases separate articles of food can be raised at will, 
and patients aver that from a mixed meal they are able to raise this or 
that particular food some length of time after it has been eaten. The 
food is said not to have an unpleasant taste, but even in some cases 
a pleasant one. If this is true in any case some time after eating, 
at may be assumed that gastric digestion is partially or wholly sus- 
pended, else the food mass would be sour and bitter from free acid and 
peptone. 

Merycismus should be distinguished from regurgitation. Both are 
associated with relaxation of the cardia, but merycismus is a voluntary 
performance. In some cases, post-mortem, the cardia has been found 
much dilated, and it is probably insufficient in most cases. The gastric 
chemistry may be normal, and no structural disease of the stomach ex- 
ist ; usually no depreciation of health results. 

Teeatmext. — The chief remedial measure consists in emphatic in- 
struction to the patient to swallow the food immediately without remas- 
ticating it, and to persistently endeavor to resist the desire to raise food. 
The intragastric electrode may be used, the faradic ciu-rent being em- 
ployed. Patients may be instructed to chew gum after meals or to hold 
a bit of licorice or some sialogogue in the mouth, or the emulsion of 
asafoetida may be given in half-ounce doses after meals, when the 
patient may find it very unpleasant to remasticate the food mixed 
with asafoetida, or the drug may have a controlling influence ujDon 
the nervous disturbance. Constitutional treatment should not be 
neglected. 

Vomiting-. — Vomiting is one of the most common of the neuroses, 
being seen most frequently in neurasthenic and hysterical women, al- 
though it is not uncommonly observed in men. It may occur at any 
age, but it usually supervenes between the twentieth and forty-fifth 
years ; it is very apt to come on at the menopause ; it results from re- 
flex irritation in many cases ; it may occur infrequently and cause but 
little loss of flesh, or it may be severe and persistent, causing pro- 
nounced emaciation, and in rare cases death may result. The pelvic 
organs are a very common source of reflex irritation, causing nervous, 
vomiting, as there exists a very intimate connection between afffectiona 
of the stomach and the pelvic organs in women, the vomiting of preg- 
nancy being an illustration of this. Floating kidney and visceroptosis 
are also fruitful causes of this disturbance. Frequently eye-strain is the 
principal causative factor. In some cases it is very difficult to determine 
whether the disturbance is due to some reflex or toxaemia, as, for instance, 
ursemia. Certain it is that in some instances, apparently dependent 
upon malposition of the uterus, the vomiting is controlled best by 
eliminative measures, such as free catharsis and the induction of pro- 
fuse diaphoresis, and in the vomiting of pregnancy hot-air baths are 
sometimes of signal service. In some cases all the food eaten is 
said to be rejected, but very little weight is found to have been lost 
even though the trouble has persisted for a considerable period. The 
stomach tube discloses plenty of food remaining in the stomach in these 
patients. Nausea is not constant, but may be marked and accom-. 

Vol. III.— 9 



130 DISEASES OF THE STOMACH. 

panied by salivation. Some persons subject to this affection learn by 
experience that certain articles of food cause them to vomit or certain 
combinations cannot be eaten, as, for instance, fruit and cream together, 
although'either may be taken alone with impunity ; they also learn to 
stop eating after a definite amount of food has been taken, one mouthful 
more causing disturbance. Vomiting may be accompanied by other 
nervous symptoms, as belching, cardiac palpitation, numbness of the 
hands or arms, or disturbance of vision. It is probable that a habit, 
may be formed which enables the patient to vomit voluntarily in some 
instances. Sometimes the disturbance is paroxysmal, and everything 
that is swallowed is quickly rejected for a number of days. 

Diagnosis. — The diagnosis involves the exclusion of diseases of the 
brain and cord or their coverings, structural affections of the stomach, 
the onset of infectious diseases, ursemia, and other well-known causes 
of vomiting. 

Treatment. — For controlling an acute attack chloral and bromide 
per rectum are more effectual than remedies given by the mouth ; fifteen 
or twenty grains of chloral and a drachm of potassium bromide in a 
mucilaginous vehicle should be given an adult by enema in one dose. 
Hyoscin hydrobromate or morphine may be given hypodermically ; 
atropine may be tried combined Avith either of these. Carbonated water, 
ice-cold, or very hot water may quiet the stomach. Sometimes the pas- 
sage of the stomach tube immediately checks an attack, and if not thor- 
ough lavage with hot water will be found to be the best measure for 
temporary relief, or the intragastric use of the positive continuous cur- 
rent may be tried. The nervines asafoetida, valerian, and sumbul may 
be employed. Nitroglycerin in small and oft-repeated doses is occa- 
sionally of great service. Local gastric sedatives are usually disappoint- 
ing in their results, yet are sometimes unexpectedly successful. The 
list includes carbolic acid, cocaine, cerium oxalate in doses of 10 or 15 
grains, the bismuth salts, chloroform water, and hydrocyanic acid. Of 
these, cocaine, cerium oxalate, and carbolic acid are most reliable, and 
it cannot be denied that they may to some extent have a central as well 
as local effect. Fasting is a time-honored and useful measure ; it should 
be thoroughly carried out, and nothing whatever allowed in the stomach 
for from twenty-four to fifty -six hours. 

Vomiting in Alcoholism. — The morning vomiting is commonly at- 
tributed to subacute gastritis, which, in fact, is sometimes the case ; 
we are satisfied, however, that in the majority of instances the symptom 
is another expression of the unbalanced nervous system that causes the 
tremor, muscular inco-ordination, and other motor disturbances. While 
it would be unwise to disregard the structural changes or the other 
functional disorders of the stomach in alcohohsm, it is nevertheless true 
that the greatest success in treatment is that directed toward the nerv- 
ous system and that which is found to " steady " the patient generally. 
Among the remedies that are most successful for relief are the aromatic 
spirits of ammonia, Hoffman's anodyne, strychnine in full doses, atro- 
pine, cannabis indica, the bromides, chloral, and arsenic. Local stimu- 
lants are often of signal benefit, and one of these is capsicum. Gastric 
sedatives are rarely of use, which may be considered as evidence that 
gastritis is not present. The discontinuance of the habit is frequently 



MOTOR NEUROSES. 131 

followed by>cessation of the vomiting; on the other hand, the symp- 
tom is temporarily relieved by the taking of the " morning dram." 

Peristaltic Unrest. — This is the opposite of atony. In some in- 
stances the stomach empties itself precipitately, especially when relaxa- 
tion of the pylorus is present; in other cases the pylorus remains 
closed, and with a full stomach the peristalsis may be seen, by careful 
inspection of the epigastrium, in distinct waves lifting the abdominal 
walls and moving from the cardia toward the pylorus. We have fre- 
quently observed large and strong peristaltic waves of an over-full 
stomach with carcinomatous pyloric stenosis — a condition that should 
be differentiated from nervous unrest. Sometimes the peristalsis is 
reversed, the waves moving from the pylorus toward the cardia, or 
irregular waves may hurry one another, and finally settle in some point 
in tonic contraction, causing, perhaps, more or less pain. This consti- 
tutes a stomach colic, so called. Regurgitation and belching are 
common results of peristaltic restlessness, or diarrhoea may result from 
the food being hurried into the intestine. 

Treatment. — Chloral and hyoscyamus may be given in small doses. 
Strontimn bromide in ten- or twenty-grain doses before meals may be 
tried. If the stomach contents are superacid, sodium bicarbonate or 
the light magnesium carbonate, with or without bismuth, should be 
given an hour or two before meals. If stomach colic occurs, opium 
may be given in sufficient dosage. Special treatment is usually un- 
necessary, as the symptom disappears under the influence of measures 
directed toward accompanying gastric disturbances. 

Atony. — This denotes a state of diminished muscular activity of the 
stomach resulting from causes operating to depress the nervous system. 
Atony may exist a long time without giving rise to any symptoms, but 
when it causes considerable delay in the onward passage of the food a 
sense of weight, fulness, and vague distress, with flatulency, usually 
supervenes. Many degrees of atony are met with. Patients present 
themselves one day with food in the stomach six or seven hours after 
its ingestion, while a few days later the same stomach is found empty 
after a like meal. In some cases gastrectasia results from atony ; we 
have a number of cases in our record books in which the lower iDorder 
of the stomach reached nearly four inches below the umbilicus when 
first examined. Sometimes hydrochloric acid is present in high per- 
centage, as in the atonic superacid (Germain See) stomach ; in other 
cases it is below normal or may be absent. Food stagnation, as a rule, 
is not as marked as in gastrectasia depending upon pyloric stenosis, but 
in a few cases we have found food present that was eaten several days 
before. Dilatation from atony may result in considerable loss of flesh. 
In one of our patients who was greatly emaciated the lower border of 
the stomach reached nearly the pubes. Under lavage and intragastric 
faradization he gained forty-five pounds in two months ; food stagna- 
tion was at first very marked, but soon disappeared under treatment. 
Constipation is the rule, and atony of the colon a frequent accompani- 
ment. 

Treatment. — Lavage should not be practised too often ; it is best 
employed at night, leaving the stomach empty until morning. Intra- 
gastric faradization is of signal benefit; the strength of the current 



132 DISEASES OF THE STOMACH. 

should be as great as can be comfortably borne by the patient, and the 
sittings should last from five to ten minutes. If hyperchlorhydria co- 
exists, " {he gastric sedative " is called for, whereas if hypo- or achlor- 
hydria is found, hydrochloric acid should be administered in large doses 
after meals. Nux vomica or strychnine may be given in large doses, 
excepting in cases "vvith hyperchlorhydria, and physostigma may be used 
as an adjuvant. jNIedical gymnastics and massage of the abdomen are 
useful in this condition. The diet should be carefully chosen ; no 
coarse, indigestible foods should be taken ; mastication should be slow 
and thorough, as it stimulates gastric motion ; the stomach should not 
be overloaded at any time. 

Relaxation of the Pylorus (Pyloric Incontinence). — This condi- 
tion is probably present in cases of precipitate emptying of the stomach, 
as in lienteric diarrhoea resulting from a persistently patulous pylorus ; 
in some cases the pylorus has been found dilated sufficiently to admit 
several fingers. Sometimes the stomach empties itself as early as an 
hour or two after a medium-sized meal. 

We quote the following illustrative case from our records : Three 
hours after a test dinner the stomach was found empty ; on the follow- 
ing day lavage was practised two hours after the same meal with a like 
result ; on the third day the stomach was examined one hour after the 
meal, and again found empty ; on the fourth day lavage was practised 
thirty minutes after the dinner, and the meal was present practically 
unchanged. 

One of the most significant symptoms of pyloric insufficiency is the 
finding of bile in the stomach contents, and the stomach digestion in 
these cases somewhat resembles that found after a gastro-enterostomy 
has been done for relief of the pyloric stricture. 

Treatment. — Faradization internally seems to offer the best results. 
It should be practised two or three times a week, preferably before a 
meal. Rest after meals is indicated. Strychnine may be given in 
ascending doses until the twenty-fifth or twentieth of a grain has been 
reached. Small doses of opium before meals have been found in some 
cases a necessary measure. The diet should be solid and moderately 
stimulating to the stomach from the addition of condiments to the food, 
as, for instance, cayenne pepper or preserved ginger. In some cases 
in which gastric peristalsis is proportionately greater than the pyloric 
contraction large doses of bismuth are beneficial. 

Pyloric Spasm. — This occurs from intragastric irritation, such as 
superacidity, or it may be simply one form of irregular gastric move- 
ment. It may delay the usual emptying of the stomach for several 
hours, and thereby give rise to moderate dilatation. Sometimes peri- 
staltic waves may be seen, especially if the stomach is well filled with 
food. 

Teeatmext. — If the stomach contents show superacidity, the alka- 
lies with gastric sedatives are indicated. If peristaltic waves are seen 
vainly working against the closed pylorus, the stomach should occa- 
sionally be emptied by lavage, and bismuth in some mucilaginous 
vehicle should be introduced into the stomach before the tube is re- 
moved. The diet should be plain, bland, and composed chiefly of milk 
with lime water or Vichy ; zwieback, soft boiled, soft poached, or raw eggs. 



MOTOR NEUROSES. 133 

Relaxation of the Cardia. — The symptoms of this condition usually 
consist in regurgitation and eructation ; sometimes it is associated with 
rumination. The degree of relaxation that may exist is for the most 
part a matter of speculation, and it is more reasonable to suppose that, 
owing to lack of tone, the cardia relaxes to normal intragastric irritation 
and pressure, rather than that the cardiac orifice is actually patulous. 

Treatment. — The treatment of this condition consists in reducing 
the acidity of the stomach contents and in the administration of nux 
vomica, physostigma, gentian, cinchona, or caluraba to excite extra- 
muscular tone. Of these nux vomica is most useful. The intragastric 
application of the faradic current is indicated. 

Spasm of the Cardia. — This condition is not uncommonly seen in 
hysteria, and may be tonic or clonic in character. In a pronounced 
case of this affection we observed spasm that continued uninterruptedly 
for two weeks. The patient was a girl eighteen years old, who gave a 
history of having had somewhat the same condition several years before, 
at which time she was fed through a tube for two weeks. AYe re- 
peatedly endeavored to pass the flexible tube into the stomach without 
success. The patient maintained that she was unable to swallow food 
of any sort. Treatment addressed to her nervous state resulted in a 
gradual disappearance of the dysphagia, and finally in cure. In some 
cases the spasm is excited by emotion, and the patients suddenly find 
that they are unable to swallow food or drink. When retching is per- 
sistent and nothing is vomited, it is probable that spasm of the cardia 
prevents escape of the stomach contents. We have sometimes noticed 
marked contraction of the cardia upon the stomach tube, causing dif- 
ficulty in withdrawing it; more commonly, however, it prevents the 
passage of the tube. 

Diagnosis. — In arriving at a diagnosis it is necessary to exclude 
organic stricture of the lower part of the oesophagus or of the cardia. 
This is done best by angesthetizing the patient, when in a case of spasm 
the tube will enter the stomach without difficulty. If it is not practi- 
cable to use an ansesthetic, the age of the patient, the history of the 
illness, the onset and character of the symptoms, the nutrition and the 
appearance of the patient should be considered. Sometimes these gen- 
eral manifestations are more reliable than information gained by the 
use of the tube under anaesthesia, as illustrated in one of our cases, in 
which an increasing cardiac stenosis was associated with spasm that 
disappeared for several weeks after the introduction of the tube under 
anaesthesia. The diagnosis of spasmodic stricture was not complete, as 
the obstruction returned and the man eventually died of cancer of the 
cardia. If the tube enters a dilated oesophagus and withdraws food, it 
is probable that organic stricture exists. There are cases that baffle the 
skill of the best diagnosticians in that they present all the manifestations 
of malignant disease or organic stricture of the lower portion of the 
oesophagus or cardia, and yet, without either surgical intervention or 
medical treatment, the dysphagia and regurgitation diminish, the patients 
gain weight and strength, and remain in fairly good health for months 
or even years. We have recently observed two instances of this nature. 

Treatment. — Sedatives acting upon the central nervous system are 
indicated, such as bromides, chloral, hyoscyamus, and morphine. The 



134 DISEASES OF THE STOMACH. 

continuous current may be used with the positive pole inside the oesoph- 
agus. If hysterical stigmata are manifest, the emulsion of asafoetida or 
the fluid, extract of valerian may be given by enema. In case of ob- 
stinate spasm it may be necessary to practise gavage or rectal alimen- 
tation. 

General Treatment of the Gastric Neuroses. — A gastric neur- 
osis is the local expression of some constitutional state or nervous 
irritation arising outside of the stomach, and therefore any plan of 
therapeutics based on local treatment alone will ultimately meet with 
failure. Local measures are of the utmost value, however, in pro- 
ducing temporary relief, and recovery is retarded and sometimes pre- 
vented until such treatment is employed. The course should be 
sufficiently broad to include, besides local, such general measures as the 
individual case may require. As far as possible the cause or causes 
should be removed or modified, this being the most important part of 
the treatment. Therapeutic measures applied to the stomach directly 
may result in temporary relief, but in the majority of cases do not cure 
so long as causative elements are operative. For this reason the eyes 
should be examined and refractive errors corrected. Hyperopic astig- 
matism is the most common form of eye-strain met M'ith in nervous 
affections of the stomach. Muscular errors are exceedingly aggravat- 
ing, and constitute a fruitful source of reflex gastric disturbance, but in 
many instances heterophorias yield to proper correction of astigmatism. 
Compound hyperopic or mixed astigmatism, with irregular axes and 
perhaps anisometropia, is a very common form of brain- and nerve-dis- 
turbing eye-strain. Abnormal conditions of the pelvic organs, particu- 
larly in women, constitute another fruitful source of reflex gastric 
disturbance. " Brain-tire " should be relieved by rest and a change of 
scene. Such conditions are most commonly seen in the North toward 
the end of the winter, when men, exhausted by business strain and 
women by social excitement, are usually relieved by a stay at some 
Southern resort or by an ocean voyage. Some individuals seem bene- 
fited by the sea, while others do best in the mountains. 

Improvement in the condition of the nervous system usually follows 
systematic muscular development, and in almost all forms of the gastric 
neuroses carefully prescribed exercise in the gymnasium or in the open 
air, especially the latter, is a necessary part of the treatment ; those 
exercises accompanied by a certain amount of pleasurable excitement 
are to be preferred. 

Floating kidney should be treated by medical gymnastics, a properly 
fitting pad and bandage, or, as a last resort, by nephrorrhaphy. Dis- 
orders of the male genitalia should receive proper treatment. Lithsemic 
patients should be directed to exercise in the open air and sunlight, and 
should be instructed to drink plentifully of pure water free from mineral 
constituents, save, perhaps, lithia, which in some instances accomplishes 
good. If the gastric chemistry allows it, a milk diet may be prescribed 
for a few days, although some lithsemic individuals cannot drink milk 
without inducing hepatic torpor, obstinate constipation, headache, and 
sometimes nausea. Alkalies, such as potassium acetate, potassium 
bicarbonate, potassium citrate, sodium and potassium tartrate and 
sodium bicarbonate, taken in plenty of ^yater from one half to one hour 



MOTOR NEUROSES. 135 

before meals, are very serviceable in these cases when indicated by 
the urine. Those suffering from renal insufficiency should be treated 
by hot-air baths, which modify the nutritive, nervous, and circu- 
latory conditions in some manner as yet not fully understood. They 
may act by favoring elimination in some degree, although Von Noorden 
and others maintain that profuse diaphoresis does not result in the elim- 
ination of urea by the skin, which substance, although itself apparently 
not a poison, may be taken as an index of the amount of other noxious 
substances eliminated by the kidneys. Constipation should be effectu- 
ally overcome : the saline waters, such as Carlsbad, Hathorn, Friedreichs- 
hall, Rubinat-Condal, or Hunyadi Janos, may be used ; aloin, podo- 
phyllin, cascara, and other vegetable cathartics are serviceable. Once 
or twice a week the colon should be flushed with two quarts of hot 
water or boric acid solution introduced through a flexible rubber colon 
tube, passed from eighteen to twenty-four inches into the bowel with 
the patient lying upon the back or right side, the hips being somewhat 
higher than the shoulders. Gouty manifestations call for the use of 
gold and sodium chloride, potassium iodide, and colchicum, together 
with a diet most in accordance with the condition of the gastric chemis- 
try that may be present, hot-air or Turkish baths, and elimination by 
way of the bowels and kidneys, etc. If the gastric condition bears a 
relation to an old syphilitic infection — as, for instance, in some cases 
of obstinate gastralgia or nausea that have fallen under our observation 
and which we have elsewhere described — potassium iodide should be 
used in ascending doses. Hydrotherapy is most valuable, the different 
forms of the cold spinal douche being employed in conjunction with the 
shower bath or the rain bath, half bath or plunge. In the use of hydro- 
therapy for any purpose attention to exact technique is of supreme im- 
portance, as Baruch has particularly emphasized. Sea bathing is decidedly 
beneficial in some cases, while with others it disagrees. Electricity in 
the form of the static spray, general faradization, or the continuous cur- 
rent, used along the spine and over the epigastrium, may be serviceable. 
Medical gymnastics are measures of the highest importance in the treat- 
ment of the neuroses. If nerve irritation is present, tonics and seda- 
tives may be judiciously combined. If the vitality is low and the case 
shows general depression, strychnine or nux vomica in increasing doses 
should be employed. The tincture of nux vomica, commencing with 
five or ten drops, increasing the dose one drop a day up to forty or even 
sixty drops three times daily before meals, as recommended by Musser, 
may be administered ; or strychnine ^^ of a grain, increasing to ^, may 
be given four times a day. Quinine in moderate doses is useful, espe- 
cially in malarial regions and in those who have had malaria. If anse- 
mia is present, iron or red bone marrow may be administered ; anaemia 
is a commonly associated condition and may be in a measure a causa- 
tive factor. In a large number of cases it will be found that blood 
pressure is persistently too low, for the relief of which the long-con- 
tinued use of small doses of digitalis or strophanthus is especially recom- 
mended. Plenty of nutritious food should be insisted upon, and we 
wish to emphasize the prime importance of physiological remedies in 
preference to over-medication. The rest-cure when it is indicated is 
often attended with signal success. 



136 DISEASES OF THE ST03IACH. 

PEPTIC ULCER. 

This morbid process, first placed on firm pathological ground by 
Cruveilhiey, must be distinguished from the various forms of ulcers 
common to other tissues as well as to the gastric mucosa. It is not an 
ulcer according to the common acceptance of the term, but is a local 
necrosis resulting from the action of the gastric juice upon a focus whose 
resisting powers are for some reason diminished. 

Localized suppuration of the gastric mucosa may result from infec- 
tion carried by the blood or by the stomach contents ; erosions may 
result from the introduction of overheated or toxic substances and from 
other causes. Musser has shown that tuberculosis, and Guzot that 
syphilis, produces ulceration of the gastric mucous membrane. Heller 
thinks that syphilis plays an important role in congenital ulcer. Alber- 
toni reported a case in which ulcer was complicated with adenoma of 
the stomach, and Turner described a superficial slough of the gastric 
mucosa in a man suffering from pyaemia. We have seen erosions result- 
ing from extravasation of blood in the substance of the mucosa in cases 
of purpura and scurvy, and Wales reports that such lesions are rarely 
absent after death from the latter affection. Quioroza reported instances 
of ulcer resulting from dysentery, puerperal septicaemia, and typhoid 
fever. The ulceration of gastric carcinoma may be added to this list, 
and yet none of these conform either clinically or histologically to the 
type of peptic ulcer, or, as it is often called, simple, solitary, round, 
perforating, or the " ulcer of Cruveilhier." 

Etiology. — There has been a general acceptance of the views of 
Virchow that ulceration follows hemorrhagic erosions resulting from 
disturbances of the circulation, and that the interruptions of the circu- 
lation for the most part are due to morbid conditions of the gastric 
vessels, and particularly to hemorrhagic necrosis of the mucous mem- 
brane. Given such local disturbance and an active gastric secretion, 
the digestion and disappearance of the necrotic areas would naturally 
follow. There has accumulated considerable evidence that thrombosis 
plays a role in the process. Berthold found disease in the circulatory 
apparatus in 170 of 294 cases; Steiner reports such changes in 71 out 
of a total of 110 cases, finding endocarditis, endarteritis, and endaortitis. 
Thrombosis in various parts was demonstrated 48 times. Janeway 
described a case in which the ulcer was directly due to a fibrinous plug 
found in the gastro-epiploic artery. Provost and Cotard produced 
ulcer in various parts of the alimentary canal by introducing tobacco 
seeds in the aorta. By experimental means hemorrhagic necrosis, and 
later ulceration, have been produced by several investigators. Hitter 
succeeded by poking a dog's stomach with a cane, and Decker reports 
like results from feeding scalding gruel to dogs. After establishing 
gastric fistulse, Quincke injured the mucous membrane of dogs by 
pinching, excising, and tying off small portions, and by applying 
thermal and caustic irritation ; the animals showed no subsequent dis- 
tress nor was the digestion impaired, and the ulcers disappeared after 
a few days, although the repair was delayed by producing artificial 
ansemia by bleeding. Von Soerhn and Silberman advance reasons for 
believing that lowered alkalinity of the blood is conducive to ulcer. 



PEPTIC ULCER. 137 

Typical rouM ulcers have been known to follow severe blows upon the 
abdomen or extensive superficial burns. 

Localized pressure applied over the epigastrium, as is required by 
some occupations — as, for instance, in shoemaking — is mentioned as a 
cause. Zielinski considers narrowing of the lumen of the gastric 
vessels through traction produced by euteroptosis a cause of gastric 
ulcer. The teaching of Pavy that the normal alkalinity of the blood 
enabled it successfully to oppose the development of peptic ulcer, and 
that the appearance of the affection must therefore in part depend upon 
the lowered alkalinity, gained much credence until Samuelson rendered 
the blood neutral and showed that the stomach continued to resist its 
own secretion, thus disproving the theory. It has been generally held 
that the gastric juice had invariably a high acidity in gastric ulcer. 
This view had the support of Riegel. More careful chemical studies 
of the gastric contents have revealed the fact that, while hyperacidity 
is the rule, it is by no means the law. Ritter and Hirsch suggest that 
the hyperacidity is quite as likely the result as it is the cause of the 
ulcer. Free hydrochloric acid is more often absent than is commonly 
believed ; Gerhardt found it absent in 7 out of 24 patients appearing 
at his clinic. There seems to be some relation between the lowered 
alkalinity of the blood and the excessive gastric acidity seen in the 
majority of cases. There can be no doubt that the presence of high 
acidity materially delays the healing of the ulcer, and there may be 
truth in the theory that in the presence of lowered alkalinity of the 
blood and a high degree of acidity in the gastric secretions a compara- 
tively slight disturbance of the part might give rise to a chronic peptic 
ulcer. Admitting these predisposing factors, there must be some other 
influence that interferes with the nutrition at the site of the lesion. 
The theory that the nervous system is responsible for the local disturb- 
ance was long ago suggested. Schiff, Ebstein, and Ewald have each 
experimented by injuring certain parts of the central nervous system 
(optic thalamus, pedunculus cerebri, and spinal cord), and succeeded in 
producing quite uniform changes in the gastric mucous membrane. 
Thalma led to the formation of ulcer by exciting spasms of the muscular 
coat of the stomach through prolonged stimulation of the left vagus. 
Through some such effect may be produced tliose gastric and duodenal 
ulcers that appear after extensive superficial burns. In this connection 
the writer has called attention to the occurrence of local necrosis in 
other parts of the body apparently depending upon nervous influences ; 
such are haematoma auris, herpes of the tonsil, herpetic gangrene, and 
Raynaud's disease. It is a singular fact that the ulcer is most frequently 
found near the pylorus, and generally toward the lesser curvature or 
upon the posterior wall of the stomach. Ewald suggests that this may 
be owing to the gravitation of the gastric juice to the lower end of the 
stomach when the patient is in the upright position. This might be 
considered the predisposing cause, but it seems necessary to include 
some other factor to account for the predilection shown by the disease 
for this region. Gastric ulcer occurs more often in women than in men 
— Ewald claims in the proportion of two to one — and this has been our 
experience. In a series of 90 cases reported by Eichhorst, when the 
diagnosis was made clinically the ratio in which ulcer appeared in males 



138 DISEASES OF THE STOMACH. 

and females respectively was as 71 to 73. More than 75 per cent, of all 
cases are found located near or in the pylorus. It rarely appears upon 
the anterior wall, but when thus located, owing to greater exposure to 
movements'of the viscus against the abdominal wall and to blows upon 
the abdomen, it is more likely to pi'oceed to perforation. It may 
develop in any portion of the stomach wall, and similar processes are 
observed in the upper part of the duodenum and lower part of the 
oesophagus. 

Pathological Anatomy. — In size the ulcer is from a half to two 
inches in diameter. It is not often more than one inch across, although 
one instance is recorded of an ulcer which was more than six inches in 
length and between two and three inches in breadth. The area of the 
stomach wall involved by the ulcer is usually round or oval in form, 
except in chronic cases, when, owing to cicatrization, it is often some- 
what irregular. Its margins are smooth, and there is an absence of 
inflammation in the adjacent portions of the mucosa, although slight 
extravasations of blood are occasionally seen in these parts. As it 
invades the deeper structures of the stomach the ulcer assumes the form 
of a truncated cone, which is more strikingly seen when the necrotic 
process reaches through the muscularis. The base of the ulcer may be 
the submucosa, the muscular coat, the serous coat, or it may end in a 
mass of connective tissue springing from the peritoneum or in some 
neighboring solid organ. As pointed out by Virchow, the direction 
taken by the ulcer bears a striking correspondence to that of the 
branches of the arteries running along the curvatures of the stomach — 
a fact which affords evidence that the cause of the ulcer is involved in 
local defects of the blood supply. In very acute cases perforation of 
the serous covering is apt to occur, particularly when the ulcer is 
located in the anterior gastric wall. Under these circumstances the 
discharge of gastric contents into the peritoneal cavity is probable. 
Perforations through the posterior wall into the lesser peritoneal cavity 
have been reported by Chiari. Through the extension of the ulcer and 
the limiting inflammation of the surrounding structures a sinus may 
be formed which allows a communication of the stomach with the large 
or small intestines, the pleural cavities, the lungs, the pericardium, and 
even the left ventricle of the heart. Gastric ulcer is often recurrent, 
and frequently continues as a chronic affection. When it recurs it is 
prone to appear near the original site. Repair takes place through an 
increase of connective tissue, which by subsequent contraction gives 
rise to a somewhat depressed, comparatively white scar, and the sur- 
rounding mucous membrane may present a puckered appearance. If 
the ulcer has been superficial or small, it is possible for repair to be so 
perfect as to escape the notice upon ordinary inspection. In frequently 
recurring ulcers and in chronic forms of the disease the excessive con- 
nective-tissue growth gives rise to marked induration around the border 
of the ulcer, which leads to decided deformity of the viscus. In this 
manner stenosis may occur at the pylorus, or when other points of the 
stomach are affected the cicatrix may be sufficient to cause the so-called 
"hour-glass contraction," thus dividing the organ into two pouches 
connected by an isthmus. We have seen three instances of this deform- 
ity, in two of which an unlike gastric chemistry existed in the two 



PEPTIC ULCER. 139 

pouches of ^ the stomach. The deformity of the stomach may be 
increased through inflammatory adhesions to other organs. It has been 
noted that in those cases in which severe hemorrhage has occurred a 
chronicity in course is usuaL Numerous instances are recorded of an 
open arterial twig in the floor of a chronic ulcer. 

Symptoms. — As a rule, in the clinical history of gastric ulcer the 
diagnostic symptoms of the disease are preceded by a period in which 
complaint is made only of digestive disturbance and anaemia. The 
appetite is unimpaired, but eating is followed by gastric uneasiness or 
distress with eructation of gas and sometimes acid regurgitation. These 
symptoms gradually or sometimes suddenly increase in severity, until 
the uneasiness becomes nausea and the distress becomes pain, which 
latter symptom is almost invariably limited to a small area situated 
over the site of the ulcer. The tenderness and pain do not shift from 
place to place, but are confined for Aveeks together to a single spot not 
larger than a half-dollar. The pain sometimes radiates to the back, 
and when the ulcer is located on the posterior wall of the stomach the 
pain may be felt in the back only, a little to the left of the tenth dorsal 
vertebra. In the majority of cases the tenderness and pain will be felt 
just to the right of the median line and an inch or two below the 
ensiform cartilage. The pain is usually described as burning or gnaw- 
ing in character ; it appears immediately after eating, is sometimes con- 
tinuous, but is generally alleviated when the stomach contents pass 
onward or when vomiting occurs. The pain is sometimes very severe, 
making sleep or rest impossible, and, although desiring food, the patient 
often denies himself, knowing that eating will increase his sufferings. 
At other times the pain is insignificant, and the ulcer may be unsuspected 
until hemorrhage makes its presence known. Vomiting in gastric ulcer 
sometimes occurs with little preceding nausea. The matter rejected is 
usually, but not always, intensely acid. At times vomiting occurs 
immediately after meals and with striking regularity, or it may occur 
at intervals of several days. 

Gastrorrhagia in connection with these manifestations is regarded as 
the cardinal symptom of gastric ulcer, but, as before stated, may occur 
without previous evidence of the disease. This, however, is not com- 
mon. As a rule, the hemorrhage is accompanied by nausea and vomit- 
ing, and the amount of blood lost is sometimes very large. It is hard 
to estimate the quantity, for the gastrorrhagia sometimes continues at 
intervals for several days, and, besides what is vomited, a considerable 
amount of blood passes the pylorus and is discharged through the bowels, 
giving rise to so-called tarry stools. It is not uncommon for the patient 
to vomit a pint or more of arterial blood, although if it has been retained 
some time in the stomach it may be clotted and dark in appearance. The 
patient may become exsanguinated, and syncope is a common event, for 
which fright is perhaps somewhat responsible. In a proportion of 
cases death from hemorrhage follows — an event that must be less fre- 
quent than believed by Brinton, as we have never seen a fatal case of 
gastrorrhagia from this disease. As will be seen, the classical symp- 
toms of gastric ulcer are localized tenderness and pain made immedi- 
ately worse by eating, nausea and vomiting, sour stomach contents and 
haematemesis, the hemorrhage being arterial in character and usually 



140 DISEASES OF THE STOMACH. 

large in quantity. The anaemia that is sometimes seen is a premonitory 
symptom of gastric ulcer, but is believed by many to be the result of 
the disease rather than a predisposing factor. It certainly is absent in 
the beginniiTg in a fair proportion oJ^ cases, but invariably appears later 
in the disease, partly because of limitations in food, the vomiting, the 
disturbance in digestion, and the loss of blood. Many cases are re- 
ported of young females who have suflPered for months from chlorosis 
and amenorrhoea who have finally developed gastric ulcer. Habitual 
constipation is the rule in these patients — a condition that is commonly 
present when ulcer is active. Attention has been called to the presence 
of neurotic tendencies in those who suffer from this disease, and some 
assert that this affection is most common in those having a nervous 
temperament. Probably this is true in a considerable number of cases, 
but it must be acknowledged that there is no special type in which the 
disease appears. The early digestive disturbances to which reference 
has been made are usually dependent upon hyperchlorhydria ; that is 
to say, there is a rapid solution of the proteids, and the starch diges- 
tion is cut short too promptly, so that amylaceous food causes irritation 
of the stomach. In the beginning of many cases the clinical picture of 
ulcer of the stomach is almost identical with that of hyperchlorhydria, 
and attention is called to the symptomatology described in the section 
on that affection (p. 112). 

Diagnosis. — The cardinal symptoms of gastric ulcer are digestive 
disturbances, followed by pain and tenderness localized to a small area, 
usually immediately to the right of the median line and slightly below 
the ensiform cartilage, and made worse by eating, first appearing im- 
mediately after meals ; nausea and vomiting of very acid stomach con- 
tents ; the appearance of hsematemesis and melsena. The vomited blood 
is abundant and arterial in character. 

In early life hsematemesis is more indicative of ulcer than in middle 
or later life, when malignant disease and cirrhosis of the liver are more 
common. It is important to exclude hsematemesis not arising from gas- 
trorrhagia. We have seen errors in diagnosis made when vomiting of 
blood occurred in chlorotic young women suffering from indigestion, and 
the blood finding its way into the stomach after haemoptysis, epistaxis, 
or bleeding from other parts. AVhen hemorrhage is absent the diagno- 
sis must be based chiefly on the localized pain and tenderness, together 
with other symptoms common to ulcer and these affections. It there- 
fore becomes important to differentiate between gastric ulcer and hyper- 
chlorhydria, acute catarrhal gastritis, gastralgia, cholelithiasis, carcinoma 
ventriculi, and intercostal neuralgia accompanying digestive disorders, 
and finally duodenal ulcer. 

In hyperchlorhydria the distress, nausea, or pain is usually tempo- 
rarily relieved by taking food, and returns an hour or more after eating 
when the total acidity has risen ; whereas in ulcer these symptoms are 
immediately made worse by eating. In hyperchlorhydria the pain and 
tenderness are not strictly localized as in ulcer. In acute catarrhal gas- 
tritis there is an accompanying constitutional disturbance, usually fever, 
anorexia, and toxsemia ; the vomited matter usually has a high acidity, 
but it depends upon the presence of the organic acids ; the tenderness 
and pain are more diffused than in ulcer. In gastralgia there is some- 



PEPTIC ULCER. 



141 



times vomiting, but there is no rule as to the nature of the stomach con- 
tents ; the pain is often aggravated by eating, and the diagnosis between 
this affection and ulcer is sometimes made with difficulty. There is 
irregularity in the duration of pain and absence of localized tenderness, 
and in other respects the history of the attack is that of neuralgia rather 
than of gastric ulcer. This is also true of intercostal neuralgias that 
accompany digestive disorders, and the tenderness along the course of 
the nerves is quite indicative of the affection. In duodenal ulcer the 
pain is most likely to occur an hour or more after taking food ; it is 
usually very intense in character, and is accompanied by localized ten- 
derness somewhat farther to the right than that seen in gastric ulcer. 
Melsena sometimes occurs without the vomiting of blood, although it 
must be remembered that hsematemesis is often present. Differentia- 
tion between carcinoma and ulcus ventriculi may be best understood by 
the following comparison of symptoms : 



Age. 
Pain. 

Tenderness. 
Vomiting. 

Hsemateme- 
sis. 

Digestion. 
Chemistry. 



General 
Condition. 



Ulcee. 



Most common be- 
fore m.id(ile life. 

Immediately after 
meals, severe, 
localized. 

Marked, localized. 



After meals ; very 
acid. 



Abundant, arte- 
rial. 



Eapidof albumin- 
oids ; starches 
delayed. 

HCl in excess, 
total acidity 
high. 

Chlorosis. 



Cancee. 



Eare before mid- 
dle life. 

Irregular, less lo- 
calized, often 
absent. 

Notmarked, some- 
times absent, 
less localized. 

Irregular, perhaps 
persistent ; mu- 
cus and perhaps 
stagnating food. 

Usually scant, 
blended with 
mucus ; coffee- 
ground appear- 
ance. 

Poor, sometimes 
absent. 

HCl absent; lac- 
tic, acetic, and 
butyric acids 
present. 

Cachexia ; tumor 
present. 



Gastealgia 
WITH Indiges- 
tion. 

At any age. 

Intense, not lo- 
calized, little 
influenced by 
meals. 

Superficial, dif- 
fuse, sometimes 
absent. 

Often absent. 



Absent. 



Slow. 
Variable. 



Acute Gas- 

TEITIS. 

At any age. 

Diffuse, not se- 
vere, increased 
by food. 

Diffuse, deep. 



Frequent ; intol- 
erance of food. 



Blood-stained mu- 
cus, and retch- 
ing is present. 

Absent. 



HCl temporarily 
absent; organic 
acids often pres- 
ent. 



Prognosis. — The prognosis of gastric ulcer has become less serious 
since the importance of an early diagnosis has been realized. While 
the proportion of neglected cases which terminate fatally by perforation 
or hemorrhage is unknown, it is found that those that receive early 
treatment almost invariably go on to cicatrization even when severe 
hemorrhage has occurred, so that if this does not prove immediately 
fatal, recovery is to be expected. In 26 out of 93 reported fatal cases 
death resulted from perforation, although hemorrhage was present in 
some of these. Formerly perforation was supposed to be necessarily 
fatal, but by surgical interference a reasonable proportion of these cases 
may be saved, as recent literature shows. Death sometimes results 
from hemorrhage when the ulcer is latent and has escaped diagnosis. 
A proportion of cases terminate in death as the result of exhaustion 



142 DISEASES OF THE STOMACH. 

caused by vomiting and pain that might be averted by satisfactory treat- 
ment. If those cases that through cicatrization lead to pyloric stenosis 
and other deformities of the stomach are taken into estimation, the 
gravity of •the disease increases. It has been said that such deformities 
are made less frequent by early treatment. The prognosis of the dis- 
ease, therefore, depends largely upon timely and appropriate therapeutic 
measures, and, although a small number may end in death, a favorable 
result may be anticipated with an early diagnosis and proper manage- 
ment. 

Teeataient. — In the treatment of gastric ulcer the aim is to re- 
lieve pain, tenderness, gastric distress, and vomiting ; to control hemor- 
rhage, to improve general nutrition ; and, finally, to promote the rapid 
healing of the ulcer. Success in the accomplishment of these aims 
largely depends upon early diagnosis. As has been stated, upon the 
chronicity of the ulcer will depend the extent of the resulting cicatri- 
zation and the subsequent deformity of the stomach. Neglected cases 
are much more likely to be attended with gastrorrhagia. Rest is almost 
indispensable in the treatment of gastric ulcer, and the safest plan is to 
require the patient to maintain the horizontal position in bed, sufficiently 
isolated to provide mental rest. This is too often omitted except when 
hemorrhage has occurred. In subacute or chronic cases the patient is 
usually allowed moderate exercise and to engage in light occupation, but 
it must be conceded that such liberty directly retards the healing pro- 
cess and leads to the continuance of the affection. The importance of 
rest can hardly be too much insisted upon, and the only excuse for its 
omission that can be advanced is uncertainty in diagnosis. Where there 
is a reasonable doubt as to the nature of the disease, it is wiser to de- 
cide in favor of ulcer, as absolute rest is not incompatible with the best 
treatment of the other affections for which ulcer may be mistaken. As 
a rule, the pain, tenderness, gastric distress, and nausea are present in 
direct ratio to the degree of the acidity of the stomach contents. When 
there is a high acidity there is much distress, whereas in low acidity the 
ulcer is often latent and sometimes unsuspected until hsematemesis ap- 
pears. The most rational method of relief of these symptoms, there- 
fore, will be the administration of those remedies that will neutralize 
the acid of the stomach contents and diminish the secretion of gastric 
juice. 

The rules that have been prescribed for the treatment of hyperchlor- 
hydria (page 113) will also apply in the treatment of gastric ulcer. The 
administration of a combination of cerium oxalate, bismuth subcarbon- 
ate, and the light magnesium carbonate in large and often repeated 
doses will be found to afford marked relief to all the symptoms, and, 
if proper rest and suitable diet are prescribed, to their rapid disappear- 
ance. We have had prepared a mixture of these three salts in the 
proportion of one, two, and four parts respectively, in the form of a 
hydrate, of which a tablespoonful may be given every hour or two 
according to indications. It will be found that this preparation acts as 
a mild purgative, which is rather desirable than otherwise, as constipa- 
tion is commonly present in peptic ulcer. When the evacuations 
become too frequent, they may be controlled by the addition of small 
doses of kino or other astringent. Sometimes the addition of creta 



PEPTIC ULCEB. 143 

prseparata and the strontium lactate or bromide is serviceable. The 
time-honored lime water, used with or without milk, is a useful antacid, 
and in some cases acts as a gastric sedative, but is of service only when 
given abundantly. The more active astringents — as, for instance, the 
iron preparations and the silver nitrate — have no real place in the treat- 
ment of this disease. The latter drug has had many advocates, but it 
has gradually fallen into disuse as the disease has become better under- 
stood. There can be no doubt that atropine lessens the gastric secre- 
tion, and some cases that are only partly relieved by the measures before 
described are made comfortable by the use of j^-^ of a grain of this alka- 
loid administered once in four to eight hours. Ichthyol often relieves the 
painful symptoms, and taka-diastase may also be of use. Opium promptly 
relieves the pain and often most of the other symptoms of peptic ulcer, 
but its use is attended with so many objections that it should not be 
employed except in case of hemorrhage. Some of the most deplorable 
instances of the opium habit have arisen from patients having recourse 
to the drug for the relief of the symptoms of chronic ulcer. When we 
consider the activity of the symptoms of this affection, it is somewhat 
surprising to note how frequently no complaint is made until hsematem- 
€sis occurs. The physician is therefore sometimes brought in the first 
place to treat hemorrhage rather than gastric ulcer. It so happens that 
the principles of therapeutics in the two conditions are not incompatible. 
In gastrorrhagia the patient should be kept perfectly at rest in bed, in 
an isolated dark room, with an ice bag over the epigastrium, and should 
be given morphine hypodermically in sufficient doses to procure com- 
plete mental and bodily composure. Fifteen minims (1 c.c.) of the 
aqueous extract of ergot or its equivalent of ergotine should be given 
hypodermically, and this should be repeated every four hours until six 
or eight doses have been given, or more frequently if the hemorrhage 
recurs. The patient's mouth may be moistened with tepid water, but 
the eating of shaved ice that has been so largely advised should be 
omitted, for the reason that it stimulates the secretion of gastric juice 
and is more likely to do harm than good. The incessant thirst that 
follows severe hemorrhage is best relieved by the injection of water 
per rectum. The patient should receive no food per os for at least 
three days after the last evidence of hemorrhage has disappeared. 
Rectal alimentation should be practised, and the food selected should 
be milk reinforced by uncooked eggs and perhaps thoroughly boiled 
pap. When using this method of alimentation the colon should be 
cleared once daily by a large lavement of saturated solution of boric 
acid. It is generally advised that when feeding by the mouth is re- 
sumed the patient should take only minute quantities of milk. There 
can be no doubt that milk is the proper, and in most cases the only, 
food allowable, in which respect we have not improved upon the dictum 
of Cruveilhier, who first described the disease and recommended a milk 
diet for its treatment ; but experience has taught us that when the 
patient begins to take nourishment in the natural way, it is proper to 
give peptonized milk or lime water in milk frequently and in consider- 
able quantity. At first a tablespoonful may be given every hour, and 
after a few portions that amount should be doubled ; the following day 
four ounces of milk may be given every two hours, provided the bowels 



144 DISEASES OF THE STOMACH. 

have been thoroughly opened by castor oil assisted by stimulating 
enemata. When castor oil is likely to induce emesis a full dose of 
calomel, followed soon by magnesium sulphate, may be preferred. As 
soon as it is thought safe to discontinue the use of morphine, which is 
usually after the lapse of forty-eight or fifty-six hours, the administra- 
tion of the gastric sedatives before mentioned should be resumed. 
These remedies should be used in conjunction with the milk diet, 
administered between the portions of milk. The stomach should never 
be over-distended with milk or water, but with this precaution the more 
the gastric contents are diluted the better. In any case of gastric ulcer, 
and particularly after gastrorrhagia, the milk diet should be continued 
until the pain and all tenderness upon pressure have subsided. Then 
a more generous diet may be allowed, but it should be gradually re- 
sumed, beginning with the addition of egg albumen, pap, and other 
forms of thoroughly cooked, dry, starchy food, such as zwieback and 
the crusts of twice-baked bread or rolls. The anaemia and prostration 
sometimes offer formidable problems in treatment when the more 
urgent and tragic symptoms of gastric ulcer have subsided. Iron 
should be employed in the form of the albuminate, and as soon as the 
ulcer is presumably healed albuminoid food should be given frequently 
and in as large quantities as is compatible with good digestion. The 
patient should be urged into the sunlight and open air, and systematic 
massage should be employed, omittiug, of course, all treatment of the 
abdomen. Along these principles of treatment most gastric ulcers heal 
quickly and the patients are restored to perfect health, unless serious 
deformity of the stomach has occurred. When convalescence is estab- 
lished the patient should be instructed to report regidarly for observa- 
tion as to returning chlorosis or other symptoms indicative of recurring 
ulcer. By this precaution a second attack may be averted, and accounts 
of gastric ulcer lasting fifteen or twenty years will be less frequently 
recorded. 



CARCINOMA OP THE STOMACH; OTHER TUMORS. 

Definition". — A malignant new growth of the stomach, usually 
primary, sometimes secondary, accompanied by gastric symptoms and 
progressive loss of flesh and strength, and with grave secondary anaemia. 
The disease seldom lasts longer than from ten months to one and a half 
years after its discovery, and ends fatally. 

Etiology. — Gastric carcinoma occurs most frequently between the 
fiftieth and sixtieth years of age. Almost as many cases occur in the 
decades between forty and fifty on the one hand and sixty and seventy 
on the other. Approximately, three fourths of all cases occur between 
forty and seventy years of age. About 13 per cent, are observed be- 
tween the thirtieth and fortieth years. It may happen in the young or 
in the very old. It is extremely rare in childhood. Sex exerts no ap- 
parent influence upon the frequency of the disease, although statistics 
give a slight preponderance to males. A predisposition to cancer is 
ftrobably inherited in some families, as not infrequently one or more 
members for several generations die of the disease. It is not, however, 



CARCINOMA OF THE STOMACH. 145 

as importantxan etiologic factor as was formerly supposed or as is con- 
sidered to-day by some. 

Gastric carcinoma has been said to be more common in Europe than 
in the United States. It has been reported as relatively infrequent in 
tropical countries, but we have no proof of the accuracy of this state- 
ment. Welch found that relatively fewer negroes than whites died of 
carcinoma in New York City, so that race may have some influence 
upon its frequency. The disease may commence in the cicatrix of a 
gastric ulcer, and chronic catarrhal gastritis and blows upon the epi- 
gastrium have been thought to predispose to its development. It occurs 
most commonly at or near the orifices of the stomach, and may be some- 
what dependent upon local irritation. The parasitic origin of the dis- 
ease has received much attention of late, some investigators having 
found sporozoan bodies in carcinomatous tissue which are supposed to 
bear a causative relation to the neoplasm. It has been recently sug- 
gested that the yeast plant may cause the disease. Woods Hutchinson 
emphasizes the theory that the pylorus among ancestral remains is espe- 
cially prone to carcinoma. 

Pathological Anatomy. — The varieties of carcinoma occurring 
primarily in the stomach are scirrhous, encephaloid, colloid, and cylin- 
drical celled epithelioma. The situation of the neoplasm is commonly 
near or involving the pylorus, while it occurs next in frequency at the 
cardia and least frequently in the fundus. The lesser is the seat of the 
growth more often than the greater curvature. The scirrhous is the 
most frequent, although the medullary and cylindrical celled epithelioma 
are also quite common forms of gastric carcinoma. Scirrhous carci- 
noma is hard, owing to its abundant stroma and its few small alveoli. 
It may appear as a diffused or circumscribed thickening of the walls of 
the stomach. It may be tolerably smooth or present hard nodules pro- 
jecting from the body of the growth. It occurs with the greatest fre- 
quency at the pylorus, where it commonly causes stenosis. The medul- 
lary is soft, appears in irregular masses, and usually ulcerates ; large 
growths sometimes resembling cauliflower are seen in this form. It is 
grayish in color, although it is well filled with blood ; it involves all 
the coats of the stomach, and so readily ulcerates that it is more likely 
to cause hemorrhage or perforation ; and metastases are more common 
in this than in other forms. Microscopically, the stroma is scanty, con- 
tains bloodvessels and numerous alveoli with cylindrical and polyhedral 
cells. Cylindrical celled epithelioma is firmer than, but may resemble, 
the medullary carcinoma. This form is probably derived from the gas- 
tric tubules, as, microscopically, spaces are seen resembling sections of 
tubular glands lined with columnar epithelium. Cysts are not uncom- 
monly seen in this form. The stroma is abundant in some and scanty in 
other instances. 

The colloid variety usually involves the whole thickness of a large 
part of the stomach ; it is sometimes called alveolar carcinoma, as many 
well-defined alveoli are seen filled with gelatinous, translucent colloid 
material, which substance is seen also in the stroma, but only in small 
quantities as a rule. Secondary colloid deposits are often seen in other 
organs, or it may spread from the stomach to adjacent organs or struc- 
tures. 

Vol. IIL— 10 



146 DISEASES OF THE STOMACH. 

Cylindrical epithelioma commonly undergoes colloid transformation. 
A form of epithelioma designated as the squamous or flat celled origin- 
ates in the oesophagus and involyes the cardia by extension. 

Secondary gastric carcinoma is rare ; it may occur, however, second- 
arily to carcinoma of the oesophagus, mouth, upper air passages, or other 
parts. The stomach is deformed in various ways by carcinoma, dilata- 
tion from pyloric stenosis being common. The capacity of the stomach, 
on the other hand, may be much diminished, as in diifuse scirrhous 
carcinoma, which macroscopically sometimes resembles a gastric sclerosis. 
Gastroptosis is common from the weight of the tumor, or more often 
from the weight of the contents of the dilated stomach. The pylorus 
may be displaced downward as far as, or even below, the umbilicus, the 
axis of the stomach being changed by such displacement. Metastatic 
growths are frequently found in the liver, peritoneum, omentum, and 
pancreas, occurring less commonly in the lungs, pleura, brain, spleen, 
and other regions. 

Symptoms. — Early in the disease there may be few or no symptoms, 
but in a proportion of cases distress, pain, and gastric flatulency occur, 
especially after meals, for a considerable period before the true nature 
of the malady becomes manifest. The symptoms may be divided into 
those relating directly to the stomach and those secondary to the gastric 
disease. The character of the symptoms depends somewhat upon the 
location of the neoplasm, and, as the pylorus is the most common seat 
of the disease, they are usually indicative of obstruction at that point. 
Vomiting may' occur at intervals early in the disease, and may not be 
copious. This may be attributed by the patient to some particular 
article of food disturbing to the stomach, as the symptoms subside and 
may not again be noticed for a considerable period. Then comes a time 
when meals are followed by vague distress, which persists or returns 
with greater frequency and is accompanied by noticeable loss of flesh 
and strength. Vomiting now becomes more frequent owing to increas- 
ing gastrectasia and food stagnation. The greater the food stagnation 
the more copious will be the vomiting, and when dilatation is extensive 
several pints may be ejected at one time. Vomiting may occur in the 
night or in the morning before breakfast, and food will be found that 
was eaten some days previously. In some cases no pain is complained 
of at any stage of the disease ; on the other hand, pain may be early 
and persistent, having its location in the epigastrium, though not as 
sharply defined as in ulcer. While usually near the pylorus, it may 
radiate in various directions, sometimes being aggravated by food and 
at other times bearing no relation to the meals. Sometimes belching 
occurs, and early may be mild and not distinctive of organic disease, 
while later it may become more frequent, and the gases expelled may 
be foul smelling, owing to fermentation and putrefaction of the stomach 
contents. Rare instances have been reported of inflammable gases 
having been belched from the stomach. If the growth is located at 
the cardia, dysphagia and regurgitation of food as soon as it is swal- 
lowed are important symptoms. If only partial obstruction exists, 
swallowing may be slow, painful, and difficult. Dilatation of the 
oesophagus usually occurs as a consequence of obstruction at the 
cardia, frequently cylindrical in form, sometimes becoming sufficiently 



CARCINOMA OF THE STOMACH. 147 

extensive to allow 500 c.c. or more of food to collect and remain for 
a considerable period. This may be washed out by the stomach tube, 
and upon examination will be found not to have undergone digestion, 
with the possible exception of that which occurs from continued sali- 
vary action or that which may have occurred from the admixture of 
prechgested foods or digestants, such as pepsin and hydrochloric acid. 
In case the fundus is the seat of the growth, the capacity of the stomach 
is apt to be much diminished, and since fulness and distress may super- 
vene upon the ingestion of a small quantity of food, vomiting may occur 
immediately after eating. We have observed a case of this nature in an 
old man who suifered almost continuous severe pain in the epigastrium 
and vomited frequently, whose stomach was found at autopsy to have a 
capacity about sufficient to admit a man's index finger. In this case food 
was tolerated only in small quantities at a time. Frequently in these 
cases the pylorus is patulous and the food passes freely into the intestine. 
Constipation is a common symptom in this disease, and is most marked 
in those cases having new growths so situated as to cause obstruction. 
It is almost always, therefore, a constant accompaniment of obstructive 
pyloric carcinoma. Diarrhoea may, however, alternate with constipa- 
tion, and may result from intestinal putrefaction consequent upon 
gastric fermentation. Hemorrhage is not usually profuse, although in 
cases of extensive ulceration — as, for instance, in medullary cancer — it 
may be abundant. For the most part, however, bleeding is slow and 
oozing in nature, the blood becoming clotted and changed in the stom- 
ach, being vomited or washed out in a condition resembling " coffee- 
grounds." Occasionally quite large clots are formed in the stomach, 
which usually undergo disintegration and pass through the stomach 
tube with little or no difficulty. Hemorrhage is more frequent in 
medullary carcinoma and cylindrical celled epithelioma than in the scir- 
rhous variety. The blood from the stomach may pass by the bowels 
in large or small quantities, usually the latter. Loss of flesh and 
strength commences early and usually progresses steadily, and late in 
the disease emaciation is very marked and weakness is profound. In 
some cases the symptoms abate for a short time and general improve- 
ment occurs, in so far that a false hope is encouraged and the clinician 
may doubt his diagnosis ; but the disease soon reasserts itself. Ansemia 
is seen in various degrees, there being early secondary chlorosis of a 
mild type, while in the late stages of the disease a severe form of 
chlorosis or a pernicious type of ansemia may be found. The red blood 
cells are not infrequently reduced as low as 1,000,000 per cubic milli- 
metre, and haemoglobin as low as 35 or 40 per cent. Usually megalo- 
cytes, macrocytes, microcytes, and normoblasts are present. In the 
chlorotic types the red cells are very pale, while in the pernicious type 
they are surcharged with haemoglobin. Gigantoblasts are also seen in 
the pernicious type. Moderate leucocytosis is found, as a rule, in 
gastric carcinoma, and may depend upon ulceration of the neoplasm. 
The so-called cancerous cachexia is not always seen, although the 
appearance of the patient is cachectic in a large proportion of cases. 
The skin often assumes a yellowish or lemon color, while the lips and 
mucous membranes may be very pale. Sometimes irregularly shaped 
areas are deeply pigmented, especially upon the hands, wrists, face, 



148 DISEASES OF THE STOMACH. 

forehead, and neck, or in some cases the skin may appear universally 
pigmented, resembling Addison's disease. The urine is sometimes 
superacid and sometimes phosphatic ; the specific gravity is usually 
somewhat low, the urea being diminished, but not more so than occurs 
in other diseases accompanied by equal malnutrition and emaciation. 
Albumin may or may not be present ; sugar, as a rule, is absent, but 
may be present, especially if the pancreas becomes involved secondarily ; 
some observers have found peptonuria and acetonuria ; indicanuria is 
quite common. In making routine examinations for indican we have 
found it in this disease in about 60 per cent, of the cases, but we do 
not find that it bears any definite relation to the absence or presence of 
free hydrochloric acid in the gastric contents, as we have found it in 
cases having free hydrochloric acid in the stomach as well as in those 
without it. In the generally depraved condition of the blood and tis- 
sues it is not a rare thing to find a few hyaline casts, especially when 
the urine is centrifugalized, and they do not necessarily indicate a ne- 
phritis. QEdema may occur along the tibia, around the ankles, or in other 
parts ; it probably results from hydrsemia and poor circulation. We 
have an interesting case under observation at the present time in which 
thrombosis of the femoral vein occurred and gave rise to oedema of the 
left leg, which persisted for a considerable period. 

Physical Examination. — The neoplasm is not always palpable, 
and if the cardia is alone involved, it cannot be felt through the abdom- 
inal walls. The lesser curvature and posterior walls may also be in- 
volved and at no time be palpable. New growths involving the pylorus 
are usually palpable. If the anterior or greater curvature happens to 
be the seat of the neoplasm, it is easily palpable, unless covered by a 
distended colon or obscured by thick or tense abdominal parietes. i?he 
stomach is frequently displaced downward by the new growth or by the 
weight of its contents, so that almost the entire viscus may be reached 
by palpation. It should be remembered that when gastroptosis is thus 
extensive the pylorus especially is liable to be dragged far out of place. 
The displacement is most marked ^^'hen gastrectasia is present. The 
tumor is usually, however, felt in the epigastrium, perhaps a little to the 
right of the median line, is somewhat movable, irregular in contour, 
and firm in consistency. When the stomach is full, it may be pushed 
one or two inches to the right of the median line, while if the stomach 
is empty, it is felt higher up and to the left of the median line. The 
axis of the stomach is changed by the altered position of the pyloric 
extremity, as will be manifest at a glance. The dilatation resulting 
from carcinoma of the pylorus may be slight or extensive. The lower 
border of the stomach may reach the pubes, as occurred in some of our 
cases, associated with some degree of gastroptosis. After the stomach is 
emptied by lavage a tumor which before was not palpable may then be 
easily felt. The presence of gastrectasia may help in diagnosis, as it is 
such a common result of pyloric carcinoma. In some cases, however, 
the disease may be considerably advanced, so far perhaps that the tumor 
is palpable, yet, notwithstanding food stagnation, no appreciable dilata- 
tion exists — a condition of things which may be explained by the oc- 
currence of hypertrophy of the muscularis coupled perhaps with frequent 
copious vomiting, which reduces intragastric pressure and distention ; or 



CARCINOMA OF THE STOMACH. 149 

the pylorus hiay be patulous, notwithstanding that it is the seat of car- 
cinoma. Indeed, the pyloric orifice has been found at autopsy to be 
larger than normal in cases that clinically presented copious vomiting 
of foul contents and other evidences of food stagnation ; it is difficult 
to explain the symptoms in these cases, although the contents have been 
supposed to regurgitate from the duodenum through the patulous py- 
loric orifice into the stomach, and thence to be vomited or washed out. 
The stomach may be inflated with gas, and then the tumor may either 
become more prominent if situated in the anterior wall, disappear if 
located in the posterior wall, or be displaced to the right or upward or 
downward. The degree of gastrectasia will be manifested by the tym- 
panitic percussion note over the gastric area, and the abdominal wall is 
also usually made to bulge out from the gaseous distention. Einhorn's 
gastrodiaphane may assist in determining the size and location of the 
neoplasm, as the transillumination shows with less intensity or not at all 
through the carcinomatous anterior wall of the stomach in contrast to 
the brighter light transmitted through the rest of the organ. By the 

Fig. 3. 



Einhorn's gastrodiaphane. 

same method dilatation and gastroptosis are ascertained with consider- 
able positiveness. The presence of thick abdominal walls renders the 
transillumination faint and inconclusive. Lymphatic glandular en- 
largement secondary to gastric cancer is most frequently found in 
the mesenteric, retroperitoneal, supraclavicular, and inguinal glands. 
Many writers mention the enlarged left supraclavicular gland as oc- 
curring with thoracic or abdominal malignant disease. Troisier particu- 
larly calls attention to this sign, but also admits its presence in other 
diseases. The gland specially referred to is to be felt behind and a little 
above the left clavicle, between the insertions of the sterno-cleido-mas- 
toid muscle. We found it enlarged in a case of carcinoma involving 
the peritoneum and mesentery, but have frequently failed to discover it 
in cases of gastric carcinoma. Secondary carcinomatous deposits may 
be discovered in the liver, peritoneum, omentum, mesentery, or spleen. 
An important matter to be considered is the fact that a fecal mass may 
simulate a new growth, and therefore the colon should be emptied by a 
large enema and the abdomen examined thereafter. In the examination 
of the abdomen certain precautions ought to be observed : the patient 
should lie on his back, with the abdominal muscles relaxed as much as 
possible, and he should also be examined sitting, standing, lying on the 



150 DISEASES OF THE STOMACH. 

side, and in the knee-chest position, in order that the size, consistency, 
contour, movabihty, and relations of the tumor may be the more defin- 
itely determined. 

After careful examination has been made by external manipulation, 
the stomach tube should be passed, as it not infrequently affords valu- 
able information as to the location of the disease. In case the cardia is 
the seat of the growth, the tube will probably meet with obstruction at 
that point, which measures about fourteen inches from the teeth in 
adults. The obstruction may be complete or incomplete, or the tube 
may enter an oesophageal sacculation from which food may be withdrawn, 
in which case it is desirable to determine whether or not it comes from 
the stomach. Food withdrawn from the oesophagus presents for the 
most part an unchanged appearance, except that it is water-soaked and 
mixed with considerable mucus ; it is not digested ; hydrochloric acid is 
absent ; there may be faint acidity from acid foods ; no biuret reaction is 
obtained unless predigested albuminoid foods have been taken ; starch 
may be digested by salivary action. If no dilatation of the oesophagus is 
manifest, organic may be differentiated from spastic stricture by anaesthe- 
tizing the patient, when, in the case of spasm, the tube or sound will 
usually pass easily into the stomach. If the fundus of the stomach is 
the seat of diffuse carcinoma, the capacity of the organ is commonly 
much diminished and a very small quantity of contents is withdrawn, 
showing perhaps no evidence of stagnation ; hydrochloric acid is usually 
absent, while lactic acid may or may not be present. When the disease 
is situated at the pylorus, and consequent dilatation of the stomach is 
present, the tube may be inserted from twenty-six to twenty-eight 
inches beyond the teeth and bring up large quantities of yeasty, foul- 
smelling, dark, semi-fluid contents, with considerable ropy, tenacious 
mucus. Foods may be present that were eaten days or even weeks be- 
fore, and disorganized or clotted blood may be found. The gastric fil- 
trate in such cases usually has a high total acidity, being frequently 85 
to 1 20 from accumulated organic acids with combined and, in a few cases, 
free hydrochloric acid. Usually, however, free hydrochloric acid is 
absent, but we have seen a number of cases in which it was present in 
the advanced stages of the disease : in some of these cases the carcinoma ■ 
was grafted upon the cicatrix of an old ulcer ; in all of them food stag- 
nation existed with more or less gastrectasia. Hydrochloric acid was 
inconstant in some, while constant in others, but in every case it finally 
disappeared, not to return ; its presence, therefore, is not positive evi- 
dence against the existence of gastric carcinoma. Considerable interest 
lies in the question of the presence of lactic acid and lactic-acid-forming 
micro-organisms in the stomach contents of carcinoma ventriculi. Lactic 
acid in the stomach must be considered under two distinct headings : 
First, its presence in the stomach as a preformed acid ; second, its for- 
mation in the stomach after food free from lactic acid has been eaten. 

In 1892, Martins and Luttke found that lactic acid was not a nor- 
mal constituent of the gastric contents, and thereupon Boas investigated 
the subject, and in 1893 announced that all products of the bakery con- 
tained an appreciable amount of lactic acid. He devised for its detec- 
tion a new method that is based upon the fact that manganese dioxide 
and sulphuric acid decompose lactic acid, forming acetic aldehyde and 



CARCINOMA OF THE STOMACH. 151 

formic acidx(see page 100). Boas advised a test meal consisting of a 
gruel made with a tablespoonful of oatmeal flour to a litre of water, 
which may be flavored with a little salt. The stomach is thoroughly 
cleansed by lavage at night and the test meal given. The contents are 
withdrawn in the morning and examined. Boas found by this method 
that lactic acid was never present during normal digestion, nor in any 
abnormal condition of the stomach excepting carcinoma, in which dis- 
ease it was almost invariably present. Cancer may exist, however, 
without the presence of lactic acid. A number of observers corrobo- 
rated Boas' findings, and with him have concluded that the presence of 
lactic acid in the stomach after a test meal, in which it is not preformed, 
constitutes an early diagnostic sign of gastric carcinoma. We have 
found lactic acid by Boas' method in cases of carcinoma of the stomach, 
and in a few cases have been able bv the assistance of this siffn, with 
other important manifestations, to make early provisional diagnoses of 
cancer when no tumor was apparent. On the other hand, we have had 
cases in which no lactic acid could be found, notwithstanding the 
observance of careful technique, and yet gastric carcinoma was found 
on abdominal section in some of the cases and at autopsy in others. In 
all except one case, in which we found no lactic acid, free hydrochloric 
acid was present, but when it finally disappeared lactic acid was found. 
Upon ordinary diet lactic acid is not infrequently present if hydro- 
chloric acid is much diminished or absent from any cause, especially in 
conjunction with motor insufficiency; therefore the conclusion seems 
warranted that in gastric carcinoma, accompanied by free hydrochloric 
acid, lactic acid is often absent even upon ordinary diet, and, while its 
presence may be of diagnostic value, it is by no means positive evidence 
of carcinoma ventriculi. 

A variety of micro-organisms is found in the gastric contents, chief 
among them being the lactic-acid-forming bacilli ; they are present also 
in chronic catarrhal gastritis, although not so abundantly nor so con- 
stantly as in carcinoma. These bacteria seem to find an especially 
favorable habitat in the degenerated epithelium of the mucous mem- 
brane in malignant disease of the stomach. Yeast cells are frequently 
found when there is food stagnation, and occasionally sarcinse ventriculi 
are present, but not as commonly as in gastrectasia from benign pyloric 
stenosis. Besides these a long, delicate, threadlike bacillus (" faden " 
bacillus — Schlesinger and Kaufmann) is often present in carcinoma, but 
has not been found in other diseases of the stomach. 

The rennet ferment and rennet zymogen are considerably diminished 
in carcinoma and also in chronic gastritis, more so in the latter than in 
the former disease, whereas in functional disturbances of the stomach 
they are apparently not affected. Under normal conditions the rennet 
ferment may be active in dilutions up to ^ (1 to 40) and the rennet 
zymogen up to y-i-Q. In carcinoma the ferment may be entirely absent, 
and the zymogen is commonly reduced as low as -^ or ■^. 

Acetic and butyric acids are commonly present in stagnating con- 
tents. The proteoses and, perhaps, peptone are present sometimes in 
excess, owing to impaired absorption. Starch digestion is usually 
retarded or entirely checked by high acidity, but if the acidity is low 



152 DISEASES OF THE STOMACH. 

it is not affected ; in cachectic patients, however, the saliva is of poor 
quality, and is therefore relatively inactive. 

Complications. — The complications are usually in the nature of 
secondary carcinomatous deposits in other parts, although any intercur- 
rent disease may perchance occur. Involvement of, or pressure upon, 
the biliarv ducts by the new growth or impacted gall stones, or duo- 
denitis may cause jaundice. The lymphatic glands, liver, peritoneum, 
or pancreas may be the seat of metastatic growths or be involved by 
direct extension of the gastric neoplasm. Peritonitis, pleuritis, or, 
rarely, pericarditis may occur. A'enous thrombosis may take place in 
the lower, less frequently in the upper, extremities. Metastatic nodules 
mav develop in the brain and cause sudden death. Gastrectasia and 
chronic catarrhal gastritis, coupled, perhaps, with some nervous disturb- 
ance of the stomach, are quite constant results of the carcinoma. Per- 
foration from deep ulcer may occur into the peritoneal or thoracic 
cavities, the transverse colon, or the small intestine. 

Diagnosis. — In the presence of many or all of the symptoms and 
phvsical signs of gastric carcinoma there is usually no difficulty in mak- 
ing a diagnosis. Many cases are atypical ; for instance, vomiting, pain, 
hsematemesis, or other symptoms may be absent; there may be no 
tumor or dilatation ; weight and strength may be fairly well main- 
tained ; therefore some cases are difficult of diagnosis, and in these it 
may not be possible to come to more than a provisional conclusion. 
The cardinal points upon which to base a diagnosis are the age, progres- 
sive emaciation, cachexia, vomiting with or without hemorrhage, obsti- 
nate constipation, and the detection of a tumor with, perhaps, gastrectasia, 
absence of HCl, presence of lactic acid, the finding of abundant lactic- 
acid-forming micro-organisms and the " faden " bacillus. Care should be 
exercised in difFerentiating the disease from gastric and duodenal ulcers, 
chronic gastritis, biliary lithiasis, and carcinoma of contiguous organs. 

Prognosis. — Carcinoma ventriculi is incurable by medical means, 
but the possibility of total extirpation of the new growth not only still 
remains a hope, but in the future may be more frequently realized than 
in the past. In 1881, Billroth performed a successful pylorectomy, and 
since that time the ojDeration has been done several times with success, 
but the larger percentage die. If the diagnosis could be made earlier, 
the disease might be eradicated by surgical means more frequently than 
has been the case heretofore. Although life may rarely be saved, it 
may be prolonged by surgical intervention, as in the cases of pyloric 
carcinomata in which gastro-enterostomy is performed. Death may 
occur suddenly from perforation into the peritoneal or thoracic cavities, 
profuse gastrorrhagia, or from metastasis into the brain. 

Treatment.— Although no medical treatment yet known cures the 
disease, much may be done to give the patient comfort. If the disease 
is located at the pylorus and has progressed too far to permit of pylor- 
ectomy, gastro-enterostomy frequently prolongs life, stops the vomiting, 
restores appetite, flesh, and strength, overcomes constipation, and may 
be warmly recommended to relieve persistent food stasis. When the 
new growth is situated at the cardia, giving rise to obstruction, with 
consequent dysphagia, regurgitation, and starvation, a gastric fistula 
should be established through which the patient may be fed. 



CARCINOMA OF THE STOMACH. 153 

Aside from surgical measures, the treatment is symptomatic and 
palliative. Vomiting may be lessened by the administration of shaved 
ice, iced carbonated waters, iced champagne, cocaine, hydrocyanic acid, 
carbolic acid, creasote, cerium oxalate, picrotoxin or morphine. If there 
is gastrectasia, lavage is the best measure for controlling the vomiting. 
Pain may be relieved by large doses of chloral or morphine. Pyrosis 
and eructation are best overcome by lavage, but may be lessened by 
sodium bicarbonate or calcined magnesia, menthol, resorcin, ichthyol, 
benzonaphthol, sodium hyposulphite, carbolic acid, sodium salicylate, 
creasote, hydrogen dioxide, potassium permanganate, or charcoal. Since 
Friedreich recommended condurango in 1874 it has been used with 
varying results. Leube and Riegel regard it as a mere stomachic, and 
that is the consensus of opinion concerning it at the present time. In 
the experience of some it stimulates the appetite and lessens vomiting 
and gastric distress. Ordinarily, the fluid extract is used, but Fried- 
reich advised half-ounce doses of the decoction, made by macerating 
half an ounce of the bark for twelve hours in twelve ounces of water 
and then boiling down to six ounces. 

The diet should consist largely of liquid and semi-solid foods, espe- 
cially when pyloric stenosis prevents the passage of large fragments of 
solid food. Peptonized milk, given in four or eight ounce portions 
every two to four hours, often agrees admirably when other foods are 
vomited or cause distress. Beef-juice, clam-juice, scraped beef, syntonin 
made by adding 56 minims of dilute hydrochloric acid to an ounce of 
egg albumen, and allowing the mixture to stand in a w^arm water bath 
for half an hour ; eggs raw or very soft boiled in the manner described 
(see page 113); stale bread, zwieback, toast, " saltines," mealy baked 
potatoes, thoroughly cooked rice, fruit-juices, tea, coffee, and cocoa may 
be allowed. If no pyloric obstruction is present, beefsteak, roast beef, 
lamb chops, roast lamb, tender breast of chicken, bluefish, weakfish, 
mackerel, trout, bass, or other delicate fish, tender cauliflower, beets, 
turnips, lettuce, and other succulent vegetables — in fact, a selected 
mixed diet — are quite permissible. Sometimes feeding by the stomach 
is unsatisfactory, and eventually resort must be had to rectal ali- 
mentation. 

Hydrochloric acid is one of the most valuable remedies in this affec- 
tion. When it is absent from the stomach contents it should be given 
in liberal and repeated doses after meals, as much as a drachm of the 
dilute acid, perhaps, being taken in divided doses after each meal. It 
sometimes causes soreness and distress, however, and it cannot be given 
indiscriminately in all cases. 

Lavage gives distinct relief if there is dilatation. It should be prac- 
tised at night two or three times a week, the stomach being left empty 
until morning. It checks the vomiting, lessens gastric weight, fulness, 
and distress, gives the patient a feeling of well-being that conduces to 
sleep, and it not infrequently overcomes the constipation. If not given 
at night, lavage should be practised in the morning before breakfast, in 
order that remaining stomach contents may be removed. 

Constipation should be treated by colon flushing, saline cathartics, 
cascara, aloin, or other mild laxatives, avoiding the employment of 
harsh drastic purgatives. 



154 DISEASES OF THE STOMACH. 

NON-CARCINOMATOUS GaSTRIC TuMORS AND FoREIGN BODIES. 

Benign tumors in the stomach are very rare, and may not give rise 
to any symptoms other than those accompanying nervous dyspepsia^ 
unless they happen to cause obstruction of tlie pylorus or cardia. Mu- 
cous (adenomatous) polypi, formed by hyperplasia of the mucous mem- 
brane, are the most common of the benign tumors. They have been 
found at autopsy scattered over the interior of the stomach, as many as 
one hundred and fifty being present in Leudet's case. They may also, 
though rarely, appear as submucous growths. Fibromata, papillomata, 
lymphomata, lipomata, and cysts may also be found. Sarcoma may 
occur in the stomach, Welch having seen two cases of lymphosarcoma 
secondary to that of the retro-peritoneal glands. In the Vienna clinic 
a case of gastric myoma was seen in 1874, and myosarcomata have also 
been observed. 

Occasionally foreign bodies in the stomach simulate neoplasms, as for 
instance gastroliths composed of shellac with food detritus, as in Best's 
case, or food concretions, as in Kooyker's, in which the gastrolith 
weighed over 800 grammes and caused death. 

Manasse, Friedlander, Langenbuch, and others have also observed 
cases of shellac concretion. 

Hair-balls in the stomach may attain enormous proportions, as in a 
case reported by W. L. Allen of Davenport, Iowa, in which a hair-ball 
17 inches long, including the part that extended into the duodenum, and 
8^ inches in circumference at the greater curvature, was successfully 
removed by gastrotomy in a girl aged sixteen years. Von Bollinger in 
1891 reported a similar large hair-ball found at autopsy in a girl of the 
same age. 

In the insane many foreign bodies are sometimes found in the stom- 
ach. Craig of Albany in 1892 reported the case of an insane woman in 
whose stomach were found one hundred and twenty articles, including 
pins, needles, screws, nails, etc. Juclson B. Andrews and Bastian re- 
ported somewhat similar cases. Foreign bodies in the stomach have 
been demonstrated by means of the a;-rays, and subsequently success- 
fully removed. 



GASTRORRHAGIA AND H^MATEMESIS. 

Bleeding from the stomach is shown by hsematemesis, by the pres- 
ence of blood in the fluid returned through the stomach tube, or by 
melaena. Hsematemesis often occurs without gastrorrhagia, in which 
case the blood may arise in the oesophagus, mouth, or air passages, as, 
for instance, in haemoptysis or epistaxis, and, having been swallowed, is 
subsequently vomited. Exceptionally blood may find its way into the 
stomach through a patulous pylorus when hemorrhage into the intestine 
occurs. Gastrorrhagia may result from local disease of the stomach or 
from constitutional diseases. Among the latter are to be mentioned 
leucaemia, pernicious anaemia, scurvy, haemophilia, Bright's disease, mal- 
aria, and some of the other acute infections. Gastrorrhagia sometimes 



GASTRORRHAOIA AND HJEMATEMESIS. 155 

_ appears in neurotic patients from unknown causes. In females it is sup- 
posed to depend on vicarious menstruation. Although this has been 
seriously questioned by many observers, we have seen two instances in 
which hsematemesis occurred repeatedly at the menstrual epoch and at 
no other time. One case was that of a young girl who suffered from 
hystero-epilepsy particidarly at the time of her menstrual periods. 
Often during these attacks she vomited blood in considerable quantity. 
She was relieved by withdrawing a few ounces of blood from the arm 
on the approach of the period. 

Congestion of the stomach following portal obstruction is a common 
cause of gastrorrhagia, and the obstruction may arise from general 
venous stasis produced by cardiac or pulmonary disease, or it may fol- 
low cirrhosis of the liver or portal thrombosis. The causes of local 
hemorrhage in the order of their importance are — first, peptic ulcer ; 
second, portal obstruction ; third, carcinoma ; fourth, gastritis ; fifth, 
erosion. Besides these, gastrorrhagia occasionally, though rarely, re- 
sults from aneurysm opening into the stomach or from ulceration 
through the stomach wall from some jDrocess arising outside of the 
organ. 

Symptoms, — Save when blood is brought up with the stomach con- 
tents or when it appears in the form of melsena there are no symptoms 
of gastrorrhagia when it is slight. When it is severe, in addition to 
the symptoms above mentioned there will be found present those phe- 
nomena common to all extensive hemorrhages. There occur faintness, 
or even syncope, accompanied or followed by vomiting of blood. There 
are coldness of the surface and sweating, especially of the extremities, 
depression in temperature, dilatation of the pupils, a sighing respira- 
tion, a small, weak, often thready pulse, yawning and stretching of the 
body, and occasionally convulsive movements. Later on blood appears 
in the stools, sometimes copiously ; it has a dark, chocolate-like appear- 
ance, and when accompanied by fecal matter is thoroughly blended 
mth it, the character of the stool thus differing from the discharges 
that occur when the hemorrhage is in the lower part of the intestine. 
The vomited blood may vary in appearance according to the extent of 
the bleeding and the length of time that the blood has remained in the 
stomach. 

Diagnosis. — There is rarely much difficulty in discovering the 
source of the blood in hssmatemesis. The history of the case will 
usually enable one to exclude bleeding from the nose and throat. 
When this is not sufficient a careful examination may determine the 
matter. Exceptionally there is some embarrassment in reaching a con- 
clusion until time has elapsed for further observation. We have seen 
cases treated for gastrorrhagia supposed to depend upon peptic ulcer 
when the bleeding arose from unsusj)ected pulmonary lesions. Large 
hemorrhages from the stomach generally arise from gastric ulcer or 
from cirrhosis of the liver. When from ulcer, the appearance of the 
vomited blood will be bright red and fluid, provided it has not been 
long retained in the stomach. If retained, it may be somewhat clotted 
and dark. When hemorrhage occurs from cirrhosis of the liver, the 
blood is dark, even if vomited immediately, and is often very abundant. 
It is rare for extensive hemorrhage to occur in cancer of the stomach. 



156 DISEASES OF THE STOMACH. 

although such an event may happen when a large vessel is opened by . 
ulceration. Generally the amount of blood is small, having a dark 
granular, " cofFee-ground " appearance, and the hsematemesis is apt to 
be frequeilt. In gastritis the hemorrhage is small and is accompanied 
with mucus or stomach contents. The same is true of erosion. 

Prognosis. — Gastrorrhagia may end in death, although experience 
shows that its course is more favorable than would naturally be ex- 
pected. The fatal cases that we have seen were secondary to hepatic 
cirrhosis. With very rare exceptions the fatal cases depend upon 
cirrhosis of the liver, gastric ulcer, or portal thrombosis. 

Treatment. — The patient should be placed in bed, kept perfectly 
at rest, and isolated from all save the necessary attendants. Mental 
and bodily excitement are alike harmful, and therefore appropriate 
doses of morphine should be given hypodermically. In pursuance of 
the same plan, food and medicine should not be allowed to enter the 
stomach for several days after the cessation of the hemorrhage. For 
the relief of thirst water may be introduced jjer rectum, and at intervals 
of eight to twelve hours a nutrient enema is advised. When the pa- 
tient is in syncope and rallies slowly alcoholic or other stimulants may 
be introduced per rectum, but there is danger in their use, and they 
must be abandoned as soon as reaction is established. The aqueous 
extract of ergot or ergotine should be employed hypodermically, and 
an ice bag applied over the epigastrium. The administration of astrin- 
gents and other hsemostatic drugs is generally worse than useless, as 
they fail to control the hemorrhage and they excite vomiting, an event 
always to be dreaded in gastrorrhagia. Antipyrine is said to have been 
effectual in some cases. 



DILATATION OP THE STOMACH; OTHER DEFORMI- 
TIES OF THE STOMACH; DISPLACEMENTS OF THE 
STOMACH. 

The size as well as the muscular power of the stomach varies in 
different individuals. When large, but capable of emptying itself 
properly, the condition is termed megastria; when of nornial size, 
yet incapable of emptying itself in due time, gastric insufficiency is 
present. When, however, the stomach is larger than normal, holding 
more than from 1500 c.c. to 1700 c.c, and allows food stagnation, true 
gastrectasia may be said to exist. There are instances in which the 
lower border of the stomach is from two to three inches below the 
umbilicus, yet the motor power is sufficient most of the time, there 
being, however, periods of deficient motility with more or less conse- 
quent food stasis. 

Etiology. — The causes of gastrectasia may be considered under 
the following headings : (a) obstruction of the pylorus or adjacent parts 
of the stomach or duodenum ; (6) motor insufficiency of the stomach. 

Carcinoma is the most common cause of pyloric stenosis ; medullary 
and scirrhus are the most frequent forms, the former often growing 



DILATATION OF THE STOMACH, ETC. 157 

rapidly and occluding the pyloric orifice by direct encroachment, or an 
irregular fungoid mass may project into the orifice and plug it in a cork- 
like manner. This form of cancer may involve the pylorus without 
causing extensive gastrectasia, owing to its tendency to ulceration, by 
which process the lumen of the pylorus may be kept tolerably free 
most of the time. Stasis of the gastric contents may be more or less 
pronounced for a few days or weeks, when c[uite suddenly considerable 
quantities of clotted blood with fragments of the neoplasm are vomited 
or washed away, and the food passes into the duodenum with tolerable 
freedom for some time thereafter. We have a case under observation 
at the present time that illustrates this occurrence, Scirrhus, being 
slower in its development, and often causing annular constriction at the 
pylorus, offers a constantly increasing obstruction to the onward passage 
of the gastric contents. At first the lumen of the pylorus is only 
slightly narrowed, and gastric muscular hypertrophy compensates suf- 
ficiently to prevent food stasis. Owing to the progressive nature of the 
disease, the pyloric orifice grows steadily narrower, and the motor 
power of the stomach is, sooner or later, no longer sufficient to over- 
come the obstacle. Then dilatation begins, and at first may be slight 
because of the accompanying muscular hypertrophy, that is yet able to 
empty the stomach if time enough is allowed and if the ingesta is small 
in amount, but not in the normal time even after a limited quantity of 
food. Scarcely two cases are exactly alike in the degree of pyloric 
stenosis and the rapidity with which the stomach dilates, some cases 
requiring many months, others only a few weeks, for the establishment 
of marked gastrectasia. Finally, when the pyloric orifice will allow 
but a minute quantity of gastric contents to pass, gastric motion is of 
little avail, and, whereas in the earlier stages of the disease active and 
forcible peristalsis was present, now the stomach gives up the fight and 
lies almost motionless, distended with gas and stagnating contents. 

The cicatricial contraction of an ulcer occasions dilatation in young 
and middle-aged adults, whereas malignant disease occurs usually after 
thirty-five years of age. The degree of stenosis varies as to location, 
size, depth, and surrounding inflammation of the ulcer. There is usu- 
ally a history of long-standing stomach trouble ; characteristic symp- 
toitis of ulcer may be elicited. It is very rare for annular constriction 
to occur from this cause. The pyloric orifice may be only slightly nar- 
rowed by a healing ulcer, the tissues about the orifice being puckered so 
as to produce a moderate though persistent obstruction with consequent 
ischochymia. In such cases compensatory hypertrophy of the muscu- 
laris may overcome the obstruction for some years, as in analogous con- 
ditions of the heart. As a rule, the more complete the stenosis in benign 
conditions the more extensive is the gastrectasia, although slight occlu- 
sion may be accompanied by great dilatation. In addition to these two 
common causes of pyloric obstruction, others less frequent, and some 
of extreme rarity, may be mentioned. 

A polypoid excrescence of the gastric mucosa near the pylorus may 
be pushed into the orifice whenever the stomach is filled, and thus cause 
obstruction. Hyperplasia of the mucosa and underlying tissues at the 
pylorus may lead to some occlusion. Torsion of the duodenum near the 
stomach from gastroptosis or from a vertical position of the organ is 



158 DISEASES OF THE STOMACH. 

said to cause gastrectasia. Congenital pyloric stenosis is a very rare 
etiologic factor. Pressure upon the duodenum, the pylorus, or the 
stomach near the pylorus may result from tumor of the liver, pancreas, 
or mesentery, from floating kidney, or from constricting bands from 
peritonitis. Ewald mentions a case in which a diverticulum of the duo- 
denum in its first part narrowed the pyloric orifice by pressure, owing 
to its distention with duodenal contents. Spastic contraction of the 
pylorus is considered by some observers to account for gastrectasia in a 
few instances. It probably plays some part in the causation, and may 
be excited by purely nervous influences or by irritating gastric contents, 
hyperchlorhydria, erosion, or ulcer. Too much importance should not, 
hoAvever, be attributed to spasm as a cause of gastrectasia, as it is 
largely hypothetical. In all forms of pyloric stenosis the motor power 
of the stomach is an important factor in determining the extent to which 
dilatation will develop. The conditions favoring muscular hypertrophy 
are good innervation, plentiful supply of well-oxygenated blood, absence 
of inflammatory or degenerative aifections of the muscularis or mucosa, 
vigorous muscular tone, and good general nutrition. In proportion as 
these factors exist in a case will hypertrophy develop and continue com- 
pensatory. As in cardiac lesions, there eventually comes a time when 
from acute or chronic disease, such as typhoid fever or chronic tubercu- 
losis, compensation fails and gastrectasia is brought about. 

Motor insufficiency of the stomach or atony leads to more or less dila- 
tation in a larger number of cases than is popularly supposed. The gas- 
trectasia thus resulting, however, is somewhat irregular as to its extent, 
persistence, and the degree of food stasis it induces. The lower border 
of the stomach may be found three or four inches below the umbilicus, 
with or without an associated gastroptosis, and yet the motor power be 
sufficient to empty the stomach normally. On the other hand, food 
stasis may occur at times, but is not so marked nor so persistent as in 
the case of pyloric stenosis. Nervous symptoms are usually prominent 
in these cases, such as hemicrania, intercostal neuralgia, nervous belch- 
ing, insomnia, cold hands and feet, and numbness in various parts of 
the body ; and one or several causes of general nervous disturbance may 
be operative, as, for instance, worry, overwork, continued nerve tire 
from late hours, with constant excitement, eye-strain, or pelvic disease. 
Anaemia, tuberculosis, diabetes, or any chronic or exhausting disease is 
likely to lead to more or less gastrectasia, owing to poor nutrition of the 
stomach, which is frequently overtaxed when the appetite is increased. 
The muscular coat of the stomach may be weakened by chronic catar- 
rhal gastritis or by an unusually large area of ulceration, sclerosis, fatty, 
amyloid, or colloid degeneration. 

Foreign bodies, such as hair-balls, coins, or gastroliths, may cause 
gastrectasia, both by weakening the muscular coat and obstructing the 
pyloric orifice. 

Finally, gastrectasia is frequently caused by daily over-distention of 
the stomach, as in beer-drinkers, gourmands, or in those who eat exces- 
sive quantities of coarse, indigestible food that cannot readily pass the 
pylorus. Gastrectasia occurs most frequently in middle and advanced 
life, as the common causes are operative during that period. Stenotic 
dilatation is very rare in childhood, while^ the atonic form and that re- 



DILATATION OF THE STOMACH, ETC. 159 

suiting from^ over-feeding, improper feeding, and catarrhal gastritis is 
not uncommonly seen in children. We have observed a number of 
eases of gastrectasia in boys from two to twelve years of age, who re- 
covered under proper dietetic management. The lower border of the 
stomach in these cases was from two to four inches below the umbilicus. 

Pathological Anatomy. — The degree of dilatation may be only 
moderate, or the organ may be so enormously enlarged as to fill a large 
part of the abdominal cavity, pressing upon and displacing other organs. 
Sometimes the dilatation exists in a pouched form, the fundus being 
the portion to dilate most readily. The capacity of the stomach may 
be enormous ; Welch mentions Blumenthal's case, in which sixteen 
pounds were vomited, and Leube a case in which it held thirteen 
pounds. We have observed a few cases in which the stomach contained 
eight pounds, and one in which it held ten pounds. The walls may be 
thick or thin ; in very marked dilatation they are usually thin from 
stretching and atrophy, whereas in stenotic cases muscular hypertrophy 
not infrequently leads to thickening. 

Fatty or colloid degeneration may be found, or connective-tissue in- 
crease with some round cell infiltration may be present. The mucosa is 
frequently in a chronic catarrhal condition, in some areas thickened, in 
others thinned. Atrophy of the glands may be observed. The special 
pathological condition causative of gastrectasia, such as carcinoma or 
cicatricial constriction, constitutes a part of the morbid anatomy of 
the affection. 

Symptoms. — Occasionally acute dilatation of the stomach occurs, 
and in the reported cases sudden vomiting was noticed which persisted 
for several days. At the outset in these cases large quantities are 
usually vomited ; later, emesis is less copious, and finally ceases. Acute 
dilatation may be precipitated by overeating with an exhausted gastric 
innervation. 

Vomiting is one of the chief symptoms of gastrectasia. In cases 
of pyloric carcinoma it may occur early, but usually is delayed until 
food stagnation is present. At first vomiting may occur at long inter- 
vals, perhaps one or more months, but each time it is noticeably copious. 
It usually affords great relief from the pressure, distention, weight, 
pain, and nausea preceding it. As dilatation increases vomiting of 
large amounts of fermenting, sour, foul-smelling contents becomes more 
frequent, until it may occur every day. In some cases, however, emesis 
is not frequent, even in the advanced stages of the disease. In other 
cases regurgitation (water-brash), accompanied by a free flow of saliva, 
constitutes the chief gastric symptom. In cases of atonic gastrectasia 
vomiting is not so common as in stenotic dilatation, and is sometimes 
altogether absent. Pain is an inconstant symptom in carcinomatous 
cases, but is more common in cases of cicatrical ulceration ; it is usu- 
ally absent in atony. Sensation of weight, distress, fulness, burning, 
and soreness in the epigastrium are often complained of in all forms 
of dilatation. 

Eructation is of common occurrence, and the gases raised from the 
stomach may be offensive in odor. II2S is sometimes belched in benign 
and malignant stenosis, being more frequent in the former than in the 
latter. In rare instances the gases have been inflammatory, being 



160 DISEASES OF THE STOMACH. 

partly composed of marsh gas. If there is no pyloric stenosis, the 
belching is often of a nervous character, the gas being odorless. Ano- 
rexia is common in malignant cases, but we have seen an insatiable 
appetite ia cases consequent upon gastric ulcer ; the appetite is often 
capricious in functional gastrectasia. 

Constipation is usually obstinate, especially with pyloric stenosis. 
Ordinary cathartics soon lose their effect, and enemata are resorted to ; 
the stools are scanty and offensive. 

Emaciation is sometimes extreme, but, contrariwise, flesh and 
strength may be fairly well maintained ; in malignant cases loss of 
flesh always occurs eventually. The most marked emaciation we ever 
observed occurred in a man about thirty-eight years of age, the lower 
border of whose stomach reached nearly to the pubes. Food stagna- 
tion was not marked nor were gastric symptoms prominent. The pa- 
tient thought he had pulmonary tuberculosis, and sought advice as to 
change of climate. Under lavage, intra-gastric faradization, and careful 
regulation of the diet he gained forty-seven pounds in ten weeks, and 
the lower border of the stomach was then found at the umbilicus. 

Anaemia of some degree always occurs, but is, of course, of a more 
severe grade in malignant cases. Ordinarily, secondary chlorosis is 
found, although a pernicious type of ansemia may be present. Usually 
the hsemoglobin is reduced ; the red cells number from 2,500,000 to 
4,000,000 ; a few macrocytes and microcytes and poikilocytes are found ; 
the red cells are pale ; leucocytosis may or may not be present. This 
picture may be modified by ulceration, which causes leucocytosis, or by 
the appearance of anaemia of a pernicious type, as occurs late in the 
disease. 

Vertigo, numbness of the extremities, insomnia, and a variety of 
nervous symptoms may be present. Tetany, first mentioned by Kuss- 
maul, is occasionally seen in gastrectasia, sometimes occurring just after 
the use of the stomach tube. The urine is usually scanty, neutral or 
alkaline in reaction ; it may be albuminous, and indicanuria is not infre- 
quent ; the urinary solids are usually low ; peptonuria or acetonuria may 
be found. 

Examination of the Abdomen. — By inspection of the abdomen 
with the patient lying on the back the stomach may be seen bulging out 
below the umbilicus if it is distended with food and gas. Peristaltic 
waves may be seen running toward the pylorus or reversed in the direc- 
tion of the cardia, these being visible only when motion is yet fairly 
vigorous, often disappearing late in the disease. In many cases inspec- 
tion yields negative results. After the stomach is emptied a pyloric 
tumor may be seen if the abdominal parietes are thin and relaxed. 
Gastrectasia may be demonstrated by the avray after the manner de- 
scribed by C. L. Leonard of Philadelphia, in which a bismuth mixture 
is introduced into the stomach to cause a shadow. 

Palpation. — Tumors of the pylorus may be felt through the abdom- 
inal walls ; frequently a tumor is more easily palpated with the stomach 
empty. A pyloric tumor may be felt in the epigastrium midway between 
the ensiform cartilage and the umbilicus or at the umbilicus, to the left 
or right of the median line in either of these positions, or between the 
umbilicus and the pubes, or, very rarely, just above the pubes. Leube 



DILATATION OF THE STOMACH, ETC. 



161 



proposed th& palpation of the tip of a stiff tube through the abdominal 
parietes ; if the end can be felt below the umbilicus, it is evidence of 
gastrectasia, atony, or gastroptosis. Evvald thinks it impossible to feel 



Fig. 4. 





Normal stomach. 



the tip of the tube through thick or tense abdominal walls ; further- 
more, it may engage in the rugse of the stomach walls and not reach 
the lower border. 

Fig. 5. 




Dilated stomach. 



Percussion. — By percussion tympanitic resonance is produced over a 
large area extending from the left free border of the ribs down as far as 
several inches below the umbilicus, sometimes as low as the pubes. The 

Vol. III.— 11 



162 DISEASES OF THE STOMACH. 

fluid contents sink to the most dependent portion of the stomach, and 
in the upright position duhiess may be heard below and resonance above. 
The positiQn of the patient may be further changed and the gastric area 
examined. Sometimes it is difficult to distinguish between intestinal 
and gastric resonance, and then the stomach should be inflated either 
by French's method of allowing the patient to drink separate solutions 
of citric or tartaric acid and sodium bicarbonate, thereby generating 
carbon-dioxide gas in the stomach, which if dilated will bulge out below 
the umbilicus, sometimes as low as the pubes, and its clear tympanitic 
percussion note enables the examiner to map out its boundaries without 
difficulty. In some instances the gas escapes into the duodenum or is 
belched as fast as it is evolved, and then a tube may be introduced into 
the stomach and air pumped in by an attached double bulb apparatus. 
In order to ensure greater accuracy the colon may be filled with fluid 
while the stomach is distended with air, and the diiferentiation thus 
made easier and more positive. Or the colon may be filled with air and 
the stomach with water, percussion being then practised. It is interest- 
ing to note that the normal stomach frequently fills upward instead of 
downward, as pointed out by Jaschtschenko and confirmed by Boardman 
Reed ; that is, if successive glasses of water are taken, the dulness does 
not extend lower, but increases upward, owing no doubt to good gastric 
tone and strong intra-abdominal pressure. If, however, gastric atony 
or dilatation be present, the first glass of water usually causes splashing 
and dulness at or below the umbilicus ; the second glass causes dulness 
still lower ; while the third and fourth glasses depress the lower border 
yet farther. This practically constitutes Dehio's method of ascertaining 
the lower border of the stomach, which, in detail, consists in allowing 
the patient in the upright position and with an empty stomach to drink 
one litre of water in four portions (about a half-pint in each portion),^ 
and ascertaining the lower border by percussion after each portion is 
taken. Another method of determining the size and capacity of the 
stomach consists in filling it through a tube, and then measuring the 
water that is drawn off" or introduced ; but, as Ewald says, " When is 
it full ? " We only have the statement of the patient to guide us. 
Schreiber used a thin rubber bag attached to the end of a stomach 
tube, and filled this with fluid or air, but, aside from its therapeutic 
use as a hot-water bag; in the stomach and its use attached to a man- 

... • • • 1 

ometer for measuring gastric motility and intra-gastric pressure, it has a 
limited value as a means of determining the size of a dilated stomach. 

Auscultation. — Gastric splashing (succussion, clapotement, clapdtage), 
elicited by repeated dippings with the fingers over the stomach, may be 
heard usually with the unaided ear. In examining for this the hands 
should be warm and laid flat upon the abdomen, the walls of which 
should be relaxed ; then the fingers should quickly dip and shake the 
stomach, thus causing a splashing sound. In health this may be heard, 
but is not so easily elicited, nor is it below a line about one inch above 
the umbilicus. In gastric atony or gastrectasia it is a very common 
sign, sometimes the succussion being loud enough to be heard several 
feet away. Like percussion-tympany, splashing may occur as low as 
the pubes. The patient is frequently able to produce the splashing sound 
by alternate sudden contraction and relaxation of the diaphragmatic 



DILATATION OF THE STOMACH, ETC. 163 

and abdomina,! muscles. Occasionally colonic splashing is elicited, and 
may be confused with that occurring in the stomach. Stethoscopic aus- 
cultation, combined with percussion, may assist in determining the 
lower border of the stomach. Eosenbach's method, of pouring succes- 
sive quantities of water into the stomach and then listening Avith the 
stethoscope for air forced through the tube by a bulb to bubble upon the 
surface of the water, may assist in estimating the size of the stomach, 
although in our experience it» has been of little value." As the air 
bubbles break upon the surface of the water in the stomach they make 
a loud metallic, bubbling sound. Einhorn's gastrodiaphane is very 
valuable in locating the lower border of the stomach. In our cases we 
have been uniformly successful with this instrument in demonstrating 
not only the size of the stomach but carcinoma involving the anterior 
wall. 

Examination of the stomach contents yields different results 
in different cases according to the cause and extent of the dilatation. 
The stomach tube should be introduced from twenty-six to twenty- 
eight inches from the teeth in order to siphon out the contents from 
the most dependent portion of the stomach ; usually, however, when 
the tube reaches twenty-two inches or thereabouts, the contents pour 
out copiously, consisting of dark or brownish, semi-fluid, foul, yeasty- 
smelling, sometimes foaming material quite characteristic of food 
stagnation. Foods may be present that were eaten several days or even 
weeks before ; especially seeds are likely to remain in the stomach. 
Usually considerable ropy, tenacious mucus is present, holding food 
particles in its meshes ; if it is not found at the first withdrawal, it is 
often seen in the wash water as repeated flushings are made. 

Free hydrochloric acid is absent, as a rule, in gastrectasia secondary 
to carcinomatous pyloric stenosis, although it may be present either in 
traces or in normal quantities. In 3 cases of pyloric carcinoma observed 
during the past year we found in 1 free HCl .05 per cent, total acidity 
45 ; in another HCl .10 per cent., total acidity 85 ; and in the third 
HCl .14 per cent., total acidity 100. Lactic acid is usually present in 
the malignant cases excepting those having free HCl, in which it is 
absent as a rule. 

With non-malignant stenosis HCl is usually present, sometimes in 
large quantities. It may, however, be persistently absent and the total 
acidity below normal ; lactic acid is nearly always absent in the presence 
of free HCl, but it is quite commonly present on ordinary diet in cases 
without HCl. Acetic and butyric acids are often present, and alcoholic 
fermentation occasionally occurs. The proteoses and peptone are 
present more or less abundantly, unless from atrophy of the gastric 
glands the pepsin and HCl are totally absent. 

Rennet ferment and rennet zymogen are present with free HCl, but 
greatly diminished in malignant cases or when there is atrophy of the 
glands. Starch digestion varies with the acidity of the stomach and 
the amount of mastication and insalivation amylaceous foods are sub- 
jected to. 

Microscopic examination often reveals many forms of bacteria, the 
chief being those giving rise to lactic and butyric acid fermentation, 
besides putrefactive organisms. Sarcinse ventriculi are considered by 



164 DISEASES OF THE STOMACH. 

Boas more common in benign than in malignant stenosis, although 
they are found in the latter, and yeast cells are frequently present. 

In sonie cases of achylia gastrica, with gastrectasia, fermentation 
and putrefaction are not as marked as in the other forms of dilatation ; 
indeed, symptoms in these cases may be slight or absent, and the acidity 
is commonly not over 4 or 5 per cent., notwithstanding considerable 
food stasis. 

Prognosis. — The prognosis in cancerous stenosis is very grave. If 
resection of the pylorus could be made very early, perhaps lives might 
be saved. Gastro-enterostomy prolongs life sometimes more than a 
year, the patients being relieved of vomiting, gaining weight and 
strength, and being comparatively comfortable. 

In benign stenosis the prognosis is not serious, so far as life is con- 
cerned, but is doubtful as to complete recovery, except in case of suc- 
cessful surgical intervention. Care in diet and great perseverance 
along the line of proper treatment often result in restoring gastric 
function, with flesh and strength. In functional dilatation the outlook 
is favorable, provided appropriate treatment be thoroughly carried out. 

Treatment. — Lavage is the most effectual therapeutic measure at 
our command in the treatment of gastrectasia. It unloads the over- 
distended stomach, withdraws toxins, cleanses the irritated and inflamed 
mucous membrane, checks vomiting, relieves nausea, distress, vertigo, 
headache, or a variety of toxic symptoms that may be present. It 
should be practised thoroughly, repeated flushings being made until 
the wash water returns clear. Solutions of boric acid, soda, common 
salt, borax, or Carlsbad water may be used. Potassium permanganate 
should be used in 1 or 2 per cent, solution near the completion of 
the treatment, especially in cases with absence of free hydrochloric acid 
and foul-smelling contents. For the catarrhal condition so frequently 
accompanying dilatation argentum nitrate is an excellent remedy. We 
use a solution of one or two grains in eight ounces of distilled water, 
pouring it through the tube after the stomach is clean and all saline 
fluids have been removed ; it is left there for a few moments and then 
siphoned out ; a small portion remaining is not washed aM^ay. This 
solution may be used with benefit two or three times a week. In cases 
of benign stenosis or spastic contraction of the jjylorus and superacidity 
one or two drachms of bismuth subnitrate or subcarbonate, suspended 
in a few ounces of mucilage of althea, tragacanth, or acacia, or mixed 
with water, may be poured through the tube into the cleansed stomach 
and left there, or a drachm or two of the aqueous fluid extract of 
hydrastis may be used with the bismuth. In associated painful condi- 
tions menthol or oil of gaultheria vapor may be used in the stomach 
by means of a double tube vaporizer, which allows the vapor to escape, 
yet maintains a moderate intra-gastric pressure ; this measure seems to 
act as an analgesic and slight motor stimulant. The best results are 
obtained when lavage is practised at night and the stomach is allowed 
to remain empty until morning. Especially is this true in benign 
pjdoric stenosis, whereas in cancerous stenosis lavage should be prac- 
tised in the morning a half to one hour before breakfast, although occa- 
sionally it may be resorted to at night. The stomach douche should 
not be used too frequently ; there is, however, no rule that can be 



DILATATION OF THE STOMACH, ETC. 



165 



applied to all cases. Many of our cases have gained flesh while having 
lavage and intra-gastric faradization from four to six evenings a week, 
while we find it best to treat other cases only two or three times a week 
or less frequently. The stomach should not be emptied until ten or 
eleven o'clock at night, in order to avoid robbing the patient of nutri- 
ment. Faradic electricity applied by the intra-gastric method is a 
valuable adjuvant to lavage, and it may be applied for five or ten 
minutes after the stomach is cleansed, and of a strength sufficient to 
contract the abdominal muscles. If secretion is depressed or gastralgia 



Fig. 6. 




Einhorn's gastric vaporizer. 



is associated, the galvanic current, from five to twenty milliamperes, 
may be used with the anode inside the stomach. While it is true, as 
Boas says, that lavage should not be used as a routine treatment in 
simple gastric atony, yet wdien atony reaches a stage allowing food 
stasis for twelve hours or longer, lavage and intra-gastric faradization 
result in positive benefit. A few treatments only are required in these 
cases, as a rule, before gastric motility is greatly improved. 

The diet should consist mostly of solid food, properly cooked, except 
in some cases of carcinomatous stenosis, in which practically no food 
passes the pylorus ; in these peptonized milk, raw eg^ albumen, with 
hydrochloric acid, meat powders, and finely comminuted starches, given 
in small quantities at frequent intervals, afford more nutriment with 
less discomfort than do solid foods. In benign stenosis with an abun- 
dance of free HCl albuminoids should comprise the larger portion of 
the food. Meats, such as beef and lamb, should be cut into very small 
pieces at table or chopped or scraped and served in the form of broiled 
meat balls ; eggs should be taken raw or very soft boiled or poached ; 
the white should not be hard ; stale bread, toast, zwieback, the crust 
of rolls, w^ater- wafers, or Graham biscuits may be eaten. Milk plain, 
peptonized, or with one-third lime water or Vichy may be taken in 
moderate quantities between meals to allay thirst in the place of large 
draughts of water, which by its weight embarrasses motility. 

In cases presenting an absence of gastric secretion the food should 
consist largely of amylaceous substances very finely comminuted and 
thoroughly masticated, and HCl may be freely administered in these 



166 DISEASES OF THE STOMACH. 

cases (see page 120). The bowels should be kept open by mild cathar- 
tics rather than strong and irritating drugs. Aloin, podophyllin, or 
cascara ma^^ be used separately or in combination. Largely diluted 
salines should be avoided, as they fill the stomach without being effect- 
ual. Pil. colocynth. comp. or pil. cath. comp., veg. imp,, U. S. P., is 
occasionally efficacious. 

Colon flushing is an excellent measure in this disease, as it cleanses 
the colon, supplies water to the tissues, and acts as a prompt diuretic. 
A soft-rubber tube about the size of a small stomach tube (No. 10 or 
11), thirty inches long, may be smeared with vaseline, passed tMenty or 
more inches into the bowel, and attached to the fountain syringe, con- 
taining two quarts of warm boric-acid solution. The patient should 
lie on the back with the hips higher than the shoulders while the injec- 
tion is being made. Medical gymnastics sometimes assist in emptying 
the stomach. A skilled masseur may succeed in forcing a portion of the 
stomach contents through the pyloric orifice by deep rhythmical manip- 
ulations from below upward and from left to right in the direction of 
the pylorus. Over-medication in this disease is undesirable, as the 
stomach is apt to be intolerant ; there are, however, some remedies that 
seem to do good. Nux vomica is an admirable remedy in atonic dila- 
tation ; it should be given in large doses. In cases of superacidity with 
stenosis from cicatricial ulcer the gastric sedative composed of cerium oxa- 
late 1 part, bismuth subcarbonate 2 parts, and light magnesium carbon- 
ate 4 parts, should be given in drachm doses, stirred in water, between 
meals and at bedtime. An illustrative case of this kind may be cited : 
A young lady giving a history like that of gastric ulcer presented her- 
self with gastrectasia, emaciation, epigastric pain and tenderness ; the 
lower border of the stomach was four inches below the umbilicus. She 
was taught to give herself lavage, which she did admirably at 10 P. m. 
three nights a week, and was given the gastric sedative between meals 
and at bedtime after lavage. The diet was chiefly albuminoid, and 
fluids were restricted by the stomach, but given by large enemata. The 
symptoms all abated ; insomnia, which had been troublesome, disap- 
peared ; in three months she gained thirty-nine pounds, and the lower 
border of the stomach rose to the umbilical level. Ordinary antiseptics, 
such as sodium hyposulphite, resorcin, potassium permanganate, benzo- 
naphthol, zinc sulphocarbolate, and others are not of much value. In 
atonic dilatation general and intra-gastric electricity, tonic hydrotherapy, 
and pleasurable exercise in the sunlight and fresh air are very beneficial. 

The surgical treatment of stenotic gastrectasia is important, and 
may consist of pylorectomy, gastro-enterostomy, pyloroplasty, Loreta's 
divulsion operation, or taking a tuck in the walls of the stomach, thus 
reducing its size (gastrorrhaphy). The best results are often obtained 
in benign stenosis, but gastro-enterostomy in cancerous cases prolongs 
life and alleviates the suffering, and is to be advised if the patient is 
not too weak or old and feeble. Einhorn speaks highly of Heinecke- 
Mikulicz pyloroplasty in benign stenosis, and has had a number of cases 
cured by it. This operation was done in one of our cases, and was very 
successful. Gastro-enterostomy or any operation that will permit the 
stomach contents to pass into the small intestine should be done, and in 
that way vomiting will be checked, weight and strength will be gained, 



DILATATION OF THE STOMACH, ETC. 167 

constipation ^will usually disappear, and good health may be re-estab- 
lished. We wish to emphasize the importance of the surgical treat- 
ment of pyloric stenosis, especially of the benign kind, in which 
pylorectomy has been successful in 54 per cent., gastro-enterostomy in 
71 per cent., pyloroplasty in 77.4 per cent., and digital divulsion in 59 
per cent. 

Gastroptosis. — Defixitiox. — A downward displacement of the 
stomach associated with enteroptosis, nephroptosis, and sometimes with 
prolapse of the liver, spleen, pancreas, and the pelvic organs. 

Etiology. — We are indebted to Glenard for a proper understanding 
of enteroptosis, although, as long ago as 1864, Dietel described floating 
kidney and its manifestations, and Cruveilhier, Virchow, and others 
called attention to the downward displacement of the abdominal viscera. 

A short time after the publication of Glenard's paper, in 1885, 
Lockwood of England in his Hunterian Lectures on Hernia (1887) de- 
scribed the prolapsed condition of the mesentery as commonly associated 
with, and antecedent to, hernia, and he also emphasized the fact that 
there was very frequently accompanying this condition a ptosis of the 
flexures of the colon, as well as of the right and left kidneys. The most 
important causes of enteroptosis are — first, the predisposing condition 
of poor fixation of the abdominal viscera ; second, lack of development 
of the abdominal muscles, causing poor intra-abdominal pressure ; and, 
third, the wearing of corsets or other tight, unyielding garments so 
commonly used by women. In the abdominal cavity, contrary to the 
rule observed in the cranial and thoracic cavities, solidity and fixation 
are sacrificed to liberty of motion of the contained viscera. In a meas- 
ure, this motion is essential to the proper function of the organs, but 
beyond certain limits, that doubtless are not the same for all individuals, 
there is danger that the viscera may drag anchor, as it were, and not be 
again readjusted. The most prominent factor in keeping these organs 
in place is that of strong intra-abdominal pressure, which cannot be 
maintained unless there be good muscular parietes, able and ready to 
contract whenever the viscera beneath are in danger either from without 
or from within. Belts and corsets not only press clown the viscera, but, 
what is even more baneful, they cause disuse and atrophy of the abdom- 
inal muscles. Some occupations also call forth little muscular exertion in 
this part of the body, as, for instance, the sedentary work of the seam- 
stress, tailor, or shoemaker, or any employment that necessitates the 
sitting or stooping position. W. Bruce Clarke ^ particularly calls atten- 
tion to the beneficial influence of rope-hauling, as in yachting and fish- 
ing, in strengthening and developing the muscles of the abdomen. 

The affection is five to six times more frequent in its occurrence in 
women than in men, as may be readily understood when we recall its 
chief causes. Besides the unwholesome effect of the conventional dress 
of women, childbearing is responsible in not a few cases for atonic and 
attenuated abdominal parietes. The pressure of the gravid uterus dur- 
ing the later months of pregnancy leads to stretching and wasting of the 
muscles. 

The condition is not often found before- adolescence, though instances 
have been cited in which it occurred in infancy and childhood. We 

^Brit. Med. Journ., Nov. 21, 1896. 



168 



DISEASES OF THE STOMACH. 



have seen two cases in boys under ten years of age. As many cases are 
seen in debilitated, neurasthenic women, it appears in some to be an 
expression of a general neurotic state. The flabby muscular conditions 
often observed in neurasthenia are doubtless in a measure due to de- 
pressed nervous tone, and it will be readily admitted that abdominal 
relaxation may thus result and cause considerable visceral ptosis ; but 
in the majority of cases neurasthenia is rather the result than the cause 
of the ptosis. Indeed, Glenard classifies the third stage as " neuras- 
thenique," 

In addition to the causes already enumerated, there should be men- 
tioned traumatism, chronic diseases giving rise to emaciation, peritoneal 
adhesions making traction upon the stomach and intestines, and removal 
of large abdominal tumors. 

Anatomical Conditions.— Glenard describes the first change in 
the process as downward displacement of the transverse colon near the 
hepatic flexure as a result of weakness of the colo-hepatic ligament. 
The ascending colon becomes prolapsed, and the transverse colon crosses 
the abdomen obliquely upward and to the left, where the firmer gastro- 
colic ligament usually holds the splenic flexure in proper position. The 
stomach occupies a position allowing its lower border to reach below the 
umbilicus, while its lesser curvature lies between the ensiform cartilage 



Fig. 7. 





Gastroptosis. 

and the umbilicus. The degrees of ptosis differ widely : the greater 
curvature may reach the umbilicus or a point several inches below. The 
gastro-duodenal ligament sometimes gives way in an unusual degree, 
and the pylorus may thereby be carried down to the level of, or below, 
the umbilicus, without a corresponding prolapse of the fundus, thus 
giving the stomach a vertical position. 

Gastrectasia may accompany prolapse of the stomach, antedating 
the latter, or it may result from stenosis dependent upon an acute bend 
in the duodenum or pylorus. Partial occlusion of the colon is brought 
about by the acute bend at the hepatic flexure, and the transverse por- 



DILATATION OF THE STOMACH, ETC. 



169 



tion is usually found empty, and may be distinguished by palpation, 
according to Glenard, as a ridge lying across the abdomen, which he 
terms " corde-colique transverse," but Boas believes this to be the pan- 
creas, which may be more easily felt on account of the prolapsed con- 
dition of the transverse colon. 

The right kidney is almost invariably displaced, and may be either 
simply palpable, movable, or floating according as it has or has not a 

Fig. 8. 





Downward displacement of the pylorus and vertical position of the stomach. 

mesonephron. The left kidney is occasionally, but much less com- 
monly, displaced. The liver is not usually out of place, though it some- 
times is, and may, indeed, be described as floating in rare instances ; the 
spleen, small intestines, and pancreas may also join in that which may 
be termed a general visceroptosis. There may also be noted the coex- 
istence of catarrhal, ulcerative, malignant, or neurotic affections of the 
stomach. 

Physical Examination. — The affection is usually seen in slender 
persons with long, narrow chests showing the marks of the corset. In 
the standing position the upper part of the abdomen sinks in and the 
lower projects. In the recumbent position there is sometimes a lateral 
extension of the abdomen, as distinguished by Glenard, and aortic pul- 
sation is usually observed. 

Gastric splashing is easily elicited in a lower than normal zone, and 
the " corde-colique transverse " before mentioned may be felt near the 
umbilicus, six to ten centimetres on each side of the median line. In 
most cases inflation of the stomach is unnecessary to distinguish its pro- 
lapsed state, although the diagnosis will be more conclusively made by 
inflation or by the use of a quantity of fluid in the stomach or by means 
of the gastrodiaphane. The colon may be filled with water or inflated 
with air, and its boundaries mapped out. The a?-ray may be employed 
for the detection of gastroptosis, it being necessary first to fill the stom- 
ach with a bismuth mixture in order to obtain a well-defined shadow. 



170 DISEASES OF THE STOMACH. 

Symptoms. — Among the symptoms chlorosis is prominent. This 
fact has received reinforcement from the studies of Meinert. There are 
usually lassitude and lowered nutrition. Subjectively, there is at times 
a sensatimi of weight, often strictly localized at some point on the ab- 
domen, occasionally amounting to severe pain. Besides this, intense 
neuralgia may occur, resembling the pain of hepatic colic. Complaint 
is made of gastric distress, made worse by eating. The stomach seems 
unable to empty itself, and the patient is painfully conscious of the pres- 
ence of food. Regurgitation is rare, although eructation of gas is com- 
mon. Constipation is the rule, but there are frequent exceptions. We 
have seen cases in which diarrhoea was a troublesome symptom. In 
many cases the symptom-complex is that of neurasthenia. 

Treatment. — The use of gastric sedatives when the stomach is 
excited, or of motor stimulants when there is gastric atony, is indicated 
as a palliative measure. Aside from temporary comfort, diet avails little. 
The symptoms are best relieved by such hygienic measures as most im- 
prove the general health. 

Increase of intra-abdominal pressure by the wearing of a properly 
iitting abdominal bandage, and the relief of downward pressure made 
by corsets and the conventional waistbands, are of undoubted value, 
provided that suitable exercise of the abdominal muscles is practised for 
a definite period each day while the bandage is in place. At best the 
bandage is a makeshift, and when the abdominal walls are sufficiently 
strong should be abandoned. Systematic muscular exercise by Swedish 
gymnastics should be urged. In severe cases resort should be had to 
surgery. Nephrorrhaphy alone sometimes affords striking relief. 

Other Displacements of the Stomach. — Other displacements of 
the stomach or portions of the organ may occur. The pylorus is often 
carried too far to the right, to the left, or downward to or below the 
umbilicus in malignant disease, with dilatation. Tumors adjacent to 
the stomach may, if large, change its position. In rare instances por- 
tions of the stomach are found in the most remote regions. Welch 
mentions that part of a dilated stomach may engage in a scrotal hernia, 
and w^e have observed an instance in which a large portion of the stomach 
was found in the left pleural cavity — an instance of diaphragmatic her- 
nia. The position of the stomach may be vertical or horizontal, and 
thus its axis planes may be changed. Very rarely the stomach is found 
upon the right side of the body with a transposition of the liver to the 
left. 

Deformities of the Stomach. — In some cases so-called "hour- 
glass" deformity results from contraction of the organ somewhere 
between the cardiac and pyloric extremities, or, as Ewald mentions, this 
same shape may be assumed, owing to exaggeration of the antrum 
pylori ; while some stomachs are sausage-shaped. Gastrectasia really 
constitutes a deformity of the stomach, and in some cases the fundus 
becomes markedly pouched like an aneurysm ; exaggeration of this 
pouching may lead to the formation of diverticuli or cavities in which 
food may lie for an indefinite period. These deformities are rare and 
are chiefly of pathological interest. 



ACUTE CATARRHAL GASTRITIS, ETC. 171 

ACUTE CATARRHAL GASTRITIS; PHLEGMONOUS GAS- 
TRITIS ; TOXIC GASTRITIS ; INFECTIVE GASTRITIS. 

Since William Beaumont in 1833 published his remarkable conclu- 
sions based upon the study of his patient, St. Martin, the subject of 
acute gastritis has found a definite place in pathology. After the lapse 
of more than half a century our conception of the morbid process has 
received but slight modification. There is, perhaps, too great a tendency 
to find the analogue of gastritis in the inflammation of the mucous 
membranes more readily observed, and by many the process continues 
to be classed as a catarrh of the stomach. Although under certain 
conditions the gastric mucosa is capable of secreting mucus abundantly, 
yet in health the goblet-shaped mucous glands are numerous at the car- 
dia only, and rapidly disappear as the pylorus is approached, so that 
few are found in the fundus and none at the pyloric extremity of the 
organ. The gastric mucosa is, in fact, a layer of tubular glands closely 
placed together, and emptied by ducts that are lined by cylindrical epi- 
thelium which is continuous on the surface of the membrane. An 
inflammation of the gastric mucosa or glandular tunic therefore ap- 
proaches an adenitis in character rather than catarrh of the ordinary 
mucous membrane. It is true that under inflammatory conditions the 
goblet-cells extend more generally in the mucosa, and hence more 
mucus is secreted ; and, besides this, the cylindrical epithelium when 
changed by inflammation is capable of secreting mucus. From this 
standpoint, therefore, the process may be regarded as catarrh, and it 
would seem that the term that most fitly describes an inflammation of 
this structure is catarrhal gastritis, which may occur either as an acute 
or a chronic affection. Before taking up the etiology of gastritis it is 
best to consider certain extrinsic factors that influence first the function 
of the stomach, and next its morbid processes. 

First, the blood supply is subject to variations regardless of the re- 
quirements of the organ, as a result of interference with the general 
and portal circulations, particularly in diseases of the heart, lungs, and 
liver. Second, there is very close relation between the functional states 
of the stomach, the intestines, and the liver, and the morbid condition 
of one of these' invariably results in a disturbance of the other two. 
Congestion, an ever-important factor in inflammation, may thus fre- 
quently embarrass the gastric mucosa through these means, when no 
cause for such congestion exists in the stomach itself. As has been 
stated when speaking of functional disorders of the stomach, that organ 
is influenced through nervous reflexes from many remote irritations. It 
is known that the stomach may be irritated, congested, its secretions ex- 
cited or diminished, its motion stimulated or held in abeyance, and its 
sensation disturbed in various ways by the gastric neuroses. It is not 
easy to draw the line between certain functional disorders and those 
structural changes that can be called inflammatory. Unquestionably, 
many so-called instances of acute gastritis are in fact cases of hyper- 
chlorhydria, gastric anacidity, or gastric hypersesthesia ; on the other 
hand, it is probable that the various gastric neuroses play an important 
role in the evolution of gastritis. Differentiation in the processes is not 
now under discussion, but it is proper to call attention to the fact that 



172 DISEASES OF THE STOMACH. 

gastritis, common though it be, does not exist as frequently as has been 
supposed. 

Acute Catarrhal Gastritis. — This afiPection occurs in various degrees 
of severity, from a mild inflammatory process unaccompanied by febrile 
disturbance to an active and deep inflammation of the mucosa accom- 
panied by marked toxaemia, high temperature, and other serious con- 
stitutional manifestations. 

Etiology. — The causes that produce congestion of the gastric 
mucous membrane and the various functioual disorders that lo^ver the 
resistance of the stomach invite inflammation. The exciting causes 
may be found in overtaxing the stomach by the ingestion of an excess 
of coarse, uudigestible food materials or of poorly prepared or irritating 
foods. The frequent repetition of such indiscretions further and further 
depresses the resistance of the stomach, and an inflammatory reaction 
occurs undoubtedly, assisted in many cases by acrid products of fermen- 
tation in the stomach contents, either with or without the invasion of 
the tissues by bacteria. Certain substances, such as shellfish, fuugi, 
and " high " game, are prone to excite gastritis in some individuals, and 
other substances that are usually wholesome may overtax the stomach 
sufliciently to induce inflammation under certain circumstances. An 
excellent illustration of this may be seen in the very young, in whom 
gastro-enteritis is easily set up by the use of substances wholesome for 
the more sturdy adult, but positively dangerous to the undeveloped 
child. Analogous to this is the gastritis that occurs from the indiscreet 
feeding of the convalescent or the aged. There is truth in the popular 
belief that taking cold will induce a mild gastritis, just in the same 
way that an enteritis with profuse diarrhoea is sometimes established. 
Gas1:ritis is almost invariably associated with the acute infections, and 
in some of these death takes place as a direct result of this complica- 
tion. By some writers this form of the disease is described as a special 
affection under the name of " sympathetic gastritis." 

When the general resistance of the patient is reduced by prolonged 
fatigue comparatively trivial indiscretions in diet will excite gastritis. 
Such dietetic faults become more harmful when, because of poor teeth 
or hurried eating, proper mastication is neglected. It is not impossible 
that dental caries, stomatitis, and disease of the naso-pharyngeal cavi- 
ties may be occasionally the source of infection in gastritis. 

Pathological, Axatomy. — The post-mortem observations of the 
stomach are notoriously unreliable, owing to the rapid disorganization 
that takes place by reason of the activity of the digestive ferments 
upon the mucosa. Studies upon animals have confirmed the descrip- 
tion given by Beaumont of the process in man. The mucous membrane 
becomes swollen and hyperasmic. Projections like deep-red pimples are 
distributed over the surface, some sharp-pointed and red, and others 
containing serum, changed epithelium, or pus ; and in other places 
irregular red patches, varying in size from a small point to an inch or 
more in circumference, are to be seen. In connection with these may 
be aphthous crusts. Abrasions and erosions of the mucous membrane 
may occur, and shreds of tissue may be dislodged. The interglandular 
substance is infiltrated with leucocytes and distended by serum. Some 
of the peptic glands are abnormally gramdar. At first the gastric 



ACUTE CATABBHAL OASTBITIS, ETC. 173 

secretion may be increased ; later on an excess of mucus appears, and 
hydrochloric acid is found absent, while in some cases fermentation acids 
are found in large amounts. 

Sympto:ms. — In the mildest cases the symptoms of catarrhal gas- 
tritis are of short duration, and consist of gastric uneasiness, with loss 
of appetite or disturbance of the sense of taste, generally accompanied 
by constipation. The tongue becomes coated and the complexion loses 
its clearness. Twenty-four hours may suffice for the restoration to 
normal condition. In more aggravated cases there is a sensation of 
uneasiness, and sometimes there are pain in the stomach and tenderness 
upon pressure. There are nausea and vomiting, first of the stomach 
contents, and then of a watery mucus. The tongue loses its tone, 
becomes broad and indented by the teeth, and is covered with thick 
white fur ; the breath is offensive, and patients complain of a disagree- 
able taste in the mouth. The bowels are generally constipated, at least 
in the beginning of the attack ; later on there may be diarrhcea as the 
result of extension of the process into the intestine. The area of 
hepatic dulness is usually increased one inch or more, and there is some- 
times tenderness over the liver. The skin, while not icteric, has a 
suggestion of that appearance, and is clammy and loaded. The pulse 
is increased in frequency, small in volume, and usually weak in force. 
There is a sensation of lassitude, often very marked, accompanied by 
headache and general malaise. The urine is scant, high colored, very 
acid, precipitates urates in abundance, and often shows a marked reac- 
tion for indican. These symptoms rarely continue longer than two or 
three days, then gradually subside, leaving a somewhat irritable stomach 
for some time after. In the most acute cases, and those in which the 
inflammatory process reaches the deeper portions of the glandular 
tubules, and in which round-cell infiltration and serous exudation are 
marked — where, in fact, there occurs a real inflammatory oedema — the 
constitutional symptoms are correspondingly serious, and it is common 
to find high temperature, frequent and thready pulse, with persistent 
and painful vomiting, and the picture of prostration that is seen in all 
severe abdominal inflammations. Schmidt, Gussman, and others sup- 
port Lebert in the position that symptomatically there is reason for 
believing in an infectious gastritis pursuing a course similar to that of 
typhoid fever. AVhile many of these cases have been reported, it is not 
shown that they are not instances of the so-called sympathetic gastritis. 
It must, however, be noted that the disease may persist with tempera- 
ture and prostration for a week or more, accompanied by marked loss 
of flesh and general disturbance of nutrition, when no other disease can 
be detected. 

Tkeatment. — The indications for treatment are to remove the irri- 
tating cause and the succeeding toxemia, and provide the stomach 
with rest. Where vomiting has been profuse it will not be necessary 
to empty the stomach, but in other cases an emetic dose of ipecac should 
be given, succeeded by large draughts of warm water. Xo food should 
be allowed, but water may be taken either very hot or with shaved ice. 
If useless retching persists after the stomach is empty, it may be soothed 
by chloroform water, menthol water, bismuth subcarbonate, or the 
cerium oxalate. The last-named drug is probably the most useful. A 



174 DISEASES OF THE STOMACH. 

mixture of one fourth of a grain of cocaine with a drop of carbolic acid, 
given in a little mucilage water, is sometimes very effectual. Where 
ipecac ha^ not been used as an emetic it may be employed frequently in 
very small doses to relieve nausea. It is always important to procure 
an early evacuation of the bowels, for which perhaps it is wise to ad- 
minister a full dose of calomel, ten grains for an adult, and follow it 
after three or four hours by an appropriate saline draught. After free 
catharsis the nausea usually subsides. Sometimes purgatives are not 
retained, and their administration must be postponed. It is not neces- 
sary to use anodynes, save in very severe cases where much pain and 
other serious constitutional symptoms are present ; then morphine may 
be given hypodermically in small doses, to be repeated guardedly. The 
unnecessary use of opium in this affection is objectionable on the ground 
that it opposes elimination, and in gastritis there is always sufficient dis- 
turbance of the entire alimentary tract to create toxaemia, which is 
responsible for many of the general symptoms. Finally, local applica- 
tions may be of service ; poultices or hot fomentations over the epigas- 
trium are very grateful to the patient, and sometimes more relief follows 
from a full hot bath than any other measure. The most sensible treat- 
ment is a mercurial purge, diaphoresis by the hot bath, complete rest in 
bed, and absolute abstinence from food until the attack has passed by. 

Phlegmonous Gastritis. — Phlegmonous gastritis is a very rare 
aifection, and is sometimes found to accompany acute infectious processes, 
at other times apparently occurring as an idiopathic aifection. In 1892, 
Mintz had been able to find but 43 reported cases. Its exact etiology 
is not known, although it has been met with more commonly in men 
than in women. It occurs as a diffuse purulent infiltration of the sub- 
mucosa and muscular layer, usually appearing as scattered abscesses, 
but occasionally localized"^ as one or two large abscesses which may be 
felt upon palpation. These may rupture internally into the stomach 
or may discharge themselves into the peritoneal cavity. 

Symptoms. — The most striking local symptom is pain of great 
severity, burning in character, in the epigastric region, accompanied by 
marked tenderness, and sometimes by a sensation of fulness or distention. 
There is occasionally constipation, but more often diarrhoea with tym- 
panites. There is absence of tenderness upon pressure over the lower 
portion of the abdomen, and movements of the patient are beheved not 
to cause the severe pain found in peritonitis. There is incessant, pain- 
ful vomiting, the tongue is heavily coated, and the breath offensive. 
The temperature reaches 104° or 105° F., the pulse is exceedingly rapid 
and feeble, and chills or chilly sensations occur. The diagnosis is rarely 
made, for the reason that the constitutional symptoms may as well 
belong to any other abscess as to phlegmonous gastritis. The disease 
resembles circumscribed peritonitis. It commonly terminates in death, 
although recoveries have been reported. 

Toxic Gastritis. — This term is limited to inflammation of the 
stomach produced by the swallowing of caustic or intensely irritating 
substances, as, for instance, the mineral acids, caustic alkalies, arsenic, 
phosphorus, mercuric chloride, and alcohol. 

Pathological Anatomy. — When the poison is sufficiently caustic 
there will be found destructive lesions of the mucous membrane of the 



ACUTE CATARRHAL GASTRITIS, ETC. 175 

mouth and pharynx. The appearance of the gastric mucosa varies 
according to the character of the poison, the amount taken, the quantity 
of stomach contents present when the poison is swallowed, and the length 
of time elapsing before its removal. When the irritative substance is 
diluted or when there is present a large amount of food material in the 
stomach, the damage to the mucous membrane may be slight, involving 
only the superficial epithelium and not extending into the glandular 
tubules. The epithelium shows cloudy swelling and fatty or mucoid 
degeneration. A marked hypersemia exists, and erosions of the mucous 
membrane may be found at scattered points where the surface was most 
exposed. More marked changes follow the introduction of the stronger 
mineral acids, and vary in appearance according to the variety of the 
acid. For instance, from strong hydrochloric acid there results a white, 
bleached-out appearance ; from sulphuric acid the tissues have a yellow- 
ish hue ; and from arsenic acid a thick croupous exudate sometimes 
covers the mucous membrane. In fact, the appearance of the lining of 
the stomach varies strikingly according to the nature of the caustic sub- 
stance taken. The inflammation extending into the tubules results in 
necrosis of the glandular structure and a round-cell and serous infiltra- 
tion of the submucosa or even deeper parts. At other times large 
patches of the raucous membrane slough off, and when repair occurs, it 
shows an increase in stroma and a decrease in glandular elements. In 
severe poisoning the mucosa is largely destroyed, and, if life is suf- 
ficiently prolonged, becomes a dark-colored bleeding slough, accom- 
panied by erosion and ulceration. Ebstein has shown that in cases of 
poisoning by alcohol and phosphorus the gross appearance of the stomach 
may not show much alteration from the normal, but microscopic exami- 
nation reveals cloudy swelling and fine granular degeneration involving 
the mucosa and submucosa, accompanied by slow destruction of the 
glandular elements and the progressive increase of connective tissue. 
Should improvement occur after toxic gastritis, the convalescence is 
slow, and the secreting function of the gland is likely to remain em- 
barrassed because of the cicatricial changes in the mucosa ; deformity 
of the organ may result from deep ulceration and resulting scars. 

Symptoms. — The patient experiences intense pain in the region of 
the stomach, made worse by the accompanying vomiting. The vomited 
matter shows bloody mucus or blood and shreds of mucous membrane^ 
and later the presence of pus. The constitutional symptoms are great 
prostration, partly the result of shock and partly of toxaemia ; there 
is rapid, feeble pulse, coldness of the extremities, a high temperature, 
and generally scant and sometimes albuminous urine ; the bowels are 
usually constipated. In mild cases the symptoms are of course less 
conspicuous. 

Diagnosis and Treatment. — There is usually history of the 
poisoning to assist in forming a diagnosis. When the mineral acids, 
ammonia, and some other substances are swallowed, the nature of the 
trouble can be approximately learned by the appearance of the mouth 
and throat. When possible it is important to ascertain the exact nature 
of the poison, as the treatment is considerably modified thereby, but 
when the history and the appearance of the fauces fail to provide the 
necessary information it is wiser not to begin special treatment until 



176 DISEASES OF THE STOMACH. 

the stomach has been emptied and the nature of the poisonous sub- 
stance ascertained. The first steps toward rehef are the dilution of the 
stomach^contents bv hirge draughts of water, to be immediately followed 
by the emptying of the stomach by an emetic or the stomach tube. 
Unless there is serious destruction of the mucous membrane of the 
pharynx, it is wnser to practise lavage, continuing it until the stomach 
is completely emptied. If a stomach tube is not at hand, a hypodermic 
injection of apomorphine should be given, and in the mean time steps 
taken to wash out the stomach. In the absence of the ordinary instru- 
ment a piece of common rubber tubing may be employed. If acids have 
been taken, large amounts of the light magnesium carbonate and a solu- 
tion of sodium bicarbonate should be immediately swallowed. When 
the poison consists of one of the caustic alkalies, lemon juice, tartaric 
acid, and the common cream of tartar or vinegar should be adminis- 
tered, well diluted. The success attending the local treatment of the 
stomach will depend upon the promptness with which it is carried out. 
Quickness in utilizing the first convenient remedy will often save life, 
whereas the time lost in searching for ideal measures may lead to a 
disastrous termination. One attendant should rapidly administer raw 
eggs, mucilage, or flour paste, while a second is taking steps to empty 
the stomach. Subsequently the bowels should be thoroughly moved 
by large doses of magnesium sulphate. Castor oil may be selected for 
the same purpose, except in phosphorus-poisoning, when all fats must 
be avoided. A solution of the cupric sulphate may be administered 
after phosphorus, and the freshly prepared hydrate of iron, or dialyzed 
iron to which salt has been added, after arsenic-poisoning. Where an 
opportunity for further treatment of the gastritis occurs the patient 
should be supported by rectal alimentation and the stomach kept at 
rest. Mucilage water with the bismuth salts is at times admissible. 
It will be found necessary to use morphine subcutaneously to relieve 
shock and depression. 

Infective Gastritis. — Inflammation of the gastric mucosa is seen 
as a complication of many acute infective diseases, and is sometimes 
described as sympathetic gastritis. Considerable attention has been 
given to the study of local infection as a cause of gastritis. In certain 
cases no other cause is found, but more often there is preceding hyper- 
semia or chronic gastric catarrh not connected with infection. So far, 
the matter possesses more pathological than clinical interest, but the field 
promises to reward further investigation. At present Ave are not pre- 
pared to state that there exists any special form of inflammatory stomach 
disease dependent upon ascertained bacterial invasion, although instances 
are not wanting of infection from streptococci, organisms of the proteus 
group, and the colon bacillus. Frankel, Deininger, and Klebs have 
described peculiar conditions of the stomach depending upon organisms 
not strictly classified. So far as knowai, the treatment is the same as 
that described for acute gastritis of the common type. 



CHRONIC GASTRITIS; EROSIONS OF THE STOMACH. 177 

CHRONIC GASTRITIS; EROSIONS OF THE STOMACH. 

Definition. — A secondary chronic inflammation of the stomach 
involving the mucous membrane and underlying tissues, sometimes 
chiefly affecting the mucous membrane, at other times the submucosa 
and muscular layer. 

Etiology. — Persistent functional disorders of the stomach are apt 
to cause catarrhal gastritis, owing to impairment of epithelial and 
glandular vitality, imperfect digestion because of excess or diminution 
of secretion, or delay in the propulsion of food onward from atony. 
It may result from repeated attacks of acute or subacute catarrhal 
gastritis, especially in cases when these are caused by over-indulgence 
in irritating and indigestible foods or alcohol. The habit of hurried 
eating, with insufficient mastication and consequent poor insalivation, 
not infrequently gives rise to catarrhal gastritis, especially when large, 
coarse masses of food are swallowed. Highly irritating condiments, 
such as mustard, pepper, and spices, too freely used, may in time induce 
a chronic inflammation which may be superimposed upon prolonged 
congestion of the mucous membrane. The disease occurs secondarily 
to some organic disease of the stomach, especially carcinoma and gas- 
trectasia ; it may also accompany gastric ulcer. Passive hypersemia of 
the stomach consequent upon the obstruction to the portal circulation 
from hepatic cirrhosis, pulmonary emphysema, chronic bronchitis, non- 
compensated valvular heart disease, or disease of the myocardium, 
renders the mucous membrane vulnerable to the invasion of bacteria 
or the irritation of fermentation resulting from their presence. The 
affection also occurs in the course of chronic diseases, such as tubercu- 
losis, gout, diabetes mellitus, and nephritis, partly depending upon 
toxaemia and partly upon reduced resisting power. Caries of the teeth 
or gingivitis, with an unhealthy condition of the mouth and nose or 
post-nasal ca\'ity — as, for instance, ozsena — may cause catarrhal gas- 
tritis, owing to numerous putrefactive micro-organisms and their prod- 
ucts that may be swallowed. Excessive use of chewing tobacco or 
alcohol is liable to induce the disease, and as an illustration we have 
observed the case of a man who made a practice of holding an unlighted 
cigar between his teeth most of the time, gradually chewing it to a 
stub, and from whose stomach we have upon several occasions washed 
a considerable quantity of tobacco with an abundance of ropy mucus. 
The patient complained of gastric discomfort and anorexia, and was 
relieved by 'discontinuing the habit. The stomach almost constantly 
contains a variety of bacteria, and it is very probable that catarrhal 
gastritis is sometimes caused by their action. 

Pathological Axatomy. — At autopsy the mucous membrane 
appears somewhat thickened, although it may be thin in areas ; it is 
covered with a layer of mucus which may be clear and thin or tough, 
grayish, and thick ; it has a yellowish gray color with areas of deep 
red injection, especially near the pylorus ; there may be small spots of 
extravasation presenting a dark purplish red appearance ; the thickening 
of the mucosa may cause numerous slight elevations, papillary in cha- 
racter, especially near the pylorus — " etat mamelonne " of the French. 
In some cases the submucosa and muscularis are considerably thickened. 
Vol. III.— 12 



178 DISEASES OF THE STOMACH. 

and, as the process is usually most marked at and near the pylorus, this 
thickening may cause more or less occlusion of the pyloric orifice ; this 
condition* really constitutes an interstitial gastritis. The nethermost 
part of the large curvature is sometimes softened, pliable, and gelatin- 
•ous, the wall being thin, perhaps consisting only of the serous coat ; 
this may be a post-mortem change, but, at all events, the process in this 
region contrasts strongly with the thickening near the pylorus. 

Microscopic examination shows the glandular cells granular and 
deformed, while the ducts are irregular, constricted, and tortuous ; some 
of the glands are separated from their ducts by the encroachment of 
newly formed connective tissue, and they appear as cysts partly or 
wholly filled with epithelial remains. A plentiful round-cell infiltra- 
tion is seen between the glands, and also a connective-tissue increase 
reaching from the submucosa upward around the glands. Sometimes 
the glandular cells are in a state of mucoid degeneration, chiefly in the 
pyloric region ; some cells are granular, while others are partly granular 
and partly mucoid ; these latter may rupture and discharge their con- 
tents into the duct of the gland. Hayem distinguishes two varieties 
of connective-tissue gastritis — mixed and interstitial. Two forms of 
mixed gastritis are described, one in which the delomorphous (parietal) 
and the other in which the adelomorphous (central) cells are affected. 
The former is accompanied by mucous transformation, and the latter 
ends in atrophy of the gland. 

Interstitial gastritis may be subacute or chronic. In the subacute 
form a marked infiltration of leucocytes occupies the whole mucous 
membrane and penetrates the gland tubes, some of which become cystic. 
In the pure interstitial or chronic form there is progressive prolifera- 
tion of the connective tissue, resulting in secondary atrophy of the 
glands and ducts, as well as the disappearance of the muscular fibres. 

Symptoms. — The symptoms of chronic catarrhal gastritis are so 
often confused with the symptoms of the diseases that cause it that in 
many cases it is difficult to draw a definite clinical picture of the affec- 
tion. The gastric mucous meinbrane has so much resisting power that 
it practically ignores insult after insult offered it by dietetic errors, 
alcohol, or other irritations. A few years ago almost every symptom- 
complex of the stomach was at once set down as due to subacute or 
chronic catarrhal gastritis, and even to-day the profession has not cut 
loose from this short-sighted, erroneous, and superficial habit. In point 
of fact, chronic inflammatory affections of the stomach are not very 
common except as a result of grave organic disease located in the 
stomach or elsewhere. In many chronic diseases — as, for instance, the 
anaemias — the stomach is the organ that bears the brunt of the com- 
plaint of all the cells of the body, and it is not surprising that it should 
be chosen to cry out and rebel in the cause of the complaining cells 
depending upon it ; but the point we wish to make is that gastritis 
exists but in a small proportion of these cases, and if the stomach and 
its contents are carefully studied there will be less often a hasty 
diagnosis of one or another form of gastritis. 

Given a case of gastritis in which secretion and motion are both 
impaired, and the symptoms usually indicate difficult digestion and 
toxaemia. Anorexia is commonly, but not uniformly, present ; indeed, 



CHRONIC OASTBITIS; EROSIONS OF THE STOMACH 179 

in some cases hyperorexia exists and leads to frequent eating, with an 
aggravation of the symptoms. Usually after meals there is a sense of 
weight, fulness, and distress in the epigastrium, perhaps amounting to 
actual pain ; eructations are common and afford relief by lessening 
gastric distention ; sometimes, however, the feeling of fulness deceives 
the patient into believing that gas is present when it is absent, and it is 
common to hear the expression : " If I could only get the gas oflP my 
stomach, I would be relieved." Burning sensations, accompanied by 
considerable nervous perturbation, are often noticed, but severe pain is 
uncommon. Tenderness upon pressure over a considerable epigastric 
area, and a sense of soreness upon forcible inspiration or contraction 
of the abdominal Avails, are not infrequently present. Nausea some- 
times occurs after meals, and may be accompanied by vomiting, or 
these symptoms may manifest themselves early in the morning or after 
breakfast only, the later meals in the day being taken with comparative 
comfort. Morning vomiting is commonly associated with alcoholic 
gastritis, and, indeed, may be as much a manifestation of toxaemia, 
renal or otherwise, as of the local gastric state. Light meals of plain 
food are not usually followed by the same degree of discomfort that is 
consequent upon heavy mixed meals ; this the patient discovers. The 
tongue may be coated with a yellowish-brown or yellowish-white thick 
fur, or it may be clean, red, or glazed with denuded epithelium ; it is 
not characteristic, as is so frequently stated. It may be pale, broad, 
flabby, and indented from anaemia and poor nutrition ; not infrequently 
two lines of froth are seen lying from a quarter to half an inch from the 
edge, one on each side, commonly indicating a nervous state. Unhealthy 
buccal conditions may cause an offensive breath. The taste is bitter 
and unpleasant in the morning, at which time the coating on the tongue 
is usually most abundant. Constipation is present as a rule, or it may 
alternate with attacks of mild diarrhoea, and intestinal flatulence is 
often present. Thirst is not as common a symptom as some have sup- 
posed ; indeed, in few of our cases has it been noticeable. Headache 
is not uncommonly present, usually being dull and heavy in character 
and accompanied by an unpleasant hebetude and indisposition toward 
mental or physical exertion. Vertigo is sometimes complained of, 
especially after eating or during a meal ; it is usually accompanied by 
a distressing fulness in the head, and perhaps slight nausea. The urine 
is apt to be superacid, high colored, of high specific gravity, and upon 
standing deposits an abundance of urates, with, perhaps, uric-acid and 
calcium-oxalate crystals ; but many exceptions are seen, and phospha- 
turia may occur, or a large quantity of pale urine of low specific 
gravity ; a trace of albumin may be found and indicanuria occurs 
in a considerable proportion of cases. The general nutrition suffers, 
and, as a rule, anaemia and a muddy, sallow, loaded skin, with loss 
of weight and strength, are seen. The blood presents the picture of 
secondary chlorosis in most instances, although a pernicious type of 
anaemia may result if the morbid process goes on to complete glandular 
atrophy of the stomach. Flint, Osier, and others have described such 
cases, and consider this condition as one of the causes of pernicious 
anaemia. We have observed a number of cases with gastric glandular 
atrophy whose blood was simply chlorotic, but we have not yet seen 



180 DISEASES OF THE STOMACH. 

pernicious anaemia associated with this gastric state, probably because 
intestinal digestion was amply sufficient to compensate for the lack of 
stomach digestion in our cases. 

Diagnosis. — The diagnosis cannot be made from the symptoms 
alone, as they may accompany divers conditions of the stomach ; they 
are, however, of some importance in connection with the cause of the 
affection and the examination of the stomach contents, which should be 
withdrawn an hour after the Ewald test breakfast of a roll and water. 
Usually considerable gastric mucus is found holding food particles in its 
meshes ; free hydrochloric acid is diminished or absent ; lactic acid may 
be present, sometimes in sufficient quantities to give a distinct canary 
color with UflPelmann's reagent, or it may be absent ; in the absence 
of food-stasis other organic acids are rarely present ; the proteoses 
and peptone are found ; starch digestion may or may not be interrupted ; 
the total acidity is not usually above normal unless gastrectasia exists or 
fermentation occurs ; rennet ferment and rennet zymogen are both di- 
minished, as has been shown by Boas and Freidenwald, the former being 
frequently absent, "svhile the latter may be reduced as low as one third 
dilution ; microscopically numerous micro-organisms, including lactic 
acid-forming bacilli, may be found. When atrophy of the gastric 
glands has occurred the total acidity is very low, being from 2. to 5. ; 
free and combined hydrochloric acid is absent, and the biuret reaction 
is not obtained, as no digestion has taken place. The wash-water in 
cases of mucous gastritis, which is characterized by excessive quantities 
of mucus both with and without food, frequently contains fragments of 
the epithelial covering of the mucosa. 

Peogxosis. — The prognosis depends partly upon the cause of the 
disease and partly upon the management of the case. If it is associated 
with, and secondary to, benign pyloric stenosis and a successful pyloro- 
plasty is done the catarrhal gastritis may be checked, leaving behind it 
perhaps some atrophy and new connective tissue formation : If it is due 
to abuse of alcohol, or dietetic errors, the correction of these may result 
in checking the process entirely, although, as is the consequence of 
chronic inflammation elsewhere, the organ will be more or less perma- 
nently disabled. If the condition depends upon irremediable cardiac, 
pulmonary, or hepatic disease its progress may be very slow but the 
prognosis is necessarily unfavorable. If the disease has progressed so far 
that atrophy of the glands has occurred the nutrition of the patient will 
depend upon the motor power of the stomach and intestinal digestion. 

Treatment. — Appropriate local treatment of the stomacli is almost 
always valuable in this disease. Lavage, not too frequently practised, at 
once removes irritating and perhaps fermenting food remnants, and if 
an alkaline antiseptic solution be used, mucus, epithelial debris, and 
micro-organisms are washed from the surface of the mucous membrane, 
and peristalsis and secretion are improved. Water at a temperature of 
105° F. should be used for lavage, and after the first part of the treat- 
ment a 2 per cent, solution of sodium chloride should be employed, as 
the chlorides are desirable when the hydrochloric-acid secretion is di- 
minished, or a weak solution of Carlsbad salts may be used ; and boric- 
acid solution is one of the best at our command. 

Lavage should be given in the morning before breakfast, in order to 



CHRONIC GASTRITIS; EROSIONS OF THE STOMACH. 181 

discover whether food remains in the stomach over night, thus giving 
evidence of stagnation. Besides, in this way the patient is not deprived 
of nutriment, as he will necessarily be, to some extent, when lavage is 
practised too soon after meals. It is, however, advantageous to wash 
out the stomach occasionally from three to five hours after a meal, in 
order to examine the contents and give the organ rest. For the latter 
purpose the stomach may be emptied about ten o'clock at night, and no 
food allowed until morning. The importance of sufficient nourishment 
should be emphasized, as patients frequently weaken themselves in fol- 
lowing senseless dietetic rules. Local application to the mucous mem- 
brane may be made by means of the stomach tube, the spray apparatus, 
or the insufflator, or galvanic electricity may be applied by the direct 
method. Silver nitrate is one of the most effective applications, and 
may be used in the strength of one to four grains (0.06 to 0.24) to eight 
ounces of distilled water, which amount is poured into the stomach after 
it has been washed clean, left there for a few moments, and then with- 
drawn; if most of it returns, it is unnecessary to use further washings, 
as a small quantity left in the stomach will be beneficial. The drug 
may be given in one fourth or one half grain doses in a half ounce of 
distilled water before meals. Its administration, however, should not 
be too long continued without an intermission of several days. Fluid 
extract of hydrastis may be used as an astringent after lavage, one or 
two drachms (4. to 8. c.c.) in four or eight ounces of water being em- 
ployed, or it may be given in half to one drachm doses before meals. 
Oil of cinnamon, oil of cloves, oil of eucalyptus, or menthol may be 
used in a vaporized oily fluid, cosmoline or albolene being employed as 
a menstruum. Pick uses a narrow tube which is inserted through an 
ordinary stomach tube at the conclusion of lavage, and with 250 cubic 
centimetres of air inflating the stomach to prevent closure of the end of 
the tube, bismuth subnitrate, dermatol, or other powders are introduced 
by insufflation. We frequently use positive galvanic electricity within 
the stomach, agreeing with Einhorn that it stimulates secretion and 
in an electrolytic manner favorably affects the chronic inflammatory 
process. 

The diet should consist of an abundance of thoroughly cooked 
starchy foods, such as stale bread (light and sweet), rolls, zwieback, 
Graham wafers, saltines, water crackers, ginger wafers, toast, and mealy 
baked potatoes in moderation ; puddings should not be allowed, as they 
are not masticated and readily ferment. The amount of albuminoid 
food should be somewhat restricted if free hydrochloric acid is absent, 
and that which is allowed should be in the most digestible forms. 
Hard-boiled eggs and tough fibrous meat, too fat meat, shellfish like 
lobsters, oysters, and crabs, sausages and smoked meats, should not be 
allowed ; cheese, salads, vinegar, condiments, and concentrated alcoholic 
drinks should be interdicted ; and of the vegetables cabbage, cauliflower, 
cucumbers, beans, and peas should be excluded. 

A. suitable dietary includes small quantities of clear soups, bouil- 
lon, and clam-juice ; tender fresh fish, such as bluefish, whitefish, 
shad, perch, trout, or bass ; choice meats not overcooked — for in- 
stance, porter-house steak that has hung long enough, roast beef, 
tender lamb chops, tongue, very thin slices of cold-boiled ham, sweet- 



182 DISEASES OF THE STOMACH. 

breads ; fresh raw eggs, soft boiled, poached, or delicate, light omelettes ; 
farinaceous foods, stale bread, toast, Graham bread, zwieback, rolls, 
crackers, spaghetti, arrow-root, etc. ; lettuce, water-cresses, celery, 
baked potatoel. Milk agrees in some cases, but is often found in large 
curds in the stomach ; it may, however, be taken if it is liberally di- 
luted with lime-water, Vichy, or seltzer, or if it is peptonized. Carbon- 
ated waters, tea and coffee in moderation, cocoa, koumyss, matzoon, 
claret, and Rhine wines may serve as beverages, although, as Sir 
William Roberts and Chittenden and Mendel have shown, wines greatly 
retard salivary digestion. Patients should have good teeth, artificial 
if need be, and should masticate slowly and thoroughly. Among the 
few drugs that are useful in this affection hydrochloric acid stands first. 
It partly supplies the deficiency of the secretion, retards fermentation, 
combines with the nitrogenous elements to form syntonin, and probably 
has some salutary effect upon gastric motility. The doses ordinarily 
employed are not large enough, as it should be given in twenty or thirty 
drops of the dilute acid in plenty of water after meals, the dose being 
repeated in an hour. As large doses are strongly acid, they should be 
taken through a glass tube to protect the teeth and render it less un- 
pleasant. The administration of pepsin is not usually necessary unless 
glandular atrophy exists, under which circumstances it may be used ; 
ordinarily, however, the wholesale employment of pepsin is unscientific 
and needless. 

Of the bitters and stomachics employed in this disease, nux vomica 
is the most valuable ; the tincture, extract, or powder may be prescribed 
Tr. nucis vomicae should be given before meals in from twenty to thirty 
drop doses, or strychnine in doses of one thirtieth to one twenty fifth 
of a grain may be used in its stead. 

Quassia and condurango are sometimes beneficial, the infusion of 
the former and decoction of the latter being the favorite preparations. 
Calumba, cinchona, gentian, chamomile, and chii'ata may be useful in some 
cases. Constipation is best controlled by the saline cathartics ; Carlsbad, 
Hathorn, Hunyadi, Friedrichshall, Rubinat-Condal, or other waters 
may be chosen according to the predilection of the patient or the physi- 
cian. Some salines are preferably used hot an hour or so before break- 
fast, in that way loosening adherent mucus from the walls of the 
stomach and carrying it onward before food is taken. Given in this 
way they also serve as diuretics, and the concentrated condition of the 
urine before mentioned is often thus corrected. It may be advisable 
at times to give moderate doses of calomel or the vegetable laxatives, 
such as aloin, podophyllin, cascara, or some purgative containing senna. 
Colon flushing may be practised occasionally with a happy effect in 
many cases, and, if constipation is obstinate, Fleiner's method of inject- 
ing from a half to one pint of warm, pure, olive oil into the colon may 
be resorted to. Tonic hydrotherapy, medical gymnastics, hot air or 
Turkish baths, out-of-door exercise, plenty of sunlight, sea-bathing, 
mountain-climbing, freedom from worry and care, all exert a happy 
effect and may be heartily recommended. 

Erosions of the Stomach. — Erosions of the gastric mucosa were 
long ago recognized and have been described by many pathologists. 
As the term implies, the defect does not penetrate deeply, but, as a rule, 



CHRONIC GASTRITIS; EROSIONS OF THE STOMACH. 183 

attacks the superficial epithelium only, sometimes involving portions of 
the submucosa. Frequently the process is implicated with slight hem- 
orrhagic infiltration, which, according to Yirchow and others, may be 
accounted for by spasmodic contraction of the muscular layer, thus 
effecting a disturbance or an arrest of the circulation in the folds of the 
mucous membrane, causing localized congestion and extravasation. As 
has been said, hemorrhagic erosion is believed by some observers to 
play an important etiologic role in peptic ulcer. As Langerhaus has 
pointed out, the seat of hemorrhagic erosion is as frequently found in 
the fundus as in the pyloric end of the stomach ; it is located upon the 
surface of the rugte of the mucous membrane, is generally multiple, and 
is often irregular in shape. 

Etiology. — The cause of gastric erosions is not altogether under- 
stood. It is generally believed to depend upon local spasms of the mus- 
cularis resulting in small extravasations of blood, also upon the presence 
of catarrhal gastritis. It is common to find both deep and superficial 
erosions in toxic gastritis. Superficial erosions frequently accompany 
other forms of gastritis. Since Einhorn in 1894 made his report upon 
clinical observations on erosions of the stomach, more attention has 
been given the subject, and there is ground for the belief that it may 
exist as a very chronic aflPection, the cause of which is unknown. 

Pathological Anatomy. — The erosions are usually multiple, 
sometimes accompanied by slight hemorrhages, appearing scattered over 
the surface of the stomach as numerous dots or streaks. Small pieces 
of the mucous membrane are frequently shed, and may be vomited or 
removed by lavage, and upon examination show the well-defined gland- 
ular structure of the gastric mucosa. 

Symptoms. — The patient usually complains of epigastric tenderness 
and moderate distress after eating. The appetite is variable and is 
sometimes absent. Vomiting is rather rare, but sometimes occurs, 
when particles of mucous membrane may be discharged. Constipation 
occurs, and there is usually considerable mental depression. The stom- 
ach contents sometimes show the presence of free hydrochloric acid, 
though it is usually diminished in quantity and may be absent. As a 
rule, the organic acids are not found. The most striking symptom of 
the affection is the frequent appearance of small portions of the gastric 
mucosa, together with a moderate amount of mucus appearing in the 
water after lavage. 

Peognosis and Treatment. — The disease sometimes continues as 
a chronic affection, and is very intractable to treatment. Recovery often 
takes place, and, so far as known, no fatal termination is recorded. Ein- 
horn recommends spraying the gastric mucous membrane with 1 : 1000 
silver nitrate solution or 1 : 100 solution of aluminol or a solution of 
ichthyol. We have used these measures, together with lavements of 
solutions of boric and tannic acids and potassium permanganate, some- 
times with apparent benefit ; in one case after six months' treatment we 
saw not the slightest improvement. Attention to the general health is 
important, and to that end strychnine, arsenic, malt, and cod-liver oil, 
fresh air, sunlight, mountain-climbing, and other invigorating exercise, 
may be recommended. 



DISEASES OF THE INTESTINES. 

By WILLIAM W. JOHNSTON, M. D. 



ULCER OF THE DUODENUM. 

Synonym. — Peptic ulcer of the duodenum. 

Definition. — A circumscribed superficial loss of substance of one 
or more coats of the duodenum, beginning in the mucosa, and due to 
a localized, molecular necrosis without any active process. 

History. — The disease was first described by Robert in 1828, but 
it was regarded as merely a pathological curiosity until Collins collected 
262 cases in his thesis. It has received but scant attention from authors 
of textbooks, pathologists, or essayists. Practically, all that is known 
of it that is of scientific value is the result of investigations in the past 
two decades. 

Etiology, — The etiology of ulcer of the duodenum is often con- 
sidered identical with that of gastric ulcer, but a separate description 
is necessary on account of certain peculiar causes and its distinctive 
clinical history. 

Of course there is much diversity of opinion in the statements of 
essayists as to the absolute frequency of this affection. Thus Perry, in 
17,652 autopsies at Guy's Hosjjital upon patients dying from all causes, 
found the lesion only 70 times (0.4 per cent.), while Letulle, in 52 
cadavers taken at random, found it 4 times (7.8 per cent.). As Op- 
penheimer suggests, it is frequently overlooked, and evidences are not 
wanting that some cases in which the disease has been definitely diag- 
nosticated at a period some years before death present no post-mortem 
evidences of it. As compared with gastric ulcer, its frequency is one 
to thirty ; but Trier places it as one to nine. Gastric and duodenal 
ulcers coexisted in 31 of 358 cases reported by Oppenheimer and 
Lebert. 

Predisposing causes seem to play but a small part in the etiology of 
this disease. Thus chlorosis, anaemia, and cachectic states, which act so 
definitely in causing gastric ulcer, have no such action here. But 
debility from any cause will greatly protract the disease once it has 
been established. Unlike the gastric ulcer, again, duodenal ulcer is 
from two to three times more frequent in men than in women. In 234 
cases collated by Collins, 63 were females. 

It is most common in the third, fourth, and fifth decades, decreasing 
progressively in frequency in the order named, but it has been found 
at all ages, from one day to one hundred years. One fact of peculiar 
interest and importance is its frequency in infancy and early childhood. 
Thus 82 of 692 cases reported occurred before the tenth year. It is a 

185 



186 DISEASES OF THE INTESTINES. 

much-discussed question whether these early lesions originate in intra- 
uterine life from defective nutrition and destructive lesions in the ves- 
sels, or result from the traumatism of labor. Klebs considers them 
due to foUicuKir hemorrhage, and, as they undoubtedly occur oftenest 
in children born after long and difficult labors, this theory has much 
plausibility. Instrumental deliveries, deliveries by the breech, and 
other conditions might easily cause hemorrhages into the mucosa and 
submucosa which would quickly lead to local necrosis. 

A great number of the primary and secondary causes of the disease 
are known. Most obvious among these are extensive burns of the skin, 
whose agency is well illustrated by Holmes' statistics. The ulcer was 
found in 16 of 124 patients dead from such burns. The rule as to 
greater frequency in men is reversed in the case of burns, the lesion 
due to this cause occurring twice as often in women as in men. How 
burns cause this distant complication is still unsettled, but they probably 
do so by the liberation of a fibrin ferment with consequent thrombosis 
of the duodenal vessels, or by the formation of some toxic material in 
the blood or aifected tissues, which toxin is excreted in the bile. In 
this connection it is important to note that Kyanitzki has separated 
from the blood of animals, suffering from extensive burns, a toxin 
which, when injected into other animals, will cause (among other 
phenomena) duodenal ulcers. 

In most of the unclassified cases the greatest support is given to 
Virchow's theory that the loss of intestinal substance is caused by the 
action of the gastric juice upon some spot that has been deprived of its 
nutrition by spastic contraction of the muscular coat, or by embolism, 
thromboses, atheroma, or other condition of the afferent vessels which 
would produce localized anaemia. That embolism would seem to play a 
small part in this process is inferred by remembering that in ulcer of the 
stomach or duodenum it is rarely seen simultaneously in other parts, 
that there appears to be no ulterior cause for the formation of emboli, 
and that in those conditions in which embolism might be anticipated — 
e. g. vegetative endocarditis — ulcers of the alimentary tract at any point 
are rarely found. Experimentally, however, embolism has been proved 
to be a cause by Cohnheim and others, who produced typical lesions by 
introducing multiple emboli into the gastric arteries. The excessive 
acidity of the gastric juice that is said to correlate this localized anaemia 
is denied by Ewald, Ritter, Hirsch, and others, who cite cases in their 
support. 

In this age of bacteriology testimony is not wanting to show that 
cases may be due to microbic infection. Letulle has thus caused it 
several times experimentally, and it is certain that the disease is some- 
times seen as a complication of some infectious diseases, especially sep- 
ticaemia and dysentery. Finally, pemphigus, erysipelas, and trichinosis 
have been mentioned as causes. 

Pathological Ax atomy. — The mucous membrane shows no evi- 
dence of any pathological change up to the immediate edge of the ulcer. 
The lesions themselves are, in almost all respects, similar to those found 
in the stomach. The vast majority of them are in the upper horizontal 
third of the duodenum, progressively diminishing in frequency from 
above downward to the papilla bilaria, which is the point of the lowest 



ULCEB OF THE DUODENUM. 187 

extension. When multiple they are invariably confined to the upper 
third. Usually they are found on the anterior wall. Thus of 127 cases 
examined 71 were on the anterior, 45 on the posterior, 10 on the supe- 
rior, and only 1 on the inferior, wall. In about 60 per cent, of the 
cases the lesion is single. If several coexist they are usually in differ- 
ent stages of development, from the earliest stage of formation to cica- 
trization. 

The ulcer is round, or more rarely oval or elliptical, in which latter 
cdse the long diameter invariably corresponds with the long diameter 
of the bowel. An average diameter is about 2 cm. ; it is rare to see 
this less than 1 cm. or more than 3.5 cm., but Axelkey has reported a 
case in which the measurements were 7 cm. X 1 cm. ; and, as suggested 
below, it may be so small that though there were definite symptoms of 
duodenal ulcer at a period some time prior to death, there may be no 
post-mortem evidences of its existence or cicatrization. The depth, of 
course, varies with the extent of penetration, but usually the floor is 
formed by the muscular coat. If the ulcer penetrates to the peritoneum, 
local adhesions usually form, but in many cases — perhaps in a larger 
proportion in this than in any other disease — they do not, and perfora- 
tion results. Even when adhesions have formed the ulcerative process 
may continue, and fistulse have been found connecting the duodenum 
with the gall-bladder or transverse colon. 

The terraced, crater-like shape is very characteristic, and when the 
ulcers are recent the edges are sharp-cut and smooth. In older cases 
they are thickened and indurated, and occasionally there is much con- 
traction and puckering of the entire intestinal wall. Eventually this 
may lead to stenosis. In very rare cases cancerous infiltration has 
occurred in the floor of the ulcers. In those cases in which jaundice 
has existed there has usually been an extension of the necrotic process 
to the walls of the common duct. 

The mucosa is, of all coats, that most aifected. Pus and granulation 
tissue are absent ; if these are produced, they disappear by digestion. 
Almost all the glands of Lieberkiihn are lost, but on the edges they 
appear as dilated cubical cul de sacs filled with a clear thin fluid and des- 
quamated epithelium. Later they are occluded at their orifices and 
become veritable cysts. The acini of the glands of Bruuner are dilated 
four or five times larger than normal, and are filled with a colorless 
mucoid mass, the retained product of their secretions. The epithelial 
cells of the acini are flattened, the nuclei shrunken, and the cell proto- 
plasm is granular. The interstitial matrix is infiltrated with small em- 
bryonic elements, and is the site of small hemorrhagic foci which extend 
into the adjacent submucosa. This latter coat is generally intact quite 
up to a very short distance from the edge of the ulcer. It there takes 
on a more or less inflammatory character, contrasting strongly with the 
necrosed tissue that forms the immediate border of the ulcer. If the 
muscular coat is involved, the fibres lose their distinctness and are 
pushed apart by interstitial infiltration of embryonic cells and vascular 
proliferation. The floor of the ulcer is invariably smooth, whatever its 
depth or the coats that it penetrates. In short, the appearance is that 
of an atonic ulcer, incapable of an exuberant reparative vitality, show- 
ing a molecular necrosis more or less slow, and exempt through this 



188 DISEASES OF THE INTESTINES. 

same cause from great suppurative or gangrenous destruction. In those 
rare cases in which progi'essive pernicious ansemia seems to arise in the 
course of thejdisease, the blood examination shows intense oligocythse- 
mia, the red corpuscles for the most part are small, and some re-formed 
macrocytes are seen. 

Symptoms. — Duodenal ulcers may be divided into — (1) Ulcers 
giving no evidence of their presence during life, but found post-mortem ; 
(2) Ulcers which cause no symptoms until perforation or sudden fatal 
hemorrhage occurs ; (3) Ulcers recognizable by characteristic symj)- 
toms. These may, after a chronic course, end fatally by hemorrhage or 
perforation, or they may be cured by treatment or without it. 

(1) From the statistics of post-mortem rooms, as opposed to the 
comparative rarity of the disease in general practice, it is probable that 
a large number of cases fall in the first category. But as they have no 
clinical value they need not be discussed here. 

(2) In the second class there are no doubt many cases that are 
wrongly diagnosticated, the principal symptom — pain — being assigned 
to gastralgia, neuralgia, or gastric ulcer. Of 150 cases collected by 
Perry, 91 presented no symptoms until twenty-four hours before death, 
which occurred either from hemorrhage or, more frequently, from per- 
foration. After either of these accidents the symptoms are the same 
as when they occur under other conditions, except that death does not 
ensue so quickly because there has been no prior exhaustion. In this 
connection it is important to note that often there are in reality minor 
symptoms which may not attract attention. But since in this class, 
again, a diagnosis can rarely be made with such precision that appro- 
priate treatment may be used, it is to the third class that most atten- 
tion should be given. 

(3) Emaciation is one of the earliest symptoms of the typical 
chronic ulcer, and a most important one. In many cases it progresses 
more rapidly than it does in any other disease. Vomiting, though not 
a constant symptom, is usually present and is chronic, coming on three 
or four hours after meals. Sometimes it occurs only once or twice in 
the course of the disease, and, more rarely, not at all. Usually it is 
due to reflex peristalsis, which, when the ulcer is near the pylorus, may 
affect the stomach only. The vomitus consists of partially digested 
food, bile, and occasionally blood. Mayer states that in most cases it 
has a coffee-ground color similar to that seen in carcinoma ventriculi, 
but of a peculiar character that is pathognomonic. An examination of 
Ewald's test breakfast in five different cases showed an absence of free 
HCl, but an organic hyperacidity from the presence of large amounts 
of lactic, and sometimes butyric, acid. This condition of the gastric 
juice Robin considers pathognomonic, but, as only five cases Avere 
examined, though found in all, it is too early to draw such a broad 
conclusion. Dyspeptic disturbances referred to the stomach are 
rare. 

The bowels are but little influenced by the disease. Constipation 
occurs in a scant majority of the cases, or constipation alternates with 
diarrhoea. Bright has described the stools of this affection as oily, com- 
posed of fat-like masses, or masses from which an oily substance quickly 
separates itself and floats upon the surface. They are unlike those seen 



ULCER OF THE DUODENUM. 189 

in pancreatil) or hepatic disease. Later ^vriters have failed to find 
them. Other appearances in the stools are described below. 

Icterus is comparatively rare, but it is more frequent than in gastric 
ulcer ; it is usually chronic, with subacute exacerbations. 

Pain, the most constant symptom, comes on about one hour and a 
half to two or three hours after meals, in the region of the duodenum, 
extending downward and backward toward the right kidney, and 
simultaneously upward to the right shoulder. It is often felt on the 
dividing line between the epigastrium and right hypochondrium, but 
seldom in the epigastrium alone. Unlike the pain of gastric ulcer, it is 
rarely referred to the back. In character it varies, being dull or acute, 
of increasing or decreasing violence, constant or intermittent and par- 
oxysmal, relieved or aggravated by pressure. It is less constant and 
intense than is the pain of gastric ulcer, and, unlike this latter, again, 
is increased when the patient lies on his right side. It is comparativelv 
rare to find it confined to a circumscribed spot in the right hypochon- 
drium in the vicinage of the lower surface of the liver, but when so 
found it is of maximum diagnostic importance. The pain is sometimes 
of a most violent character, causing the patient to scream and to seek 
rapid changes of position in search of relief. 

Hemorrhage is ver}' common, and according to both Krauss and 
Oppenheimer occurs in at least one third of all cases. It is often 
unnoticed, as the blood, much altered, passes in the stools. Bleeding 
may occur gradually as capillary oozing, or the quantity may be large 
from erosion of some large vessel. When of moderate severity there 
are abdominal symptoms simulating indigestion. Hsematemesis is not 
apt to occur except when the hemorrhage is great, and is then unusually 
sudden and copious. Attacks of it have happened from one to fifteen 
years before death. 

Melsena is somewhat more frequent than ha?matemesis, the relation 
being as 5 to 4. The blood during its transit through the bowel is 
always digested, and is expelled in black, rarely red, masses mixed with 
fecal matter or distinct and separate from the fseces. The color is so 
like that of fecal matter darkened with bile, bismuth, or iron that an 
error is often made. If the hemorrhage has been great or continued, 
large passages from the bowel may consist of nothing but blood. In 
this case the vessel may be one third filled Avith a homogeneous, tarry 
mass, easily mistaken for fecal matter. Hemorrhages lead to progres- 
sive anaemia and debility, or to sudden anaemia and collapse symptoms. 
They are the immediate cause of death in about 14 per cent, of the cases. 

Perforation is common, and is by far the most dangerous event in 
the course of the disease, being almost invariably fatal. Very few 
recoveries have been recorded, and in these, with one exception, death 
■ensued a short time later from intercurrent complications. Of 262 
eases reported by Collins, perforation occurred in 175. The symptoms 
attending this event are those accompanying perforation elsewhere — 
pain, perhaps vomiting and tympanites, with collapse. Of 41 cases, 24 
died in the first twenty-four hours, 9 on the second day, and in only 
4 was life prolonged beyond one hundred hours. What proportion of 
these cases offered symptoms that would have led to a diagnosis some 
time before death is not known. 



190 DISEASES OF THE INTESTINES. 

The urinary analysis is of merely confirmatory value, and some 
authors deny even that. When typical, the urine is dark yellow, some- 
times milky or dark brown, and its specific gravity, because of an 
increase in urea, is high. 

Complications and SEQUELiE. — These are comparatively few. 
The most important is stenosis from cicatricial contraction, which is 
especially liable to occur if there have been multiple ulcers in the upper 
third of the gut. When occurring above the papilla of Vater, as it 
does in all typical cases of ulcer, the condition can seldom be diagnosti- 
cated from stricture of the pylorus p. 141. Another sequela is obstruc- 
tion of the common bile duct by cicatrization of ulcers which have 
extended to this locality. Fistulae occasionally form between the lumina 
of the duodenum and colon, or between those of the duodenum and 
gall bladder. In 5 cases, collected from the entire literature upon the 
subject, it is reasonable to suppose from the symptoms and physical 
signs that cancerous infiltration in the locality of the ulcer had occurred. 
In only two of these cases were post-mortem examinations permitted ; 
in both the diagnosis was verified. 

A most interesting complication of this disease, and, fortunately, an 
extremely rare one, is progressive pernicious ansemia. Apparently it 
is due to two complementary factors : (1) repeated hemorrhages occurring 
with such frequency that they exhaust the reparative functions of the 
blood-making organs ; and (2) disturbances of nutrition which result 
directly from the duodenal lesion and aggravate the exhaustion due to 
hemorrhage. The clinical picture in the two cases which Devec has 
collected is typical. 

Peritonitis is a condition usually seen only after perforation, and 
when circumscribed and attended by the formation of plastic lymph is 
rather an attempt toward reparative processes than a true complication. 
The attempt, however, except in four cases collected, ends as such, and 
death usually occurs in from eighteen to twenty-four hours. In a case 
reported by Lockwood, the history and autopsy led to the inference that for 
six years a sac of plastic lymph, resulting from peritonitis after perforation, 
had shut off the lumen of the duodenum from the general peritoneal sac. 

Diagnosis. — The lesion most frequently confounded ^vith duodenal 
ulcer is gastric ulcer. The points of chief differential value may be 
tabulated as follows : 

Duodenal Ulcer. Gastic Ulceb. 

1. Occurs most often in men. 1. Occurs most often in women. 

2. Pain (in typical cases) in the right hypo- 2. Pain under ensiform cartilage or in left 

chondriura from one to three hours epigastrium. Usually at once after 

after meals. Pain in back very rare. eating. Pain in back very common. 

3. Dyspeptic disturbances rare. Vomiting, 3. Dyspeptic disturbances generally present. 

with pronounced cardialgia, rarer than Vomiting, with cardialgia, common, 

in gastric ulcer. 

4. Hsematemesis rare. 4. Hsematemesis common. 

5. Melsena common. 5. Malsena rare. 

6. Icterus (commoner than in gastric ulcer. 6. Icterus almost never occurs. 

7. Frequent after extensive burns of body. 7. Very rare after burns. 

8. Perforation and peritonitis very common. 8. Perforation and peritonitis more un- 

common. 

9. Dui-ation of chronic cases, months to 9. Duration less ; progress more rapid. 

many years. 

10. Test meal less characteristic. 10. Test meal more characteristic. 



ULCER OF THE DUODENUM. 19I 

Cases in which duodenal pain of chronic, intermittent character is 
the only symptom may be mistaken for gastralgia or enteralgia, but 
these conditions are more common in women, and are associated with 
neurasthenia, uterine disease, anaemia, chlorosis, malaria, or cold. They 
bear no relation to the taking of food, and are not increased by pressure. 

The pain of chronic intestinal indigestion is not so severe nor so 
circumscribed, and is accompanied by borborygmi and occasional 
diarrhoea. Acute intestinal colic may be recognized by the etiology, 
time of occurrence, seat, character of the pain, and subsequent history. 
There are other lesions, as jaundice in the one case and the escape of a 
calculus from the bladder in the other, mesenteric or visceral cancer, 
which may be attended with pain in the same region, but the progress 
of the case, the growth of a tumor, and the emaciation would clear 
up this point. 

In a certain number of cases where the symptoms are latent a 
diagnosis is impossible up to the moment of a profuse intestinal hemor- 
rhage. The character of the blood passed, and the exclusion of other 
sources of hemorrhage by the negative character of the history, may 
justify a diagnosis from this symptom alone. 

In those suspicious but indefinite cases following a somewhat atypical 
course in which there suddenly appear symptoms of perforation a diag- 
nosis may often be made. But the sudden onset of such symptoms 
without a suspicious history should not lead to a dogmatic diagnosis. 
There are too many causes of peritonitis by perforation, and perforation 
by duodenal ulcer is too rare, for one to diagnosticate with certainty, 
though the possibility of its occurrence should always be borne in mind. 
Significant facts are that the symptoms come on suddenly two or three 
hours after meals in persons apparently in good health, and that the 
pain is almost invariably under the liver in the right hypochondrium. 
These are the only diagnostic elements, but there is scarcely any other 
lesion which, after so latent a course, will give rise to perforation. In 
some cases the symptoms have simulated acute hemorrhagic pancreatitis, 
intestinal obstruction, acute retention of urine, or lead colic. Often a 
diagnosis in these most obscure cases is impossible until after the sectio 
cadaveris. 

One would be justified in making a diagnosis of duodenal ulcer if a 
man, otherwise in good health, between thirty and forty years of age, 
suffers from attacks of severe pain below the edge of the liver to the 
right of the median line, the pain coming on from two to four hours 
after meals, lasting from two to four hours and then gradually lessen- 
ing. Such a symptom, without gastric indigestion or the evidence of 
any organic lesion, pursuing a chronic course during a year or more, 
with remissions and exacerbations according to the simplicity or in- 
digestibility of the diet, could be reasonably attributed to duodenal 
ulcer as a cause. This diagnosis would be confirmed by the occurrence 
of intestinal hemorrhage of the character described, or of perforative 
peritonitis. 

Prognosis. — An unfavorable termination has been thought to be 
the rule, but this opinion was based on an imperfect knowledge of the 
disease. It is now known to be frequently not recognized until at the 
autopsy cicatrices of healed ulcers are found. If a diagnosis could be 



192 DISEASES OF THE INTESTINES. 

made early, so as to begin a proper treatment, there is every reason to 
think that the results would often be successful. The recovery, as 
evidenced post-mortem, of many untreated cases would substantiate this 
fact. But the most favorable cases may suddenly take on aggravated 
symptoms, and there is constant clanger of hemorrhage or perforation, 
for neither the depth of erosion nor its proximity to large vessels can 
be conjectured from its clinical course. At best, the course of the 
disease is usually irregular ; when most unexpected favorable or unfav- 
orable conditions may arise, so that a definite prognosis in any particular 
case is impossible. Only in general terms can it be stated that those 
cases which offer a chronic course will usually pass on to recovery, and 
that those whose clinical liistory is signalized by an abrupt onset will 
generally terminate unfavorably. Recurring profuse hemorrhages 
indicate a large growing ulcer. What opinion may be based upon the 
intensity of the pain is not determined. 

Treatment. — The seat of the lesion below the pylorus differentiates 
its treatment but slightly from that of gastric ulcer. In the former 
case the return to a more liberal diet is possible much earlier than in 
the latter. Cicatrization is hastened by rest both of the body and of 
the viscus involved, so that hygienic measures form a large part of the 
treatment. Rest and an exclusive milk diet kept up for a long time are 
essential measures. Yet, though milk contains all the elements neces- 
sary to nutrition, in some cases it is distinctly injurious because of the 
character of the gastric juice. It must not be forgotten that much of 
the digestion of milk is carried on below the papilla of Vater, and that 
it often leaves the stomach in small curds which are capable of much 
mechanical irritation. Predigested milk may, therefore, be needed. 
Beef, chicken and other meat extracts which may, in large part, be 
assimilated by the stomach, will often be well borne. Albumen water 
is also excellent. Food must be given in sufficient quantities to sustain 
nutrition, for the danger of anaemia and emaciation is extreme, and, as 
observed by Luttke in his experiments upon duodenal ulcer artificially 
produced, repair is much more protracted in debilitated conditions. 

Donkin suggests absolute rest of the stomach for a period varying 
with the duration of the disease and the severity of the case. Except- 
ing narcotics only, nothing is to be given by mouth in any case. Rectal 
feedings, at intervals of from two to six hours, should consist of 75 
grammes of beef or other meat extract, alternating with 15 grammes 
of brandy, with opium or belladonna in appropriate dosage if the part 
becomes irritable. In cases treated in this manner everything pro- 
gresses satisfactorily, and after three weeks at the farthest a little milk 
or bouillon may be given by mouth, but the enemata are still continued. 
These are progressively diminished, however, both in frequency and 
amount, so that after from four to five weeks all aliment is assimilated 
by the stomach. In the course of this treatment the patient loses 
flesh very considerably, but by absolute repose this is prevented from 
progressing very far, and after recovery flesh is very quickly taken on 
again. Despite this nutritional retrogression this method has been suc- 
cessful in several cases that would yield to no other treatment. 

When hemorrhage occurs, ice is given, with opium, ergot, acetate of 
lead, etc., and the ice bag is applied externally. Aliment should be given 



CANCER OF THE DUODENUM. 193 

by the rectum only until the patient has reacted well. Copious enemata 
of hot normal salt solution, or venous or subcutaneous transfusion, will 
assist in bringing about this result. 

It is doubtful whether there is any remedy which favors cicatrization 
by its local eifect, unless nitrate of silver may be said to have this 
property. Bismuth, chalk, bicarbonate of soda, or more especially sul- 
phate of soda, as recommended by v. Ziemssen, pancreatin, pepsin, 
etc., which have a beneficial influence only by their influence upon 
gastric secretion, have been tried and recommended. Salicylate of 
bismuth is a remedy that has lately gained a favorable reputation in 
this connection. 

When general peritonitis occurs from perforation, laparotomy, sutur- 
ing of the wound after excision of the ulcer, and a general lavage of 
the abdominal cavity are indicated. This has been practised four times, 
once with success. When the peritonitis is circumscribed, the appro- 
priate treatment is evident, and that it is not reprehensible, though a 
forlorn hope, is evidenced by Luttke's case (among others), in which 
recovery ensued after the evacuation of 500 grammes of pus. 



BENIGN TUMORS OF THE DUODENUM. 

Benign tumors of the duodenum are exceedingly rare. Those found 
in the museums are usually cauliflower-like, papillomatous masses near 
the opening of the bile duct or between it and the pylorus. Adenomata 
have been described, and one remarkable mass consisted of conglomerate 
racemose glands lying between the muscular bundles of the intestine. 
Many of these tumors produce no symptoms whatever ; in other cases 
there is gastric indigestion with pain between the shoulders and tender- 
ness over the umbilical region. In others, where the neoplasm is at or 
near the papilla of Vater, there occur jaundice, irregular pyrexia, and 
perhaps hemorrhage. A diagnosis depends upon the symptoms of pro- 
gressive obstruction and the perception of a mass in the region of the 
duodenum. The course of the disease is usually (if it has given rise to 
any symptoms at all) quite irregular, and occasional periods occur 
when all symptoms disappear entirely. Death ensues in from three 
months to two years. The teeatment is surgical. 



CANCER OF THE DUODENUM. 

Etiology. — The comparative rarity of primary malignant disease 
of the duodenum may be estimated from the report of 1800 autopsies 
upon persons dying of all diseases, in which this lesion was found in 
10 cases only. Nevertheless, the duodenum is more frequently the seat 
of carcinoma than any other portion of the intestinal tract except the 
rectum. Of 12 cases in which the small intestine was primarily in- 

VoL. III.— 13 



194 DISEASES OF THE INTESTINES. 

volved, the duodenum ^vas the seat of the neoplasm in 9, and fully one 
third of all primary cancers involving the gut between the pylorus and 
the sigmoid flexure are located here. 

Heredity is said to have some influence. There is usually an ante- 
cedent history of chronic indigestion. Males are more frequently 
affected than females in the proportion of three to one. The average 
age at death in cases of carcinoma is forty-eight years, but in one case 
it was twenty-seven, in another eighty. In sarcoma the average age at 
death is thirty-one. Secondary growths of malignant disease in the 
duodenum due to metastasis are rare, but secondary disease by exten- 
sion from contiguous parts is half again as frequent as primary disease. 
Usually such extension is from the pancreas, lymphatic glands of the 
mesentery, or pylorus. 

Pathological Anatomy. — Carcinoma of the duodenum is some- 
what more common than sarcoma, and scirrhus is seen more often than the 
encephaloid or colloid forms. All forms of primary malignant growth 
are far more frequently found in the upper than in the middle or lower 
thirds of the duodenum, though any or all parts of it may be involved. 

Car'cinoma occurs either as a nodular mass, or more commonly as an 
excavated ulcer with elevated and thickened edges. The ulcerative pro- 
cess may extend deeply and lead to perforation of the gut or to the 
formation of fistulae with adjacent cavities. In one case the mesenteric 
artery was eroded ; in another a large extra-intestinal abscess was 
formed which passed downward and opened in the iliac fossa. Wher- 
ever located the disease has a tendency in most cases to spread in the 
mucous and submucous tissues, becoming annular or cylindrical. Some- 
times the ring is incomplete, and there is only a plate of malignant 
tissue, but where the patient has not died of intercurrent disease a 
definite tubular shape is generally found. 

At the site of the neoplasm, especially if this has been of rapid 
growth, the lumen of the tube is much diminished, being sometimes as 
small as a goosequill. Above it there is dilatation proportionate to the 
degree of stenosis. If the upper part of the duodenum has been in- 
volved the pylorus is patulous and the stomach dilated. Below the 
stricture the calibre of the tube is diminished. 

Necrologists differ diametrically on the influence of carcinoma of the 
duodenum, |9er se, upon the common bile duct ; some citing cases where 
it caused occlusion, others where it seemed to cause dilatation. In a 
certain proportion of cases occlusion does occur, but is then usually due 
either to extension of the disease to the head of the pancreas with con- 
sequent pressure, or to the wall of the duct. Jaundice, which occurs 
in about one third of all cases, is probably always due to occlusion. 

In about 20 per cent, of the cases the disease has extended to the 
contiguous organs, pancreas, liver, biliary ducts, peritoneum, retro- 
peritoneal glands, etc. Histologically, though differing in the amount 
of connective-tissue stroma and in vascularity, the growths originate 
from the crypts of Lieberkiihn, or, in very rare cases, from Brunner's 
glands. " The essential constituent cells," says Pick, " generally present 
a clean outline, the protoplasm granular and scant, and the nuclei large, 
usually round and with one or two pronuclei. The cells arrange them- 
selves in twisted, folded chains, or in irregular masses, in the centre of 



CANCER OF THE DUODENUM. 195 

which they have lost their definite cylindrical shape and undergone fatty 
degeneration." 

Sarcomata show the same tendency to annular or tubular develop- 
ment as do the carcinomata, but in marked contradistinction they 
oftener lead to thickening and dilatation than to deep ulceration and 
stenosis. A general cliiFuse infiltration may cause a thickening of the 
wall as much as three fourths of an inch. The mucous membrane is 
sometimes found stretched over the growth ; at others it is remarkably 
rugose, and the valvulse conniventes, when specially aifected, form thick 
encircling ridges. In other cases there is slight ulceration, but it is rare 
to see this extending deeply, though in one case it eroded the pan- 
creatico-duodenalis artery. Occasionally sarcoma takes the form of 
isolated flattened or rounded nodules scattered through the duodenum. 
Unlike carcinoma, the immediate disease in the intestine does cause 
occlusion of the bile duct in at least one half of the cases, probably by 
thickening of the intestinal wall. In contrast with carcinoma also, 
secondary deposits by metastasis are frequent, occurring in about 85 per 
cent, of all cases. Usually the retro-peritoneal glands and kidneys are 
the parts affected. 

The cells are round, of striking similarity to each other, and consist 
of a large nucleus colored in mass by carmine, with several nucleoli. 
The protoplasmic zone about these is extremely thin or absent. At no 
point in their evolution are these cells fusiform or cylindrical ; they give 
rise to no secretion, but form a mass in whose depths there is a charac- 
teristic embryonic network of connective tissue. 

Symptoms. — Cancers of the duodenum present two trains of symp- 
toms : (1) Those which occur in common in all cases ; and (2) Those 
dependent upon the location of the neoplasm. 

The symptoms common to all forms are progressive emaciation and 
cachexia, with an anaemic tint or pigmentation of the skin ; digestive 
disturbance, characterized by anorexia, vomiting of an extremely vari- 
able nature, occasional hsematemesis (the blood being usually altered), 
and in most cases intestinal symptoms, consisting most frequently of 
constipation alternating with diarrhoea. This last may be the only 
indication of intestinal disease. 

Pain is invariably present in the epigastrium or in the right hypo- 
chrondrium ; in one case it Avas referred to the left hypochrondrium in 
the axillary line. At best, pain is a very uncertain element in the 
diagnosis or localization of the disease. There is also increased sensi- 
bility to pressure. 

In about one half the cases there is a tumor of variable mobility, 
usually seated a little below and to the right of the epigastrium, and 
evident only on deep palpation. Frequently there are signs of gastric 
dilatation and a slight ballooning of the epigastrium which contrasts 
conspicuously with the retraction of the rest of the abdomen. As a 
rule, there is no indication of stenosis of the bile ducts. 

These diverse symptoms have a value only when associated, but 
present nothing pathognomonic. 

The symptoms peculiar to neoplasms when localized definitely depend 
upon its situation, above or below the papilla of Vater. When above 
the diverticulum there is usually a history of chronic dyspepsia, and the 



196 DISEASES OF THE INTESTINES. 

transition from health to disease has been slow and insidious. There is 
epigastric flatulence with a sense of weight and fulness after meals, 
abdominal pain, sharp and circumscribed (at first vague and dull), 
usually occurring at about from one to two hours after meals. Then 
eructations and vomiting supervene. In other rare cases the patient 
has presented no symptoms whatever until the appearance of persistent 
vomiting, flatulence, and acute, violent pain in the epigastrium. Occa- 
sionally, progressive asthenia and emaciation are the only symptoms. 

In typical cases, until in advanced stages, the stomach is usually 
regarded as the part diseased. Pain is referred to the epigastrium, or 
to the vicinage of the dividing line between this and the right hypo- 
chondrium. It gradually increases in intensity until vomiting occurs, 
when it is relieved. In this, and in its frequently periodic or spasmodic 
character, it suggests stenosis of the pylorus. This periodicity is due 
to reflex spasm of the muscular wall of the stomach, a condition some- 
times so intense that it is perceptible to the hand. The nature of 
emesis varies according to the stage of the disease. At first it is slight 
and occurs only after long intervals, but these gradually shorten, and 
when the disease is well established vomiting is almost constant. Later, 
again, vomiting is rare or may be absent altogether. Loss of appetite, 
however, continues. There is intolerance for meats more than for any 
other food, but not to such an extent as in gastric cancer. The 
abdomen is generally flat, except in the epigastrium, where slight me- 
teorism is always evident. A deep, methodical palpation will reveal, in 
about one third of the cases, a movable tumor lying to the right of the 
median line between the lower border of the thorax, the umbilicus, and 
the gall-bladder. As a rule the bowels are constipated, but the stools 
are not decolorized. 

When vomiting appears, the course of the disease is accelerated ; it 
may be complicated by purpura or cardiac weakness. Apyrexia is the 
rule, but in some cases there is high, irregular fever, due to the resorp- 
tion of the products of bacteriological activity or to vegetation and 
necrosis of the neoplasmic masses. Death usually occurs in from seven 
to eight months. 

When the cancer is below the papilla of Vater the symptoms are 
the analogues of those mentioned above, except in a few details. 
Bilious vomiting, which is very rare in cancer of the first part of the 
duodenum, occurs in this form, owing to the bile passing into the 
stomach by regurgitation. However, many sarcomata below the di- 
verticulum cause dilatation of the intestine at the site of the disease, 
and bile, though present in the vomitus, is found in far smaller amounts 
than when stenosis occurs. Hydrochloric acid is found free in the 
vomitus or not, according to whether bile is absent or present in the 
gastric contents. An important fact in this connection is that a short 
time after thorough gastric lavage, and before food has been again 
taken, chyme regurgitated from the duodenum may be withdrawn from 
the stomach. The bowels are extremely constipated, and the stools 
somewhat decolorized and oflensive. A small, immovable tumor is 
usually noticed on deep palpation in the lower duodenal region. 

In all cases of periampullar cancer vomiting, flatulence, and other 
signs of gastric dilatation are dominant symptoms. Icterus, with con- 



CANCER OF THE DUODENUM. 197' 

comitant signs of lack of bile in the intestine, is present in the majority 
of cases, and comes on either suddenly or gradually. Distention of the 
gall bladder, fever of an intermittent type, and fetid, fatty stools are 
often seen. It is only in rare cases that a tumor may be made out, for 
when the neoplasm is located here death results usually from peritonitis 
at an early stage of the disease. 

Diagnosis. — A differential diagnosis of the " sus-Yaterian " cancer 
from cancer of the pylorus is extremely difficult. Indigestion of albu- 
minoids and fats is less marked in this form than in gastric cancer. 
On a priori grounds it would appear that an examination of the gastric 
juice would give important indications of the location of the growth, 
but the coexistence of dilatation of the stomach and gastric fermenta- 
tion complicates the situation greatly. Thus, in some cases of duodenal 
cancer there is an utter absence of free HCl, a very small quantity of 
combined HCl, but a large amount of organic acid, a condition occur- 
ring in carcinoma ventriculi and in some cases of duodenal ulcer. 
Insufilation of the stomach has not yet been employed, and, because of 
the almost invariable pyloric insufficiency after a certain time, it is 
doubtful whether this procedure would be of use when a diagnosis is 
most difficult. On theoretical grounds only is the method of value 
early in the disease. 

Many cases of duodenal disease have their origin by extension from 
gastric tumors, and the recognition of such extension is usually not 
made until the autopsy. 

A diagnosis of the exact location of the neoplasm, whether at the 
pylorus or in the upper part of the duodenum, is usually unnecessary if 
its existence can be determined early enough in the disease for extir- 
pation. 

Ulcer of the duodenum offers in many cases either a definite etiology 
or a latent course suddenly becoming evident ; it is oftener accompanied 
by hemorrhage and severe paroxysmal pain, is not so often attended 
with vomiting, presents no tumor, is not characterized by such cachexia, 
and runs an entirely different course. 

Chronic duodenitis offers early symptoms of jaundice, has a more 
diffuse pain, often accompanied by exacerbations of fever, is not asso- 
ciated with a tumor or profound changes in the gastric juice, and is 
amenable to treatment by diet. 

Stenosis of the pylorus, whether from intrinsic or extrinsic causes 
other than cancer, is unaccompanied by cachexia, hsematemesis, or cha- 
racteristic changes in the gastric juice ; the dilatation of the stomach 
is usually greater, and a significant history is reported. 

Ulcer of the stomach occurs most frequently in women, at an earlier 
age, is usually unaccompanied by tumor, though induration may be felt, 
and is accompanied by hyperacidity of the gastric contents. In ulcer 
severe pain occurs soon after eating, and is sometimes relieved thereby. 
Vomited blood is great in amount, and sensitive points, corresponding 
to the seat of the ulcer, may be determined on palpation. Atonic 
dyspepsia with gastralgia is not accompanied by tumor or the significant 
changes in the gastric juice, but by neurasthenic symptoms. It occurs 
most frequently in women ; the pain is not so definitely localized, and 
bears no constant relation to the ingestion of food. 



198 DISEASES OF THE INTESTINES. 

Of the intrinsic causes of duodenal stenosis, cicatricial contraction 
is the most common. In such cases a history of syphilitic, tuberculous, 
chemical, or siinple ulcer is usually obtainable. As, however, extensive 
ulceration may exist, and throughout its course be entirely latent, 
stenosis has often resulted from unsuspected cicatrization. Spasmodic 
narromng of the duodenum has been recognized as a part of a general 
neurosis. Obstruction by biliary calculus is preceded by signs of biliary 
lithiasis and biliary colic. Duodenal benign tumors are exceedingly 
rare, and generally they do not run so rapid a course, are less painful, 
and are less frequently accompanied by hemorrhage or intestinal indi- 
gestion. 

Extra-duodenal causes of stenosis are numerous. A circumscribed 
peritonitis with exudate compressing the intestines is generally accom- 
panied by more acute pain on pressure, and in the great majority of 
cases results from inflammation of the gall bladder. " Tumors of the 
mesentery, hydronephrosis, cysts of the right kidney, hydatid cysts or 
other tumors on the lower surface of the liver, aneurysm of the abdom- 
inal aorta, deep phlegmon of the abdomen, and many tumors of the 
abdominal wall have been associated with symptoms of duodenal occlu- 
sion. But in all cases the comparative mildness of the intestinal symp- 
toms and the diversified signs previously calling attention to some other 
viscus (e. g. urinary troubles in hydronephrosis) should suggest some 
extrinsic cause of stenosis. An attentive study of the connections of 
the tumor, of its seat, its mobility, its excursions with respiratory 
movements, its sonority, etc., phenomena all varying according to the 
peculiarities of each particular growth, will perhaps indicate the true 
condition" (Pick). 

It is well to remember that displacement of an abdominal viscus 
(particularly the kidney) will cause stenosis of the duodenum. In one 
instance it was due to prolapse of the pylorus permitting the bile to 
readily flow into the stomach and thus occasion violent, continual 
vomiting. The symptoms were promptly relieved by the use of an 
abdominal binder. Nicaise and Glenard state that exaggerated tension 
of the mesentery will obliterate the canal of the third part of the 
duodenum. In these cases a diagnosis lies along the lines indicated 
above, and absence of cachexia with occasional hemorrhage or melsena 
implies the absence of cancer. 

Infra-duodenal stenosis, whether due to benign or malignant 
growths, is always accompanied by much general ballooning of the 
abdomen, while in duodenal cancer, whatever its exact seat, this is 
slight and confined to the epigastrium, the rest of the abdomen being 
retracted. In duodenal cancer constipation is the rule. Blood, if found, 
is altered in color, but is never in large amount, as in duodenal ulcer. 

Cancer of the head of the pancreas rarely or never occludes the gut ; 
in most cases vomiting is either slight or is more frequently absent. 
Hemorrhage is excessively rare until the gut has been invaded, and 
there are few of those symptoms of gastric intolerance which play such 
a conspicuous role in the course of cancer of the duodenum. 

If the neoplasm is around the diverticulum of Vater the symptoms 
are multiform, for, independently of the common evidences given by all 
malignant growths, they are in the main the same as if the cancer were 



INTESTINAL INDIGESTION. 199 

located above and near the pylorus or below the ampulla, the prepon- 
derance of either train of symptoms depending directly upon the loca- 
tion of the greater part of the growth. In either event, however, 
icterus occurs in a large proportion of cases, and this, Avith the svmp- 
toms detailed under supra- or infra-ampullar cancer, will determine its 
exact location and diagnosis. 

Peogxosis. — Death usually takes place in seven or eight months, 
but in one case it occurred as early as the third, in another as late as 
the fourteenth month. 

Treatment. — There is apparently no reason why excision of the 
growth should not be practised with the same hope of success as attends 
operation for similar conditions in the stomach or other parts of the 
abdominal cavity. Doyen has reported a case where excision of pyloric 
cancer, and of duodenal cancer which was due to its extension, was 
practised with a favorable result. But while this operation may be 
possible if the neoplasm be in the first or third portion of the gut, 
gastro-enteric anastomosis is the only intervention possible if it impli- 
cate the second portion. Indeed, because of proximity of the duodenum 
to the pancreas, liver, and gall bladder, and the possibility of extension 
of the disease to these parts before an operation is consented to, French 
authors affirm that this latter operation alone is justifiable wherever the 
neoplasm may be located. Though so broad a conclusion is unjusti- 
fiable, it emphasizes the necessity for an early diagnosis and prompt 
intervention by as radical a means as the circumstances of the case will 
allow. 



INTESTINAL INDIGESTION. 

Befoee the phenomena of intestinal indigestion can be fully under- 
stood, there must be a clear idea of those processes of digestion which 
normally occur. To this end a short resume of the most essential facts 
will be given before the immediate subject itself is discussed. 

Digestion begins in the mouth under the action of several salivary 
ingredients, the most noteworthy of which is ptyalin. This is an 
unorganized ferment or enzyme of the amylolytic or diastatic group, 
which has the property of causing successive hydrolytic splittings of 
the starch molecule, so that the conversion of starch into sugar is indi- 
rect, through several forms of dextrin. The sugar that is ultimately 
formed was until recently supposed to be grape sugar, or dextrose (Qllg 
Og), but experiments now show that it is maltose (Ci^HjoOuHgO), which is 
more closely related to cane sugar. As rapidly as formed the products 
of ptyalin digestion are removed by dialysis if sufficient time be given ; 
this is practically instantaneous upon the part of the starchy food with 
which ptyalin comes in contact if the capsules of the starch grains be 
broken. There is rarely enough trituration in the mouth to bring about 
complete digestion of all the starchy food taken. Within certain limits 
the time necessary to effi?ct the transformation varies inversely as the 
quantity of the enzyme, but no secretion is sufficiently profuse to act 
thoroughly in the mouth alone unless mastication is adequate. 



200 DISEASES OF THE INTESTINES. 

The opinion formerly held that the action of ptyalin is at once 
checked in the stomach is based upon the fact that free hydrochloric 
acid, in the test tube, to the extent of only 0.003 per cent. (Chittenden) 
will practical l}' stop all amvlolytic action. Later experiments, howeyer, 
by the same investigator show that this not only does not occur in the 
gastric juice, though it should contain 0.05 per cent, of the acid, but 
that in this medium, in the early stages of digestion, the ferment is 
much more active than under other conditions. Salivary digestion of 
starch is only commenced in the mouth, for it continues in the stomach 
for about half an hour. It is then stopped by the acid proteids, fatty 
acids, or large amounts of hydrochloric acid. It is noteworthy that 
ptyalin and its correlative ferments are not found in the saliva of infants 
under from three to six months of age. 

Gastric digestion is due chiefly to the action of pepsin and rennin 
in a solution acidified by free and combined hydrochloric acid. Pepsin 
is a typical proteolytic enzyme which has the peculiarity of acting only 
in acid media. Peptic digestion therefore, properly considered, is the 
result of the combined actions of pepsin and HCl. By it solid or liquid 
proteids are split up into simpler substances which are rapidly diffusible 
through animal membranes. The ultimate end-product is peptone, but 
this is the result from the successive metamorphoses of several inter- 
mediary substances. The proteid is first converted into acid albumin 
or syntonin by the combined action of the acid and the ferment, the 
importance of the former here preponderating. Syntonin now takes 
up water, and two simpler proteids, known as primary albumoses or 
proteoses, are formed. Each of these again undergoes hydrolytic cleav- 
age, forming secondary or, as they are now called, deutero-proteoses. 
Finally these disintegrate and peptone is formed — the limit of gastric 
digestion. Prom the formation of syntonin the process is merely that 
of a succession of hydrolytic changes whereby soluble proteids are 
reduced to smaller and smaller molecular weights. The other most 
noticeable chemical differences between the mother proteid and the 
peptone are the lesser amount of carbon and the greater amount of 
oxygen in the latter. 

Rennin is the gastric ferment whose sole function appears to be the 
coagulation of milk. When this is ingested it undergoes a jDrocess 
strikingly similar to the clotting of blood, both in its superficial charac- 
teristics and the nature of its chemical changes. Cow's milk sets into 
a solid clot, which shrinks and presses out a clear albuminous fluid, the 
whey, but human milk forms loose white flocculi, much softer and easier 
of digestion. Though thus far rennin has been the only active factor 
in digestion, here, at least upon the clot which has precipitated — i. e. the 
casein — its action ceases and the ulterior change into peptone is due to 
pepsin. Dilute acids coagulate milk with facility, and it has been 
suggested that coagulation in the stomach may be due in part at least 
to lactic or hydrochloric acid, but the far greater potentiality of rennin, 
and the greater digestibility of the clot wdiich it forms, indicate that it 
is the only agent in the process. 

Hydrochloric acid finds its utility in its disinfectant properties, and, 
as suggested above, in its influence upon the digestion of proteids. The 
gastric juice of healthy persons contains a variable number of varieties 



INTESTINAL INDIGESTION. 201 

of micro-organisms, but they are always present in small numbers, and 
experiments would prove that this paucity is due to the presence of the 
acid. Though several observers have found fungi which flourish in the 
normal stomach, it is noticeable that they do not change the character 
of the gastric juice, and it is possible that in limited quantities they 
may have some correlative function in digestion. We are continually 
introducing with our food mould and yeast fungi and bacteria, which 
but for the hydrochloric acid would set up fermentation of various 
kinds, or which, develojjing in the system, would be the cause of numer- 
ous zymotic diseases. Various bacteria — i. e. those of cholera, typhoid 
fever, tetanus, anthrax, and dipiitheria — are destroyed or their growth 
prevented by the gastric juice, so that they only gain ingress when this 
secretion is in abeyance, as through the drinking of water between 
meals. 

Beyond its liquefaction by animal heat, and the digestion of its 
capsule there is little change which a fat globule undergoes in the 
stomach. Starches likewise Mould appear to be little aifected by the 
purely gastric secretion, though in some instances they have been 
rendered soluble or changed into erythrodextrin. Unboiled starch is 
certainly not altered at all. 

A most important factor in digestion is the peristaltic movement of 
the stomach, whereby a thorough agitation of its contents is caused. 
Thus each fragment is brought in contact with its secretions and the 
stomach wall, through which, if digested, a part is readily absorbed. 
Water, many salts, sugars, and a few other diffusible substances enter 
the system in small quantities through the stomach wall, but the fats, 
starches, some albuminoids, and most of the peptones pass through the 
pylorus to be further elaborated and absorbed from the intestine. Gas- 
tric digestion lasts from three to five hours, and though small quantities 
of aliment may be passed through the pylorus at intervals during the 
process, the greater part, including all the fat, is expelled at once when 
gastric digestion is complete. 

Recent observations show that gastric digestion is dispensable, or of 
subsidiary importance, for various animals in which the stomach had 
been extirpated thrived as well after as before the operation. 

The complex diffluent mass that enters the intestine is destined to 
here undergo its most j^rofound changes. It will be well to consider 
seriatim the effects produced upon it by bile, pancreatic secretion, and 
intestinal juice, all of which are agents in its digestion. 

The first of the fluids, the bile, though containing practically no 
enzyme and therefore incapable of causing a decomposition of carbo- 
hydrates, proteids, or fats, plays an auxiliary but not unimportant part 
in the digestive processes here. Upon starches its action is practically 
nil. But when it comes in contact with the acid products of stomach 
digestion a precipitate is produced, composed essentially of unchanged 
native albumins, bile acids, and pepsin. The immediate result is the 
instantaneous arrest of peptic digestion and the establishment of condi- 
tions necessary for the proper exercise of pancreatic functions. Upon 
fats, however, rather than any other aliment, bile has its most noticeable 
action. The steapsin of the pancreatic juice, to anticipate somewhat, 
forms, from the decomposition of some of the fats, free acids, which, 



202 DISEASES OF THE INTESTINES. 

combining^ in part with some of the alkaline salts in the bile, form soaps 
which emulsify the rest of the fat. Absorption of fats is thus permitted 
and is facilitated by the presence of the free acids from the bile. 

Recent observations show that the bile is sterile, but this does not 
mean that it is antiseptic. The bacillus mallei, B. typhi abdominalis, 
B. coli communis, comma, spirillum, pneumococcus, etc. have all been 
found in it. Under conditions of digestion, however, there are formed 
free bile acids which do not exist before the bile comes in contact with 
the chyme, and these exert an antiseptic action which is at least strong 
enough under normal conditions to control the action of native or foreign 
germs. 

The pancreatic juice is composed of water, salts, albuminoids, and its 
three specific ferments, amylopsin, trypsin, and steapsin. Amylopsin is 
the similar of ptyalin, but is much more powerful. Inasmuch as the 
starches form a large part of our diet and as salivary digestion of these, 
though important, is comparatively subsidiary, their digestion takes 
place almost entirely in the small intestine, and mainly by virtue of the 
action of amylopsin. A similar enzyme, however, is found in the pure 
succus entericus, but its action is supplementary. Both these ferments 
act in the same way as does ptyalin. 

Tryptic digestion resembles peptic digestion in that it concerns the 
proteids, but the two processes differ in many respects. In the latter 
the hydrolytic changes are gradual and the successive steps in the 
formation of peptone can be easily traced, but in the former the solid 
proteid undergoes a transformation directly to secondary proteoses and 
the intermediary steps are skipped. Next amphopeptones are formed 
in all respects similar to the end-products in gastric digestion. Neither 
of these could be further affected by pepsin, but trypsin splits them 
into two constituents, hemi- and antipeptone, and further elaborates one 
of these (hemipeptone) into much simpler non-proteid bodies, most of 
w^iich are amido acids. The final products of complete tryptic digestion 
therefore are antipeptone and a variety of organic structures, mainly 
these amido acids. The most easily separated of these acids are leucin 
and tyrosin, both capable of ready assimilation, but not so valuable in 
tissue reconstruction as peptone. 

Steapsin is that ingredient of pancreatic juice concerned in the diges- 
tion of fats. Though it is commonly spoken of as a fat-splitting 
enzyme, it must not be supposed that it acts in this manner upon all 
fats present. Only a small portion is thus acted upon and disintegrated 
into glycerin and free fatty acids, but these help to emulsify the balance 
of the fats. Such emulsification is effected by the union of the fatty 
acid w^ith alkaline salts, especially sodium carbonate, which are always 
present in the pancreatic and intestinal juices. But it is in the bile that 
these alkaline salts are so disposed that such union and consequent for- 
mation of soaps and emulsions most readily occur. 

The succus entericus contains no agent which has direct effect upon 
either the proteids or fats, but by virtue of the sodium carbonate which 
it contains it is indirectly valuable in the emulsification of these latter. 
But upon carbohydrates its action is important, for it not only contains 
an amylolytic enzyme capable of forming maltose, but inverting en- 
zymes which convert maltose into dextrose and cane sugar into dextrose 



INTESTINAL INDIGESTION. 203 

and Isevulose". The disaccharids which form the largest part of our 
diet are cane sugar, milk sugar, and maltose, which last is also the 
commonest end-product in artificial digestion of starches. All starches 
and sugars (except lactose, which may be absorbed unchanged) are finallr 
absorbed as dextrose, an ultimate form to manufacture which the action 
of the intestinal juice is necessary. 

These phenomena of digestion occur chiefly in the small intestine. 
Though the process may be continued in part after the food has entered 
the colon, no new factors in digestion itself are here added, and the 
changes of general interest are chiefly concerned with the bacteriological 
decomposition. Many food products that have been formed higher up 
are here absorbed. 

Of the absorption of peptones and proteoses, either in the large or 
small intestine, it may be briefly stated that this, greatly assisted by the 
epithelial cells, occurs directly into the bloodvessels. But at the time 
of such absorption these substances are radically changed into others 
which have not yet been isolated, but are probably native albumins or 
serum albumin. Water, salts and sugars also pass directly into the 
bloodvessels, osmosis in each case being assisted by the epithelial 
cells. The fat droplets are taken up and passed directly through the 
substance of the epithelial cells ; thence they are conveyed through a fine 
reticulum into the lacteals and common duct. 

The intestinal movements that are so necessary in digestion and 
absorption are controlled by nervous arrangements, but may occur 
independently of the nervous system. The ganglia of Auerbach and 
of Meissner in the intestinal wall are sufficient for the development of 
the peristaltic waves. Paralysis by section of the splanchnic leads to 
hypersemia of the intestinal vessels and increased peristalsis ; stimula- 
tion of the splanchnic causes anagmia of the intestinal wall and imme- 
diate arrest of movement. 

As has been suggested above, the gastric juice has a noticeable influ- 
ence in destroying putrefactive and many pathogenic organisms which 
find their way into the stomach. All fermentations and putrefactions 
which there occur, with only possible minor exceptions, are normally due 
to enzymes. But in the small and much more so in the large intestine 
the conditions are more favorable to the growth of microbes, and hence, 
side by side with the digestive processes properly so called, others due 
to these agents are going on. In man organized ferments play a second- 
ary part in the processes in the small intestine, and digestion appears Xo 
be most typically physiological when their activity is least conspicuous 
and when certain at least of the products of their activities are smallest 
in amount. Though many alkaline salts are found in the intestine, and 
though the secretions in it are alkaline, it has often been shown that the 
reaction of the intestinal contents is acid. Possibly this is due to the 
formation of amido acids by trypsin or to the disintegration of bile, or 
normally in slight degree to bacteriological activities. At any rate, all 
of these have a distinctly destructive and inhibitory influence on the 
development of all micro-organisms. 

It is a strange and puzzling fact that the hydrobilirubin, the indol, 
skatol, and phenol which are the results of the putrefaction which goes 
on in preponderating measure, if not exclusively, in the large intestine 



204 DISEASES OF THE INTESTINES. 

should be in part absorbed, and after entering the portal blood make 
their way through the liver and be excreted somewhat modified in the 
urine. That tjiese bodies play a part in influencing the metabolic pro- 
cesses of the body scarcely admits a doubt. The phenols, the indol, and 
even the fetid skatol, all resulting from the lifework of putrefactive 
bacteria, illustrate the general law that the products of living organisms 
are prejudicial to and capable of destroying organisms of the kind 
which produced them, for all these bodies are more or less antiseptic. 

Etiology. — The causes of intestinal indigestion may be predispos- 
ing, primary, or secondary. For convenience and to avoid repetition 
the two last may be considered together. 

Predisposing Causes. — (1) Age. — It is usually said that though the 
condition may occur at any age it is commonest between the thirtieth 
and fortieth years. Though undoubtedly this is the case with adults, 
yet the prevalence of the disease among children is such that certainly 
they are to be considered more subject to it than older persons of any 
age. A United States census report shows that 76 per cent, of all 
cases of death from intestinal diseases occur before the tenth year. 
Many cases of so-called intestinal catarrh are really cases of intestinal 
indigestion, and the catarrh is secondary. It is with reason that the 
second summer of dentition is regarded with most apprehension by both 
mothers and practitioners, for it is then, when debilitating influences 
and those favoring the decomposition of food and multiplication of 
micro-organisms are most potential, and when the child is accommodat- 
ing itself to a new dietary, that its digestive organs have not yet under- 
gone the development necessary to new requirements. At this time 
putrefactive or fermentative bacteria can easiest effect an entrance and 
lodgement. 

(2) Sex has little or no influence. Intestinal indigestion is more 
frequently seen in men, but is rather the result of personal habit than 
of any sex predisposition. Ov^ereating and eating of indigestible food 
are especially vices of men. 

(3) Heredity of idiosyncrasy in some few instances plays an import- 
ant part. Almost every practitioner has seen cases in which the use 
of some particular food, as eggs or shellfish, is invariably followed by 
acute intestinal indigestion. Occasionally every member of a family 
may have the same idiosyncrasy. 

(4) Previous attacks of intestinal indigestion may be said to predis- 
pose to others with the same liability as exists in all catarrhal inflam- 
mations. Although most cases of intestinal indigestion that call for 
treatment are subacute or chronic from the outset, there are many 
whose beginning may be traced to a few closely succeeding occurrences 
of the acute form. 

(5) It is closely connected with the neurasfhenic constitution, whether 
as effect or cause is not always clear. 

The following are primary and secondary causes of intestinal indi- 
gestion : 

1. A Faulty Composition of the Chyme. — A satisfactory condition 
of this mass is dependent upon the character of the ingesta and the 
manner in which they have been disposed of by the mouth and stomach 
digestion. ''Both in regard to his digestive juices and the alimentary 



INTESTINAL INDIGESTION. 205 

principles siAmitted to their operation man does not differ in any 
essential particulars from the lower animals, and yet it would seem as 
if the function of digestion were less perfectly adjusted and its equili- 
brium more easily disturbed in man than in them. The cause of this 
discrepancy is to be sought for partly in the quicker and more universal 
sympathies of his nervous system, and partly and chiefly in the extra- 
ordinary complexities which civilized man has introduced into his 
dietary. He has departed and is departing more widely from the 
simplicity and uniformity of primitive natural life. Scarcely any two 
of his meals are exactly alike, and although the adjustive power of his 
digestive organs keeps pace in the main with this increasing complexity, 
the process of adjustment in many individuals seems to lag a good deal 
behind their requirements" (Sir Spencer Wells). On the other hand, 
a monotonous diet js noticeably conducive to intestinal derangements, 
especially if the few things taken are in any way difficult of digestion. 
Milk is the only substance containing all the elements in such propor- 
tion as the economy approximately requires, and it is for this reason 
that it only can be taken by most persons for long periods with any 
degree of satisfaction. The digestive secretions correlate each other ; 
there is a variable though definite limit which they may hold each to 
each. Too much demanded of one class of digestive ferments — the 
amylolytic, for example — to the partial or complete exclusion of the 
others will first fatigue and then disorder their secretion. A milk or 
liquid dietary prolonged beyond the first year is accompanied with a 
feeble digestion that becomes indigestion with the slightest provocations. 

Overeating of proteids is a frequent cause of dyspepsia, for these, 
if they cannot be completely digested, are especially liable to permit 
the multiplication of micro-organisms. Too much starchy food, on 
the other hand, interferes first with gastric digestion of proteids, and, 
if it ferment in the stomach, produces there lactic and butyric acids 
sufficient to practically destroy the intestinal ferments when they reach 
them later. 

Irregularity in the hours of eating and a fliulty distribution of the 
amount of food disturb the harmony of digestion. Very light break- 
fasts and late and large dinners are distinctly injurious. Diners-out 
rarely go through a season without one or two internal revolts. The 
habit, now quite common in cities, of deferring the breakfast proper 
until midday leaves the system too long without support ; intestinal 
indigestion is becoming common among those Americans who have 
lived abroad and adopted European customs. 

The functions of buccal and gastric digestion have already been 
discussed. The chewing of tobacco, and to a less extent the habit of 
smoking, are causes of deficient, altered, or depraved saliva, and sec- 
ondarily of altered pancreatic secretion. Hasty mastication results in 
imperfect trituration of the starch granules, a deficient secretion of 
saliva, and consequent imperfect salivation. The wall of the starch 
granule, cellulose, unless broken by boiling or trituration is practically 
impervious to any digestive fluid, so that its contained nutritious ele- 
ments are lost. The importance of thorough mastication is great — far 
greater than is realized by our patients. Too many eases of gastric 
or more especially duodenal indigestion are directly traceable to this 



206 DISEASES OF THE INTESTINES. 

alone. Instead of an absorption of saccharine materials from the 
stomach, or even their formation there, the mass of undigested starch 
remains a dea^ weight, affecting the digestion and absorption of other 
aliments that should be disposed of here, and becoming soaked with 
fluids which will interfere with its own proper disposal later on. All 
the starch that has been eaten is often passed into the intestines, having 
undergone practically no buccal digestion whatever. The overstrained 
secretion of amylopsin, though able to rise to occasional emergencies, 
is unable to cope with continual demands upon it. Failure of its 
secretion is accompanied by failure of secretion of other ferments. 
Possibly the most prolific ultimate cause of intestinal indigestion is 
deficient mastication and insalivation of food. 

The influence of gastric upon intestinal indigestion is important. A 
poor disposal of the proteids, hypoacidity favoring fermentation or 
putrefiictiou, hyperacidity with the early destruction of ptyalin swal- 
lowed with the food, too great sensitiveness of the stomach walls lead- 
ing to evacuation of the viscus before gastric digestion is complete, 
and many similar and other conditions are first steps toward duo- 
denal indigestion. 

2. Perversions in the Qualifi/ or Quantity of the Bile, Pancreatic, or 
Intestinal Juices. — Hot weather, especially if associated with humidity, 
not only leads to indigestion by altering the food and preparing it for 
decomposition, but by debilitating the individual through the depression 
of the nervous system and by inhibiting secretory activity. The appe- 
tite, which, according to the demand upon it, has diminished pro rata, 
is often kept up to its former standard by will stimulation. The ali- 
mentary tract, though it contains no more than could be readily disposed 
of under normal circumstances, now retains a mass which the dimin- 
ished secretions cannot digest and which ferments and putrefies. Sexual 
and emotional excesses, exhausting occupations, lack of sleep, grief, and 
mental depression, conduce to indigestion through the effect of their 
influence on the nervous system. Such occupations as horse-shoeing, 
tailoring, etc., in which the body is bent forward, tight lacing or other 
modes of compression, all cause a local anaemia and perverted secretion. 
Anaemia, rachitis, syphilis, continued febrile disorders, etc. often stand 
in direct etiological relation with the disease, and the connection of 
indigestion of fats with the strumous diathesis is so evident that Bennett 
ascribed the origin of phthisis to this defect. The influence of the mind 
upon intestinal is even greater than upon gastric digestion, for no other 
reason perhaps than that the former is a more complex function and less 
easily relieved than the latter. Prolonged or excessive mental labor 
does not do so much harm as worry, over-anxiety, and the high tension 
which a large or technical business demands. Professional men, who 
become overburdened with responsibilities and who sympathize too 
much with the distresses of others, or who have too many of their own, 
are very prone to suffer from this disease. 

The precocious mental development of children is a fruitful source 
of indigestion. In short, the disease may be caused by any condition 
of the general organism which results in a depressed innervation or less- 
ened blood supply of the intestinal glands. 

Perverted intestinal secretion may also be caused by purely local 



INTESTINAL INDIGESTION. 207 

conditions. ^ Intestinal catarrh is invariably accompanied by greater 
or less disturbances of digestion. The steps in the disposal of carbo- 
hydrates are much altered and the absorption of all aliment is delayed. 
Conversely, however, as suggested above, many cases of intestinal catarrh 
must be regarded as the result rather than the cause of intestinal indi- 
gestion. Disease of the pancreas or liver, cancer of the duodenum, 
fatty, sclerotic or amyloid degenerations, trauma, abscess, occlusion of 
the excretory duct of the pancreas or liver by catarrhal swelling, cal- 
culi, or the pressure of extrinsic or intrinsic tumors, or, in fact, any 
pathological condition of any one of these organs, is followed by intes- 
tinal digestive disturbances. 

3. Fermentation or Putrefaction of the Intestinal Contents. — Decom- 
position of food may occur from the reciprocal action of several food 
stuffs upon each other, with the development of fatty acids, gases, etc. 
In some patients, substances that most persons can easily dispose of 
prove incapable of simultaneous digestion. But it is to bacteriological 
activities rather than to the influence of different aliments upon each 
other (for such influences are indefinite and capricious) that most fer- 
mentative or putrefactive processes, which assume pathological propor- 
tions, are due. Though such bacteriological processes occur to a limited 
■extent, even in health, throughout the entire intestine, it is very easy 
for them to exceed those bounds which may be called normal. As 
stated above, digestion is probably most nearly perfect when the micro- 
organisms present are fewest and least active. 

It has already been said that those agents which inhibit the over- 
development of bacteria are bile acids, the amido acids resulting from 
tryptic digestion, and, possibly, the acids resulting from the action of 
bacteria or fungi themselves. Since ptomaines are not produced under 
normal conditions in the intestine, these cannot be said to normally 
exercise an inhibitory influence. Hence the bactericidal factors of most 
importance are these : the bile must be of such a character that the bile 
acids can be readily formed ; conditions favoring the formation of these 
acids — i. e. a normal chyme and pancreatic secretion must be present^ 
and tryptic digestion be completed. These factors, though of continu- 
ally varying proportional importance, should complement each other. 

The number of germs in the intestinal canal is extraordinarily 
variable, so that one cannot fix upon a norm. Many things influence 
their number, such as the kind of food and length of retention of 
the intestinal contents, but it is probable that this latter is the chief 
influence. Of those that are found but a small number can be grown 
in ordinary culture media, and only the pathogenic bacteria of the 
intestinal canal, thus j)ropagated, can be easily identified. They vary 
not only with the diet, but also with the methods of preparing food. 
Putrefactive and fermentative processes occur normally in the large 
intestine, but there the ultimate derivatives of digestion have already 
been formed and are being rapidly absorbed. 

It is to the ptomaines of the micro-organisms and to the absorption 
of undue amounts of substances usually regarded as excrementitious, 
indol, skatol, etc., that most of the later phenomena attending intes- 
tinal indigestion are due. 

It is to be remembered that practically all cases of intestinal indiges- 



208 DISEASES OF THE INTESTINES. 

tion, however caused, are attended by a pathological multiplication of 
micro-organisms ; that these, in the intestine, tend to perpetuate and 
aggravate the abnormalities which attended their origin ; and that 
nothing which 'does not look toward their removal and the eradication 
of the products of their activities from the intestine and from the sys- 
tem can be expected to influence the course of the disease. 

4. Exaggerated or Deficient Peristalsis. — Aliments primarily irrita- 
ting or rendered so by faulty digestion exert upon the intestinal plexi a 
stimulating influence which is soon followed by exaggerated peristalsis. 
Under most circumstances this is beneficial, ridding the canal of delete- 
rious matters. But when such peristalsis is due rather to over-sensitive- 
ness, either from a general or local neurotic condition or from more 
gross local disease — e. g. ulcer, cancer, tabes mesenterica, inflammation, 
etc. — it often assumes pathological proportions. Deficient peristalsis 
may be caused by constitutional peculiarities, sedentary or irregular 
habits, drug-taking, general atony, peritoneal adhesions, chronic disease 
of the mucosa, or any of the many agencies that can cause stricture of 
the tube. The results are retention of food long after all nutritious 
elements have been absorbed, and decomposition of the residuum. Para- 
sites then produce their specific ptomaines and elaborate by-products, 
which when absorbed may cause profound constitutional disturbance. 
The bacteria that multiply from the retention of food will also directly 
interfere with the proper digestion of subsequent meals. 

5. Defective absorption may folloiv local disease of the mucosa or a 
faulty elaboration of aliments by the digestive secretions. The causes of 
this latter have already been discussed. Fat-absorption is especially 
affected by disease of the mucosa, for the cells then appear unable to 
take up the emulsion and pass it through their substance as they should. 
In this condition also the change of proteid derivatives into serum 
albumin and of the various forms of sugar into dextrose is imperfect 
or impossible. As these latter changes of the food, which occur partly 
in the liver, are not, properly speaking, steps in the immediate process 
of digestion, no further reference to them is here necessary. 

Pathology. — Thus far acute and chronic intestinal indigestion 
have been treated for the sake of convenience as one disease, but from 
this point, except in those aspects which they have in common, they 
will be discussed separately. 

The lesions described below are found in a limited number of cases, 
generally the severer forms, in which duodenal catarrh and indigestion 
have been coincident. It is reasonable to believe that the lesion in the 
acute form is slight in many instances, and that its duration is short. 

Acute Form. — The mucous membrane is swollen and hypersemic, 
varying in color from light rose to dark purple. This hypersemia may 
be localized or diffuse or mottled, and is frequently much more severe 
in one part of the bowel than in another. It is usually most intense 
around the solitary follicles and Peyer's patches and on the tips of the 
valvulse conniventes. Hemorrhages over an area one half a centimetre 
in diameter have been described. In mild cases the follicles and patches 
appear as small white bodies standing out in bold relief against the 
injected zone surrounding them ; in severe cases they may become as 
large as a pea and are indurated and knotty. The surrounding inflam- 



INTESTINAL INDIGESTION. 209 

matory area may be necrosed and catarrhal, and follicular ulcers may 
form, but no deeper parenchymatous changes occur. 

Microscopically the bloodvessels of the mucosa and submucosa are 
found more or less injected, and there are small extravasations, most 
frequently between the crypts of Lieberkiihn. The interstices between 
them are often distended by the characteristic signs of a true inflam- 
matory catarrh — the round cells. These are most numerous in the 
upper portion of the submucosa immediately beneath Briicke's mus- 
cles. The swelling of Peyer's patches and solitary follicles is due to 
proliferation of their own cells and a round-cell immigration. The 
epithelium of the mucous membrane is generally detached, and though 
this occurs post-mortem within six hours in many cases, it is probable, 
from correlative circumstances, that in this disease it is an ante-mortem 
change. The epithelium of the glands appears sometimes unchanged, 
sometimes opaque and swollen. Lieberkiihn's glands are occasionally 
altered in position, etc. ; they may be dilated throughout or only at the 
fundus, bottle-shaped, occasionally curled, and rarely raised or sunken. 
The deeper layers of the submucosa show hypersemia with round-cell 
infiltration around the bloodvessels. There is no change in the muscu- 
laris or the deeper coats. The surface is covered with a variable amount 
of mucus. The mesenteric and less frequently the retroperitoneal 
lymph glands are enlarged. 

Chronic Form. — In this condition the appearances are very similar 
to, or are quite identical with, those seen in chronic intestinar catarrh. 
The mucous membrane may be entirely unaltered, or pale and covered 
w4th mucus. More frequently, however, it is softened, of a slaty gray 
or bluish color, with grains of pigment in the villi and in and between 
the follicles. The lining epithelium has undergone fatty or granular 
degeneration and is shed over areas of variable extent. Hyperplasia 
of the connective tissue beneath the epithelium and of all lymphatic 
elements occurs, causing the closed follicles to project prominently 
above the surface. Eventually the walls of the entire intestine become 
greatly thinned or hypertrophied. 

In this connection it would be well to mention atrophia intestinalis — 
a disease which may follow an acute or chronic intestinal indigestion 
(far more frequently the latter) or may come on insidiously. Micro- 
scopically there may be noticeable atrophy of the small intestine, whose 
mucous membrane, from the destruction of its villi, appears smooth 
and velvety. In the large intestine this appearance is absent. Des- 
quamation of epithelium is not noticeable in the early stages, but as the 
disease progresses this phenomenon follows. The glands of Lieberkiihn 
become smaller and shorter, until, from the continual compression of 
the interstitial tissue they disappear altogether. The villi undergo 
changes analogous to those in the glands — i. e. they become narrow, poor 
in cells, glassy, and finally cannot be recognized. The interstitial tissue 
spreads everywhere, but simultaneously contracts like cicatricial tissue, 
so that the entire area of mucous membrane is remarkably diminished. 
Next to the mucosa, the most profound change is seen in the muscular 
coat. The fibres there may be hypertrophied, but usuallv they are 
shrunken and in extensive areas have disappeared ; in other cases' they 
are separated by cellulai infiltration or appear to be drawn rather than 

Vol. III.— 14 



210 DISEASES OF THE INTESTINES. 

forced apart. The ganglia of Meissner's and Auerbach's plexi undergo 
fatty degeneration. 

The changes in the character of the succiis entericus in each of 
these conditions must be profound, and the diminished powers of 
absorption, especially in atrophia intestinalis, would account for almost 
any degree of emaciation. 

No changes in the pancreas peculiar to intestinal indigestion have 
yet been described, and the lesions of cancer and ulcer, in the course of 
which intestinal indigestion is incidental, are given elsewhere. 

The exact alterations in the pancreatic secretions have also not been 
studied. It is known, of course, that one or all ferments may be 
abnormal, that they may be present in diminished amount or in excess, 
that the oscillations of the proportional relations between them (varying 
according to the character of the food) may not occur as they should, 
and that the potentiality of each or all may be diminished. In a gen- 
eral way the results of such abnormalities may be inferred, but of the 
ultimate chemical differences which they occasion, and which are of 
such great interest in auto-intoxication, we are ignorant. 

What has been said of the pancreas and the pancreatic juices in this 
connection may also be said of the liver and the bile. This latter suffers 
remarkably little change even in advanced hepatic disease, and this change 
is not sufficient to cause much disturbance in intestinal digestion. 

The character of the chyme when it leaves the pylorus varies widely 
within limits of health, but in almost all cases of gastric disease it is 
sufficiently altered to modify in part at least the processes of intestinal 
digestion. To detail the abnormalities of the chyme would be useless, 
but in general terms it may be said that they depend upon an excessive 
amount of hydrochloric or upon acetic, lactic, and butyric acids, various 
gases, chiefly hydrogen and carbon dioxide, large masses of sarcinse and 
torulse, and faultily digested proteids. What processes, then, transpire 
in the intestines should be evident from a review of the physiology of 
intestinal digestion. An excess of HCl is more easily dealt with than 
are the products of fermentation. The combined intestinal secretions 
may prove insufficient to lower the degree of acidity to such a point 
that trypsin will not be disintegrated. 

But the most conspicuous chemical phenomena in both acute and 
chronic indigestion, and those that must be especially emphasized, are 
due to the activity of micro-organisms. Normally these are either 
absent from the small intestine, or if present their activities are feeble 
and not accompanied by the elaboration of ptomaines. In the large 
intestine there are fewer influences of an inhibitory character and 
several micro-organisms are normally found there. 

Those agents Avhich control bacteriological multiplication are the 
acids (lactic, acetic, etc.) normally set free in the digestion of food, and 
the bile acids, which are liberated as soon as the bile begins to undergo 
its physiological decomposition to aid in the emulsification of fats. It 
must be remembered that the normal reaction of the contents of the 
small intestine is acid (Gamgee) ; any condition, such as catarrhal, or 
nervous influence, etc. preventing proper digestive processes, and the 
proper formation of these acids will, therefore, directly conduce to the 
multiplication of germs, or their irruption may be so potential that all 



INTESTINAL INDIGESTION. 211 

usual means^of resistance are overcome. The absence of ptomaines is 
due to the bile or the oxygen in the intestine. Normally there is a free 
diffusion of this element between the blood in the mucous membrane of 
the canal and the intestinal contents, and it is not until osmosis of this 
gas is seriously interfered with that ptomaines can be developed. 

Numerous micro-organisms are capable of inducing putrefaction of 
albuminous substances, but those definitely known to play a role in 
intestinal indigestion are comparatively few.^ 

In the initial stage of this process aerobic and facultative bacteria 
usually play the most important part, while in active putrefaction they 
are supplemented or perhaps very largely replaced by " strict " anero- 
bics, — organisms which have yet received comparatively little study. 
Among the facultative anaerobic bacteria perhaps the most important 
and ordinary exciters of putrefaction are bacilli of the proteus group ; 
they are of common occurrence and possess to a high degree the power 
of causing putrefactive decomposition. 

When intestinal contents and normal fseces are examined a very 
large number of micro-organisms are to be found. Even the milk faeces 
of sucklings are no exception in this regard, since normally at least two 
varieties of bacilli are present in them — namely, B. lactis aerogenes, which 
is more abundant in the small intestine, and B. coU communis, more 
abundant in the large. No true putrefaction occurs, however, for milk 
casein is not changed by either of these bacilli. In catarrhal enteritis 
the alvine discharges contain a much larger number of micro-organisms, 
while in diarrhoea associated with toxic symptoms one or more species 
of the proteus group {ut supra?) appear to be constantly present. Thus 
the bacterial condition of milk faeces is comparatively simple, and well 
illustrates from a negative standpoint the relation between bacterial 
growth and some forms of intestinal indigestion. 

^ Over fifty known species of micro-organisms have been identified at various times 
in the faeces passed by patients suffering from intestinal indigestion and catarrh. The 
numerical relations between them are not always the same. The following bacteria 
that have been found in the large or the small intestine are most constantly present in 
the dejecta of such patients : 

1. B. Bisehleri (resembling the B. coli communis). Acts on grape sugar, forming ethyl 
alcohol, inactive lactic acid and acetic acid, and gas. No action on albumin. 

2. Slrepiococcus liquefacienn ilei. Acts on grape sugar, forming inactive lactic acid ; no 
action on albumin, but liquefies gelatin. 

3. B. ilei (Frey). Decomposes sugar into succinic acid and active lactic acid and 
alcohol ; no action on albumin. 

4. B. ovale ilei. Decomposes sugar in the presence of paralactic acid ; no action on 
albumin. 

5. B. gracilis ilei. Acts virtually as B. ovale ilei; no action on albumin. 

6. B. liquefaciens ilei. Acts on grape sugar only under favorable conditions ; most 
vigorously on albumin. 

7. B. lactis aerogenes. Acts on sugar, forming alcohol in large amounts, sarcolactic 
acid, succinic acid, and active lactic acid. 

8. B. putrificus coli. Especially concerned in the decomposition of albuminous sub- 
stances. 

9. B. coli communis. Has an intense action on sugar, forming ethylic alcohol, acetic 
acid, and dextrogenous paralactic acid. 

10. Proteus vulgaris. Liquefies gelatin and disintegrates proteids. 

11. Proteus mirabilis. Liquefies gelatin and disintegrates proteids. 

In addition to these micro-organisms, Nothnagel enumerates four different varieties 
of bacilli, nine cocci, and four fungi that are present, he says, simultaneously in some 
cases of intestinal indigestion. 



212 DISEASES OF THE INTESTINES. 

The particular products formed by albuminous putrefaction will 
depend on the nature and condition of the proteid, the conditions under 
which it is placed, and the particular micro-organisms inducing the 
change. Toxic proteids are formed by bacterial growth, under certain 
conditions, both from living protoplasm and from proteids not associated 
with living tissues ; but they are not normally found in acute putrefac- 
tive changes. The greatest resistance offered to albuminoid decomposi- 
tion is in the initial stage of the process, the peptonization of the pro- 
teid, and if this be already completely accomplished by other than 
bacterial ferments (as in pancreatic digestion), then the conditions are 
much more favorable for active bacterial growth with the characteristic 
formation of ptomaines and other putrefactive products. Under the 
influence of trypsin part of the proteids are converted into amido acids, 
certain bases (lysine, lysatine, and ammonia), and tryptophan. Putrefac- 
tive bacteria cause first the elaboration of these bodies, or their activities 
may more easily begin at this point. Later other substances are formed,, 
certain of which (phenol and paracresol) are the products of decomposi- 
tion and the reduction and oxidation of tyrosin, while others (indol,, 
skatol, skatol carbonic acid) are aromatic compounds not related to 
tyrosin. These represent the specific decompositions of the albuminous 
molecule distinguishing bacterial from tryptic proteolyses. In addition 
there are formed fatty acids, certain bases, nitrites, hydrogen, and hydro- 
gen sulphide. The end-products are carbon dioxide, water, ammonia,, 
nitrites, hydrogen, and hydrogen sulphide. 

Unlike this decomposition of proteids, that of the carbohydrates is a 
normal process in the small intestine, but not to such an inordinate 
extent as may follow bacteriological activities. It is, in fact, upon car- 
bohydrates that most bacteria exert their influence, as a glance at the 
appended list will show. 

Though carbohydrates undergo four different methods of fermenta- 
tion, it is sufficient here to state that the end-products of these are 
amylic, succinic, acetic, propionic, butyric, lactic, and paralactic acids,, 
alcohols, and various gases, among which hydrogen, oxygen, and carbon 
dioxide are the most conspicuous. 

In addition to these products and those mentioned as resulting from 
bacterial proteolyses, others distinctly poisonous are elaborated in the 
digestion of both proteids and carbohydrates, more particularly the 
former. No definite chemical formulae for these (ptomaines, toxins,, 
toxalbumins, etc.) can be given, but three general classes may be recog- 
nized : 

1. Alkaloidal bodies composed of pyridin (CgHjN) or chinolin 
(CeH,N). 

2. Diamins (putrescin, and cadaverin), as frequently demonstrated. 

3. Toxalbumins — i. e. poisonous albuminous bodies. 

The villi, weakened by contact with abnormal substances, are event- 
ually paralyzed, so that they can no longer adequately exercise a dis- 
criminating inhibition upon the ingress of digestive products. The 
ready absorption of toxic materials is the result. Though these are 
normally found in the portal vessels in small amounts, they are then 
easily disposed of, in greater part at least, by the liver, for this organ 
has a distinctly destructive influence over almost all such organic 



INTESTINAL INDIGESTION. 213 

poisons. It^is only when they are absorbed in large amounts, as after 
intestinal indigestion, that the hepatic functions prove inadequate ; they 
then find their way into the general circulation, vitiating or at least 
impairing the nutrition of all tissues with which they come in contact. 
As will be shown in the discussion of urinalysis, certain toxic substances 
are normally absorbed from the intestine in small amounts, are passed 
through the liver and general circulation, and excreted by the kidneys. 

Aside from general congestion there may be no lesions whatever dis- 
coverable after death from auto-intoxication. Tyrotoxicon, a product 
formed by the action of putrefactive bacteria upon cheese and to a less 
extent other proteids, has repeatedly been found in the tissues of persons 
dying through its immediate agency, yet it has seldom caused any gross 
lesions (in other localities than the intestine) that can be discovered by 
the most careful post-mortem examination. The same may be said of 
several other toxic substances occasionally elaborated in the course of 
intestinal indigestion. 

In addition to those lesions in the intestine mentioned above there 
are some focal manifestations which may be summarized briefly : 
The superficial lymphatic glands are swollen and congested. The 
spleen is often much enlarged, tense, and deep purplish red in color. 
The kidneys are congested, sometimes the adrenals also. The mes- 
enteric glands are swollen, oedematous and hemorrhagic. The liver 
is dark, often deeply congested, and presents to the naked eye foci of 
yellowish or yellowish white color which at times are surrounded by 
hemorrhagic zones. The microscopic examination of the lymph glands 
shows hemorrhages into their substance, many necrotic lymphatic ele- 
ments, and rapid cell-multiplication by karyokinesis. The spleen under- 
goes similar changes. In the liver the capillaries are dilated and their 
endothelial cells are fragmented and necrotic. But it is in the hepatic 
cells themselves that the process reaches its height. The yellowish and 
yellowish Avhite areas mentioned correspond to areas of coagulation 
necrosis, of which several varieties have been described.^ Such foci 
are often surrounded by large quantities of nuclear detritus probably 
swept thither in the lymph current. 

In chronic cases from intestinal indigestion degenerative changes of 
a much slower character than these and a correlative proliferation of 
connective tissue, replacing the necrotic elements can be seen. Such a 
process has been observed in the kidneys, muscles, spleen, lymph glands, 
central nervous system, intestines, and more especially the liver, where 
cell necrosis is always most profound. There is nothing peculiar or 
distinctive in the location of such fibrosis nor in the manner of its 
occurrence. 

Symptoms axd Physical Sign's. — Three classes of the acute form 
may be recognized — (1) mild, (2) severe, and (3) toxic. 

(1) In cases of the^jr-s^ class there is a sense of abdominal uneasiness 
or, much more frequently, paroxysmal griping pains, referred to the 
umbilical region. Some tenderness may exist in this region ; the pain 
may be relieved by pressure. Vomiting, due either to immediate gas- 
tric irritation or to reflex stimulation is comparatively rare. Diarrhoea 

^ Flexner : " Pathologic Action of Certain So-called Albumins," 3Ied. News, Aug., 
1894, p. 116. 



214 DISEASES OF THE INTESTINES. 

is of almost invariable occurrence at some period of the attack. In the 
majority of cases the abdomen is distended and highly tympanitic ; in 
others it is reti'aeted, rigid, and knotty from the irregular contraction 
of its muscular walls. Boborygmi accompany abdominal distention. 
While the pains last, if they are intense, the countenance has an anx- 
ious, frightened expression as in colic, the pulse is depressed, the respi- 
rations are shallow, and the skin is cold. The tongue is usually coated 
and the head aches. In this form fever is slight or absent. The mildest 
attacks may cause only a feeling of abdominal distress, tympanites, 
boborygmi, and slight diarrhoea. 

(2) The great majority of cases fall under the second class, where the 
symptoms are less uniform. The onset may be gradual, after several 
days of listlessness and impared vitality, or more frequently it is sudden 
and abrupt. The local symptoms are much the same as in tlie former 
class. Pain is paroxysmal and griping, or heavy, dull, and felt only at 
some definite point. Usually it begins near the umbilicus and thence 
shifts to various parts of the abdomen ; "it does not intermit as in colic, 
but exacerbates and then changes to a dull feeling of distress." Pres- 
sure increases it greatly, and the patient lies on his back as in peritonitis 
with the legs flexed to I'elieve the tension of the abdominal muscles. 
Tympanites, flatulence, and borborygmi indicate the formation of gas. 
Succussion sounds may be elicited. 

Diarrhoea succeeds this active onset ; the stools vary in number from 
two to twenty in twenty-four hours. At first they are soft, of normal 
fecal odor, and either brown or yellow ; later they become thin, watery, 
and frothy, and when the bile has been drained away are grayish. The 
odor is then putrid, sour, cadaveric, or musty ; later the stools may be 
odorless. Mucus and particles of undigested food, especially proteids, 
are present in variable amounts. The reaction is neutral or alkaline, 
less frequently acid, and is determined as much by the character of the 
food as by bacteriological activities. Microscopically are seen epithelial 
cells, round cells, occasional blood cells, bacteria (chiefly the varieties 
already mentioned) Charcot's crystals, crystals of oxalate of calcium, 
calcium phosphate, ammonio-magnesium phosphate, cholesterin, and 
fatty acids. Pus is seldom present. 

Usually there is vomiting at the outset ; this quickly subsides, and it 
may not occur at all during the entire course of the disease. The 
tongue at first is moist, covered with a thin wliite fur, later it is red, 
dry, and glazed. In children it is " raw." The breath is always offen- 
sive. There is pronounced thirst, but no desire for food. In children 
aphthous stomatitis may develop. 

The general symptoms are well marked. In the majority of cases 
there is a sharp chill, and when the attack is established fever runs 
high— 103° to 104° F. In some rare cases in children the evening 
temperature may be 105°, falling to normal during the night, to rise to 
a considerable height again during the ensuing day. At the outset the 
pulse is full, tense, and bounding; later it is small, tense, and wiry. 
The skin is hot and dry, but profuse sweating occurs at night. Cramps 
in the lower extremities, especially in the calves and in the feet, may be 
a most distressing symptom. Convulsions are frequent in children. 
Headache is one of the most common symptoms, persisting long after 



INTESTINAL INDIGESTION. 215 

the acutenesfe of the attack is past. For several days after disappear- 
ance of the fever the patient is dull and apathetic. 

(3) In the third class of cases the symptoms are those of an obscure 
but violent toxsemia. The onset is sudden, with intense vomiting, at 
first of mucus, later of coifee-ground material. This vomiting is the 
most noticeable symptom, sometimes the only one. Occasionally there 
is slight icterus, but in no case is this well marked. In rare fatal cases 
the temperature is subnormal, coma rapidly supervenes, and the patient 
dies in collapse. 

Allied to this toxic type, and in many respects analogous with it, is 
cholera infantum. In the vast majority of cases this is due to intestinal 
indigestion and consequent auto-intoxication. The particular symptoms 
which it offers are possibly caused by those conditions of digestion 
peculiar to children, and the correlative actions of several micro- 
organisms or classes of these. It is also probable that the profound 
general symptoms in the algid stage of cholera nostras are due, in part 
at least, to the absorbed toxic products of indigestion, while the local 
symptoms in the vast majority of cases are caused by the direct action of 
all those irritants resulting from intestinal putrefaction and fermentation. 

Chronic Indigestion. — The larger part of those cases of chronic 
gastric indigestion which apply for treatment are necessarily com- 
plicated by more or less intestinal disturbance, but the profession has 
yet to learn that in the greater number of the indigestions the latter 
condition is of major importance. Chronic intestinal indigestion has 
never received the attention that it deserves ; it is seldom even men- 
tioned in standard works on the practice of medicine. Yet cases of the 
disease are of such frequent occurrence that they should be recognized 
and discussed under a separate caption. 

One of the most invariable symptoms is flatulence, coming on from 
one and a half to three hours after meals. It is due chiefly to fer- 
mentative processes, and is therefore worse after the ingestion of carbo- 
hydrates. Coincident with it are a sense of distention and heaviness, 
tenderness, and perhaps vague abdominal pains, especially in the right 
hypochondrium. Acute pain is comparatively rare. The greatest dis- 
tention may occur near the umbilicus, or it may be evenly diffused and 
general. Constipation is the rule in adults, and the stools, hard and 
dry, are expelled with difficulty. Sometimes they are coated with 
shreds of mucus. Diarrhoea may alternate with constipation, or if 
there be much enteric catarrh the diarrhoea may be constant. The 
passage of unaltered food, as fragments of meats, vegetables, or fruits, 
indicates the nature and extent of the lesion. Sometimes there are 
short intercurrent symptoms, evidenced chiefly by an aching sensation 
in the right hypochondrium, jaundice, and the passage of colorless 
stools. The appetite may not be much impaired, but it is fitful and 
irregular. There is invariably a bad taste in the mouth, the breath is 
offensive, and the tongue is large, pale, and coated. 

The general symptoms are in part due to auto-intoxication, but often 
they, with the intestinal trouble itself, are the manifestations of a 
primary central nervous disturbance — neurasthenia. There is no doubt, 
however, that in this latter case they are aggravated by the coexistent 
intestinal indigestion. 



216 DISEASES OF THE INTESTINES. 

The general nutrition suffers ; the skin is hard and dry, pale, or of 
a sodden, muddy hue. In advanced cases it is icteroid or bronzed. 
Erythema, urticaria, acne, eczema, psoriasis, and many allied conditions 
occur with such frequency in the course of this disease that it is by 
some authorities considered their most usual cause. Polymyositis is 
usually observed. The bones may become the seat of nodosities and 
the synovial membranes of the small joints especially are liable to 
inflammation and subsequent infiltration. 

The action of the heart is disturbed, partly from mechanical but 
mostly from nervous influences. There may be tachycardia, bradycardia, 
arrhythmia cordis, debilitas cordis, etc. It is not rare to find one or more 
of the cardiac sounds somewhat altered. The general circulation is 
languid and irregular; cold hands and feet and cold sweats urgently 
testify to the former, and irregularity or suppression of the menses to 
the latter condition. The temperature may be increased ; more fre- 
quently, however, it is normal. Dyspnoea, Cheyne-Stokes, or stertorous 
breathing indicates implication of the respiratory centres. The expired 
air may have an odor of hydrogen sulphide, acetone, or ammonia. 

The symptoms presented by the special senses correspond to those 
in other chronic intoxications. Autophony, tinnitus aurium, deafness, 
muscse volitantes, hemiopia, diplopia, and many perversions of taste 
and smell have been observed. 

Of the symptoms more immediately referable to the nervous system, 
headache is the most constant and persistent. It may be occipital, 
frontal, diffuse, or felt only as a constricting band about the head. 
There are other symptoms found in connection with intestinal indiges- 
tion which are due to an associated neurasthenia. These are wrongly 
regarded as caused by the indigestion, and therapeutic measures based 
upon this view invariably fail of success. Such symptoms are vertigo, 
syncope, collapse, partial or general convulsive seizures of variable 
duration, paralyses, fugacious painful contractions of certain muscle 
groups, angeio-neurotic oedema, protean sensory disturbances, restlessness 
or apathy, insomnia, and waking in the early hours of the morning with 
cardiac palpitation. Lassitude, general debility, incapacity for any pro- 
tracted mental or physical work, hypochondriasis, melancholia, and irri- 
tability of temper are also common. 

Whether neurasthenia or indigestion be of prior occurrence, each 
has a retroactive effect upon the other, and it is noticeable that those 
cases of neurasthenia in which digestive disturbances are prominent 
will usually run a most severe course. That this is due to faulty elabo- 
ration and assimilation of food is evident, but just how far purely toxic 
products are a factor is indeterminable. It is altogether probable that 
their influence has been overestimated. 

The urinary changes common to both acute and chronic intestinal 
indigestion are important. The total amount of fluid is reduced, it is 
high colored, and the specific gravity is slightly increased. The pres- 
ence of acetone, diacetic acid, and sulphuric ether has often been 
established. An increase in the amount of the ethereal sulphates, 
especially indican, invariably occurs in all cases of intestinal putrefac- 
tion, if peristalsis does not quickly empty the bowel. It is therefore 
most evident in cases of chronic indigestion. Traces of albumin are 



INTESTINAL INDIGESTION. 217 

often present. Uric acid, the urates, and urea are excreted in absolutely 
less but relatively larger amounts. There are usually crystalline 
deposits of uric acid and calcium oxalate. 

The relation of diseases of the skin to defective duodenal digestion 
is not admitted by most dermatologists to be that of effect and cause, 
but that they are coincident, especially in childhood, is undoubted, and 
that the cure of the intestinal defect is followed by improvement in 
the condition of the skin is equally certain. 

Complications axd Sequelae. — Gout and lithsemia are definitely 
traceable to intestinal indigestion. The increased activity of both liver 
and kidneys, necessary to meet the prolonged absorption of imperfectly 
digested foods and toxic materials, is such that the way is readily paved 
for chronic disease of either or both of these viscera. Many cases of 
hepatic cirrhosis and chronic interstitial nephritis are the ultimate 
lesions in long-standing cases of this form of indigestion. 

Appendicitis is probably often the final stage in intestinal indiges- 
tion which leads to catarrh of the csecum, and consequent multiplication 
of bacteria with infection of the local peritoneum. 

Diagnosis. — Acute Forms. — A diagnosis must be made from gastric 
dyspepsia, gastralgia, enteralgia, ulcer of the duodenum, perforation, 
intestinal obstruction, biliary colic, hepatalgia, appendicitis, nephralgia, 
and neuralgia of the dorsal and lumbar nerves. 

Gastric dyspepsia is attended by pain in the epigastrium immediately 
after eating, vomiting is frequent, and the vomitus consists of food that 
is either unaltered or in a state of acid fermentation. There is eructa- 
tion of gases. The intestinal symptoms are not prominent. 

In gastralgia and enteralgia the patient is ansemic, neurotic, or 
neurasthenic, and the attack does not necessarily have any relation to 
the ingestion of food. There is no tympanites, no fever nor diarrhoea. 
Pressure relieves the pain, and increase of meat diet and tonic treat- 
ment cure the disease. 

In ulcer of the duodenum the seat and time of pain are the same 
as in duodenal indigestion, but the intensity of suffering is out of all 
proportion to the phenomena of simple indigestion. Sooner or later in 
most cases a diag'nosis is made clear bv the vomiting of blood or more 
frequently by melaena. 

In perforation there is a suspicious history of ulcer or cancer, and 
the facies, prostration, and collapse indicate that the disease is far more 
profound than in simple indigestion. If the patient live long enough 
the pain is accompanied by great distention and extreme tenderness. 
Alonzo Clark's sign — obliteration of hepatic dulness from the presence 
of air in the peritoneal cavity — is of extreme value in doubtful cases. 

Intestinal obstruction is accompanied by persistent vomiting often 
becoming fecal, obstinate constipation, and great prostration. Fever 
is present or the temperature is subnormal. An examination should be 
made at those points where herniee are of most frequent occurrence, and 
the abdomen palpated and percussed in an attempt to establish the 
presence or absence of fecal accumulations or the sausage-shaped tumor 
of intussusception. 

Biliary colic is known by intense and sudden pain in the epigastric 
region and by severe nausea and vomiting ; it often ends suddenly and 



218 ■ DISEASES OF THE INTESTINES. 

there is ensuing jaundice ; there is probably a history of former attacks, 
and gall-stones may be found in the faeces. 

Hepatic neuralgia (the existence of which is denied) is said to pre- 
sent the symptoms of biliary colic, to recur after more or less definite 
intervals, and to be accompanied by great tenderness over the liver 
and by neurotic symptoms. None of these occur in intestinal indi- 
gestion. 

The pain of the onset of appendicitis is occasionally noted in the 
epigastrium. The accompanying tenderness and flatulent distention 
might create a suspicion of acute duodenal indigestion. But in appen- 
dicitis the excessive tenderness on pressure over McBurney's area, the 
general tympanites, the more pronounced constipation, the flexion of 
the right thigh and the higher fever serve to localize the disease in the 
appendix. 

The pain in nephritic colic is paroxysmal, with intervals of compar- 
ative ease, and is unassociated with fever. It comes on suddenly, is 
most intense and is felt usually in the loin, shooting along the ureter to 
the bladder. The localization of the pain is not constant, however, and 
since it may occur in the umbilical region, where the pains of intestinal 
indigestion are usually felt, its value must not be over-estimated. The 
most valuable diagnostic symptoms are vesical tenesmus, strangury, the 
frequent passage of small quantities of high-colored or bloody urine 
loaded with uric-acid crystals, the numbness of the corresponding thigh, 
and retraction of the testicle. 

The dorsal and lumbar nerves are subject to neuralgic affections 
which exhibit paroxysms of pain unaccompanied by fever. When this 
condition occurs in those nerves supplying the abdominal parietes, a 
diagnostic sign of the greatest importance is its unilateral distribution 
and the presence of hypersesthetic areas. Neuralgia of the intestinal 
or mesenteric plexi is diiferentiated by the absence of diarrhoea and 
tympanites, its frequent recurrence, and the sense of extreme prostration 
which attends it. A history of malaria is often obtainable. The most 
reliable sign from a purely diagnostic standpoint is its ready ameliora- 
tion by antineuralgic treatment. 

Cases of intestinal indigestion that are moderately severe are usually 
easier of diagnosis than are those of either the mild or toxic type. A 
differentiation from catarrhs of various parts of the alimentary tract 
is the most difficult. Practically in all acute indigestion there is more 
or less catarrh, and vice versa, though in catarrh of the lower part of 
the ileum and the colon there may not be that degree of indigestion 
which the frequency of the stools may appear to indicate. Hard and 
fast lines cannot be drawn. The absence of indican or other increased 
ethereal sulphates from the urine, the presence of mucus in large 
amounts, not intimately mixed with the other ingredients of the stool, 
the absence or a very slight degree of lientery, and the presence of bile 
in proximately normal amounts, are indications that the condition is 
one of colitis. When, however, the stools are thin and fluid, contain- 
ing mucus intimately mixed with homogeneous fluid fecal matter 
stained with bile, and when there is decided lientery, the catarrh is 
duodenal and is complicated with indigestion. Which was of prior 
occurrence and is the real disease is determinable only from the history. 



INTESTINAL INDIGESTION. 219 

Fortunately,^ in such conditions the indigestion is usually cured by 
curing the catarrh. 

In those cases coming on with a chill, high fever, tympanites, and 
the passage of numerous fluid stools, a diagnosis depends in great part 
on the history and is often reached with difficulty. In many respects 
it may be so similar to several infectious diseases, especially those which 
follow an anomalous course and in which intestinal symptoms pre- 
ponderate, that a decision may be impossible until the case has been 
watched for severaldays. In children the disease may simulate those 
cases of scarlatina in which the lesion involves the intestine rather than 
the skin. A diagnosis would here be based on the temperature chart, 
a history of exposure, the marked prostration, and the tendency to 
collapse. 

Typhoid fever, especially in a child, is often mistaken for gastro- 
intestinal indigestion. In the latter the temperature rises more sharply, 
the remissions are slighter (there may be intermissions), and the final 
drop is more sudden. As a rule, a continued fever which lasts a week 
without any definite local cause is enteric fever. 

The intermissions which are sometimes seen in the fever, the night- 
sweats, diarrhoea, tympanites, etc., occasionally suggest acute tubercu- 
losis. The history and cause of the disease will clear up this diagnosis. 

In diarrhoea due to purely nervous influences the stools are passed 
independently of the ingestion of food, and there are no objective signs 
of intestinal indigestion. Usually there has been a nervous crisis and 
the patient is neurotic. 

Those cases which conform to the toxic type can be diagnosed only 
by the exclusion of acute mineral poisoning, peritonitis, hemorrhagic 
pancreatitis, and acute intestinal obstruction. The nature of the vom- 
itus excludes the first. The second is excluded by the absence of any 
suspicious history, the superficial respirations, and the usually slower 
course of the symptoms. Hemorrhagic pancreatitis and the cases of 
intestinal obstruction which run the most rapid course are accompanied 
by more violent pains, and the ethereal sulphates are absent from the 
urine. In only one of eight cases of which the notes are at hand was 
a diagnosis made, and it was then based more upon the history of inges- 
tion of food which was tainted than upon the immediate symptoms. 

Chronic Form. — Attention must be given to the mode of life, hours 
and manner of eating, kinds of food, and general habits of the patient. 
In chronic gastritis there is invariably some intestinal disturbance, so 
that it cannot be clearly differentiated. Chronic intestinal indigestion 
may, however, obviously occur without gastric indigestion. In this 
case the pain (if there be any), or at least the feeling of heaviness or 
"distention, is not localized in the epigastrium and there are no eructa- 
tions of gases and acid fluid and no vomiting. The loss of flesh from 
gastric is much less than from intestinal disease, and hypochondriasis, 
irritability, and other mental symptoms are not so evident. 

In cases of intestinal cancer or cancer of the mesentery there is more 
rapid wasting than in intestinal indigestion ; possibly a tumor is palp- 
able, there may be melsena, the pain is more severe and is localized 
more sharply, and an examination of the blood reveals the characteristics 
incident to carcinomatous disease. 



220 DISEASES OF THE INTESTINES 

A diagnosis of the differences in digestion due to defects in specific 
ingredients of the pancreatic or intestinal secretions is not yet a matter 
of precise knowledge. A poor digestion of the carbohydrates, with 
which the intestinal juice and amylopsin have especially to deal, is 
indicated by constipation, flatulence, and tympanites ; a poor digestion 
of the proteids by a greatly increased amount of the ethereal sulphates, 
especially indican in the urine, some tympanites, and more pronounced 
general symptoms ; and a poor digestion of fats by their appearance in 
the stools. 

Intestinal neuroses are not accompanied by emaciation ; the patient 
has a strong, healthy appearance though a diarrhoea may have existed 
for years. A diarrhoea upon which diet has no influence begins gener- 
ally at the hour for normal defecation or immediately after eating. 
For a time the stools are frequent and they then cease for a longer 
period. 

The general neurotic symptoms which so often accompany intestinal 
indigestion are now regarded as often being with it the manifestations 
of a primary disease of the nervous system. A diagnosis of either 
neurasthenia or intestinal indigestion is reached, according to the pre- 
ponderance of local or general symptoms, the history of the case, and 
the response to different lines of treatment. Usually the one condition 
will complicate the other if it last long enough. A history of nervous 
symptoms before the intestinal disease began, or a greater intensity of 
these than could be well attributed to it alone, are the most valuable 
indications that the indigestion is merely a symptom. 

Prognosis. — In the acute cases of the mild and usually in those of 
the severe type the prognosis is favorable, depending altogether upon 
the intensity of the symptoms. In the purely toxic cases it is almost 
invariably fatal. 

Of chronic cases it may be said that, if treated early and energeti- 
cally, cure may be expected. Death from the immediate intestinal 
disease occurs only in the toxic cases, but may follow the renal and 
hepatic complications and sequelae. Discouraging symptoms are 
anaemia, debility, coexisting gastric dyspepsia, emaciation, and hypo- 
chondriasis. In strumous children the prognosis is less favorable. 

Since everything hinges npon the extent to which the patient sub- 
mits to the strict directions of his physician, his whole life must be 
made subordinate to the plan of treatment ; and upon this the prog- 
nosis depends. 

In organic disease of the pancreas, intestine, or liver the prognosis 
varies with the nature and curability of the lesion. 

Treatment. — As acute cases occur most frequently in children of 
from eight to eighteen months of age, during which period weaning, 
dentition, and the danger from summer heat occur, the child should be 
sent to the country for the whole of the heated season ; or if it remain 
in the city should be protected from the effects of heat as far as possible ; 
wherever it may be, great attention should be paid to the selection of a 
diet suited to the age and individual peculiarities. 

A most important part of the treatment of the attack is the man- 
agement of the diet. For the first twelve or even twenty-four hours 
all food should be withheld, but small quantities of boiled water, of 



INTESTINAL INDIGESTION. 221 

rice or barley water, may be given every hour, to compensate for the 
fluid lost in the stools. Breast-fed infants must not nurse until vomit- 
ing has stopped, and when the feedings are resumed they should be 
brief, and the intervals between them long. For hand-fed infants, until 
all acute symptoms have subsided dependence should be placed rather 
upon animal broths and juices, in small quantities, than upon cow's milk. 
This may then be resumed, largely diluted or peptonized, and the return 
to the former diet must be gradual. Albumen water, made by mixing 
the uncooked white of an egg with half a pint of sterilized water, is 
often retained when milk is rejected. For adults the preparation may 
be made more palatable by the addition of ice, the juice of half a lemon, 
and a small quantity of sugar. The diet must be fluid for several days 
after all acute symptoms have subsided, and the first semisolid aliment 
should consist of such readily digested food as gelatin, cetraria, soft- 
boiled eggs, etc. Inasmuch as regulation of the diet is the most impor- 
tant part of the treatment of these cases, the physician must be specific 
and definite, leaving nothing to the caprice of the patient, and he must 
see that his orders are obeyed. 

In the adult cases no medicinal treatment may be demanded in the 
largest number of cases ; absolute rest and diet will be all that is 
needed. Intense pain may require opium in some ; morphine hypoder- 
matically for adults is to be preferred, with mustard poultices to the 
abdomen. Tympanitic distention is relieved by turpentine stupes and 
by a large rectal injection of hot water. 

Since acute intestinal indigestion implies the presence of fermenta- 
tive decomposition and irritating substances in the intestine, the diar- 
rhoea that accompanies it is immediately beneficial, and should not be 
checked until all such irritants be passed. It is only when pain is 
great and the stools very frequent that it should be even controlled. It 
usually occurs soon after the symptoms begin to develop, but in most 
cases is followed by a diarrhoea which is indicative rather of catarrhal 
inflammation than of the primary indigestion itself. As this catarrh is 
necessarily in its turn the cause of subsequent indigestion its medicinal 
treatment must be discussed here. 

The treatment usually begins with the administration of calomel, 
castor oil, magnesium sulphate, or aromatic syrup of rhubarb, in order 
to remove any irritating substance which in spite of the diarrhoea may 
remain in the bowel. One of these drugs is given when the patient is 
seen first. Magnesium sulphate is of very recent popularity in this 
disease and its comparative claims have not yet been established, though 
it has given many excellent results. This is probably because it occa- 
sions free osmosis of serum without increasing the blood supply, and 
thus lessens the degree of congestion. Castor oil should be given in 
emulsion. Calomel in small repeated doses, combined with sodium 
bicarbonate, is perhaps the best laxative for children and infants. 

Attention must be given to the stomach in order to prevent the 
passage into the intestine of undigested food and the products of gas- 
tric putrefaction. The viscus will empty itself in some cases ; if it does 
not, an emetic or lavage is needed. 

About six hours after the administration of the purgative some of 
the remedies for diarrhoea or the so-called intestinal antiseptics may be 



222 DISEASES OF THE INTESTINES. 

given. Salol, gr. i-v, with bismuth subnitrate gr. v— x, every two to 
four hours, is ii favorite combination. The possibility of doing good 
by antiseptic medication is not admitted by all. Albers, who is usually 
regarded as the best authority upon the subject, states that while many 
bacteria in the intestinal contents are readily passed in the stools, others 
remain behind in the intestinal glands and follicles, where, being pro- 
tected by a film of mucus, they cannot be reached by antiseptic drugs. 
Yet these are the bacteria which are the first to give up for absorption 
their chemical products and which it is the most desirable to destroy. 

Many germicides which act in test tubes are worthless as reme- 
dies in the intestine unless, as Ewald states of all of the remedies of 
this class, they be given in doses sufficient to fill the intestine, in which 
case they would be toxic to the organism. Calomel has long held a 
most enviable reputation, but its efficacy is not shown to depend entirely 
upon its purgative properties. Fecal retention is the condition that 
leads to bacterial multiplication and albuminoid and carbohydrate de- 
composition ; Pfunger has shown that a medicine has an influence upon 
these processes directly in the proportion in which it is efficient as a 
purgative. 

Though this' view with regard to the more distinctly pathogenic 
organisms, as B. typhi abdominalis, is now well established, the major- 
ity of the profession still adhere to the belief that in indigestion and 
catarrhal states, when the micro-organisms are of less irritant type, 
antiseptics are efficacious. It is possible that in such cases the diver- 
gent results may be reconciled on the assumption that the insoluble 
agents prevent the further migration of such germs into the intestinal 
wall, while those already there are disposed of by phagocytosis, and 
that the soluble agents while in process of absorption exercise their 
function upon those already in the tissues. Drugs of this class are 
ineffective unless given in large doses. Insoluble antiseptics are calo- 
mel, bismuth subnitrate, bismuth salicylate, menthol, naphthalin, cresol, 
paracresol, thymol, creasote, and ichthyol. Soluble remedies comprise 
carbolic acid, salicylic acid and its salts, tannic acid, resorcin, silver 
nitrate, saccharin, mercuric chloride, potassium permanganate, and hy- 
drochloric acid. Salol, benzonaphthol, and cresalol are synthetic prep- 
arations that are decomposed in the upper part of the intestine, the 
first into carbolic and salicylic acids, the second into benzoic acid and 
naphthol, and the third into salicylic acid and cresol. Nosophen or its 
bismuth salt, eudoxin, in from five- to eight-grain doses, and the oils 
of cloves and cinnamon in drop doses, have recently been used with 
reputed success. 

Fel bovis would supposedly be the ideal antiseptic, but is utterly 
inert unless conditions are such that bile acids may be set free, and such 
conditions seldom exist in the diseases in which it is given. Those 
intestinal antiseptics that are decomposed in the stomach because of its 
acid reaction are very likely to be decomposed in the intestine also, for 
in indigestion, because of the acetic, butyric, propionic, and other acids 
elaborated, the normal acid reaction of the contents of the upper bowel 
is much intensified. Keratin is a much better protective from the action 
of the gastric juice than are other substances, and is more likely to be 
dissolved in the intestine. Often, however, such solution does not occur. 



INTESTINAL INDIGESTION. 223 

In those^ cases where there is not much inflammation, arsenite of 
copper, in gr. yot doses every three hours, has been advised. Its mode 
of action and its exact value have not been definitely determined. If it 
does no good in thirty-six hours, its use should be stopped. Astringent 
drugs, some of which .are at the same time antiseptic, are tannin, 
alum, cotoin, paracotoin, tannigen, bismuth subnitrate, and bismuth 
subgallate. 

To further accomplish intestinal disinfection rectal irrigations with 
soluble drugs are employed, and are frequently of the greatest service. 
They act directly, and the mechanical influence of the water used ren- 
ders them far more efficacious than are drugs given with the same 
object by the mouth. 

The solutions used and the amount per pint are : silver nitrate, gr. 
iij-v ; potassium chloride, 3j ; tannin, 3ss-j ; iron sesquichloride, gr. xv ; 
boric acid, sij ; creolin, gr. viij ; salicylic acid, gr. xv ; quinine hydro- 
chlorate, gr. viij. 

If cold water be used with these enemata, they are mild and grateful 
antipyretics ; whether the water be cold or warm, they prove as service- 
able as any means we have in emptying the lower bowel of faeces and 
bacteria, arresting peristalsis, and favoring the expulsion of gas. 

Chronic Forms.— As in acute, so in chronic cases of intestinal indi- 
gestion, prophylaxis is of noteworthy importance. The necessity of 
perfect mastication, insalivation, and gastric digestion have already been 
emphasized in the section on etiology, but it may be well to repeat that 
no good results can be expected until these processes are normal. At- 
tention to faulty teeth, or habits that waste or weaken the saliva, as 
smoking or chewing, is often the first step toward a cure. 

Much of the treatment is hygienic and dietetic. In the great major- 
ity of cases perhaps the greatest benefit is derived from a change of 
climate and scene, and in not a few this has proved the only means of 
accomplishing a cure. A sojourn at the mineral springs is especially 
advantageous, for here there is not only another environment, but bath- 
ing and the use of drinking-water are indulged in to a much greater 
extent than under other circumstances. The importance of systematic 
baths has long been appreciated in Europe, and it is to be regretted 
that hydrotherapy is not more available nor made use of more gener- 
ally in this country. Much of the improvement that ensues after a 
summer spent at the seashore is traceable to the daily plunge in the 
surf. Eveneef has demonstrated the great utility of cool bathing in all 
cases where the absorption of fats is deranged, and pertinently insists 
upon the use of sponge baths. In a fair proportion of cases daily appli- 
cation of the cold douche to the back or abdomen, the cold pack to the 
abdomen, or in selected cases a general hot bath, will prove a convenient 
means of inducing a revolution in digestive activities. 

The mineral waters so much used by dyspeptics are of utility by 
inducing the patient to drink water freely. They are especially service- 
able in cases where there is hyperacidity of the gastric juice, obstinate 
constipation, or a gouty diathesis. 

The waters most serviceable in this connection are those of Vichy, 
Ems, Kissingen, Homburg, Wiesbaden, and Saratoga. 

The benefit derived from a course at Aix, Vichy, or Carlsbad is in 



224 DISEASES OF THE INTESTINES. 

great part due to the leisure, enforced diet, and entire change of sur- 
roundings that result from a European trip. Many confirmed cases of 
indigestion, especially those following overwork and worry, are quickly 
benefited by the regimen of a foreign cure. At home, fresh air, mod- 
erate exercise, diversion, and relaxation are of great help. 

The routine advice as to exercise is often productive of great harm ; 
these patients are so often suffering from neurasthenia that it is rest 
rather than exercise which is needed. Where neurasthenia is the chief 
pathological condition a rest cure, total or modified, is a necessary pre- 
liminary to treatment. 

For very feeble persons, and especially for women and sufferers from 
neurasthenia, massage should take the place of exercise. The Swedish 
movement cure has been much over-estimated and abused, but in suit- 
able cases it will expand the thorax and abdomen, hasten the circulation 
and quicken all the functions of nutrition and secretion. 

The rules for diet should be emphatically impressed upon the 
patient. At the commencement of the treatment an exclusive milk 
diet continued for one or t\vo weeks will shorten the duration of treat- 
ment. Skimmed milk is sometimes of service as a continuous diet, as 
larger quantities of it may be taken without distaste or a sense of reple- 
tion. In this connection it is intei'csting to note that Gilbert and 
Domenici have recently discovered that an exclusive milk diet influ- 
ences in a remarkable degree the number of micro-organisms in the 
alimentary canal. In experiments ujdou men they found that the 
number of these organisms was reduced from 67,000 to 25,000 per 
gramme, and the weight of the fseces passed had fallen from 175 to 73 
grammes. Sterilized milk has no greater effect than ordinary milk. 

Inasmuch, however, as patients will not tolerate this diet long, 
recourse must be had occasionally to koumyss, meat extracts and broths, 
albumen water, barley water, etc. 

A change to solid food should be made gradually. Proteids should 
be allowed before fats and carbohydrates. Sweetbreads cooked in milk 
are well suited for a beginning ; raw oysters, fish, especially the varie- 
ties that contain very little fat, are easy of digestion. Poultry, finely 
minced, may then be eaten, and after this rare beef and mutton may be 
added to the diet. When bread is given, it should be light and porous, 
dry and browned in the oven. Toast disagrees with some. Light bis- 
cuits and crackers are often better digested than bread. Vegetables can 
be given later in small quantities and when the patient is convalescent. 
Lettuce, kale, spinach, and celery contain less starch than do others and 
are therefore less objectionable. Fruits, as oranges, pears, or grapes, if 
they are digested after trial, prove beneficial. 

Instead of the light breakfast and late heavy dinners, early break- 
fast, midday dinner, and light tea are to be preferred. The patient must 
avoid excess in eating. 

Fatty, saccharine, and farinaceous foods, sauces, condiments, and all 
indigestible articles, are to be forbidden. The too free drinking of 
water, especially of ice water, at meals, impedes digestion. Carbonated 
waters, especially Apollinaris Avater, are less objectionable ; Avines and 
beer are as a rule to be condemned, but dry champagne, for those Avho 
like it, is the best form of stimulant. In some cases whiskey, well 



INTESTINAL SENSORY NEUROSES. 225 

diluted, given'^at meal time, does well for those accustomed to the use 
of stimulants. Good Scotch whiskey is often to be preferred. 

The bowels must be kept open, by the cultivation of regular habits 
or by small cool water enemata. Sodium sulphate, calomel, podophyl- 
lin, or the laxative mineral waters may be required. In children, since 
diarrhoea instead of constipation is the rule, there is not so much need 
for purgation, but an occasional dose of calomel or castor oil will ensure 
the removal of any irritating substance and thus be of service. 

Many patients, especially children, will need a general tonic. 
Perhaps the most serviceable preparations are the carbonate, lactate, or 
pyrophosphate of iron. The syrup of the iodide of iron, quinine, strych- 
nine, and hydrochloric acid in combination may prove beneficial. The 
bitter tonics should not be given, except for loss of appetite, and in 
those cases only where there is no gastric disturbance. 

INTESTINAL SENSORY NEUROSES. 

Enteralgia ; Colic ; Enterodynia ; Hypercesthesia or Neurasthenia intesti- 
nalis ; Neuralgia mesenterica ; Ancesthesia intestinalis. 

The intestines may be the seat of various sensory neuroses, either 
as an accompaniment to various diseases or as original nervous dis- 
turbances. 

The principal type of this disorder to be considered is that form 
known as — 

Colic, Enteralgia, or Enterodynia. — This is chiefly a neuralgia of 
the mesenteric nerve fibres, and may or may not be accompanied by 
a spasmodic contraction of the muscular coat of the intestine. It has 
been likened to such unstriped muscular spasm as occurs in uterine, 
biliary, or nephritic colic. The spasm, though, may occur alone without 
causing pain, under which circumstances it would be difficult to recog- 
nize it. 

Pathology. — Pathologically, the condition is a sharp, short muscu- 
lar tetanus involving chiefly a portion of the intestine, and foUoAved by 
an excitement of the intestinal nerves which is manifested by a severe 
pain termed colic, or a hypersensitiveness to normal irritants. The func- 
tional activity of the bowel may be increased as in an active peristalsis, 
but, taken alone, under these circumstances there may be no pain what- 
ever, as in this case the muscular excitation extends along the whole 
length of the bowel and is not a limited or localized spasm. 

Etiology. — The causes of the increased sensibility of the intestinal 
nerves may be some unusual or abnormal irritant from within, reflex 
excitation, or blood changes ; there may be an intensification of the 
normal physiological processes with hypersesthesia. This latter is a 
local condition existing in the mesenteric plexus of nerves. 

Internal irritants may be food composed of some irritating or indi- 
gestible substance ; large amounts of food or articles prone to decom- 
position. Ice water, ice cream, and other cold fluids or solids, especially 
when the individual is in a heated state, are often the cause of imme- 
diate pain. Some change in diet where an individual has been follow- 
ing a uniform regimen acts in the same way. Individual and family 
idiosyncrasies are known to produce sensory reactions to foods that are 
Vol. III.— 15 



226 DISEASES OF THE INTESTINES 

without eflPect on other individuals. Shellfish, cheese, eggs, and certain 
fruits are known to act in this way. 

All the factors contributing to the origin of an intestinal catarrh 
may be the cause of colic (colica catarrhalis or injlammatoria). Here 
it may be noted that the colic is not due to increased peristalsis, but to 
some tetanic contraction of some part of the bowel. Peristalsis is a 
normal process, and its increase, as in diarrhoea, may occur without pain. 
Usually, when colic accompanies this condition of enteritis, increased 
peristalsis may follow the colic, or vice versd. This has been known as 
colica biliosa or colica cestiva. 

Foreign bodies, as gall stones ; entozoa ; cathartics, as castor oil, 
colocynth, and senna ; scybala or large fecal accumulations undergoing 
putrefaction, — are frequent causes of colic. Colica stercoralis is produc- 
tive of severe pains. Sometimes acute constipation occurs at intervals 
of several months, producing attacks similar to the above form. 

Associated with this condition may be mentioned gaseous formation 
due to putrefaction or to substances easy of decomposition, whereby the 
bowel is abnormally distended, bringing on a spasmodic contraction of 
the muscles and causing a painful irritation of the nerves {colica jiatu- 
lenta). This is possible in a single portion of a loop of intestine, but a 
general distention, such as occurs in meteorism, may be without colic 
and would not be classed with this form. 

Another peculiar nervous condition properly classed as a secretory 
neurosis is the accumulation of large masses of mucus (colica mucosa), 
which is recognized by the passage of mucous casts. 

Reflexly, a colic may be caused by taking " cold " as the result of 
wetting the feet or any part of the body {colica rheumatica). Colic 
may accompany uterine, ovarian, bladder, or kidney disease as a result 
of reflex irritation, probably through the sympathetic splanchnic nerves. 

Certain conditions of the blood, containing toxic substances from 
absorption (ptomaines, etc) or the retention of normally formed excre- 
tory products, as urea or uric acid, act by causing irritation of the intes- 
tinal nerve-endings, with a consequent hypersensitiveness, as well as an 
increased activity of the muscular structure. 

Many pathological processes may be accompanied by colic, as, for 
example, appendicitis, probably due to spasm of the muscular wall of 
that structure ; intestinal ulcers, as in the duodenum ; strangulated 
hernia or any incarceration or obstruction of the bowel. Changes pro- 
duced in the nerves themselves, as in lead or copper poisoning, are 
spoken of in a separate section elsewhere (see Chronic Metal-poison- 
ing). Enteralgia may be, as already noted, purely a nervous phenom- 
enon without any explanatory cause, except that there exists a general 
irritability of the sensory nerve fibres so frequently present in hysteria 
and neurasthemia {nervous enteralgia or colica nervosa). 

Symptoms. — The approach of an attack of colic is not always the 
same. It is usually of sudden onset, with pain of a pinching, tearing, 
cutting, or boring character, lasting a few minutes at a time, or it may 
even last several hours. Remissions and exacerbations of these attacks 
occur ; other reflex symptoms appear, depending upon the degree of 
acuteness of the condition ; the number of periods of pain may vary 
from one attack to paroxysms lasting for several hours or days. 



INTESTINAL SENSORY NEUROSES. 227 

A moderalely severe attack is characterized by a sharp, cutting pain 
located in the abdomen, particularly in the umbilical region, and spreading 
out to other regions. There may be other symptoms, as nausea, eructa- 
tion of gas, and flatulent distention. The j)ain will disappear abruptly, 
and may be followed by recurrences. In the intervals the patient may 
feel perfectly well, as the chief symptom disappears entirely. The face 
may look pinched, flushed, or pale during the attack, and sweat fre- 
quently appears on the forehead after the attack. 

In the severe cases the patient is suddenly seized with a griping 
pain in the abdomen ; the hands are placed over the seat of suifering, 
the knees and thighs are drawn up to the abdomen, or the patient throws 
himself face downward across a lounge or bed. The pulse may be 
small, frequent, and intermittent. The spasm of the muscles may ex- 
tend to the cremasterics, which is shown in a retraction of the testicles ; 
the anal muscles may also be affected, the anus being drawn inward. 
The bladder may be involved, in consequence of which a draAving, press- 
ing sensation is felt in the bladder and rectum. In extreme cases the 
thumbs are flexed in the palms of the hands, and other and more 
general muscular contractions occur. The patient may become uncon- 
scious or may show signs of delirium. 

On the disappearance of the pain the patient feels exhausted ; he 
assumes a comfortable position only to be disturbed on the return of 
pain. 

In a more severe colic the patient is suddenly stricken with an 
abdominal pain ; the face is pinched and has an agonized look. His 
feet and hands are cold and a cold perspiration covers the body. The 
posture of the patient is that of one doubled up, his hands over the 
seat of pain and thighs flexed on the abdomen, which may be distended 
and tympanitic ; there may be borborygmi, and the expulsion of flatus 
may bring slight relief. The pulse is small, rapid, and irregular, and 
collapse may supervene. The abdominal walls may become tense or 
even drawn inward toward the spinal column, the muscles being entirely 
rigid and hard, or there may be marked distention, knuckles of the 
bowel standing out in relief. 

Reflex symptoms, as palpitation, dyspnoea, syncope, strangury, and 
general convulsions, may occur. 

The appearance of large masses of mucus in the stools has led to 
the description of the form of enteralgia termed coUca mucosa. Accord- 
ing to Nothnagel, DaCosta, A¥oodward, and others, this is chiefly a 
nervous phenomenon occurring in neurotic individuals who sufi^er from 
habitual constipation ; they are subject to sudden colicky pains radiating 
over the abdomen from the left abdominal region along the line of the 
descending colon. This is followed by the passage of large membra- 
nous masses of mucus. The attacks are of variable frequency. Van 
Swieten attributes the condition to some disturbance in the biliary 
secretion, because of the fact that the stools after the passage of the 
mucus are poor in bile. Potain thinks these alterate with liver colic, 
and therefore associates the two. 

Mesenteric neuralgia and nervous enteralgia appear with sudden 
sharp pains, simulating any colic above described, but are accompanied 
more frequently by pains in other regions and hypereesthesia of the skin. 



228 DISEASES OF THE INTESTINES. 

In the hysterical patient other sensory, motor, and sympathetic phe- 
nomena occnr in which there is an exaltation of the functional activity 
of the nerves, of the abdominal organs. 

Intestinal Anaesthesia. — Another form of intestinal neurosis is an 
an£esthesia of the bowel. Xo attempt could here be made to describe 
the symptomatology of this affection involving the upper portions of 
the canal. The condition is met with in cases of spinal disease and 
seuilitv, and may be a derangement of sensibility, as found in some 
hvsteric cases. The chief symptom is constipation. If the rectum is 
involved, the passage of a stool is involuntary and is recognized by the 
patient from the odor alone. A chronic constipation may ensue, and a 
serious condition, as ulceration or rupture of the bowel, may follow. 

Diagnosis. — Some difficulty may arise in the distinguishing of 
enteralgia from some inflammatory process, as enteritis or peritonitis. 
We may even have enteritis as a cause of the colic, but the occur- 
rence of diarrhoeal stools and fever, with the history of the ingestion 
of improper food, etc., may serve as a distinction between the two. 
Where enteritis is chronic a point of value is that in this condition 
there is tenderness along the line of the colon, and food may have some 
influence in the production of pain, whereas in enteralgia the pains are 
often independent of food, the appetite is good, and there is local ten- 
derness. 

In peritonitis we have fever, vomiting, great distention, and exces- 
sive sensibility to touch and movement sufficient to differentiate it from 
enteralgia, with the knowledge of causes likely to lead to peritonitis. 

Where other pathological processes exist a physical examination and 
a previous history would aid in the diagnosis of ulcers, intestinal ob- 
structions, tumors, cancer, etc. 

The pain occurring in rheumatism of the abdominal muscles is in- 
creased on any movement of the body, and a soreness exists on pressure ; 
other muscles are frequently involved. 

In hyperesthesia of the abdominal wall we have great superficial 
tenderness, and when a fold of skin is taken up and the crest of it is 
slightly jDinched great pain is elicited. It occurs frequently in hyster- 
ical individuals, so that both a nervous enteralgia and skin hyperesthe- 
sia may exist together ; pain then exists both on slight touch and on 
deep pressure. 

In gastralgia, in biliary, renal, and uterine colic, the pain is localized 
over the area of the organ affected. 

Whenever the cause is ascertainable no difficulty is met in the diag- 
nosis of colics due to flatulent indigestion, fecal accumulation, chronic 
lead-poisoning, the rheumatic or gouty diathesis, or entozoa. 

The exclusion of all local causes and pathological processes in a case 
of colic, and the coincidence of characteristic nervous phenomena, make 
the difPerentiation of hysterical or neurasthenic cases a comparatively 
easy task. They are known by pains occurring at frequent intervals, 
and sometimes of nearly continuous character, lasting longer than ordi- 
nary colics. They are frequently mistaken for other forms of colic, 
and, as they require treatment quite different from that appropriate to 
the latter, it is most important to recognize the general causative 
condition. 



INTESTINAL SENSORY NEUROSES. 229 

Prognosis, — The attack usnally lasts but a moment, the paroxysms 
continuing until the cause is removed. This is rarely more than twenty- 
four hours. Sometimes one attack or paroxysm occurs which may last 
from a few minutes to an hour. 

Rarely does death occur in enteralgia unless it is followed by rupture 
of the bowels from excessive gaseous distention (Oppolzer), or from con- 
vulsions, as occurred in a child from obstruction by worms (Wer- 
theimber). 

The duration of the disease depends upon the cause. The neuras- 
thenic form is the most persistent. 

Treatmext. — For simple enteralgia relief is quickly obtained by 
the use of morphine given hypodermically, or opium in some form by 
the mouth or rectum. A hot bath, or hot fomentations applied to 
the abdomen, are often grateful. 

Constipation, so common a symptom in enteralgia, is best relieved 
by an enema. The same should be given where there are flatulency and 
gaseous formation. 

When due to '^cold" (C rheumatica) the use of opiates and heat 
applied about the body, with free diaphoresis, may be sufficient. Phe- 
nacetin and salol or salicylate of soda may be given with advantage for 
several days. When due to hysteria, care in diet and antispasmodics, 
as the bromides and valerian, change of climate, hydrotherapy, mode- 
rate exercise, massage and electricity, and the continued use of arsenic 
have been very successful remedies. 

If pathological or inflammatory processes exist, the treatment should 
be directed to the disease as indicated in each case. 

Rectal injections daily^ for constipation in cases of anaesthesia of the 
lower bowel, should be ordered ; if overlooked, mechanical means for 
removing the hard, stone-like masses must be resorted to. 

The form attended with mucous discharges must be treated by meas- 
ures directed to the nervous system and to the digestion. 



DISEASES OF THE mTESTINES (Continued) 

By henry M. LYMAN, M. D. 



ACUTE INTESTINAL CATARRH. 

Synonyms. — Acute inflammation of the intestines ; Enteritis catar- 
rhalis acuta ; Catarrhus intestinalis acutus ; Enteritis ; Muco-enteritis ; 
Entero-colitis ; Acuter darmkatarrh ; Entente. 

Definition. — Acute intestinal catarrh is an acute inflammation of 
the intestinal mucous membrane. This may become chronic, and even 
though it be circumscribed at the outset it may extend to the whole 
intestinal mucous tract. It is sometimes a local manifestation of an in- 
flammatory process involving nearly if not quite all the mucous surfaces 
of the body. 

Etiology. — Acute intestinal catarrh frequently exists as an original 
uncomplicated disease, but it is also often encountered as a disorder that 
is secondary to some other malady. As examples of the former variety 
may be mentioned those cases of intestinal inflammation that are pro- 
duced by errors of diet. The ingestion of an inordinate quantity of 
coarse and imperfectly masticated food is always followed by inflamma- 
tion of the gastro-intestinal tract, termed gastritis in the stomach and 
enteritis in the bowels. Such inflammation, though acute, is usually 
confined to the mucous membrane, constituting a gastro-intestinal ca- 
ta-rrh. 

In many instances it is not so much the quantity as the quality of the 
food that must be incriminated. Unripe fruit, half-grown and badly 
cooked vegetables, are often causative of catarrhal inflammation of the 
bowels, with consequent diarrhoea, during the summer months. Tainted 
meat, fish, milk, ice cream, custards, etc. that have been spoiled by par- 
asitic fungi often excite a violent gastro-intestinal catarrh. Sour beer 
and wines that have undergone unhealthy fermentation may in like 
. manner occasion the disease. Excessive draughts of cold water and the 
use of foul water, especially if mingled with sewage, are often followed 
by catarrhal enteritis. Witness the diarrhoeas that are rife in Chicago 
after the winter rains have washed the contents of the sewers into the 
lake from which the drinking Avater of the city is drawn. Conversely 
is Avorthy of note the cessation of diarrhoea among the soldiers in the 
CIa^I War when they were made to drink the water of the Mississippi 
instead of the ditch water in their camps. 

A frequent cause of intestinal inflammation lies in sudden refrigera- 
tion of the body, especially during copious perspiration. Many an in- 
experienced youth has lost his life by reason of a plunge when oA'er- 
heated into a cool stream of water, or from a nap under a tree for 

231 



232 DISEASES OF THE INTESTINES. 

which the only preparation consisted in exposure of the sweating abdo- 
men to the refreshing breezes beneath the dense canopy of shade. 

Traumatic causes may excite severe intestinal inflammation. Falls, 
blows, kicks t-hat have invaded the abdominal M-all, may result in 
inflammation of the intestinal tract. In like manner, the introduction 
of foreign bodies from the mouth or through the anus may excite the 
disease. Large gall-stones and fecal concretions may act in a similar 
manner. It is in the same way that long continued constipation may 
assist in lighting up an inflammation. The action of parasitic guests, 
such as intestinal worms, amoebse, and various other microbes, will be 
fully considered in the appropriate sections of this treatise. 

Certain chemical substances may exert a powerful eifect upon the 
gastro-intestinal mucous membrane. Thus the excessive or too pro- 
longed use of mineral waters may excite an intestinal catarrh. Caustic 
alkalies, the mineral acids, corrosive sublimate, arsenic, tartar emetic, 
and the various cathartics of vegetable origin may all produce a similar 
result. 

The action of the infectious microbes within the body is frequently 
accompanied by intestinal inflammation that, occurring under favorable 
conditions of temperature, atmospheric moisture, etc., may simulta- 
neously aifect large numbers of patients at once. A familiar example 
is presented by many of the epidemics of camp diarrhoea that have 
decimated whole armies, or by the widespread diarrhoea that often 
accompanies the invasion of a community by Asiatic cholera. Such 
epidemics are especially incident among children, young people, and 
other particularly susceptible subjects during hot, changeable, and un- 
seasonable weather; hence their greater prevalence in the tropical 
regions of the earth and during the late spring and early autumnal 
months. 

Young children and feeble adults are particularly sensitive to the 
ordinary causes of gastro-enteritis. This is especially notable among 
those who have inherited a predisposition to tubercular or arthritic dis- 
eases. Their mucous membranes are inordinately sensitive to the exci- 
tants of inflammation. In many instances a catarrhal inflammation 
attacks the respiratory tract, and thence invades the stomach, whence it 
extends into the intestinal canal. This extension may be due to simple 
continuity of tissue, or it may depend upon the fact that gastric disorder 
occasions the passage of undigested or ill-digested food into the intestine, 
where it excites inflammation by direct irritation of the mucous surface. 
An example of invasion of the intestinal tract by contiguous inflam- 
mation is furnished by the course of peritonitis, which frequently pene- • 
trates the mural tissues of the gut and involves the mucous membrane. 
Eczema around the anus sometimes extends into the rectum. The 
rectal surface is also sometimes inflamed by the entrance of gonorrhoeal 
pus that has trickled from the urethra and vagina or has been intro- 
duced in other ways. 

Direct violence to the mucous surface, such as may be caused by 
bougies and other foreign bodies that have been forced into the bowels, 
may excite a catarrh of the intestine. The same result may follow 
hernial strangulation, invagination, or t-\Wsting of the intestine. Con- 
pression of the intestines by the growth of abdominal tumors may occa- 



ACUTE INTESTINAL CATARRH. 233 

sion a degree of stagnation in the blood current that favors the incidence 
of inflammation upon the intestinal surfaces. In Uke manner a turgid 
condition of the intestinal capillaries, caused by obstruction of the 
portal vein, either by local obstacles or by cirrhosis of the liver or by 
hindrances to the circulation arising from morbid conditions of the 
heart or lungs, may suffice to determine the occurrence of intestinal 
catarrh. Hence the frequency with which such catarrhal conditions 
are noticed in connection with pulmonary tuberculosis, chronic renal 
inflammation, and cachexia induced by malaria, syphilis, etc. In fact, 
there are very few of the infectious diseases of any considerable dura- 
tion that are not liable to complication by such catarrhal conditions. In 
many instances convalescence is long retarded by the persistence of 
gastro-intestinal catarrh. Whether the intestinal inflammation and 
ulceration that sometimes follow extensive burns of the skin are due to 
nervous derangement or to simple infection is not yet decided. 

Pathological Axatomy. — In severe and fatal cases of acute 
enteric catarrh the mucous membrane of the intestine remains somewhat 
thickened and reddened, even after death. The blush of redness may 
be generalized over the entire surface, or it may appear in spots of 
irregular shape and size. Sometimes the superficial vessels are rendered 
more consj)icuous by distention, and are bordered by a margin of pink 
<3olor, presenting a beautiful arborization upon the inner surface of the 
bowel. When there has been a high grade of inflammation minute 
extravasations of blood are visible, and the superficial layers of epithe- 
lium are in process of exfoliation. The submucous layer of the intesti- 
nal wall is often also infiltrated with a serous fluid causing a true 
inflammatory oedema of the tissue, but in uncomplicated cases the 
muscular and peritoneal coats of the intestine do not share in the 
inflammatory process. 

The lymph glands that open through the mucous membrane of the 
intestine appear enlarged, prominent, like little sago grains imbedded 
in the intestinal lining, and surrounded by a fringe of dilated capillaries. 
Pressure causes the evacuation of a slightly turbid fluid, showing that 
the glandular structure participates in the oedematous swelling, and that 
its elements share in the consequences of inflammatory cellular prolifer- 
ation. By extension of this process to the deeper lymph glands in the 
mesentery they also become enlarged and softened. 

So far as the pathological appearances that depend upon hypersemia 
and swelling are concerned, it cannot be doubted that to a certain degree 
their intensity is diminished by the reduction of intravascular pressure 
that follows death. For this reason it is probable that the full measure 
of pathological change is never displayed upon the autopsy table. 

Besides the morbid appearances that have been already mentioned, 
erosions of the mucous membrane and considerable ulcerations may be 
occasionally observed. These losses of substance are due to the me- 
chanical effects of the exudative process, either affecting the interfol- 
licular spaces, or to inflammatory necrosis of the glandular elements 
themselves. 

Symptoms. — Many of the symptoms of acute intestinal catarrh are 
dependent upon perversion of the special functions and anatomical 
structure of the portion of the bowel that is chiefly affected. Catarrhal 



234 DISEASES OF THE INTESTINES. 

affections of the duodenum and of the portion of the intestine that is 
connected with the appendix vermiformis will be discussed in another 
place. AYe may therefore proceed at once to consider the symptoms 
of the most common form of intestinal inflammation — ileo-colitis, or 
catarrhal inflammation of the ileum and colon. 

The onset of the disease may be gradually ushered in with prodromal 
symptoms of general discomfort and indigestion ; but in many instances, 
especially after great fatigue and exposure, the attack is sudden. There 
is a chill followed by feyer, or successiye chills and feyer may be 
deyeloped with only a brief interyal between the paroxysms. There 
is considerable thirst; the temperature rises to 101°-102° F. ; the 
tongue becomes red, pointed, and furred ; there is a copious diarrhoea, 
so that sometimes it is difficult to avoid the fear of an incipient typhoid 
feyer ; appetite fails ; there is considerable prostration of strength, 
which in severe cases may border on collapse, especially in the case of 
elderly or enfeebled patients, who are rapidly exhausted by the pain 
that accompanies the course of the disease. Children and nervous 
subjects not infrequently manifest some degree of delirium, or even 
convulsions, which in such persons often replace the chills that 
ordinarily occur. 

The most constant and conspicuous symptom is diarrhoea. The 
number of the stools varies with the severity of the attack ; sometimes 
the impulse to defecation is constant, and the patient can scarcely leave 
the seat of the commode or water-closet. Increased peristaltic action 
determines this phenomenon, but the quantity and quality of the 
fecal discharges are dependent upon the quantity and quality of the 
food, and also upon the amount of inflammatory exudation from the 
mucous lining of the bowel. During the initial stage of the attack 
the stools contain masses of undigested food mixed with more or less 
perfectly formed fjeces. To these evacuations of the normal contents 
of the intestinal canal succeed discharges of a semifluid consistence, at 
first colored with bile, but soon followed by watery stools that contain 
very little if any biliary pigment, and are mixed with a considerable 
quantity of mucus, which is often streaked with blood. The color of 
the stools now varies from a light yellow to a gray, light brown, or 
greenish tint. Frequently the stools become green in color after ex- 
posure to the air. In severe cases the discharges finally become very 
fluid, and contain a great number of epithelial cells that have been 
thrown off from the mucous membrane, so that the stools look as if 
composed of rice water, or, if they contain blood pigment, like water 
in which raw beef has been washed. The normal fecal odor disappears, 
and is replaced by a smell like that of prostatic mucus and semen. In 
certain cases masses of fermenting or putrefying matter may be voided 
if the diet of the patient has been unfavorable to digestion. 

It often happens that the disease, especially when associated with 
acute gastritis, rushes rapidly to a fatal termination. One or two days 
or a week may hurry the patient into a fatal collapse. In many 
instances a number of weeks may elapse before a decision is reached, 
and the sufferer, now better and now worse, is buffeted by the waves 
of alternate hope and despair. Sometimes the disease gradually assumes 
the form of a chronic enteritis, which may none the less certainly prove 



ACUTE INTESTINAL CATARRH. 235 

fatal, though prolonged for many months. But in milder attacks the 
severity of the symptoms relaxes after a few days ; the stools recover a 
fecal odor and consistency ; painful diarrhoea ceases ; and presently all 
is well again, though for a long time the intestinal canal may remain 
inordinately sensitive to every cause of irritation. 

Among the various symptoms of acute enteric catarrh may be par- 
ticularized a notable distention of the abdomen. By the processes of 
fermentation and putrefaction the bowels become inflated with gas, 
causing great increase of tympanitic resonance over the whole of the 
belly. The different coils of intestine are thus sometimes rendered 
evident through the abdominal wall, and their peristaltic movements 
may become visible if the patient be somewhat emaciated. The dia- 
phragm is crowded upward by gaseous pressure, and the heart and lungs 
may be considerably displaced and embarrassed in function. The liver 
also may be lifted above the margin of the costal border. The passage 
of faeces through the anus is often accompanied with an outbreak of 
flatus 'that gives only temporary relief. Conversely, the attempt to 
void wind is often followed by a simultaneous discharge of liquid 
matter. AVith these movements there is an audible gurgling and 
bubbling sound that marks the transfer of air and water from one 
intestinal coil to another as their contents are urged onward by peri- 
staltic action. 

The variable color of the stools has been already noted. Their con- 
sistency also varies with the amount of water and mucus that they con- 
tain. During the early stage of the disease numerous relics of food are 
evident in the dejecta, and sometimes intestinal worms or other parasites 
may be discovered in the discharges. Sometimes, when the patient has 
pre\'iously suffered long with obstinate constipation, hard and gritty 
masses of dried-up fecal matter — genuine coproliths — become dislodged 
from the intestinal sacculi, and are revealed to the eye along mth the 
other intestinal contents and products of inflammation. Microscopical 
examination of the stools renders visible all the debris of the food that 
has been swallowed, such as muscular- and connective-tissue fibres, 
starch grains, fibres and cells from plants, and droplets of fat. Epi- 
thelial cells from the intestinal mucosa are very numerous, together 
with the round cells and blood-corpuscles — white and red — that follow 
the course of inflammation. All the varieties of bacterial growth that 
are native to the intestine are ^^sible, but it is not usual to encounter 
any particular pathogenic microbes in uncomplicated cases. jS^umerous 
crj^stals may be discovered, such as the ammonio-magnesium phosphate, 
the neutral calcium phosphate, calcium oxalate, cholesterin, and the 
so-called Charcot's crystals. 

The urinary secretion is greatly reduced in quantity, and during the 
period of copious diarrhoea it may be almost completely suppressed. It 
is frequently loaded with urates, is strongly acid, and its passage is 
sometimes followed by painful scalding sensations in the urethra. 
Occasionally the urinary sediment contains red blood-corpuscles, round 
cells, renal epithelium, and hyaline casts. Albumin may be also present 
in the urine. In certain cases the spleen is perceptibly enlarged. 

The febrile movement that accompanies the disease is variable : 
sometimes the temperature rises to a degree and persists for a period 



236 DISEASES OF THE INTESTI^'ES. 

that awaken a suspicion of typhoid fever. Successive chills sometimes 
occur, and, if the patient be a child or an unusually excitable person, 
convulsions and delirium may diversify the picture. 

The duration* of the disease may be limited by one or two days, or 
it may continue for as many weeks. The period of convalescence is 
often marked by considerable debility. 

When the inflammatory process is confined to the mucous surface 
of the small intestine diarrhoea is absent. The watery exudations under 
such conditions are reabsorbed in the colon, and do not reach the anus. 
Colicky pains about the umbilicus, loss of appetite, some slight febrile 
reaction, and a general feeling of prostration are the principal symp- 
toms. Considerable information may be derived from a microscopical 
examination of the stools, which in such cases contain minute masses 
of mucus mixed with fecal matter, and are often colored with bile pig- 
ment which can be demonstrated by Gmelin's test. Still more valuable 
indications are furnished by the urine, in which, as a consequence of 
putrefactive changes in the small intestine, the presence of indican may 
be readily demonstrated by the hydrochloric acid test. 

Inflammation of the caecum and vermiform appendix are considered 
in another part of this volume. (See Appendicitis, p. 277.) The 
symptoms of colonic catarrh are merged in and associated with those 
of inflammation of the small intestine to such a degree that they 
cannot be separately described, and they have been already sufficiently 
narrated. 

When the mucous membrane of the rectum is the principal seat of 
inflammation, the impulse to defecation is more urgent than in disease 
of the upper segments of the alimentary canal. Tenesmus is very 
severe, and there is frequently considerable tenderness on pressure over 
the left iliac fossa. The patient is continually tormented with colicky 
pains in the lower portion of the abdomen, and by an incessant impulse 
to void the rectal contents. These consist chiefly of mucus mixed with 
a variable quantity of blood, and they are rendered further notable by 
the complete absence of fecal matter or by its very rare appearance. 
Digital examination finds the rectum hot, swollen, and sometimes closed 
by spasm of the sphincter ani muscle. The mucous membrane is red, 
rough, and covered with mucus. After the inflammation has continued 
for a considerable time, as in chronic diarrhcea, a paralytic condition of 
the rectal and anal muscles succeeds the previous state of spasm, and 
the anus gapes open, permitting the acrid products of inflammation to 
flow forth over the buttocks. Severe intertrigo may be thus set up. 
Sometimes there is prolapse of the rectum, and in severe cases the 
inflammatory process may invade the perirectal tissues and create an 
abscess, with subsequent formation of a fistulous canal between the 
rectal pouch and the external surface of the body. 

Diagnosis. — Acute enteric catarrh is easily recognized. During 
the prevalence of an epidemic of Asiatic cholera the question may be 
raised as to the possibility of mistaking the one disease for the other, 
but a microscopical examination of the stools will soon decide which of 
the two maladies is present. The absence of the cholera bacillus deter- 
mines in favor of the simple catarrhal affection. In like manner, the 
discovery of typhoid bacilli in the stools or in blood drawn from the 



ACUTE INTESTINAL CATARRH. 237 

spleen or roseolous spots decides in favor of typhoid fever. The course 
of the temj)erature and the occurrence of the well-known eruption at 
the end of the first week also furnish corroborative evidence. With 
other intestinal disorders the disease can hardly be confounded. 

Peogxosis. — Only in cases that are complicated with serious disease 
of other important organs^ or in cases that have been enfeebled by other 
causes, is the prognosis discouraging. When the conditions for con- 
valescence are unfavorable, frequent relapses follow slight errors of diet 
or exposure, and the disease may become transformed into a chronic 
intestinal inflammation. 

Treatment. — In every acute inflammation of the alimentary canal, 
especially if pain and fever be present, the patient should be kept in 
bed. A warm poultice or a hot fomentation should be laid over the 
entire surface of the abdomen, and should be covered with thick woollen 
cloth or oiled silk or thin rubber tissue. For travellers the specially 
prepared artificial linseed poultices are invaluable. AVhen painful colic 
is a prominent symptom a drachm of chloroform may be stirred in with 
the hot water and meal during their preparation for the cataplasm. The 
patient must be furnished with rice water, crust coffee, hot milk, or 
pure water for his drink. Only liquid food should be permitted, such 
as hot milk, barley gruel, oatmeal gruel, or gruel prepared from any 
one of the various food powders that are furnished for infants. In 
short the diet should be that of a newly weaned infant. Animal broths, 
such as clam broth, oyster broth, chicken broth, and veal broth, may 
be allowed. Alcoholic stimulants should only be given in cases of 
collapse when the stomach is not seriously inflamed. As a general rule, 
the gastro-intestinal mucosa when suffering inflammation is very intoler- 
ant of alcohol, or should receive it only in a state of high dilution. 

At the commencement of the disorder, especially if it has been pre- 
ceded by imprudent use of food or by the ingestion of unwholesome or 
corrupted articles of food, such as tainted meats, etc, the alimentary 
canal should be evacuated without delay. Ten grains of calomel with 
five grains of sodium bicarbonate should be administered in a wafer, 
and this should be followed within an hour by a tablespoonful of castor 
oil. The oil may be floated upon a spoonful of coffee or of orange- 
juice, or it may be mixed with the froth of beer. The older physicians 
usually employed the powder of jalap in connection with calomel, but 
this drastic purgative should only be used among the most vigorous 
patients. For women and children small doses of calomel may be 
given at short intervals, followed by a glass of the solution of magne- 
sium citrate or by half a glass of Rubinat water or by a Seidlitz powder 
or a drachm or two of Rochelle salts. By thus relieving the intestine 
of all its irritating and toxic contents recovery may be often reached 
without additional treatment. 

But if, in spite of such thorough evacuation of the intestines and 
drainage of the capillaries of the mucosa, diarrhoea should still persist, 
it will be found necessary to combat the inflammation by the use of 
remedies that are antiseptic and astringent. Most useful in this stage 
are the compounds of bismuth. The salicylate, the subnitrate, the sub- 
carbonate, or the subgallate of bismuth may be administered in ten- 
grain doses after each movement of the bowels. Half a grain of opium, 



238 DISEASES OF THE INTESTINES. 

and in cases marked by cardiac weakness a grain of camphor, may be 
added to each dose. In certain quasi choleraic conditions, when a posi- 
tively styptic effect is desirable, recourse should be had to the mineral 
astringents, such as acetate of lead, nitrate of silver, alum, sulphate of 
iron, solution of the persulphate of iron. These should be combined 
with opium sufficient to prevent irritation and to calm pain. As the 
case progresses and a tonic astringent influence is needed the vegetable 
astringents should be employed. These are numerous, but owe the 
greater part of their efficiency to the tannin that they contain ; hence 
the reputation that is connected with decoctions of strawberry or 
raspberry or blackberry leaves. Tannic acid may be given in doses of 
two to five grains every two or three hours. The various extracts and 
tinctures of catechu, krameria, hasmatoxylon, and coto bark are often 
useful in conjunction with opiates, esj)ecially the camphorated tincture 
of opium. After convalescence is established great care is needful to 
avoid errors in diet and exposure to cold. For many patients a woollen 
band should be ordered, to be worn around the abdomen even after 
complete restoration to health. 

When inflammation is restricted to that portion of the intestine 
which lies below the ileo-csecal valve, local treatment may be added to 
the methods just described. The colon may be irrigated by the aid of 
a fountain syringe containing a quart or more of warm water, to which 
a teaspoonful of table salt has been added. By placing the patient in 
different positions, so as to favor the expulsion of gas previous to the 
entrance of water, the colon may be easily filled and thoroughly washed 
out. Great comfort, extending even to a whole night's sleep, may be 
often procured by this simple expedient. If the disease does not yield 
promptly, and especially if it tend to become chronic, this irrigation of 
the bowel may be followed by an equally extensive application of a weak 
solution of silver nitrate to the mucous lining of the colon and rectum. 
The solution should be very weak at first — one part of the nitrate to 
one thousand parts of water, half a grain to the ounce, or fifteen grains 
to the quart. As tolerance becomes established the strength of the solu- 
tion may be gradually increased to four or five times the original figure. 
. If the course of the inflammation be attended with colic that does 
not yield promptly to the ordinary doses of opium by the mouth, it will 
be necessary to resort to the use of morphine and atropine hypoder- 
mically. For this purpose the soluble tablets that contain the two drugs 
to the amoimt of one quarter of a grain of the first and the one hun- 
dred and fiftieth of a grain of the last should be employed. 

When the inflammatory action chiefly involves the rectal mucosa, 
great relief from tenesmus may be obtained, after the bowel has been 
cleansed by irrigation, from the use of rectal suppositories that contain 
morphine and atropine. The equivalent of one of the soluble tablets 
just mentioned may be incorporated with a little cocoa butter, and then is 
introduced by the aid of a suppository holder above the internal sphincter 
of the anus. Unless thus placed high up in the rectum it may aggra- 
vate the desire to stool. 



CHRONIC INTESTINAL CATARRH. 239 

CHRONIC INTESTINAL CATARRH. 

Etiology. — Chronic inflammation of the intestinal mucosa may be 
determined by the gradual passage of an acute attack into the prolonged 
variety of the disease, or it may result from frequent relapses of the 
acute form, due to many diiferent causes that either retard or arrest con- 
valescence. The causes that excite acute inflammation of the mucous 
lining of the intestine may therefore in this sense be reckoned as causes 
of chronic inflammation. But the real causes that convert an acute at- 
tack into a persistent disease are undoubtedly of a diiferent nature. The 
same thing may be said of the conditions that favor the gradual inci- 
dence and evolution of a primarily chronic catarrh of the intestine. All 
causes that operate to embarrass the abdominal and intestinal circulation 
of blood and lymph are thus prejudicially active. Hence the universal 
association of catarrhal conditions of the intestine with cardiac and pul- 
monary disease, hepatic disease, portal obstruction, etc. Certain toxic 
conditions also favor the development of intestinal catarrh. Prominent 
among these may be mentioned malarial poison, tubercular excreta, and 
the toxins that are generated in gouty states of the body or during the 
course of renal diseases. Many severe and protracted cases owe their 
existence to the pernicious activity of parasitic protozoa in the large 
intestine. 

Pathological Axatomy. — On opening to inspection the intestine 
in a case of chronic catarrhal inflammation the mucosa is found evi- 
dently thickened, changed in color, and covered with a rather tenacious 
layer of mucus. The swelling of the membrane is conditioned by the 
inflammatory increase of the connective-tissue elements throughout both 
the mucous and the submucous layers of the intestine. The lymphatic 
follicles and their appendages are also increased in size. When this 
hypertrophic condition obtains the vessels of the mucosa and submucosa 
exhibit a thickened parietal structure and the veins are somewhat di- 
lated. In cases of moderate duration the inner surface of the intestine 
is of a dark red color, owing to excessive vascularity associated with 
protracted stagnation of the blood. But in cases of long standing the 
same surface may present a dark, slaty hue by reason of the accumula- 
tion of blood pigment in the extravascular tissues and spaces. A fa- 
vorite seat of such pigmentation is found in the coronal network of 
capillary vessels that surrounds every lymph follicle and intestinal 
gland. Hence the prominence that by this method of staining is given 
to the orifices of the follicles and glands that open into the intestinal 
canal. They also yield a more or less abnormal secretion — sometimes 
watery, sometimes slimy, sometimes sero-purulent or puriform — that 
smears the free surface of the mucous membrane. 

The terminal consequences of chronic intestinal catarrh may be hy- 
pertrophy or atrophy of the intestinal wall, or it may result in chronic 
ulceration of the parietal tissues. In many instances all these changes 
may be associated in the same subject. 

When, as a consequence of catarrhal inflammation, h}^ertrophy of 
the intestinal wall is produced, the increased thickness of the mucosa 
may actually cause an appreciable reduction of the diameter of the in- 
testinal canal. This change is most conspicuous in the small intestine. 



240 DISEASES OF THE INTESTINES. 

where the swollen valvulae eonniventes make themselves prominent, 
and also in the region of the ileo-caecal valve. The connective tissue 
becomes increased in amount, and sometimes the peritoneal investment 
of the gut exliibits evidence of thickening and loss of translucency 
through similar exudative and proliferative processes involving its serous 
surface. 

Intestinal atrophy is not an uncommon event in cases of chronic 
catarrh, such as occur among children and weakly individuals. The 
intestinal wall becomes extraordinarily thin, and the glandular and 
muscular structures undergo atrophy. The csecum appears to be the 
central focus of this process, which extends in lesser degree upward and 
downward through the intestinal canal. 

Ulceration of the intestinal lining originates in two different ways — 
either as a simple solution of continuity in the substance of the mucosa, 
or as a necrotic inflammation of a follicular sac that lies imbedded in 
the intestinal wall. The first variety is originated by a superficial ero- 
sion at some point upon the mucous surface. Of a circular form at first, 
the necrotic process and the coalescence of neighboring erosions finally 
convert the growing ulcer into an irregular excavation with overhang- 
ing borders that are undermined by inflammatory action in the sub- 
mucous tissue. Sometimes an islet of mucous membrane that has 
escaped death remains visible in the centre of an ulcerated patch. Gran- 
ulations sometimes spring up along the border of the excavation, and 
serve to increase the irregularity of its margin. 

As a consequence of the suppuration that accompanies ulceration 
submucous abscesses are sometimes formed. These burrow among the 
tissue elements of the intestinal wall, and may result in actual perfora- 
tion of its peritoneal investment. So long as ulceration is confined to 
the intestinal coats a discharge of pus with the faeces may be the only 
visible product. But sometimes a blood vessel is eroded, and hemor- 
rhage quickly follows. When the peritoneal cavity is opened by per- 
foration the intestinal contents are not always permitted to enter that 
serous sac. Adhesions to an adjacent surface of intestine, stomach, 
liver, or other abdominal organ frequently result, and the ulcerative 
opening is thus sealed up. Sometimes pus accumulates in a cavity that 
is thus formed by marginal adhesion between two intestinal folds or 
peritoneal surfaces. Such abscesses, however, are liable to enlarge, and 
gradually work their way to a great distance along the line of least re- 
sistance. They may finally form a communication with any of the 
cavities, vessels, or hollow viscera of the abdomen and thorax, or they 
may penetrate the abdominal wall and thus reach the external world. 
When adhesive inflammation fails to form an adequate Avail for the ad- 
vancing abscess, the peritoneal cavity is liable to be invaded by a fseco- 
purulent discharge, setting up violent peritonitis that is usually fatal in 
a very short time. 

AVhen the ulcerative process can be checked cicatrization may be 
completed after a time. But even this favorable result may have dis- 
advantageous consequences. The overlying peritoneum becomes thick- 
ened, and the frequently pigmented scar undergoes contraction to an 
extent that sometimes occasions notable deformity and stenosis of the 
intestine. 



CHRONIC INTESTINAL CATARRH. 241 

The process of exudation, that in the early stage of inflammation 
occasioned simple swelling and thickening of the intestinal mucosa, may 
invade the structure of the solitary lymph follicles that are so numerous 
in the wall of the colon. The glandular elements increase and crowd 
upon one another until necrosis begins. By this process the cavity of 
the follicle becomes filled with dead and dying caseated cells which are 
loosened and thrown oif into the fseces. In this way the intestinal wall 
is studded with a vast number of minute excavations which are real 
microscopic ulcers. In the walls of these cavities the ulcerative process 
goes on, undermining the mucosa and enlarging in every direction, so 
that finally, by the coalescence of numerous openings, ulcers of great 
extent and depth are formed. It is in the colon that this result attains 
its greatest development, but sometimes the rectum also shares in the 
results of the destructive process. In these ulcers may be frequently 
discovered the little sago-like masses that often appear in the stools. 
When cicatrization occurs the resultant scar is smooth and pigmented 
like the corresponding scar that is formed by the healing of the ordi- 
nary intestinal ulcer of erosive origin. 

In certain cases the connective tissue of the intestinal mucosa pro- 
liferates so actively, under the stimulus of inflammation, that numerous 
polypous excrescences appear upon its surface. These polypi are most 
numerous throughout the length of the colon, and may be sometimes 
found intruding into the rectum. Occasionally the inflamed follicles in 
the mucous membrane do not ulcerate, but, becoming obstructed by 
closure of their orifices, they develop into cysts in the intestinal wall. 
In this way the inner surface of the colon may be considerably diversi- 
fied by the formation of ulcers, polypi, and cystic cavities. 

Symptoms. — Chief among the symptoms of chronic catarrhal inflam- 
mation of the intestine are changes in the character of the stools and in 
the process of defecation. Intestinal torpor and infrequent evacuation 
of the bowels are among the earliest consequences of the reduction of 
muscular vigor that results from chronic inflammation so near to the 
muscular coat of the intestine. Probably the nervous mechanism of 
the intestinal wall suffers in the same way, so that its response to irrita- 
tion by the fecal contents of the gut is less prompt and efficient. Periods 
of diarrhoea frequently alternate with corresponding periods of consti- 
pation, just as in the inflamed bronchi and trachea violent fits of cough- 
ing succeed to seasons of calm during which the products of inflamma- 
tion accumulate in the respiratory passages. In many cases, however, 
frequent loose stools are voided every day, or they may occur only in 
the morning, leaving the patient in comparative comfort during the 
greater part of the day and night. 

The stools generally contain an abnormal quantity of mucus. Even 
if the ffeces are cylindrical and semi-solid, they are often covered with 
an abundant coating of slime, in which may be sometimes discerned the 
presence of blood and pus. Mucus is more liberally furnished as the 
inflammatory process approaches the rectum, and when that portion of 
the intestinal canal is invaded, the discharges often consist almost 
entirely of mucus. Blood and pus are evidences of ulceration, and so 
were once considered the sago-like masses of starch that sometimes 
make their appearance, though occasionally they exist in simple cases 

Vol. III.— 16 



242 DISEASES OF THE INTESTINES. 

that have not yet reached the ulcerative stage. When the stools are 
thin and watery by reason of rapid propulsion through the intestinal 
canal, they not, infrequently contain undigested fragments of food that 
have been hurried downward from the stomach. Microscopical exami- 
nation of the stools will readily differentiate these particles from the 
variously degenerated epithelial and connective-tissue cells that exist in 
the discharges. By the same method it is possible to detect the ova of 
the different worms that sometimes inhabit the intestines, and to dis- 
cover the amoebae coli and other parasites that may excite inflammation 
of the mucosa. 

There is a form of chronic intestinal inflammation that is character- 
ized by the production and exfoliation of pseudo-membranous masses 
or pellicles that sometimes present the appearance of casts of the 
mucous membrane. In certain cases they are solidly cylindrical, like 
hyaline casts from the renal tubules. In others they are hollow or flat- 
tened and band-like, resembling the mucous lining of the intestine itself, 
or, to the eyes of the laity, presenting the forms of dead and tape-like 
worms. Treated with chemical reagents, these false membranes are 
found to be composed chiefly of mucin, albumin, fibrin, and globulin. 
Occasionally a low form of incipient organization may be discovered, 
and rudimentary bloodvessels are visible in the extruded mass. But 
this is unusual, and the substance must be ranked as a pellicular exuda- 
tion that is formed as a result of chronic inflammation, very much as 
the vegetations that form upon the inflamed valves of the heart are 
produced. Sometimes, however, these membranes appear to exist inde- 
pendently of inflammatory action. In such cases they are probably the 
result of perverted secretion and of a disturbance of the trophic functions 
of the nervous mechanism of the alimentary canal. This hypothesis is 
rendered probable by the fact that many of these patients are middle- 
aged, neurotic, neurasthenic, and hypochondriacal females with blue 
eyes, fair complexion, and other evidences of delicate organization. 
The discharge of a false membrane is usually preceded by long-contin- 
ued constipation and by the frequent occurrence of colicky pains in the 
umbilical region. Sometimes the whole mass is voided at once, usually 
with the ordinary fecal discharge ; but sometimes it appears at intervals 
in divided fragments, with or without the faeces. Sometimes these 
deliveries are of frequent occurrence, but in many instances they are 
effected only at long intervals of time. 

The uneasiness that is occasioned by chronic catarrhal inflammation 
of the intestines is frequently aggravated by the accumulation and 
movement of gas in the bowels. This difficulty is increased by the use 
of certain articles of food, notably those of vegetable origin. Such 
flatulence originates some time after eating, and is caused by the fermen- 
tation or putrefaction of the contents of the intestine. 

When the bowels are moved only at considerable intervals of time, 
the colon is the principal seat of gaseous production resulting from 
putrefaction of the retained fseces. Accordingly, the act of defecation 
is often preceded by colicky pain in the lower part of the abdomen, and 
great relief is experienced after expulsion of the intestinal contents. 
If the small intestine be distended also, the descent of the diaphragm 
is hindered, and there is complaint of pseudo-dyspnoea. Often in such 



CHBONIC INTESTINAL CATARRH. 243 

cases the he'krt is disturbed in its action and beats violently or irregu- 
larly, causing considerable interference with the circulation of blood. 
Various nervous phenomena, sometimes of an hysterical character, may 
appear. Dizziness, flushing of the face, and throbbing in the temples 
are not uncommon events in such cases. The extremities are usually 
cold, and the pulse is habitually feeble, owing to the great impoverish- 
ment of the blood, which somethnes reaches to a degree that is sugges- 
tive of the most dangerous forms of anaemia. The urine also becomes 
scanty, and is often loaded Math brickdust sediment. Under such 
circumstances the patient becomes gloomy, hypochondriacal, sleepless, 
and sometimes even insane. These changes are due to imperfect nutri- 
tion of the tissues and intoxication of the brain with the products of 
intestinal decomj)osition. 

The duration of chronic intestinal catarrh is very lengthy — some- 
times it coincides with the life of the patient. In extent it sometimes 
pervades the whole intestine, but it is occasionally limited to a particular 
portion of the bowel. Usually it involves the ileum and the colon at 
the same time. When seated in the upper portion of the small intes- 
tine it is generally associated with chronic gastric catarrh, and is indi- 
cated by chronic jaundice and by the presence in the fseces of micro- 
scopical particles of mucus and epithelium that are colored with bile. 
In cases of chronic inflammation of the ileum there is an increase of 
indican in the urine, but beyond this there are no reliable symptoms of 
an uncomplicated inflammation limited to that portion of the gut. In 
chronic inflammation of the rectum there is a certain amount of tenes- 
mus, but it is far less urgent than during an acute inflammatory attack. 
Sometimes the discharges consist chiefly of muco-purulent matter, and 
sometimes there is prolapse of the rectum, followed by an irritating 
intertrigo upon the soft parts around the anus. Occasionally the inflam- 
matory process extends into the perirectal connective tissue, causing 
abscesses and subsequent Jistulce in ano. 

Ulceration of the intestinal mucosa, especially in its colonic portion, 
tends to become permanent. The presence of pus or of pus mingled 
with blood in the stools is an almost certain indication of such lesions. 
When ulceration is confined to the rectum and lowest portion of the 
colon the fecal cylinder, though normally consistent, will carry pus, 
blood, and mucus upon its surface. Rectal ulcers can be recognized 
by the touch or by the use of the rectal speculum. The minute sago- 
like bodies that are often present in the fseces, and were formerly held 
in high repute as indicative of the existence of follicular ulcers in the 
colon, are now believed to have their origin in undigested starch from 
the food, and they are often present in the stools when ulceration is 
unknown. The presence of broken-down connective tissue in the intes- 
tinal discharges is a very rare event, but one of great diagnostic value 
when it occurs. It should never be forgotten that diarrhoea is often 
absent in cases of circumscribed inflammation and ulceration of the 
intestinal canal, so long as the greater portion of the mucous membrane 
remains intact. 

Diagnosis. — So characteristic are the phenomena of chronic catarrhal 
enteritis that a review of the symptoms is sufficient for the establish- 
ment of the diagnosis. Since identical symptoms may follow inflam- 



244 DISEASES OF THE INTESTINES. 

mation that has been excited by various causes, a careful investigation 
is often needful in order to determine the origin of the disease. Some 
difficulty may jittend the effort to localize the lesions of the mucous 
membrane, but this can be surmounted by careful observation. Even 
though complicated by peritoneal or other abdominal disorders, the 
character of the stools suffices to explain the nature of the disorder. 

Prognosis. — Chronic catarrhal enteritis is a disease that often per- 
sists for a lifetime. Under favorable conditions it may continue for 
many months or for a number of years. To life it is most dangerous 
during the extremes of childhood and old age. When caused by incur- 
able disorders or associated with permanent diseases, such as tubercu- 
losis, chronic nephritis, degeneration of the liver, heart, etc., it often 
becomes the despair of the therapeutist. Death often results from in- 
tercurrent diseases that are rendered dangerous and incorrigible by the 
cachexia that underlies the mucous inflammation itself. In elderly 
patients who are the victims of the gouty predisposition various renal, 
cardio-vascular, and respiratory diseases are often associated with the 
course of chronic enteritis, and are frequently the determining cause of 
death. 

Treatment. — In every case of chronic catarrhal inflammation of 
the bowels the patient must be guarded against sudden chilling of the 
external surface of the body. Warm clothing in the winter and suf- 
ficient protection in the summer are essential to health. Many persons, 
even in tropical countries, find it necessary to wear a flannel bandage 
around the abdomen through the entire year. During the cooler hours 
of the morning and evening thicker clothing must be worn, and the 
bed-clothing must be sufficient to protect against chilliness during the 
hours of sleep. 

The diet must be carefully regulated. Unless some personal idio- 
syncrasy should prevent, milk should constitute the principal portion of 
the food. It should never be taken cold, except in the form of frothy 
koumyss. Nor should it be boiled, for by that process it is deprived 
of its antiscorbutic properties. Simply heated to a temperature of 
160° F. and taken at the temperature of ordinary hot drinks, it is 
palatable and curative. The starchy elements of food are best repre- 
sented by rice that is cooked in a steamer, so as not to be stirred into a 
pasty condition. Well salted, it may be eaten with hot milk, and 
should be so thoroughly masticated that every kernel is reduced to pulp 
in the mouth. With this may be eaten the thick crusts of Vienna 
bread, zwieback, toasted crackers, and toasted bread that has been 
thoroughly dried in the oven before it is torrefied at the fire. A small 
quantity of butter may be permitted with this food, unless there be an 
over-acid state of the stomach. Soups and broths that have been 
thoroughly strained, cooled, skimmed free from fat, and freshly heated 
are usually well tolerated. Stewed maccaroni and vermicelli are also 
excellent articles of food when not prepared with cheese or other sub- 
stances that are difficult of digestion. 

But when starchy food does not agree with the gastro-intestinal 
mucosa, the patient becomes uncomfortably flatulent, and it is necessary 
to make larger use of animal food. Very tender meats thoroughly 
chewed, minced meat, scraped raw beef, uncooked oysters, soft eggs,. 



CHRONIC INTESTINAL CATARRH. 245 

and hot mill^ should form the principal portion of the diet until con- 
valescence is fairly established. In many cases great benefit is derived 
from the use of fermented milk. I have seen an obstinate case yield 
to koumyss taken in portions of a mouthful once every half hour. The 
fermented poi that forms the principal food of the Pacific Islanders is 
an excellent article in these cases. 

The selection of drugs with which to medicate chronic catarrh of 
the intestinal mucous membrane is dictated by the topography of the 
disease. When the upper portion of the intestine suffers, there is con- 
stipation ; when the ileum and colon are involved, there is diarrhoea ; 
Avheu the rectum is the seat of inflammation, there is bloody diarrhoea 
and tenesmus. Accordingly, in upper intestinal catarrh it is necessary 
to administer laxatives. It is well to administer a few gently evacuant 
doses of calomel and podophyllin : 



Hydrargyri chloridi mitis, 



Resinse podophylli, gr. ^ ; 

Sodii bicarbonatis, gr. j. 

Tabella una fiat, 
Sig. One such tablet every four hours till the bowels are moved. 

Then the solubility of the fseces may be maintained by subsequent 
exhibition of pills containing aloin, strychnine, and belladonna, or com- 
pound rhubard pills, or aloes and myrrh pills. The compound licorice 
powder of the German Pharmacopoeia is an excellent household laxative 
that may be given in doses of one or two teaspoonfuls in a glass of 
water every night or morning. Certain aromatic cordials containing fluid 
extract of cascara sagrada are often of great service, since they are at 
the same time laxative and tonic. A very pleasant laxative, prepared 
from the pulp of tamarinds, may be found in the shops under the form 
of a conserve. Various fruit syrups reinforced with an electuary of 
senna are frequently employed by the laity, and are not without value. 
A teacupful of wheat bran, moistened with Avater and swallowed before 
breakfast, is for many a most effectual and agreeable laxative. It is 
the basis of certain invalid foods that are announced as curative of con- 
stipation. Sometimes an increase in the quantity of water that is 
drank — a tableglassful- on rising and retiring — is sufficient. AVhen 
there are evidences of constipation from nervous irritability the action 
of belladonna is often favorable. This substance may be given alone 
in doses of one quarter of a grain of the extract two or three times a 
day, or it may be combined with other laxatives in pill form. 

In many cases of chronic catarrh involving the small intestines 
great benefit often accrues from the use of the bitter saliue mineral 
waters. Of these, the Saratoga waters afford an admirable example. 
Of the European waters the Rubinat spring is one of the best. From 
four to six ounces of the water should be taken on rising in the morn- 
ing. Followed shortly after with a glass of ordinary table water, the 
bowels will be evacuated without pain or other disagreeable effect. The 
German waters from Friedrichshall, Hunyadi Janos, Piillner, or Seidlitz 
may be used in the same way, either at the springs or at home. For 
those who cannot afford the luxury of bottled waters, solutions of Epsom 



246 DISEASES OF THE INTESTINES. 

salts or Glauber's salts may be prepared by any apothecary. Epsom 
salts are to be preferred when the tongue is fairly clean ; the sodic 
sulphate when, the tongue is coated and yellow. 

Inasmuch as chronic catarrh and constipation are associated with 
inefficient muscular action in the coats of the intestine, general muscular 
gymnastics are to be recommended. Massage and kneading of the 
abdomen may be useful. Faradization of the abdominal wall is 
indirectly beneficial in a similar way. The introduction of the nega- 
tive pole into the rectum is often followed by active peristalsis, very 
much like that which is excited by the introduction of a glycerin suppo- 
sitory or a glycerin enema into the bowel. 

When the colon is involved in the catarrhal process, so that we have 
to deal with an ileo-colitis of chronic character, the treatment must con- 
sist in the evacuation of the bowels, their disinfection, and medication 
with astringents, very much after the manner of treatment that is useful 
in acute ileo-colitis. Much benefit is to be obtained from daily irriga- 
tion of the colon with salt water at the temperature of aliout 105° F. 
For this purpose the water of the Glen wood Spring in Colorado and 
the Carlsbad water in Europe may be recommended. When ulceration 
of the colon exists, these irrigations may be followed by a subsequent 
daily enema consisting of a weak solution of nitrate of silver. The 
value of antiseptic injections is well illustrated by the effects of enemas 
of brandy, which are sometimes employed by the laity. Though in- 
tensely painful, they are very effectual in the production of cure. Far 
milder, and perhaps equally beneficial in cases of chronic ulceration, is 
the effect of oil — castor oil or olive oil — taken daily for several weeks 
in succession. 

When chronic ileo-colitis is complicated with malarial infection, re- 
moval to a healthy locality is the most essential pre-requisite to a cure. 
Many a victim of camp diarrhoea in tropical and subtropical countries 
has lost health and life through neglect of this precaution. Pure air 
for the lungs, pure water for the stomach, and cold sponge-baths for the 
skin are often the most helpful agents in these cases. When to these 
are added simple and wholesome food, like milk and fresh ripe fruits 
(grapes, apples, oranges), there is little left to be desired. 

In the membranous forms of ileo-colitis we encounter some of the 
most incorrigible cases that can be presented. The internal administra- 
tion of arsenic and haematopoietic stimulants afford, in conjunction with 
the other measures above mentioned, the best means of relief. It is 
always necessary to take into consideration the anaemic, neurotic, and 
neurasthenic condition that underlies the local affection in these 
patients. 

Of various pathological conditions of the intestine, such as diffuse 
phlegmonous inflammation of the intestinal wall, or fibrinous inflamma- 
tion of the same structures sometimes discovered post-mortem after 
severe diarrhoea, dysentery, typhoid fever, etc., nothing need be said in 
this connection, since they cannot be recognized clinically during the 
life of the subject. 



INTESTINAL ATONY; CHRONIC CONSTIPATION. 247 



NERVOUS DIARRHCEA. 

Synonyms. — Diarrhoea nervosa ; JSTervSse diarrhoe. 

Delicate, nervous, neurasthenic, and hysterical individuals under the 
influence of unwonted excitement of any kind are often subject to a 
transient diarrhoea that can be explained only by the hypothesis of an 
increased peristaltic action through the intervention of the nervous 
system. In a somewhat similar way are to be explained the gastric and 
intestinal crises, marked by violent though brief vomiting and purging, 
that occur during the course of a central disease of the spinal column, 
such as tabes dorsalis. 

In many of the victims of gastro-intestinal dyspepsia there may be 
an almost constant peristaltic movement of the intestines that gives rise 
to great uneasiness. Sometimes it assumes a real colicky severity, and 
causes constipation of the bowels by its irregular and retrograde move- 
ment of the intestinal muscles. It is usually experienced by the victims 
of neurasthenia and by Avomen who suifer with uterine diseases or with 
hysteria and hypochondria. 

The TREATMENT rcsolvcs itself into management of the diet, exer- 
cise, hydropathic measures, and gentle laxatives. 



INTESTINAL ATONY; CHRONIC CONSTIPATION. 

Synonyms.— ^Atonia enterica ; Darmatonie. 

Etiology. — Hereditary causes are active in the production of this 
very common disorder. Especially frequent is it in families Avhere the 
possession of wealth exists without knowledge of its use for the pro- 
duction of happiness. Like the other disorders of nutrition that are 
frequently associated with and aggravated by it, intestinal atrophy is 
often the result of faulty habits that have been acquired by a previously 
healthy individual. Thus, it is frequently experienced by members of 
the mercantile class, professional people, students, seamstresses, shoe- 
makers, and others who have exchanged an active out-door life for the 
muscular torpor of a sedentary occupation. 

Chronic intestinal atony is frequently induced by habitual neglect 
of the calls of Nature to stool. By reason of pre-occupation with busi- 
ness cares or through ignorance of the consequences of neglect, regular 
habits are not maintained, and the normal daily incitement to evacua- 
tion of the bowels ceases to make itself felt. During cold weather in 
the country the cheerless lack of comfort and convenience about the 
out-houses leads women and children to postpone the act of defecation 
until frequently the habit has been lost. 

Diet is of great importance in chronic constipation. Comparison of 
the faeces of a dog with those of a calf shows that vegetable food fur- 
nishes a more copious supply of fecal matter than is yielded by animal 
food. Accordingly, it is a daily observation that people who live upon 
flesh, milk, eggs, cheese, etc. are much more prone to constipation than 



248 DISEASES OF THE INTESTINES. 

the inhabitants of tropical countries, wlio live on rice, potatoes, fruits, 
and starchy preparations. Still, it is noteworthy that vegetable food 
does not wholly counteract the effects of inactivity and muscular weak- 
ness. Under sivcli conditions fecal stagnation may distend the atonic 
bowels, and thus exaggerate the difficulties of the case. The same thing 
may be often observed among infants who are brought up by hand on 
cow's milk. This form of constipation is due, in part, to the difference 
between mother's milk and that of the lower animals, and in part to the 
imperfect nutrition of the ill-fed child. It is usually the fact that deli- 
cately organized individuals, with slender muscles and feeble nerves, are 
constant sufferers from debility of the intestinal muscles. Acquired 
atony of these muscles is an almost uniform consequence of debilitating 
diseases, chlorotic and ansemic conditions, and neurasthenia. Over- 
activity of the brain and its chronic disorders, such as hysteria, hypo- 
chondria, and melancholia, are fruitful causes of intestinal atony. It 
often originates during convalescence from exhausting diseases, and is 
almost always experienced at some time in the course of other intes- 
tinal maladies. Among old people it frequently results from the 
atrophy that accompanies senility. At the other extreme of life it is 
not a common affection before the age of puberty and the formation of 
sedentary habits at school or elsewhere. 

Symptoms. — The most conspicuous symptom of intestinal atony 
is persistent constipation. Instead of the daily impulse to evacuation 
of the bowels, the patient often passes many days without a stool ; 
sometimes the call to defecation is only experienced while under the 
influence of laxative or purgative drugs. In such obstinate cases the 
faeces become very dark in color, and they are sometimes hardened and 
dried like masses of charcoal. The normal fecal odor is lost, and is 
replaced by a peculiar stench that is characteristic of imperfect defeca- 
tion. The fecal cylinder undergoes various modifications of form : 
sometimes it is transformed into bulky masses of irregular shape, more 
or less moulded by the sacculi of the colon ; sometimes it is disinte- 
grated into little pill-form shreds that resemble beans or the dung of 
sheep and goats ; occasionally it assumes the form of slender, long- 
drawn-out cylinders, as if passed through a narrow stricture. Fre- 
quently the feces are smeared wdth mucus and are marked with fresh 
blood. 

The effects of chronic constipation are very notable in their influence 
upon the functions of the brain. There is a feeling of universal dis- 
comfort, fulness and pressure in the head, throbbing in the temples, 
ringing in the ears, dizziness, and faintness if exposed to great heat. 
Great depression of the spirits, extending even so far as hypochondria 
and melancholia, are not infrequent. These disturbances are chiefly 
consequent upon insufficient defecation of the tissues, and upon their 
auto-intoxication with poisonous toxins that are absorbed from the 
stagnant intestinal pool. It is in this way that respiratory oppression, 
cardiac palpitation or intermission, insomnia, and transient attacks of 
. ephemeral fever are excited. 

Physical examination of the abdomen frequently reveals a distended 
condition of the colon, and sometimes isolated fecal masses can be dis- 
tinguished through the abdominal wall. These fecal tumors usually 



INTESTINAL ATONY; CHRONIC CONSTIPATION. 249 

occupy the descending colon above the sigmoid flexure. They are not 
painful on pressure, and, if not too much indurated by long residence, 
they can be indented by firm compression between the thumb and 
fingers. Hemorrhoids are frequently coincident, and sometimes there 
is prolapse of the rectum as a consequence of excessive straining at 
stool. 

DiAGXOSis. — It is not always easy to distinguish between simple 
intestinal atony and other diseases attended with chronic constipation. 
Chronic intestinal catarrh, most frequently confounded witli atony of 
the bowels, may be differentiated by the fact that the constipated fseces 
in catarrh are often covered with mucus and blood, while in cases of 
uncomplicated atony they are free from mucus, and are stained with 
l)lood only wdien the bowel is wounded during their evacuation. Intes- 
tinal stricture presents many points of resemblance, but can be differ- 
entiated whenever the form of the fecal mass and other palpable evi- 
dences of local constriction afford characteristic information. 

Peog]s:osis. — Intestinal atony does not particularly endanger life, 
but it is for many people a source of almost constant discomfort and 
inefficiency from early youth till the latest period of old age. Without 
the removal of its causes the disorder is incurable, and in too many 
cases these are irremediable. 

Treatment. — The first thing to be formed is the habit of regular 
evacuation of the bowels. At a certain hour, preferably soon after a full 
meal, when the peristaltic action of the alimentary canal is thoroughly 
excited, the patient should attempt the act of defecation. This should 
be done without haste — sitting long at stool if need be — until the intes- 
tinal molimen is triumphantly aroused. Among the leisurely classes 
half an hour a day may be profitably consumed in this way, and its 
tedium may be eradicated by reading some cheerful book during the 
period of expectation. Copious draughts of water should be taken at 
intervals during each day, but iced drinks are to be avoided on account 
of their unfavorable effect upon the gastro-intestinal mucosa and mus- 
culature. Slothful habits must be exchanged for outdoor activity — 
walking, riding, bicycling, mountaineering. Diet should be so regulated 
as to include an abundant supply of vegetables and fruits. The late 
Dr. Byford was accustomed to prescribe for his constipated patients a 
ripe apple, to be eaten, skin, seeds, and core, before breakfast every 
morning. Honey, syrup, cream, and butter also have a gently laxative 
effect. 

It is usually necessary to have recourse to the various laxatives that 
are useful in chronic intestinal catarrh. Chief among these may be 
mentioned the various preparations of cascara sagrada, pills containing 
aloin, strychnine, and belladonna, compound rhubarb pills, aloetic 
dinner pills, and occasionally a blue pill. In certain old and obstinate 
cases it is said that nothing but full doses of calomel will prove effectual. 
When complicated with the arthritic predisposition laxatives that con- 
tain sulphur — compound licorice powder, compound sulphur tablets, etc. 
— are to be preferred. A course of mineral waters usually gives at 
least temporary relief. Under all circumstances it is necessary to be 
supplied with numerous laxatives, so as to be able to furnish a fresh 
prescription when the old one has lost its effect. 



250 DISEASES OF THE INTESTINES. 

INTESTINAL HEMORRHAGE. 

Synonyms. — Enterorrhagia ; Entero-hsemorrhagia ; Darmblutung. 

Etiology.— ^Hemorrhage from the intestines may occur from so 
many causes operating under such widely different conditions that it 
is advisable to consider as a whole the significance of this multifarious 
symptom. Thus examined, its causes may be classified under three 
general categories connected with abnormal states of the intestinal con- 
tents, or with pathological changes in the intestinal structure, or with 
general and infective diseases that predispose to hemorrhage in all parts 
of the body. 

Slight bleeding from the intestinal mucosa frequently follows the 
evacuation of long-retained and hardened faeces. This usually occurs 
in the lower bowel, sometimes from a rupture of the mucous membrane 
during laborious defecation, sometimes from mechanical injuries during 
the passage of foreign bodies, fragments of bone, etc. that have been 
swallowed. In certain cases hemorrhage is the direct result of injury 
caused by a sort of impalement with various articles thrust violently 
through the anus into the rectum. Insane people thus injure them- 
selves, sometimes with bottles, inkstands, pieces of wood, or anything 
else that happens to excite their fancy. Bleeding may also occur after 
the ingestion of caustic and corrosive poisons, or even after excessive 
doses of ordinary purgative remedies. The presence in the intestine of 
certain parasites, notably Anchylostomum duodenale and Distomum 
haematobium, causes persistent and dangerous hemorrhage through 
laceration of the intestinal wall by their teeth. 

Among the local causes that implicate the intestinal structure trau- 
matic lesions have been already mentioned. Ulceration of the bowels 
is, however, the most common local cause of bleeding. Since ulceration 
is one of the most frequent events in diseases of the intestines, while 
hemorrhage is a comparatively rare occurrence, it is interesting to note 
the protective influence of the thrombi that form in the adjacent blood- 
vessels during the course of the ulcerative process. Inflammation of 
the mucosa is often attended with bleeding that, though usually incon- 
siderable, may, especially among elderly patients, assume formidable 
proportions. Somewhat similar in nature are the inflammation, ulcera- 
tion, and hemorrhage that sometimes occur in the small intestine as a 
consequence of extensive burns or scalds involving the cutaneous surface 
of the body. Intussusception of the bowel is usually accompanied by 
continuous oozing of blood from the strangulated vessels in the invagi- 
nated portion of the intestine. A quite analogous discharge takes place 
whenever the blood circulation in the portal system is obstructed either 
by reason of local disorder within the abdomen or by general causes 
operating upon the heart and lympho-cruoral circulatory apparatus. In 
this way hemorrhage from the bowels may result from cardiac disease 
or from pulmonary resistance to the passage of blood from the right 
ventricle to the left auricle. Amyloid disease of the bloodvessels has 
been known to originate the symptom ; and it is not an uncommon event 
to witness hemorrhage in diseases of the liver and portal vein that en- 
croach upon the capacity of the hepatic and portal vessels. In like 
manner embolic obstruction of the mesenteric arteries or the rupture 



INTESTINAL HEMOBBHAGE. 251 

into the intestine of an intra-abdominal aneurysm may cause a discharge 
of blood through the bowels. 

The various infective diseases are frequent causes of intestinal hem- 
orrhage, either by reason of the ulceration which they excite in the 
mucosa or througli the general dyscrasia which results from the action 
of their infections and toxins upon the tissues. Thus, syphilis, dysen- 
tery, and typhoid fever produce hemorrhage, usually as the result of 
ulceration. In many instances of early bleeding from the nose and 
intestines in typhoid fever, before intestinal ulceration has occurred, the 
incident must be ascribed to the general dyscrasia of the blood. This 
undoubtedly is the cause of the hemorrhages sometimes observed in 
desperate cases of cholera, and so frequently in yellow fever, plague, 
pyaemia, septicaemia, and malarial fever. It is doubtful whether Fre- 
richs' ascription of malarial hemorrhages to clogging of the liver with 
melanin is correct, though excessive deposits of this substance may 
result from the same causes that determine the hepatic obstruction. In 
scurvy, purpura, haemophilia, uraemia, and cholaemia hemorrhage should 
be regarded as a consequence of the various causes that have aifected the 
nutrition of the vascular apparatus as well as of the blood. 

Vicarious hemorrhage from the alimentary canal is sometimes wit- 
nessed when the menses are suppressed. In such cases blood is dis- 
charged from the stomach more frequently than from the bowels — the 
reverse of what takes place when from any cause the male sex exhibits 
the symptom. 

Pathological, Anatomy. — On examination of the intestinal 
mucosa after death ulcerated surfaces, with still open vessels from 
which blood has been recently discharged, can be often discovered. In 
other cases naught but the evidences of capillary oozing can be demon- 
strated. Sometimes, as in typhoid fever, both conditions coexist. It is 
probable that the hemorrhage in the majority of typhoid fever cases is 
from the capillaries rather than fuom larger vessels. 

The whole length of the bowel is sometimes filled with blood, even 
in cases where there has been no discharge of blood through the anus 
before death. In some cases the effused liquid has undergone coagula- 
tion ; sometimes it remains permanently fluid through the absence of 
the constituents of fibrin. Sometimes the coagula are condensed into 
hard and carbonaceous masses like coproliths. In other instances the 
disorganized blood exhibits a brownish flocculent appearance, like the 
grounds of beef tea ; sometimes it is tarry in color and consistence and 
exhales an offensive odor. In many instances the quantity of blood is 
small, and it is diluted with a considerable amount of serous exudation, 
to which it gives the appearance of water in which raw meat has been 
washed, and in which pus and mucus can be discovered. 

Any considerable loss of blood is followed by a pallid appearance 
of the abdominal organs. When hemorrhage is long continued or fre- 
quently repeated the internal viscera and the glandular structures in the 
gastro-intestinal wall undergo fatty degeneration as a consequence of 
the deficient amount of oxygen that is furnished to them by the impov- 
erished blood. 

Symptoms. — Intestinal hemorrhage sometimes remains concealed, 
so far as any external appearance of blood is concerned. The patient 



252 DISEASES OF THE INTESTINES. 

passes more or less rapidly into a condition of collapse, with all the 
symptoms that are characteristic of excessive bleeding, and may die 
without any discharge of blood from the anus. Sometimes, however, 
the accumnlatioif of blood in the intestine is so large that the abdomen 
is dull on percussion, and may be actually distended to a considerable 
degree. 

But in by far the majority of cases the fact of intestinal hemorrhage 
is proved by the evacuation of bloody stools. The color and consistence 
of these depend upon the place and the manner of their formation. 
As a general rule, the higher their origin the blacker their color. 
When formed in the upper part of the small intestine the discharges 
are black and tarry ; M'heu the bleeding occurs in the colon the principal 
portion of the stool may consist of fecal matter smeared with blood and 
slime. Sometimes the blood is retained long enough to become dried 
into hardened coprolithic masses that look like rounded fragments of 
coal. In dysenteric hemorrhages the blood is mixed with serous liquids, 
so as to resemble w^ater in which raw beef has been washed, or it may 
be associated with large quantities of mucus, or, in chronic cases, with 
pus and slime. Hemorrhage that is caused by the growth of intestinal 
polypi is usually of a bright red color, and is accompanied by a con- 
siderable discharge of intestinal mucus. 

Microscopical examination reveals blood-corpuscles in every stage 
of decomposition. Nothnagel and others, viewing the stools of typhoid 
fever patients, have discovered microscopical quantities of blood pres- 
ent even as long as thirty-six hours before the actual occurrence of 
visible hemorrhage. 

Intestinal hemorrhage is sometimes attended with violent tenesmus 
and retention of faeces. E. Ingals has reported a case of this character 
in which the administration of a large dose of castor oil was followed 
by the evacuation of a potful of hardened fseces, with immediate relief 
from all the previous untoward symptoms. When hemorrhage occurs 
from the upper portion of the duodenum, blood may regurgitate into 
the stomach and be evacuated by the act of vomiting. 

Palpation of the abdomen must be, in all cases of intestinal hemor- 
rhage, conducted with great caution, for in many instances even the 
sliglitest movement of the body is at once followed by an increased 
flow of blood. When the case becomes persistent for some time, 
oedema and transient albuminuria may appear, just as in any other form 
of acute antemia. 

Diagnosis. — In every case of reported hemorrhage from the bowels 
it is necessary first to ascertain the actual presence of blood in the stools. 
This is important, because the dark, slaty-colored masses that are some- 
times voided during the course of obstinate constipation may be mistaken 
by an inexperienced observer for altered blood. The same thing is true 
of the dark green, intensely bilious stools that are sometimes discharged 
when the liver overflows with bile. Nor may it be forgotten that the 
administration of iron or bismuth will color the fseces with the black 
sulphides of those metals, causing the stools to appear very much like 
the black and tarry discharges caused by hemorrhage from the upper 
portion of the small intestine. Various fruits and other vegetable 
coloring matters, such as raspberries, red currants, red wine, and hsema- 



INTESTINAL BEMOBEHAGE. 253 

toxylin, may impart a suspiciously bloody color to the intestinal contents. 
But careful mixture of the faeces with water, which, if blood be present, 
is speedily colored with haemoglobin, or in still more doubtful cases the 
use of the microscope and spectroscope, will soon decide the question as 
to the presence or absence of blood from the stools. 

Having determined the fact of a hemorrhagic discharge from the 
anus, it is necessary to ascertain the source of the blood, since it may 
have reached the intestines from the mouth, nose, pharynx, larynx, 
lungs, oesophagus, or stomach. The blood may have been swallowed by 
a malingerer or by a newborn infant during the act of parturition or by 
a nursling whose mother's nipples were in a bleeding condition. All 
these possibilities should be passed in review. 

As to the location of the hemorrhage, some difficulty may arise. It 
is almost if not quite impossible to distinguish between discharges of 
blood from the stomach and from the duodenum. Hemorrhages from 
the small intestine are usually darker than those from the lower bowel, 
and they are either of purer blood or are more thoroughly incorporated 
with the intestinal contents than when their origin is in the large intes- 
tine. Examination of the rectum sometimes discovers the source in 
wounded hemorrhoidal veins or rectal ulcers or polypi of the lower 
portion of the mucosa. In typhoid fever bleeding is usually from the 
small intestine, while in dysentery it is from the colon or rectum. In 
chronic colitis it appears upon the external surfaces of the fecal cylinder, 
instead of being homogeneously mixed with the stools. 

The cause of intestinal hemorrhage can be determined only by refer- 
ence to the past history and present condition of the patient. The 
incidence of sudden collapse in typhoid fever, in the absence of other 
causes, should always awaken the susjDicion of latent bleeding from the 
intestinal wall. 

Prognosis. — In all cases of intestinal hemorrhage the outcome de- 
pends upon the cause and the extent of the loss of blood. In car- 
cinoma of the bowels and in tuberculosis, or in extensive ulceration of 
the intestines, hemorrhage may rapidly lead to a fatal result. But in 
typhoid fever, when moderate bleeding occurs at an early stage of the 
disease, it often produces a salutary result, like what is often witnessed 
after simple epistaxis. If, however, the hemorrhage occurs after the 
formation of deep ulcers, or if it is copious and persistent, it is a most 
formidable symptom of danger. 

Treatment. — The diet should be a matter of prime consideration 
in cases of ulcerated bowel, for coarse food may by local irritation of a 
deep ulcer excite a hemorrhage. When bleeding has begun the patient 
should be placed in bed, with the foot of the bedstead sufficiently 
elevated to favor the flow of blood into the head and upper portion of 
the body. Only milk, ice, and cold drinks should be allowed. An ice- 
bag or a coil of cold water should be laid over the abdomen, as near as 
possible to the point of hemorrhage. The movements of the bowels 
should be restrained with sufficient doses of opium. Five drops of the 
liquoj ferri pernitratis or persulphatis may be given in half a tumbler 
of water every two hours. Gallic acid, five grains every four hours, is 
very efficient. Ergotol, or the aqueous extract of ergot, may be in- 
jected hypodermically in full doses every six hours. 



254 DISEASES OF THE INTESTINES. 

When the seat of hemorrhage is in the colon or rectum considerable 
benefit may be obtained from the use of astringent injections, such as 
tannic acid, one^rain to the ounce of ice water, or a quarter of a grain 
of nitrate of silver to the ounce of water. 

Hemorrhages that accompany malarial infection require large doses 
of quinine in addition to the ordinary treatment. 

If collapse be imminent, alcohol may be given in moderate doses if 
there be evidence of arterial constriction in any portion of the body or 
extremities. The heart should be aided with camphor, musk, and 
capsicum : 

I^. Moschi, 

Pulveris camphorse, 
Pulveris capsici, da. gr. j ; 

Fiat pilula No. j. 
Sig. Give one such pill every two to four hours. 

In desperate cases recourse should be had to the hypodermic injec- 
tion of one grain of camphor dissolved in ten parts of olive oil. Trans- 
fusion of blood under such circumstances does not give a favorable 
result, for with a renewed supply of blood a renewal of bleeding occurs. 



INTESTINAL CANCER. 



Synonyms. — Carcinoma of the bowels ; Carcinoma intestinale ; 
Darmkrebs. 

Cancer of the intestine occurs usually as a primary disease of the 
affected part. Its favorite seat is at the junction of the rectum with 
the sigmoid flexure of the colon. Next in order of preference ranks 
the sigmoid flexure itself; then follows the head of the colon, including 
the ileo-csecal valve and the point of union between the ceecum and the 
ileum. Beyond this point the small intestine usually escapes until the 
gastro-duodenal portion is reached, where the parts adjacent to the 
orifice of the common bile duct and the entrance of the pylorus are 
comparatively often involved. Various mechanical explanations of this 
distribution have been offered, but none of them are satisfactory. 
According to Leube, 80 per cent, of intestinal cancers are found in the 
portion below the sigmoid flexure, while only 5 per cent, invade the 
small intestine. In the rectum colloid cancer is most common, though 
pigment cancers are sometimes found in that region. As in the stomach, 
so throughout the alimentary canal, carcinomatous growths assume the 
characteristics of scirrhous, encephaloid, and colloid cancer, so that the 
general appearance of the neoplasm corresponds to its histological 
structure, precisely as in similar growths within the gastric wall. In 
the intestine, however, there is a marked tendency to concentric inva- 
sion of the entire circumference of the bowel, so that the occurrence 
of stricture and occlusion of the canal are common events. Less fre- 
quently does the neoplasm develop as an isolated tumor projecting into 
the lumen of the gut. Occasionally, the cancerous invasion simultane- 



INTESTINAL CANCER. 255 

ously occupies distant segments of the alimentary canal, instead of 
being concentrated upon a single division. 

Intestinal carcinoma is usually composed of cylinder epithelial ele- 
ments, except in the lower part of the rectum, where the pavement 
epithelial cells predominate. It would therefore appear that the de- 
velopment of intestinal cancer originates, as in the stomach, from the 
glandular structures of the mucosa. The submucosa and the muscular 
coat may be subsequently invaded, and even the peritoneal investment 
may be finally involved. 

When constricted by cancerous infiltration the portion of the intes- 
tine that lies above the stricture becomes dilated and filled with more 
or less stagnant faeces. The mucous membrane exhibits evidence of 
chronic inflammation, erosion, and ulceration ; and sometimes actual 
rupture of the bowel may occur. Below the stricture the intestine 
collapses and falls into a condition of atrophy. When the neoplasm is 
of an encephaloid character the stricture may be occasionally relieved 
by sloughing and evacuation of the obstructive portion of the growth. 
Such processes may be followed by an imperfect cicatrization ; but, like 
all cicatricial tissue, these scars exhibit a tendency to contraction, by 
which stenosis may be again established. In many instances, however, 
there is no time for healing ; the breaking down of the diseased mass 
is followed by alarming hemorrhage or by actual perforation of the 
intestinal wall, opening a communication between the alimentary canal 
and the cavity of the peritoneum or of the uterus, vagina, bladder, 
stomach, or even through the abdominal wall into the external world. 
Fecal abscesses may be thus originated behind the peritoneum. The 
lymph glands and still more remote organs, like the liver and the pelvic 
viscera, may be invaded by a process of secondary cancerous infiltration. 

Etiology. — Intestinal cancer occurs more frequently among men 
than among women, and it usually appears after the fortieth year of 
life. A few cases, however, have been reported among children even 
as early as the first few days after birth. An occasional connection 
between the scars of ulceration and subsequent cancerous growth has 
been remarked. But as to the real course of malignant new growths 
in the intestinal canal we are still quite ignorant. 

Symptoms. — Intestinal cancer may run its whole course without any 
■decisive or conspicuous symptoms. Not infrequently there may be 
experience of abdominal pain, irregular action of the bowels, alternate 
constipation and diarrhcea, progressive emaciation, increasing exhaus- 
tion, and, finally, death without any clearly apparent cause — a train of 
symptoms that only find their explanation in the post-mortem discovery 
'of malignant disease of the bowels. Sometimes the first notable indica- 
tion of disease consists in the sudden occurrence of intestinal occlusion 
through the lodgement of undigested masses of food above an annular 
•cancer. Such an event should be suspected when in an elderly subject 
sudden obstruction of the bowels is developed without any evident 
reason. In like manner, the manifestations of chronic peritonitis may 
be sometimes traced to a latent intestinal carcinoma. When the lower 
portion of the colon and the rectum are invaded an atrocious pain is 
•experienced beneath the sacrum, radiating into the sexual organs and along 
the nerves that emerge from the pelvis, so that by an incautious observer 



256 DISEASES OF THE INTESTINES 

sciatica might be suspected. Only when an intra-abdominal tumor con- 
nected with the bowels can be demonstrated is it easy to recognize the 
actual existence of an intestinal neoplasm. But when a tumor is mani- 
fest, and when 'the fseces exhibit characteristic changes, the recognition 
of the disease is not difficult. Investigation of the abdominal contents 
may be effected by external palpation, by rectal examination, in females 
by vaginal exploration, and by a combination of all these methods. 
When it is possible by palpation through the abdominal walls to recog- 
nize the presence of a tumor, an irregularly oval or rounded mass will 
be discovered, usually below the level of the umbilicus wdien connected 
with the movable portions of the intestine, because under such condi- 
tions it is more easily borne downward by its own w^eight ; but if 
located in the ileo-csecal region or if held fast by inflammatory adhe- 
sions, it will remain fixed in the same portion. Such tumors are 
usually quite sensitive to pressure, and cannot be moulded by the 
fingers like the fecal scybala which sometimes linger in the intestinal 
canal. When intestinal stenosis has been established the dimensions 
of the tumor frequently undergo very rapid and considerable variation, 
often in a few hours changing form and size to an astonishing degree, 
sometimes even disappearing completely for several successive days. 
These alterations are due to the filling and emptying of the intestinal 
pouch that forms above the obstructive tumor. The percussion note 
that is procured by percussion over such masses is a dull, tympanitic, 
muffled resonance, such as might be expected from a putty-like sub- 
stance lying amidst coils of more or less air-filled intestine. 

When the rectum is the seat of carcinoma exploration should be 
performed with the finger through the anus, because instrumental exam- 
ination with specula is exceedingly difficult and painful. It is compara- 
tively easy with the finger to detect stenosis or ulceration of the gut ; and the 
uneven, slimy, and bloody surfaces of such a tumor can be readily investi- 
gated. In the same way fragments of broken-down and decomposing 
tissue can be obtained for inspection, olfaction, and microscopical examin- 
ation. Sometimes when straining at stool a prolapse of the infiltrated 
rectal wall takes place, so that a portion of the cancerous mass becomes 
actually visible outside of the anus. When the neoplasm is situated 
higher up, beyond the reach of the finger, it may be frequently explored 
with the aid of a rectal sound, and in some cases valuable information 
may be obtained by an attempt to introduce water into the bowel with 
a fountain syringe, noting the degree and distance of the obstruction 
thus encountered. 

Obstinate constipation is the rule in the majority of cases. When 
the bowel is merely strictured the faeces may be flattened or be voided 
in small lumpy masses, like the dung of sheep. But in certain cases 
there is complete occlusion of the bowels. This may persist for many 
days, sometimes for weeks, and may occasionally yield suddenly, either 
through the giving way of the degenerated obstructive mass or through 
ulceration and perforation occurring between two adjacent loops of 
intestine that have become adherent through inflammation above and 
below the tumor. Severe hemorrhage sometimes follows the breaking 
down of the softened substance of the new growth, especially when it 
is of the encephaloid variety. 



INTESTINAL CANCER. 257 

Special symptoms are often due to the particular location of the 
carcinoma. Thus, when the duodenum is invaded persistent jaundice 
may accompany the progressive emaciation and cachexia by reason of 
compression of the common bile duct. If the pyloric region be en- 
croached upon, the vomiting and dilatation of the stomach that depend 
upon pyloric stenosis may occur. 

When the lower extremity of the small intestine is the seat of can- 
cerous stenosis there may be only rational signs to guide the diagnosis 
until the phenomena of fecal vomiting and intestinal occlusion appear. 

When located in the rectum a cancerous growth may exist for a 
considerable time without serious interference with the general health. 
But the evacuation of the bowels is almost always attended with 
such pain that the sufferer delays as long as possible their movement. 
Frequently there is a troublesome diarrhoea, with distressing tenesmus 
and prolapse even of the mucous lining of the rectum. A foul, ichorous, 
and irritating discharge, mixed with pus, blood, and minute fragments 
of broken-down tissue, is not uncommon. The hemorrhoidal veins are 
frequently enlarged, and the resulting tumefaction must not be mistaken 
for cancerous growth. 

The DUEATiox of intestinal cancer is about four years. Its normal 
course is free from fever, but sometimes there may occur a paroxysm or 
period of fever that is due to a local process of inflammation in any or 
all of the tissues adjacent to the neoplasm ; or it may be the result of 
general auto-infection from the diseased territory ; or it may originate 
in the actual passage of broken-down cancerous and septic matter into 
the general circulation of the body. 

Death frequently occurs through simple starvation and exhaustion 
of the tissues. The limbs become oedematous ; thrombi may obstruct 
the veins and send emboli into the capillaries of the lungs with a fatal 
result. In certain cases death is preceded by coma from thrombosis in 
the cerebral sinuses and meningeal veins ; in other instances it is the 
result of a species of auto-intoxication, with an abundance of acetone 
and diacetic acid in the urine. Indican is usually present in the urine, 
as in other forms of marasmus accompanied by gastro-intestinal auto- 
intoxication. Sometimes death occurs rather as the result of secondary 
cancerous invasion of the liver or other important organs. Intestinal 
occlusion, and invagination of the bowel as a consequence, may directly 
lead to death. Perforation of the bowel through ulceration or rupture, 
and peritonitis that may be either local or generally diffused, are not 
uncommon causes of death. Such perforations may lead to the forma- 
tion of fecal abscesses and pyaemia, or they may open a communication 
between the intestine and any one of the hollow organs in the abdom- 
inal or pelvic cavities, thus hastening the fatal termination. 

DiAGXOSis AND PROGNOSIS. — The diagnosis of intestinal cancer is 
often attended with great difficulty. Annular invasion of the intestinal 
walls may take place without the production of any appreciable tumor. 
When by palpation of the abdomen the presence of a tumor has been 
recognized, it is often impossible to determine its exact connections, 
whether it be a neoplasm involving the pylorus, the liver, the pancreas, 
the kidneys, the mesentery, or the abdominal lymph glands. Some- 
times an encapsulated peritonitis may simulate a carcinomatous mass, 

Vol. III.— 17 



258 • DISEASES OF THE INTESTINES. 

aud an enormous gall-stone that has ulcerated its way into the intestine 
may be in like manner mistaken for a small occluding tumor of cancer- 
ous nature. The obstinate constipation and final cessation of intestinal 
defecation thai are often experienced are not infallible indications of 
cancerous growth, for the bowels may be occasionally compressed and 
closed by the pressure of tumors that have been formed entirely outside 
of the alimentary canal. Enteroptosis, by reason of the increasing 
weight of a growing tumor, may also serve to embarrass the localizing 
diagnosis of the disease, since the abdominal viscera are often dragged 
out of place by the enlargement of such neoplasms. It is only when 
the cancerous mass is situated in the rectum or about the sigmoid flexure 
of the colon that its recognitioh and situation are rendered easy. The 
occurrence of constipation, tenesmus, and painful discharges of blood, 
mucus, and pus should lead the physician to make a thorough examina- 
tion of the rectum and lower portion of the colon. The prognosis is 
uniformly bad. 

Treatment. — Active treatment of intestinal cancer falls within the 
territory of surgery rather than of medicine. Occlusion of the bowels 
may be relieved by operative measures for the establishment of an arti- 
ficial anus. This method is most successful when the large intestine is 
the seat of obstruction, because an opening into the small intestine inter- 
feres to such an extent with digestion and absorption of aliment that 
death from starvation usually follows the operation. Cancers of the 
rectum have been resected, scraped, cauterized, and otherwise subjected 
to the most elaborate surgical treatment, but with only one result — 
miserable death, even after apparent temporary relief of certain minor 
symptoms. 

When the symptoms of intestinal stenosis begin to manifest them- 
selves the diet should be so regulated as to exclude starchy substances 
that increase the faeces, and should be made to consist chiefly of milk, 
eggs, soups, broths, anct animal substances that contain comparatively 
little residual matter. Gentle laxatives should be directed against 
constipation, and the bowels should be often flushed with copious clys- 
ters of warm salt water (a drachm of table-salt to the pint). If the 
rectum and colon are the seat of the disease, appropriate disinfectants, 
such as potassium permanganate, in a 1 per cent, solution, or half an 
ounce of liq. aluminii acetat. to a pint, should be added to the water. 
The hypodermic exhibition of morphine and atropine is often demanded 
by reason of severe abdominal pain. Tenesmus and rectal pain may be 
counteracted by the introduction, at bedtime, of a rectal suppository 
containing one third of a grain of morphine sulphate with one eightieth 
of a grain of atropine, incorporated in a sufficient quantity of cocoa 
butter. 



SARCOMA OF THE INTESTINES; OTHER TUMORS. 

Sarcoma of the intestines is a rare disease, and during the life of the 
patient it cannot be accurately differentiated from ordinary carcinoma- 
tous neoplasms. The tumors spring from the submucosa, and may be 



INTUSSUSCEPTION OF THE BOWELS. 259 

of either priinary or secondary origin. They usually increase more 
rapidly than cancerous growths, and speedily involve other organs. 
Rarely do they cause intestinal stenosis, but more frequently do they 
lead to paralytic dilatation of the bowel and to consequent stagnation 
of faeces. 

Lipoma, ang-ioma, lymphang-ioraa, myoma, and cystoma are 
occasionally encountered upon the dissecting table, but they need be 
mentioned only as pathological curiosities. 



INTESTINAL POLYPI. 

Intestinal polypi sometimes are of a fibromatous character, spring- 
ing from the submucous tissues. Sometimes, however, they are of mucous 
origin, and are connected with an overgrowth of the mucous glandular 
substance. Their favorite seat is in the rectum, where they may exist 
as solitary or multiple tumors. Most frequently they are met with 
among children who have suifered with worms or with gastro-intestinal 
catarrh. They are often accompanied by a diarrhoea with bloody and 
slimy stools — in fact, the occurrence of such a diarrhoea in a child should 
lead to a careful examination of the rectum. Sometimes the tumor pro- 
lapses and makes its appearance through the anus when the patient is 
at stool. Sometimes it becomes detached from its slender pedicle and 
is discharged with the fseces. In certain cases the fecal cylinder ex- 
hibits upon its side a furrow ploughed by its passage over the mass. 
When intestinal polypi reach a considerable size they may by their 
weight cause intestinal invagination with prolapse of a portion of the 
bowel. Occasionally the existence of a polypous mass gives rise to the 
symptoms of intestinal occlusion, with subsequent relief when the 
tumor breaks loose and is discharged. 

Tuberculosis of the Intestine is described in Vol. I. pp. 813-816. 
Syphilis of the Intestine is described in Vol. I. -pj). 872, 880, 881. 
Dysentery is described in Vol. I. pp. 339-389. 
Diphtheritic Dysentery is described in Vol. I. pp. 349-351. 



INTUSSUSCEPTION OF THE BOWELS. 

Synonyms. — Intussusceptio ; Invaginatio ; Darmeinschiebung. 

Definition. — Intussusception consists in the entrance of one por- 
tion of the intestine within another by an infolding of the bowel, so that 
the external fold ensheaths the inner. This condition is not infre- 
quently discovered upon the post-mortem table as a result of the in- 
creased peristalsis that is caused by the arrest of circulation that accom- 
panies death, bat in such cases there are no pathological conditions to 
account for the incident, nor are there any signs of adhesion or strangu- 



260 DISEASES OF THE INTESTINES. 

lation of the walls of the gut. It is usually the small intestine that is 
the seat of these irregular manifestations of peristaltic action. The 
direction of the movement may be either upward or downward. 

But when ttue intussusception occurs during life the intrusory move- 
ment is almost always from above downward — the upper segment is 
received within the lower. The invaginated portion is therefore sur- 
rounded by a double sheath consisting of the infolded portion of the 
lower segment and of the external part of the still unfolded intestine 
that surrounds the entire mass and forms its sheath. Besides the intus- 
suscepted portion the sheath also contains the mesenteric leaf that is 
attached to the mesenteric seam of the intestine. By the traction of 
this membrane the lower orifice of the invaginated segment of the bowel 
is drawn upward, so that it assumes the form of a longitudinal slit 
rather than that of a circular opening. The line where the upper 
opening of the sheath grips the intussuscept is called the neck of the 
invagination. Here inflammation is rapidly established, and by the 
swelling thus occasioned strangulation of the ensheathed portion of the 
bowel is considerably aggravated. The process of invagination may be 
initiated by the down-dragging weight of a tumor that is attached to 
the inner surface of the intestine ; or there may be a paralytic dilatation 
of the intestinal tube that permits the intrusion of the adjoining segment 
in which peristaltic contraction is still active. Under either circum- 
stance the process, once started, is maintained and aggravated by a 
spasmodic condition of the intestinal muscles in the neck of the sheath, 
and by the weight of the tumor, if there be one, or of the column of 
faeces that forms by accumulation above the constriction. The upper 
segment of the intestine is thus urged on deeper and deeper into the 
sheath, which is proportionately lengthened at the expense of the lower 
segment. In this way the colon may swallow its upper portion, together 
with a great length of the ileum, until the colonic coil is effaced, leaving 
only a straight tube that spans the abdomen from one iliac fossa to the 
other. In this way the intussuscept may reach the anus and project 
for several inches externally to that opening. Sometimes, by a process 
of adhesive inflammation at the neck of the sheath, so great a degree 
of strangulation may be effected that the invaginated portion sloughs 
off, and is discharged through the rectum in the course of a sort of 
natural healing process. But under the most favorable conditions there 
must be danger of hemorrhage during the separation of the gangrenous 
parts, or of general peritonitis or septic poisoning. Should cicatrization 
be successfully accomplished, there would still be danger of subsequent 
contraction and stenosis at the site of the scar. In such case copro- 
stasis, great distention of the intestines with gas, and upward pressure 
of the diaphragm against the heart and lungs would occur. 

It occasionally happens that only partial invagination of one side of 
the intestinal wall takes place. This incomplete intussusception usually 
occurs when the weight of a tumor dragging the inner surface of the 
intestine causes a portion of the parietes to sink downward into the 
lumen of the bowel. In such cases there is always the probability that 
a partial intussusception may be finally converted into a complete 
descent of the gut. 

Intussusception may be eifected in any portion of the intestinal 



INTUSSUSCEPTION OF THE BOWELS. 261 

canal, but it "is most common at the ileo-csecal junction. Here the 
ileum descends into the colon, sometimes drawing after itself the vermi- 
form appendix and the upper portion of the large intestine. According 
to the statistics collected by Brinton and Leichtenstern, invagination 
occurs with the following frequency : 

Brinton. Lichtenstern. 

Ileo-csecal invagination 56 per cent. 44 per cent. 

Ileo-colonic " 8 " 

Iliac " 28 " 30 " 

Jejunal " 4 " 

Colonic " J^ " 18 " 

100 per cent. 100 per cent. 

Etiology. — Allusion has been already made to certain causes of 
intussusception, such as segmental atony of certain portions of the intes- 
tine and the downward and inward traction of polypoid tumors upon 
the inner surface of the bowel. Occasionally it has been witnessed in 
connection with cancerous growths involving the wall of the alimentary 
canal. It is not uncommonly connected with chronic catarrhal condi- 
tions of the mucosa ; hence it may occur after obstinate constipation or 
as a consequence of chronic diarrhoea after dysentery or typhoid fever. 
It has been experienced after blows or falls or other violence to the 
abdominal viscera. It is especially among children that it is encoun- 
tered ; perhaps more frequently among boys than among girls. Fully 
half of the cases are experienced during the first year of life, and of 
this half about two thirds occur between the fourth and sixth months 
of infancy — an age when intestinal disorders are frequent, and when 
irregular and spasmodic contractions of the muscular coats of the ali- 
mentary canal are easily provoked. 

Symptoms. — Intussusception is usually indicated by the sudden 
incidence of paroxysmal pain within the abdomen. So severe is this 
that among young children, who form so large a proportion of its 
victims, the attack is ushered in with loud crying, or even with con- 
vulsions, as in the worst forms of colic. So close is the similarity that 
the seat of the pain, which is usually around the navel, affords no guide 
to the exact location of the disease. The stools often become thin, 
slimy, and bloody. The blood, which is sometimes almost wholly free 
from admixture with other substances, exudes from the mucous surface 
of the invaginated and strangulated portion of the intestine. When the 
lower portion of the colon and the rectum are involved, either by actual 
intussusception or by pressure from above, frequent tenesmus is expe- 
rienced. When there is complete obstruction of the bowel or when its 
upper segments are involved, there may be continued vomiting. At 
first the abdomen may be somewhat flaccid and not particularly sensi- 
tive to pressure, but usually it soon becomes greatly distended and in- 
tolerant of manipulation. Since the ileo-csecal portion of the intestine 
is the most common seat of invagination, it is not an uncommon event 
to discover a smooth, elastic, and sausage-like tumor in the right iliac 
fossa, extending toward or beyond the umbilicus. Frequently attention 
is arrested by a constantly patulous state of the anus, from which open- 
ing trickles a slender stream of blood and slime. The finger may then 
be readily passed into the rectum, where sometimes the descending 



262 DISEASES OF THE INTESTINES. 

mass of strangulated intestine can be easily reached, and the abolition 
of all wrinkling and folding of tlie rectal mucosa under the influence of 
downward pressure can be accurately noted. 

If the invaginated portion of the intestine should descend through 
the anus, it may be recognized as a red, slimy, and cylindrical mass, 
covered with bloody mucus that oozes from the swollen surface. Some- 
times the tumor recedes and disappears by spontaneous reduction, after 
which the gaseous and fecal contents of the upper intestine resume their 
normal course, and rapid convalescence takes place. Relapses, however, 
are not uncommon. But in many instances, instead of improvement, 
the severity of the symptoms increases ; the bowels become completely 
occluded, giving rise to the phenomena of intestinal obstruction ; the 
belly is swelled, tense, and painful, with all the usual manifestations of 
peritonitis ; and the patient sinks into a state of collapse, followed by 
death. In young children this event is often preceded by muscular 
spasms and convulsions dependent upon cerebral aujemia and progres- 
sive exhaustion. 

Occasionally the strangulated segment of the intestine becomes gan- 
grenous, and is sloughed off at the neck of the tumor, where an adhesive 
inflammation has united the remaining segments of the sheath and of 
the upper intestine. This process of spontaneous cure takes place 
usually between the middle of the second week and the end of the 
third in the course of the disease. Sometimes the dead mass comes 
away piecemeal, but in other cases the whole is thrown off at once. 
Cruveilhier reports a case in which not less than ten feet of the bowel 
were thus discharged. Unfortunately, recovery does not always follow 
the relief that is thus obtained. Fatal hemorrhage, perforation of the 
intestine, peritonitis, septicaemia, thrombosis of the mesenteric veins, 
hepatic and pulmonary abscesses may develop and destroy life ; or, if 
all these dangers should be evaded, the contraction of the scar at the 
line of union may yet produce stenosis of the bowel with all its lethal 
consequences. 

The duration and the severity of the symptoms of intussusception 
depend upon the extent of the invagination and the completeness of 
intestinal occlusion. In the worst cases death, preceded by shock, 
may occur within a few hours. Severe cases may continue for a week, 
and those of moderate intensity may last for a month before reaching a 
fatal termination or recovery. Incomplete cases, in which the bowel 
still permits some passage of fseces, have been known to endure for 
many months or even for a whole year. 

Diagnosis. — The difficulties of diagnosis are not usually very great. 
The disease may be recognized by a consideration of the symptoms, 
especially when in the abdomen of an infant a firm longitudinal tumor 
makes its appearance, or when from the gaping anus a bloody slime 
continually trickles. But it must not be forgotten that a similar con- 
dition of the rectum and anus may be induced by the descent of a large 
polypus. And in cases where peritonitis has originated at an early 
period the existence of an invaginated mass may be concealed by the 
general swelling and painful condition of the abdominal contents. Very 
similar conditions are also present in cases of twisting and knotting of 
the intestines. 



CONSTRICTION AND OCCLUSION OF THE INTESTINES. 263 

Peognosss. — The death-rate in cases of intussusception is very high 
— about 70 per cent. The chances of recovery are greater when there 
is not complete occlusion of the intestine and when peritonitis has not 
occurred. When sloughing and discharge of the intussuscept takes 
place the mortality is less, though still very large, being about 41 
per cent. 

Treatment. — The first thing to be attempted in the treatment of 
intussusception is to arrest the peristaltic movement of the intestine. 
This should be effected by the frequent administration of opiates in 
small doses until the pupils are contracted. To a grown person may 
be given half a grain of opium every hour till the effect is produced. 
To children should be administered the deodorized tincture in doses of 
one to five drops according to the age of the patient. The colon should 
be slowly distended several times a day with warm water from a foun- 
tain syringe. But after the case has progressed for several days this 
operation must be performed with great caution for fear of rupturing 
the weakened bowel. For the same reason inflation of the bowel with 
air from a bellows, or by the liberation of carbonic acid gas above the sig- 
moid flexure, is not a very commendable operation. All these methods 
of procedure are more likely to be successful if conducted while the 
patient is under the influence of ether or chloroform. The hips should 
be greatly elevated — in fact, young children can be with advantage mo- 
mentarily suspended by the legs, when sometimes the bowel replaces 
itself with an audible gurgle, followed by the escape of gas and fseces 
from the anus. AVhen the invagination implicates the lower portion 
of the colon, so that it can be reached through the rectum, an attempt 
may be made to replace the mass by pressure upward with a well-oiled 
rectal bougie. The patient, if old enough to be manageable, should be 
placed in the knee-elbow position — arms folded under the chest and 
the pelvis reared up as high as possible — when the admission of air 
into the rectum will greatly aid the force of gravity in producing the 
return of the intussuscept to its normal place. It must be admitted, 
however, that relapses are not infrequent. 

When other methods have failed the question of laparotomy arises 
for consideration. This should be attempted before the incidence of 
peritonitis. Herz reports 30 per cent, of recoveries among 20 cases 
subjected to operation. Treves reports a mortality of 72 per cent, in 
133 cases of surgical interference. He adds the statement that when 
reduction was easily performed the mortality was 30 per cent., but when 
difficult it was 91 per cent. 



CONSTRICTION AND OCCLUSION OF THE INTESTINES. 

Synonyms. — Enterostenosis et ileus ; Darmvereugerung und Darm- 
verschluss. 

Etiology. — The various processes by which intestinal stenosis and 
occlusion are affected have much that is common in their causes and 
symptoms. The same causes that produce constriction of the bowel 



264 DISEASES OF THE INTESTINES. 

may finally lead to its complete closure. These conditions usually orig- 
inate in the intestinal wall, in the intestinal contents, or in neighboring 
organs of the body. Thus the growth of tumors of a cancerous or 
polypoid character in or upon the wall of the intestine, or the contrac- 
tion and induration of cicatricial tissue in the same locality, may obstruct 
and finally close the passage. In the same way the rectum may be nar- 
rowed by the growth of hemorrhoids or syphilitic indurations. Some- 
times occlusion is effected by twisting of the gut, or by intussusception, 
or by the occurrence of internal hernia, as when an intestinal loop slips 
through an abnormal opening in the mesentery, or the suspensory liga- 
ment of the liver, or a broad ligament of the uterus. Strangulation in 
the foramen of Winslow has been known to occur, as well as in all the 
other forms of internal hernia that may result from congenital or ac- 
quired defects of structure. In like manner inflammation of the peri- 
toneum may cause stenosis or occlusion, either directly by paralysis of 
the intestinal wall or by plastic effusion that compresses the bowel and 
constricts its lumen. In this way may be produced bridles of organized 
lymph bands of adhesion, by which the intestine may be gripped long 
after the subsidence of the original disturbance. 

Obstruction of the intestine is sometimes caused by local paralysis of 
its muscular layer at some point where it has been exposed to injury by 
a blow upon the external surface of the abdomen, or by peritoneal in- 
flammation after the reduction of a hernia, or by a laparotomy. Ob- 
stinate constipation amounting to occlusion is sometimes experienced as 
a consequence of more general paralysis due to cerebral and spinal 
diseases. 

The condition of the contents of the bowel is sometimes such as to 
close the lumen of the tube. In one of my own cases an old coprostasis 
sealed the intestines until, after much urging with large injections of 
hot water, forty-three coproliths passed the anus. Huge gall stones 
occasionally ulcerate their way into the small intestine, where they pro- 
duce stenosis or, in rare instances, complete occlusion. Among children 
and childish adults the bowels are sometimes filled up with the large 
seeds of grapes, pomegranates, cherries, and their like. Eichhorst has 
recorded a case where a man with an occluded rectum, confessing to 
having eaten a " few cherries," was relieved only after one thousand 
and ten cherry-pits had been scooped out of his rectum. In like man- 
ner, almost everything of a solid character that can be swallowed has 
been known to obstruct the alimentary canal. Sometimes a considerable 
number of round-worms may lodge in the intestine. I once saw a ball 
of these lumbricoid parasites as large as a lemon that had been voided 
by a child of five years after several days of suffering from intestinal 
occlusion. 

The intestine is sometimes compressed and may be completely oc- 
cluded by the growth of all sorts of tumors in the adjacent organs. 
Inflammatory exudations or hemorrhagic effusions within the cavities of 
the abdomen or pelvis may exert a similar pressure. Cancerous growths 
in the mesentery or in the liver, stomach, pancreas, kidneys, uterus, 
ovaries, and bladder may produce the same result. Tubal pregnancy 
has also been known to effect the same consequences. In at least one 
instance a floating kidney has been known to descend upon the sigmoid 



CONSTRICTION AND OCCLUSION OF THE INTESTINES. 265 

flexure of the colon, developing continued symptoms of obstruction that, 
until the death of the patient, were ascribed to malignant disease. 

Intestinal obstruction is less frequent among females than among 
males, and with them it is usually due to pelvic and peritoneal inflam- 
mations, connected with pregnancy and parturition. Among males it is 
the laboring class that furnishes the largest contingent of sufferers. 
Children are, more than adults, liable to obstruction by invagination, 
while adults more frequently experience the forms due to coprostasis and 
the arrest of gall stones. Among the Russians, who are said to be gifted 
with an extraordinary length of intestine, the bowels are frequently 
stopped by twisting or knotting of the gut. 

Statistics vary considerably regarding the incidence of this disease. 
Leichtenstern estimates that in Germany there is 1 death from occlu- 
sion out of every 300 to 500 from all other causes. Fagge reports 1.4 
per cent, of the deaths in Guy's Hospital during fifteen consecutive 
years as occasioned by intestinal obstruction. But Eichhorst, at the 
Zurich clinic, among 12,073 medical patients could discover only 4 who 
Avere suffering in this way. 

Pathological Anatomy. — Wherever the bowel is constricted or 
occluded the portion above the point of constriction becomes dilated 
with faeces and gas, so that the intestinal coils are greatly exaggerated 
and uncommonly prominent. If the seat of obstruction is in the duo- 
denum, the stomach participates in the dilatation. Below the site of 
constriction the intestine remains empty and collapsed. When stoppage 
of the bowel occurs suddenly, the intestinal wall soon undergoes atrophy, 
growing thin and pale ; but if obstruction be slowly developed, as when 
caused by the contraction of cicatricial tissue or by the growth of a 
parietal tumor, the muscular coat of the intestine becomes hypertrophied 
through compensatory hyperplasia of the muscular tissue. Experiments 
upon animals show that such hyperplasia does not take place when 
obstruction is rapidly developed. 

Sometimes the mucosa above the constriction exhibits evidences of 
ulceration. This has been usually attributed to mechanical injury by 
retained faeces, etc., but it is more probably due to changes in the inner- 
vation of the injured intestinal wall, rendering it more susceptible to the 
action of chemical and microbic agents within the cavity of the bowel. 
The serous investment of the intestine frequently exhibits extravasations 
of blood that are due to the same causes. Peritonitis, either from per- 
foration of the intestinal wall or generalized over the entire peritoneum, 
is not an uncommon incident. 

The internal organs of the body frequently appear to be very dry in 
consequence of the loss of water through excessive vomiting. Some- 
times catarrhal pneumonia is excited by the passage of vomited matters 
into the trachea and bronchi. 

It is not usual to find more than one point of occlusion in the same 
intestine. Multiple constrictions are very rare. Knotting together of 
separate intestinal coils usually occurs at the sigmoid flexure, which 
becomes involved with the coils of the ileum. Twisting of the intestine 
upon its own axis usually occurs in the ascending colon. Twisting 
about the mesenteric axis is generally observed at the sigmoid flexure, 
where the mesenteric folds permit unusual freedom of motion. Accord- 



266 DISEASES OF THE INTESTINES. 

ing to Leichtenstern, 59 per cent, of the cases of intestinal torsion are 
found in the immediate vicinity of the sigmoid flexure. 

Symptoms. — The symptoms of stenosis of the intestinal canal are 
chiefly connectecl with difficulty of evacuating the bowels, while the 
symptoms of complete occlusion are marked by total arrest of defeca- 
tion. In many cases there is a persistent torpor of the bowels, which 
may be mistaken for simple constipation so long as it can be relieved 
by the use of coarse food, fruits, and vegetables. Sometimes, however, 
the ingestion of such articles, containing seeds, husks, and undigestible 
fibres, may suddenly transform a case of mere stenosis into complete 
stoppage of the bowel. 

In many instances, especially when the rectum is narrowed by syph- 
ilitic or cancerous disease of its wall, there is set up a severe catarrhal 
inflammation of the mucosa above the point of constriction, and chronic 
diarrhoea exists as a consequence. When no such looseness of the 
bowels is excited, the faeces are often modified in their form, so as to 
be voided in little pellets like sheep's dung, or they are flattened out 
like pieces of tape. Sometimes, when the contracting induration is 
confined to one side of the bowel, the fecal cylinder is merely grooved 
on one side where it is crowded against the obstruction. In estimating 
the importance of these appearances it must not be forgotten that neur- 
asthenic victims of chronic constipation sometimes void ribbon-like 
fseces as a result of nothing worse than intestinal torpor — a condition 
in which spasmodic stricture may easily occur. When the colon or the 
rectum is the seat of constriction, evacuation of the bowels is commonly 
attended with great pain. Hemorrhoids are of frequent occurrence by 
reason of pressure upon the large rectal veins. 

Inspection of the abdominal surface during the course of the disease 
often discovers great distention of the belly through retention of fseces 
and gas. If the patient be somewhat destitute of subcutaneous fat, the 
coils of the distended bowel may be noted immediately beneath the wall 
of the abdomen. Often the peristaltic movements of these coils can be 
readily perceived as the muscular coats contract in the effort to urge 
the intestinal contents through the constricted portion of the canal. 
Audible sounds, caused by the displacement of the liquid and gaseous 
constituents of the fseces, can often be heard under such circumstances, 
and the movement of the intestinal contents can be plainly distinguished 
when the palm of the hand is laid upon the abdominal surface. By 
careful observation in this way it is sometimes possible to locate very 
exactly the site of the constriction. Exploration through the rectum 
and vagina should never be omitted. When the finger cannot reach 
high enough, it may be aided by the use of a rectal sound. Introduc- 
tion of the entire hand and forearm into the rectum and lower bowel 
has been sometimes accomplished as a method of investigation, but, 
obviously, this is an operation that can be performed only under pro- 
found ansesthesia, and it is permissible only when the surgeon is gifted 
with a small and adroitly guided hand, since the risk of rupture is 
much greater than in experimentation upon the dead subject. Very 
little information can be derived from the use of the rectal speculum 
or from rectal injections ; but in female patients the exploration of the 
pelvis through the vagina and rectum is often of great service. 



CONSTRICTION AND OCCLUSION OF THE INTESTINES. 267 

Wlien cbmplete occlusion of the bowel has occurred the condition 
has received from the older authors a number of expressive names, such 
as ileus, miserere, passio iliaca, and volvulus. Three principal symp- 
toms indicate its existence : arrest of fecal evacuation, retention of flatus, 
and vomiting of the contents of the alimentary canal. The cause of 
the arrest of downward movement in the intestine is sufficiently obvious, 
and the occurrence of vomiting is readily explained by reference to the 
reversal of peristaltic action that sooner or later follows stoppage of 
the bowel. Occasionally, however, this symptom does not appear until 
very late in the course of the disease. The matters thus ejected consist 
at first of the ordinary contents of the stomach mixed with fungous 
parasites and masses of normal fecal substance. But after a little these 
are replaced by a thin, watery, offensive liquid that contains fecal debris 
in a highly diluted state. Toward the end of life vomiting sometimes 
ceases and is replaced by an obstinate hiccough. All these symptoms 
of reversed peristaltic action with fecal discharge have been referred to 
colonic obstruction alone ; but this is an error, for I have myself wit- 
nessed the characteristic vomiting of fseces when the seat of obstruction 
was above the ileo-csecal valve, in the lower portion of the small intestine. 

The general abdominal symptoms are similar to those that have been 
already described as a consequence of intestinal stenosis, but they are 
usually carried to a greater extreme. The distention of the belly is 
greater and the intestinal coils are more conspicuous. Dulness on per- 
cussion can be sometimes discovered over the seat of obstruction, and a 
tumor can be felt at that point in a certain number of the cases. Lo- 
calized pain accompanies palpation of the abdominal wall under such 
circumstances, and the peristaltic movements of the bowel are often at- 
tended with colicky pangs. The urine is greatly diminished in quantity 
by reason of the evacuation of fluid that is connected with the act of 
vomiting. It usually contains indican, because the indol that is formed 
in the small intestine is no longer discharged with the fseces, but is re- 
absorbed into the blood and appears as indican in the urine. When the 
function of the pancreas is arrested by Coincident disease of that organ, 
the urine contains no indican, because under such conditions indol is no 
longer formed in the small intestine. 

The patient rapidly sinks into a state of collapse almost like that of 
cholera. He tosses uneasily from side to side and can find no relief. 
The temperature is frequently subnormal, but it may exhibit irregular 
ascensions upon the scale. The pulse is usually weak and rapid. Con- 
sciousness is ordinarily retained until the very last moment of life. In 
certain cases a species of auto-intoxication is evident, with symptoms 
that resemble the phenomena of poisoning Avith atropine. 

A fatal result is sometimes reached in a very short time, as if pro- 
duced by a violent shock to the nervous system. Occasionally a miser- 
able existence is prolonged for many days, or even for a number of 
weeks before exhaustion ends the torment. Sometimes death occurs 
suddenly by reason of suffocation through the entrance of vomited 
matters into the trachea. In other cases dissolution is hastened by the 
upward pressure of incarcerated gases against the diaphragm and the 
thoracic organs. In certain instances death follows the occurrence of 
rupture of the over-distended intestine, either directly as a consequence 



268 DISEASES OF THE INTESTINES. 

of the shock, or indirectly as a result of subsequent peritonitis. In 
many cases peritonitis occurs without perforation of the bowel, and its 
incidence is often insidious, without pain even on pressure over the seat 
of inflammation. Occasionally a loop of intestine above the obstruc- 
tion becomes adherent to the parietal peritoneum, and an artificial anus 
is formed by ulceration through the intestinal coats and the abdominal 
wall at the point of adhesion. In like manner, an occasional cure is 
effected by a similar process of union and ulceration between a loop 
above the occluded portion and another below it. Again, similar fistu- 
lous passages have formed between the intestine and the uterus, bladder, 
or vagina. Encapsulated abscesses may form within the abdominal 
cavity ; pysemic infection may occur ; metastatic abscesses may occupy 
the liver ; and the lungs may be invaded by infectious emboli. Recov- 
ery is not a very frequent result, though it does sometimes occur spon- 
taneously or as a consequence of treatment. Sometimes the obstructive 
mass appears thrown off in the stools as a tumor, a slough, or some 
foreign body that had been lodged in the bowel. But usually recovery 
is ushered in by the return of flatus and fseces to the evacuations, after 
which the patient gradually enters upon convalescence. 

Diagnosis. — The recognition of the fact of intestinal obstruction is 
usually unattended wdth difficulty, but the determination of the exact 
situation and cause of the trouble is often one of the most obscure prob- 
lems in medicine. 

The place of obstruction must be inferred from careful examination 
of the abdomen. The presence of indican in the urine is a valuable 
sign, since it indicates that a large portion at least of the small intestine 
is free for the performance of pancreatic digestion. It must not be for- 
gotten, however, that the existence of peritonitis alone may increase the 
quantity of indican. The same thing is also remarked when cancerous 
growths are developed in the rectum, even though peritonitis be absent. 
As a general fact it may be assumed that when obstruction exists in the 
small intestine all the symptoms are exaggerated beyond what obtains 
when the large intestine is the seat of occlusion. Still, it must be ad- 
mitted that this rule has its exceptions. 

The particular cause of the obstruction can be ascertained with toler- 
able certainty when the point of occlusion can be reached through the 
rectum or vagina, or when the existence of a strangulated hernia can be 
demonstrated. Sometimes the diagnosis is greatly simplified by the 
sudden discharge through the anus of a tumor or invaginated portion 
of the intestine that has sloughed off, or a gall stone or coprolith of 
preternatural magnitude, or of some foreign body that had been lodged 
in the bowels. When old people experience obstruction of the intestines, 
it is frequently due to the growth of a latent cancer involving some por- 
tion of the gut. In fact, the existence of latent abdominal cancer 
should always be suspected in the obscure and wasting decline of ad- 
vanced age. Incarceration of an intestinal loop should also be sus- 
pected if the patient has previously suffered with adhesive peritonitis. 
In every case, moreover, careful search for hernias of every sort should 
be made. Especially true is this of females, in whom an unobserved 
femoral hernia may lead to strangulation and gangrene of the intestine, 
with fatal consequences to the patient. 



CONSTRICTION AND OCCLUSION OF THE INTESTINES. 269 

Still, in spite of every effort there are cases that elude explanation 
until a post-mortem examination reveals the existence of a local inflam- 
mation or a simple paralysis of some portion of the intestinal tract. I 
have seen an infant die of obstruction above the sigmoid flexure within 
a week after birth, having never voided anything but a few drops of 
meconium, and on examination no cause of occlusion could be discovered 
except an inflammation involving the entire circumference of the bowel 
for a space of about two inches in the descending colon. Similar 
appearances of intestinal occlusion are sometimes encountered as a 
result of peritonitis or appendicitis or abdominal tumors, especially 
when they involve the mesentery. Arsenical poisoning and Asiatic 
cholera occasionally produce the phenomena of intestinal occlusion, with 
fecal vomiting, etc., but they may be differentiated by chemical and 
microscopical examination of the excreta. 

Peognosis. — The prognosis depends upon the degree of occlusion. 
Obviously, an intestinal stricture that is still pervious is less dangerous 
than one that is completely closed. In cancerous cases the outlook is 
exceedingly unfavorable, even though the intestine should remain per- 
meable. In non-malignant cases much depends upon the accessibility 
of the constriction and upon the energy and wisdom of the treatment. 
Under any circumstances the mortality is very great. According to 
Goldammer, medical treatment gives 30 per cent, of recoveries. The 
surgeons claim all cases of occlusion as fit subjects for laparotomy, but, 
according to Schramm, the mortality in 199 cases submitted to surgical 
treatment was not less than 61 per cent. Curtis, reporting 328 cases 
operated on with antiseptic precautions, gives a mortality of 68.9 per 
cent., which is about the same as the result of purely medical treatment. 
Among the later series of cases are 122 laparotomies, reported by 
Schramm, in which, by strict antiseptic methods, the mortality was 
reduced to 53 per cent. 

Treatment. — When dealing with cases of simple narrowing of the 
intestinal tube, the diet should consist of liquids that leave a minimum 
of fecal residue. If solid food is taken, it must be very thoroughly 
chewed. The bowels must be kept freely open with laxatives and the 
various mineral waters, so that no hardened faeces can collect above the 
stricture. When located in the rectum the constriction may be reached 
through the anus, and may be sometimes relieved by dilatation or by 
more radical surgical measures. 

In all cases of complete occlusion of the bowels, especially if of 
sudden incidence, the first thought should be directed to the possibility 
of hernia, and the entire abdomen should be explored with reference to 
that accident. It is true, moreover, that intestinal occlusion may occur 
as an independent affection in patients who suffer with hernia — a fact 
that does not diminish the difficulties in the way of diagnosis. 

When occlusion has been effected as a consequence of the presence 
of coprolithic masses in the colon, it is necessary to thoroughly irrigate 
the bowels with a powerful stream of hot water from a large fountain 
syringe. This operation should be repeated as often as the strength of 
the patient will permit. After an evacuation has been thus procured 
the irrigation should be repeated at least twice daily, and purgatives 
should be administered. For this purpose the compound infusion of 



270 DISEASES OF THE INTESTINES. 

senna with magnesium or sodium sulphate should be given daily. If 
thoroughly sweetened with licorice, prunes, and raisins, this is not a 
particularly disagreeable draught. Castor oil, reinforced with a drop 
or two of crotoi>*oil, is a very efficient purgative ; and in certain cases, 
when the colon is fully charged with hardened faeces, it is well to attack 
the obstruction with tlie combined oils through the mouth and stomach, 
and with well-warmed injections of castor oil from below. Sometimes, 
however, it is necessary to precede the injection by a process of scooping 
the faeces from the rectum with a spoon, or with the fingers and Avhole 
hand in the bowel, before the tube of an irrigator can be introduced. 

When the obstruction cannot be reached through the rectum or 
vagina, especially if torsion or incarceration of the bowels be suspected, 
the operation of laparotomy should be performed Avithout delay. This 
should be done at the earliest possible moment, lest the occurrence of 
rupture of the intestinal wall or the incidence of peritonitis add to the 
dangers of the case. 

Many surgeons have preferred the operation for an artificial anus to 
laparotomy. It is true that after thus opening the bowel above the 
point of occlusion the gravity of the symptoms sometimes subsides, and 
the faeces may even resume their normal course. But in other cases, in 
spite of the temporary relief afforded by an artificial opening, gangrene 
or diffusive peritonitis may still originate and extend from the primary 
seat of difficulty. According to Curtis, in 62 cases of enterostomy the 
mortality was only 51.6 per cent., and among the cases of recovery in 
59.4 per cent, the faeces resumed their normal course through the bowels. 

In difficult cases that cannot be treated by surgical operation it is 
necessary to relieve pain and to quiet the peristaltic movement of the 
intestines by the administration of opiates by the mouth or by hypoder- 
mic injection until the pupils are contracted and the patient can lie in 
quiet. This course is preferable to the use of drastic purgatives, which 
sometimes appear to aggravate the existing obstruction by the swelling 
of the mucosa which they excite. In many instances great benefit has 
accrued from repeated irrigations of the stomach with the gastric 
siphon. The operation should be performed three or four times every 
day. The relief in cases of fecal vomiting and accumulation of gas in 
the stomach and distended bowels is inestimable, and is sometimes fol- 
lowed by a cure in cases of invagination or incarceration of the intes- 
tine. Similar results have sometimes followed the injection of air into 
the rectum or the liberation of carbonic acid gas in the lower colon by 
the introduction of a solution of twenty grains of sodium bicarbonate 
in water, immediately followed by an equal quantity of dissolved tar- 
taric acid. 

Puncture of the distended coils of intestine with a fine trocar intro- 
duced through the abdominal wall has been successfully performed, 
and a cure has sometimes followed the operation. The same thing can 
be said of faradization of the intestine by the introduction of one elec- 
trode into the rectum, while the other is applied to the abdominal sur- 
face in the region of the caecum and colon. Massage of the abdomen 
is to be thought of only when occlusion is due to coprostasis or to the 
presence of foreign bodies in the bowels without the existence of 
peritonitis. 



HEMOBBHOIDS. 271 

INTESTINAL MISPLACEMENT; ENTEROPTOSIS. 

The term " enteroptosis " is made to include misplacement and 
descent of any or all of the abdominal viscera. When the intestinal 
tube is at fault it is usually the transverse colon that falls out of place 
(coloptosis). This happens usually with feeble, nervous women, fre- 
quently after childbirth, sometimes as a consequence of congenital 
length and laxity of the mesentery. It may also occur as a result of 
obstinate constipation or of violent muscular exertion of any kind. It 
is in ansemic, neurasthenic persons that it is frequently witnessed, and 
it is in its turn often an efficient factor in the aggravation of the condi- 
tions by which it is caused. This results largely from the uneasiness 
and abdominal distress to which the patient is a permanent victim. 
Chronic constipation, bad digestion, and considerable emaciation are 
commonly observed. 

The existence of coloptosis ca« be readily demonstrated by inflating 
the colon with air. The distended bowel can be then easily discerned 
through the abdominal wall, unless that be uncommonlv laden with 
fat. 

Intestinal displacement occasions no special danger to life, but it is 
certainly a source of great inconvenience, to say the least, and it may 
cause great emaciation and depression of spirits. 

The TREAT^siENT should consist in provision of a well-fitting abdom- 
inal band or supporter, by which the pendulous abdomen can be lifted 
up and retained in its normal position. Constipation must be prevented. 
Daily cold sponge baths and other methods for the improvement of the 
general health must be persistently employed. 



HEMORRHOIDS. 



SY:tfONYMS. — Piles ; Phlebectasia hsemorrhoidalis ; Hsemorrhois ; 
Hsemorrhoiden ; Goldene Ader. 

Etiology. — Hemorrhoids consist in a more or less varicose enlarge- 
ment of the hemorrhoidal veins. This condition may be induced as a 
local expression of a general morbid state of the circulatory apparatus, 
leading to dilatation and varicosity of the veins in other parts of the 
body and limbs, or it may result from accidental causes, such as obsti- 
nate constipation and violent straining at stool. In certain cases hem- 
orrhoids are produced by obstruction to the portal circulation through 
the liver, and they are often the result of causes which also operate to 
produce at the same time a chronic catarrhal inflammation of the rectal 
mucosa. In like manner they are frequently associated with that vast 
-array of symptoms that is presented by the victims of the gouty diath- 
esis. In other cases, on the contrary, they seem to be the result of 
purely local causes, such as chronic proctitis or strictures of the rectum 
occasioned by cancerous or syphilitic disease involving that portion of 
the bowel. 

Just as pressure from within the rectum can produce hemorrhoids, 



272 DISEASES OF THE INTESTINES. 

so may they be occasioned by pressure from pelvic growths or tumors 
outside of the intestinal canal. Witness the common results of preg- 
nancy. Enlargements and tumors of the uterus, ovaries, and prostate 
sometimes operate in the same way by hindering the rectal circulation. 
A similar result is not infrequently caused by obstructive diseases of 
the portal vein or of the liver, or by pressure upon the large abdominal 
vessels during the growth of intra-abdominal tumors — a result that is 
especially favored by the absence of valves in the rectal and portal 
veins. 

Ascending still farther, we may find the hindrance to the return of 
blood from the lower bowels located in the form of diseases of the heart 
and lungs which interfere wdth the proper movement of the blood. 
Thence stagnation in all the veins, with consequent hemorrhoidal de- 
velopment in the rectum. Such conditions are frequently induced by 
a life of indolent luxury, in which excesses at the table unite with lack 
of exercise to induce obesity and all those errors and diseases of nutri- 
tion that are associated with the gouty condition. It is probably for 
this reason that in many instances heredity^ seems to play a part in the 
etiology of the disease : hemorrhoids are not hereditary, but their causes 
in the way of wealth, luxury, and indolence may be sometimes trans- 
mitted from generation to generation. 

For the same reasons that induce gout more frequently among men 
than among Avomen, hemorrhoids are most often experienced during the 
fourth and fifth decades of life, the period when the passions and appe- 
tites are most freely indulged. To find young children suffering with 
piles is a rare event, and only to be looked for under wholly abnormal 
conditions. 

Pathological Axatomy. — For obvious reasons, the position and 
growth of piles can be studied more conveniently upon the living body 
than upon the dead subject. We find them formed above and below 
the sphincter ani muscle — hence their classification as external and 
internal hemorrhoids. Sometimes they are wholly external and below 
the sphincter ; sometimes they are above the muscular ring and internal ; 
sometimes both varieties are present at the same time. Usually they 
occupy the immediate neighborhood of the sphincter, but they are some- 
times found as high as the sigmoid flexure, constituting a generally 
varicose condition of the rectal veins. The form of the different hem- 
orrhoidal clusters is consequently subject to great variation. External 
piles may be so numerous and so large as to appear like a bluish black 
collar composed of irregular links or disks surrounding the anus, or 
they may exist as occasional, circumscribed, wartlike tamors placed at 
considerable distances from each other around the anal opening. In 
the case of old hemorrhoids the individual tumors are usually covered 
with a dense cuticle, but recent growths, especially upon their anal sur- 
face, possess a very thin and transparent investment, through which the 
dilated veins in the centre of the mass can be discerned. 

Above the sphincter ani muscle internal piles present a great variety 
in form and size. They are simply covered by the rectal mucosa, and 
are usually broad and flat, Avith an equally sessile base ; but sometimes 
they are raised upon a comparatively slender stalk, almost like that of 
a rectal polypus. Not unfrequently such hemorrhoidal growths pro- 



HEMORRHOIDS. 273 

lapse throughvthe anus and become strangulated by spasmodic contrac- 
tion of the sphincter ani muscle. 

Chronic catarrhal inflammation of the rectal mucosa is a very com- 
mon complication of hemorrhoids. This may proceed to the extent of 
ulceration and suppuration, occasioning a constant annoying muco-puru- 
lent discharge from the rectum. The deep connective tissue of the 
bowel may also be involved in this process, even to the occurrence of 
abscess in the rectal wall. Such abscesses may open internally or exter- 
nally, or in both directions, constituting incomplete or, in the last case, 
complete rectal fistulas. 

The veins that are implicated in the hemorrhoidal structure may 
undergo various changes. They may dwindle and return to normal 
conditions, as after parturition, or they may become obliterated by the 
formation and organization of thrombi within their lumen. These 
thrombi occasionally undergo calcareous degeneration, with the conse- 
quent production of phleboliths in the once permeable veins. Some- 
times the close pressure of one dilated vein upon another leads to the 
gradual atrophy and disappearance of their intervening walls, so that 
their cavities coalesce, with the production of a sort of angio-cavernous 
tumor. 

Symptoms. — Every one knows how irregular is the connection be- 
tween symptoms of rectal distress and actual lesion of the hemorrhoidal 
vessels. In many instances there is great complaint, with scarcely any 
local change to account for it, while in other cases considerable varicosity 
of the rectal veins may exist without corresponding uneasiness on the 
part of the subject. 

But, as a general rule, the presence of hemorrhoids gives rise to 
great discomfort. There may be a constant sensation as if the rectum 
were occupied by a foreign body, or there may be complaint of burning 
and smarting about the anus, with spasmodic muscular jerking and 
throbbing in the rectum. Sometimes the act of micturition is attended 
with extraordinary j)ain. All such symptoms are induced or greatly 
aggravated by long-continued sitting, horseback riding, or excessive in- 
dulgence in venery and in the pleasures of the table. When the anal 
orifice is closely encircled by a ring of inflamed piles — especially when 
the adjacent mucosa at their base is fissured or ulcerated — the act of 
defecation is often attended with such agony that it is postponed as long 
as possible, only thereby adding to the suffering of the patient when the 
bowels are finally evacuated. In certain cases the patient may actually 
faiut or be convulsed by reason of the severity of the pain. Sometimes, 
also, the whole of the alimentary canal participates in the disturbance 
that is thus excited, and the entire nervous system is upset by the com- 
motion, so that there will be tenesmus, nausea, vomiting, palpitation 
of the heart, difficulty of breathing, determination of blood to the 
head, noises in the ears, disturbances of vision, dizziness, faintness, and 
loss of consciousness. Such cases, however, are fortunately of rare 
occurrence. 

Sometimes, when the hemorrhoids are internal, the most notable 
symptoms are connected with a constant leaking through the anus of a 
slimy, muco-purulent discharge from the inflamed mucosa. But the 
most characteristic discharge consists of mucus and blood that are fur- 

VoL. III.— 18 



274 DISEASES OF THE INTESTINES. 

nishcd by a continuous capillary oozing from the rectal surface. Occa- 
sionally there is actual rupture of a dilated vein, so that the patient may 
be drenched with his own blood. More frequently, however, the veins 
do not give way* even though greatly distended or obstructed by clotted 
blood in the centre of the hemorrhoidal tumor. 

These sanguineous discharges, unless of extraordinary amount, usu- 
allv confer great relief upon the patient. A moderate hemorrhage soon 
makes an end of the cerebral or thoracic symptoms by which it was pre- 
ceded. Since it has its origin very near the anal orifice, the blood that 
is evacuated has a bright and fresh color, is nearly pure, and is not 
mixed with fecal matter. It may be smeared over the exterior of the 
fecal cylinder, but is not incorporated with its substance. Very rarely 
is the quantity sufficient to endanger life by its loss, but in many cases 
of chronic hemorrhoidal bleeding the patient may become greatly re- 
duced, and may exhibit all the symptoms of profound ansemia. 

The prolapse and strangulation of pendulous internal hemorrhoids 
lead to most painful and sometimes dangerous situations. The patient 
lies groaning on his side, with his thighs drawn up against the belly, 
and exhibits every symjDtom of the most intense suffering. Unless 
placed under the influence of ether the attempt to replace the mass with- 
in the sphincter ani muscle only adds torture to the pain that is already 
experienced. If reduction of the piles cannot be effected they soon 
become gangrenous, and the patient may succumb to the consequences 
of septic infection. 

Hemorrhoids are of limited duration when dependent upon transient 
causes like constipation, pregnancy, etc., but in the majority of cases 
they have their origin in chronic disorders of the circulatory apparatus 
or of the respiratory and digestive organs, or they are an expression of 
nutritional vices that are based upon the habits that produce obesity and 
other diseases of the gouty type. Consequently, like the conditions 
with which they are inextricably associated, they usually persist with 
greater or less degrees of severity throughout the remainder of life. 

Diagnosis. — The recognition of hemorrhoids is not difficult, since 
external piles are easily inspected and internal piles can be readily 
reached with the finger or the speculum. It is only needful to keep in 
mind the distinction between enlarged hemorrhoidal veins and such dis- 
eases as cancer of the rectum, broad condylomata, and an unusual ful- 
ness of the folds in the pouches of the rectum. A ready means of 
distinction consists in the fact that such tissues do not bleed on puncture 
with a fine trocar, whereas hemorrhoidal tissues bleed freely when thus 
treated. 

Peogxosis. — So far as the life of the patient is considered, the prog- 
nosis is good. Only in cases of strangulated and gangrenous hemor- 
rhoids is there any considerable danger. But the prospect of perma- 
nent cure without relapse except by surgical operation is far from en- 
couraging. 

Treatment. — Prophylactic measures are of the greatest importance 
in the management of hemorrhoids. Constipation must be obviated by 
appropriate treatment. The diet must be properly regulated so as to 
avoid the forms of malnutrition that follow habitual excess in eating 
and drinking. The idle and luxui-ious members of self-indulgent fam- 



HEMORRHOIDS. 275 

ilies must be made to use their muscles in healthy exercise and to over- 
come the propensity to excessive venery that accompanies an indolent 
life. Xot only alcohol, but strong tea and coifee, must be abandoned — 
in fact, one must look with suspicion upon the majority of the comforts 
of civilized life. 

When constipation and a moderate hemorrhoidal tendency are pres- 
ent, the bowels should be kept gently open by the daily use of small 
doses of compound licorice powder or of Garrod's tablets containing in 
each a grain of bitartrate of potassium with five grains of pure pre- 
cipitated sulphur. As usually furnished, these tablets are too hard 
and disagreeable to the taste, but with a little care they can be made 
as agreeable as any sweetmeat. After every evacuation of the bowels 
the parts adjacent to the anus should be thoroughly washed and wiped 
with tissue-paper. The best and most convenient method consists in 
irrigating the anus with a barber's spray attached to the cold-water 
faucet of a foot-bath tub, over the side of which the patient can place 
his hips in the sitting posture. 

Great benefit may be often obtained from a summer at Saratoga 
Springs or at other similar alkaline sulphate sources. Laxative waters 
that are strongly impregnated with sulphur are useful in arthritic cases 
accompanied with piles. For chronic patients who have become ansemic 
from frequent losses of blood the iron waters are to be recommended. 
Plethoric patients derive benefit from the so-called milk and grape cures. 
Almost any change of diet, climate, and occupation is attended with at 
least temporary benefit ; hence the advantage of an outing among the 
mountains or by the seaside. 

When external piles are troublesome it is frequently necessary to 
smear them with various oleaginous substances. If painful, they may 
be anointed with unguentum gallee cum opio. If pain is felt in the 
deeper recesses of the rectum, it may be necessary to resort to the use of 
anodyne suppositories containing morphine and atropine. Inflammatory 
conditions call for local applications of lead water and laudanum or of the 
liquor aluminii acetici (one part to one hundred of water). Blennor- 
rhagic conditions of the rectum call for daily injections with cold water, 
followed by injections of astringents like tannic acid (ten or fifteen grains 
in a fountain-syringeful of water), or a grain or two of nitrate of silver 
in a similar cjuantity. 

Excessive hemorrhoidal bleeding should be treated, just like a case 
of epistaxis, by local applications, ice-plugs, rectal tampons, and, above 
all, by a full dose of calomel and bicarbonate of sodium. Moderate 
bleeding will ordinarily yield to a mercurial cathartic associated with 
the internal administration of the astringent preparations of hydrastis 
canadensis. In mild cases the internal use of the distilled extract of 
witch hazel in teaspoouful doses is often sufficient. Hot-water injections 
are sometimes more grateful to the patient than cold, and are often quite 
as eifectual. 

Prolapse and strangulation of internal hemorrhoids call for truly 
surgical methods of treatment. The patient should be etherized, after 
which it is comparatively easy to dilate the anal orifice, incise the hem- 
orrhoidal tumors, evacuate their contents, and replace the remaining 
masses above the sphincter muscle, confining them in place by an anal 



276 DISEASES OF THE INTESTINES 

pad supported by a well-adjusted T bandage. But if, as I have seen, 
the agonized patient refuses such treatment, the slower methods of calo- 
mel catharsis, antiseptic poulticing, and anodyne applications must be 
employed — somefimes with gratifying results. In many instances the 
application of several leeches to the anus will bring great relief through 
the unloading of turgid veins that is thus effected. But, as a general 
fact, when hemorrhoids continue to relapse and to torment the patient 
in spite of the above indicated measures, it becomes necessary to invoke 
the intervention of the surgeon. 



APPENDICITIS. 

By \V. F. McNUTT, M. D., M. R. C. S. Edin., etc. 



Synonyms. — Ecphyaditis ; Typhilitis ; Csecitis ; Perityphlitis ; Para- 
typhlitis ; Phlegmon of iliac fossa ; Iliac abscess ; Tuphlo-enteritis ; 
Typhlo-enteritis. 

Definition. — Inflammation of the appendix vermiformis. 

Pathologically, typhlitis or csecitis and perityphlitis are not syn- 
onyms of appendicitis ; inasmuch, however, as csecitis and appendicitis 
cannot be in most cases, at the present time, clinically differentiated, we 
will consider under the head of Appendicitis the whole group of symp- 
toms which go to make up both of these diseases. When we are able 
to interpret their diacritica signa we will limit the use of the word 
appendicitis to inflammation of the appendix, and use the word 
csecitis, or typhlitis, where the inflammation is confined to the csecum. 
When we are able to diagnose inflammation of both csecum and the 
appendix we can coin the term typhlo-appendicitis ; and when we can 
diagnose appendicular colic we may coin the terms appendalgia and 
* ecpliyadalgia. In the mean time there is no objection, but much pro- 
priety, in substituting the term appendicitis for typhlitis and perity- 
phlitis, for the reason that the group of clinical phenomena which consti- 
tutes these diseases is much more frequently produced by appendicitis 
than by typhlitis. 

We do not, however, believe, as do Talamon and some other writers, 
that the word "typhilitis" is doomed to disappear and give place to the 
name " appendicitis." On the contrary, we hope that in the near future 
we will be able to as readily and clearly differentiate between csecitis 
and appendicitis as we can now diagnose bronchitis from pneumonia. 
Not a few writers are so carried away with the new term or new disease 
appendicitis that they deny even the possibility of such a disease as 
typhlitis. Talamon's translator grows so enthusiastic that he " relegates 
typhlitis and perityphlitis to the land of myths and fables." Such 
writers must surely forget that no portion of the alimentary canal, from 
the upper end of the oesophagus to the anus, is exempt from inflamma- 
tion ; that fecal impaction is one of the frequent causes of inflammation 
and ulceration ; and that the sigmoid, the rectum, and the csecum are 
the three places in the alimentary canal most liable to impaction. We 
are aware that Munchmeyer, Behier, and some others deny the pos- 
sibility of stercoral impaction producing inflammation of the mucosa. 
Surely, stercoral impaction of any part of the intestine or appendix 
will distend the walls, compress the bloodvessels, disturb nutrition, and 
thus denude the mucous membrane of its epithelium. Micro-organisms 

277 



278 APPENDICITIS. 

will invade this pathological soil, Avill multiply as the sands of the sea, 
will infiltrate, devastate, and penetrate the Malls. In many cases the 
group of characteristic symptoms that we now call appendicitis is pro- 
duced in this way. It is not necessary to theorize about the possibility 
of disease of the caecum. Surgical operations and post-mortem exami- 
nations have demonstrated inflammation and ulceration of the csecal 
mucosa and perforation and gangrene of its walls. Since typhlitis, 
perityphlitis, and perforative typhlitis are well-established diseases, we 
are at a loss to understand how they are "doomed to disappear" or 
how they are to be " relegated to the land of myths and fables." Un- 
fortunately, diseases are as difficult to suppress as Banquo's ghost, and 
typhlitis, like the poor, will be always with us. 

The word typlditis seems to have been first used by Albers. The 
term perityphlitis is, I believe, thought to have been first used by Gol- 
beck ; Oppolzer was the first to use paratyphlitis. Appendicitis is not 
in the 1874 edition of Dunglison, and not even in the National Medical 
Dictionary, though it was published only three years ago ; nor is the 
word to be found in the new third edition of Vierordt's 3Iedical Diag- 
nosis, published this year. Yet Mestivier reported a case of perforation 
of the appendix in 1759, Wegeler 1 in 1813, Melier 4 in 1827, and Cop- 
land cases in 1834. 

Etiology. — A careful consideration of the causes of appendicitis is 
of the greatest importance. In a typical case of course a diagnosis is 
easily made. In many cases, however, it will be found necessary to 
weigh all the etiological factors in this protean abdominal disease as an 
aid in diagnosis ; and to enable us to determine the pathological con- 
ditions which call for surg-ical interference the causes are best studied 
under the headings of (1) predisposing and (2) exciting. 

(1) Predisposing Causes. — Climcde seems to have no appreciable 
influence, and season only so far as cold and wet weather may predis- 
pose persons to inflammation of the abdominal organs. 

Age by all writers is considered a very important predisposing 
factor ; age, per se, is not, however, in any sense, a predisposing cause 
of appendicitis : it simply engenders habits and occupations which pre- 
dispose the individual to appendicitis. Age, therefore, is of great clin- 
ical importance in a matter of differential diagnosis. The disease is not 
frequent at the two extremes of life. It has been advanced that the 
exemption of young children is largely owing to the peculiarities of the 
tube and mucous membrane about the caecal orifice, that the tube is 
funnel-shaped, and that the opening is better guarded by the valve of 
Gerlach. On the other hand, in old age, it is claimed, the exemption 
depends upon the widening of the mouth of the tube by atrophy of the 
membrane, and should a foreign body find its way into this widened 
tube, it would be more easily expelled by the muscular contraction 
which its presence would excite ; according to this, appendalgia would 
be more frequent in advanced life, which is not the case. This theory 
was constructed when it was supposed that nearly all cases of appen- 
dicitis were the result of lodgement of foreign bodies. Nursing chil- 
dren rarely suffer, while between the ages of two and ten we may count 
upon meeting with about 10 per cent, of all the cases of appendicitis; 
betAveen the ages of ten and thirty, about 65 per cent. ; between the 



ETIOLOGY. 279 

ages of thirty and fifty, about 20 per cent. ; and only about 5 per cent, 
will occur after the age of fifty. It -vnW thus be seen that quite 80 per 
cent, of all the cases of appendicitis are met with between the ages of 
ten and forty. This showing makes age an important etiological factor 
from a clinical standpoint. It does not seem to indicate, however, that 
the appendix is more easily inflamed between the ages of ten and forty 
than before and after these ages, but on account of habits and occupa- 
tions before ten and after forty there is an absence of causes. 

Nevertheless, these years iu a measure correspond to the most active 
developmental period in the history of the appendix, according to Pier- 
sol.^ He gives from the tenth to the twentieth year as the most active 
in the life-history of the appendix. In the declining years of life 
changes take place in the mucous membrane which lessen the canal, and 
Lieberkiihn's follicles become atrophied. These changes, according to 
Piersol, frequently result in complete obliteration of the lumen. If, 
however, it was the condition of the appendix, and not the habits and 
occupation of the individual, that produce 80 per cent, of these cases 
between the ages of ten and forty, women should as surely have appen- 
dicitis as frequently as men. Then, again, in those cases of obliteration 
of the lumen which is so frequently found in old age may it not be the 
result of catarrhal appendicitis, and not as a process of involution, as 
considered by Piersol, Ribbert, Zuckerkandl, and many others ? 

Sex. — About 80 per cent, of the cases of appendicitis occur in males, 
only 20 per cent, in females. On account of this showing writers gener- 
ally consider sex, like age, a very important predisposing etiological 
factor in appendicitis. Most writers on the subject are free to confess 
that they have no explanation to offer why the male suffers so much 
more frequently from aj)pendicitis than the female. In textbooks on 
anatomy no difference of construction or structure between the male and 
female appendix is mentioned. Clado, however, claims that he has dis- 
covered a fold of peritoneum passing from the ovary to the appendix 
or its mesentery, and that this fold carries an artery. Should this 
anatomical difference be found to exist, the terminals of the artery of 
this fold no doubt anastomose with the terminals of the appendicular 
artery. Thus the appendix of the woman has a better blood supply, 
and consequently a greater vitality, than that of the man, and will not 
so readily suffer from nutritive disturbances, gangrene, perforating ul- 
cerations, etc. That this ovarian appendicular ligament is not always 
present is certain ; that it may be occasionally is probable. It is en- 
tirely unnecessary to construct imaginary anatomical differences to ac- 
count for the greater percentage of appendicitis in men than in women. 
We need look no farther than habits and occupations for an intelligent 
and sufficient explanation of the circumstances. , No one would think, 
for instance, of claiming that a woman's arteries are, on account of their 
anatomical structure, less liable to aneurysm than a man's, yet we know 
that men, owing to their habits and occupations, are as much more sub- 
ject to aneurysm than women as they are more subject to appendicitis,. 
the greater relative percentage in man being about the same for each, 
disease. It is a good rule to remember that when the comparative fre- 
quency of disease in the corresponding organs differs in the sexes, the 

^ TJniv. Med. Mag., Sept., 1895. 



280 APPENDICITIS. 

cause of the difference is not ahvays in the histology, anatomy, or 
physiology of the organ, but in the habits of living, dressing, occupa- 
tions, etc. of the sexes. 

Anatomy. — Th^ circulation of the appendix and its anatomical re- 
lation to the digestive tract are fruitful predisposing causes of appendi- 
citis. Impaction of any part of the intestinal tract is liable to cause 
atony or inflammation or ulceration or perforation at or near the seat of 
the impaction. In most cases of intestinal impaction, however, the 
fecal matter can be dislodged before perforation takes place, and if it 
has caused inflammation or ulceration, the parts often recover soon after 
the dislodgement has been once effected. When the csecum is the seat 
of impaction and the fecal matter finds its way into the appendix or is 
forced in, it is not likely to be removed by the cathartic that empties 
the caecum, as the appendix is off the line of travel, as it were, being a 
blind pouch or diverticulum from the caecum, and well calculated from 
its anatomical relation to retain its scybalous contents. If a branch of 
the Sylvian artery becomes obstructed by embolism or thrombosis, the 
part of the brain supplied by that particular branch is likely to suffer a 
nutritive disturbance, and, should the same accident happen to an artery 
of the stomach, a round or perforating ulcer is likely to occur. In both 
instances the trouble arises because there is no free anastomosis of the 
extremities of these arteries with the terminals of other arteries. The 
appendix vermiformis depends for its blood supply upon a small termi- 
nal artery, a branch of the ileo-colic, whose terminals do not obtain 
blood from any other source by anastomosis, hence its great liability to 
perforation and gangrene. The appendix is usually about four inches 
in length, and is supplied by a mesentery or fold from the lower fold of 
the ileum for only about one half of its length. 

The peritoneal fold that runs from the ileum to the mesentery of 
the appendix contains no arteries. Any great distention of the caecum 
with fecal matter or gases is liable to disturb the nutrition of the 
appendix by drawing on its mesentery and thus lessening the blood 
supply. 

Ancemia of the Appendix. — Anaemia is one of the marked predis- 
posing causes of appendicitis. There are very many causes for anaemia 
of the appendix ; for instance, strain on or torsion of the artery, throm- 
bosis or embolism, contraction of the wall on a foreign body, and 
hyperplasia of new fibrous tissue of the appendix and its mesentery, 
the latter constituting stenosis or stricture of the appendix from cir- 
rhosis. The introduction of scybala or other foreign bodies which pro- 
voke contraction of the walls of the appendix interrupts its venous 
circulation and lessens its vitality. That the nutrition of the appendix 
is disturbed as above described is evidenced by the fact that often 
when the wall of the appendix is found contracted on a foreign body 
there is an intense passive congestion ; the perforation or gangrene 
is above the foreign body — that is, nearer the terminal point — and 
gangrene has been found with a greatly distended caecum where no 
foreign body was present in the tube, but was the result evidently 
of torsion or strain on the appendicular artery and nerves. Scybala 
cause nutritive disturbances by obstructing the lumen of the tube in 
addition to disturbing the circulation. The occlusion of the tube pro- 



ETIOLOGY. 281 

duces an accumulation of the secretion of the mucous lining, which dis- 
tends the walls, compresses the veins, establishes a passive congestion of 
the appendix, and makes an excellent culture tube for intestinal micro- 
organisms. What with the congestion and distention of the walls, the 
appendix suffers a neurotic as well as a circulatory disturbance, and 
inflammation, perforation, and gangrene result. 

Habits and Occupation. — The few cases of appendicitis which appear 
in infancy are as liable to occur in the female as in the male child, 
and for the very simple reason that their habits and occupations are 
the same. When boys arrive at the fighting, kicking, Avrestling, climb- 
ing, swimming, etc. age, they develop more cases of appendicitis than 
do girls of the same age. Many writers have sought for diiferences in 
the anatomical construction to account for appendicitis being so much 
more frequent in boys than in girls and in men than in women. We 
have not the slightest doubt that habits and occupation satisfactorily 
account for the occurrence. Wrestlers and gymnasts ; house-carpenters 
who throw themselves across timbers and draw up heavy weights ; 
clerks who stand upon ladders and take down heavy Carpets and bolts 
of cloth ; and many other occupations that call for great exertion, espe- 
cially in strained positions, — in my exjDerience often develop the disease. 
In short, any occupation or exertion that produces violent contraction 
of the abdominal muscles and compression of the intestinal contents 
may either force the gases of the colon into the appendix, thus expand- 
ing it and the valvular opening, and making it easy for the intestinal 
contents to enter, or probably not infrequently may force the fecal 
matter directly into the appendix, or may so strain or twist the meso- 
appendix that thrombosis of the artery may result. 

My own experience has furnished many examples of appendicitis 
which resulted directly or indirectly from occupation. School-boys, 
for instance, furnish a goodly percentage of cases, which can generally 
be traced to running, leaping, wrestling, or some other direct violence. 
The habits of life which are conducive to functional and nutritive dis- 
turbances of the bowels, such as constipation, atony, catarrh, gener- 
ation of gases, etc., predispose the individual to appendicitis. 

Constipation as a cause of primary appendicitis is certainly much 
over-estimated by Avriters on the subject. The number of cases of con- 
stipation are out of all proportion to the number of cases of appendi- 
citis ; besides, constipation is more common with women than with men. 
The reason why constipation is not a more frequent predisposing factor in 
appendicitis is simply because in most cases of constipation the accumu- 
lation of fecal matter is in the sigmoid or the rectum, or both. Consti- 
pation only becomes a predisposing factor in appendicitis when the accu- 
mulation is in the csecum. When the csecum becomes over-distended with 
faecal matter the opening into the appendix necessarily becomes enlarged, 
and any violent contraction of the abdominal walls induced by occupa- 
tion, or perhaps straining at stool, or falls or blows, may readily force 
fecal matter into the appendix ; or the stercoral impaction may produce 
a csecitis which invades the appendix. Or the overloaded and weighted 
csecum may so drag upon the mesoappendix that the artery becomes 
compressed and nutritive disturbance follows. Ramm/ in considering 

1 Ewald's Year-hook, 1897, p. 170. 



282 APPENDICITIS. 

the nature of appendicitis, concludes that it is " due to the incarceration 
brought about by sudden dilatation of the caecum. This causes reten- 
tion of the contends of the appendix, hypersemia, epithelial desquama- 
tion, and consequent infection." No such accident can possibly happen 
from constipation when the accumulation of fecal matter is in any other 
part of the alimentary canal, unless in rare cases the colon and csecum 
are so distended by gases that they are liable to be displaced and drag 
upon the mesoappendix, or it may be possible for the gas to dilate the 
appendix, thus rendering it a ready receptacle for fecal matter or foreign 
bodies. 

Diarrhoea. — Some writers consider this condition as predisposing to 
appendicitis. AVhen inflammation of the csecum is the cause of the 
diarrhoea the inflammation may readily extend to the appendix. When 
the diarrhoea is the result of ileo-colitis the appendix may very well 
become involved. Inflammation of any other part of the alimentary 
canal will not necessarily involve the appendix. 

Diet. — Over-eating and drinking are well-established predisposing 
causes of appendicitis. Indigestible and too highly seasoned foods, by 
provoking catarrhal conditions, by distending the bowels with fecal 
matter and gases, are also etiological factors. Catarrh of the c£ecum or 
about the ileo-csecal opening may either invade the appendix directly or 
may act as a predisposing cause by giving rise to scybala, it being a well- 
recognized fact that scybala are met with in persons who are suflering 
with intestinal catarrh. Catarrh of the bowels disturbs two very import- 
ant functions — viz. the secretions of the mucous membranes and peri- 
stalsis. With suspension of the peristalsis that portion of the bowel 
soon becomes distended with dried fecal matter or scybala, and when 
the condition occurs in the csecum or lower portion of the ascending 
colon, it becomes a fruitful source of appendicitis. In the writer's 
experience appendicitis in children is very frequently preceded by catar- 
rhal discharges from tlie bowels, more especially when the seat of the 
catarrh is an ileo-colitis. Since it is well established that most of the 
cases of peritonitis have their origin in appendicitis, and so many cases 
of appendicitis are caused by the lodgement of seeds in the appendix, 
much more care should be exercised in eating fruits. Many people are 
exceedingly careless about swallowing fruit seeds. In fact, patients 
often state that they have been told by their physician to swallow the 
seeds and skins of grapes or raisins for constipation. The practice is 
very dangerous. Cases of appendicitis have had their origin in the 
lodgement of a single grape seed. To swallow cherry stones, orange 
seeds,, lemon pits, etc. is equally dangerous. A case of appendicitis 
occurred under my own observation which commenced within twelve 
hours after partaking pretty freely of grapes, the patient having swal- 
lowed seeds and skins. The habit of swallowing whole mustard seed 
for constipation is a bad practice. Physicians are often responsible for 
this dangerous prescription. 

Infectious Diseases. — Any one of the infectious diseases may be the 
predisposing cause of appendicitis, but typhoid fever, diphtheria, ab- 
dominal grippe, tuberculosis, and syphilis are more likely to produce 
the trouble than the eruptive diseases. In all these ulcerated processes 
— viz. typhoid, diphtheria, tuberculosis, and syphilis — it is most prob- 



EXCITING CAUSES. 283 

* 

able that ^the caecum and the mucous membrane about the ileo-csecal 
opening are the primary seat of the ulceration ; however, as the mucous 
membrane of the appendix is generally provided with solitary glands, 
it may become the seat of specific ulceration independent of the caecum. 
The specific ulcerations of the caecum may so disturb the function of 
the appendix that it becomes invaded by the ordinary micro-organ- 
isms of the alimentary canal. It probably is the rule that the acute 
infectious diseases are predisposing causes, and very rarely the exciting 
causes. 

Relapsing Appendicitis (Remittent Appendicitis). — Nothing is more 
certain than the influence of a pre\aous attack in predisposing a per- 
son to appendicitis ; we see this in our every-day practice. Once having 
had an attack, the patient is never absolutely safe from a recurring 
attack while the appendix remains, or unless the lumen becomes com- 
pletely obliterated, which it occasionally does from repeated attacks 
(appendicitis obliterans). The relapses are usually produced by the 
presence of the foreign body still in the appendix, or it has left an 
ulcer or subacute inflammation of the mucous or submucous tissue, or 
there has been produced an interstitial inflammation of the appendic- 
ular walls. Again, the predisposing causes of the first attack may still 
be present — by the enlargement of the appendicular opening, for in- 
stance, which consequently leaves the organ exposed to the lodgement 
of foreign bodies and less able after each attack to expel them. 

Stenostomia Appeyidiculce Vermiformis. — Contraction of the appen- 
dicular opening is no doubt an occasional predisposing cause of appen- 
dicitis, and perhaps a very frequent cause of appendalgia. The stenosis 
is no doubt due to caecitis or ulceration near the opening, the inflam- 
mation, or rather the cicatrization, narrowing the orifice. The accumu- 
lation of mucus in the appendix necessarily produces appendalgia, and 
the pain is only relieved when the spasmodic contraction of the walls 
of the appendix forces its contents through the narrow opening into 
the caecum, which, of course, relieves the distention. Stenosis of the 
appendix, however, does not occur necessarily only at the caecal open- 
ing. Stenosis may and often does' occur in any part of the appendicu- 
lar lumen ; no better medium could be obtained or place invented for 
the culture of intestinal micro-organisms than the niucus which accu- 
mulates above the stricture. ^ 

(2) Exciting- Causes. — The only cause for appendicitis, according to 
a layman's view of the disease, is a " foreign body in the blind pouch." 
A layman's opinion of a disease may not be worth much ; in this 
instance, however, it is significant, as the common people must have 
obtained their notions of this disease from the medical profession, which 
goes to show that only a few years ago the profession scarcely suspected 
any other causes than that of a foreign body as the exciting cause of 
appendicitis ; it was fruit seeds, cherry pits, or other small seeds, or 
foreign bodies that might have been swallowed, such as fish bones, pins, 
small coins, buttons, etc., or scybala or gall stones or enteroliths. Now 
that a reaction has set in against foreign bodies being the only exciting- 
cause of appendicitis, there is danger of going to the other extreme and 
attributing too small a percentage of the cases to these causes. Some 
writers name not more than 3 or 4 per cent, as about the number to be 



284 APPENDICITIS. 

expected as the result of foreign bodies. According to Talamon/ " Out 
of a total of 760 cases of appendicitis obtained by collecting the statis- 
tics and observations of divers authorities (Fitz, Matterstock, Krafft, 
Fenwick, Maurin,'Iloux, etc.), in 450 the presence of such foreign 
bodies was noted in the appendix itself, sometimes in the pus of the 
periappendicular abscess — 60 per cent." Fowler/ however, says : " The 
possibility of the production of the disease by foreign bodies is not 
denied ; the statement is simply made that, as a clinical fact, in my ex- 
perience it is of rare occurrence." Perhaps surgeons are too apt to 
conclude that there is no foreign body present if they do not find one in 
the appendix or in the pns cavity. Where the foreign body is a scyba- 
lum, it is always possible that it may have softened before the operation, 
either in the pus sac or within the appendix, by the accumulation of 
mucous secretion, or how easy for a small foreign body, such as a grape 
seed, to escape detection ! When the scybalum or other round-shaped 
foreign body has obstructed the mouth of the appendix, the consequent 
accumulation of fluid in the cavity may have forced the obstruction into 
the csecum, not, however before serious pathological changes may have 
been inflicted upon the walls of the appendix — lesions which may after- 
ward terminate in ulceration, perforation, or gangrene ; or the case may 
become a relapsing one on account of interstitial inflammation having 
been instituted. Then, too, there is a bare possibility that such cases 
may be nothing more than appendalgia. 

Traumatism. — We learn by experience that a goodly number of cases 
of appendicitis are the direct result of blows, falls, lifting heavy weights, 
wrestling, etc. ; 3 such cases have come under my own observation re- 
cently : one boy was kicked by a schoolfellow ; another was punched 
with a stick over the csecum ; the third, a man, fell. 

Stenosis. — There can be no doubt that stenosis of the mouth of the 
tube acts as an exciting cause, readily producing inflammation by dilating 
the tube, and thus interrupting the nutrition of the walls and preparing 
a proper soil for the destructive work of micro-organisms. 

Ccecitis. — Of course inflammation of the caecum very readily in- 
vades the appendix by extension, regardless of the etiology of the cse- 
citis. It must be remembered that the typhlitis which caused the 
appendicitis may have subsided, either because the caecum has a better 
blood supply, or the impaction or foreign body may have been removed 
by cathartic medicine, while the inflammation in the less highly vital- 
ized appendix may have resulted in perforation or gangrene. For in- 
stance, we not infrequently see a very mild catarrh of the stomach 
extend into the duodenum, and, though scarcely sufficient to disturb 
the patient, invade the ductus biliaris communis, causing tumefaction 
of the mucous membrane and obstruction of the duct, and a violent 
attack of jaundice ensues which may even endanger the life of the 
patient and necessitate a surgical operation. In the mean time, the 
duodenal catarrh may have subsided. We cannot see any reason which 
would lead us to infer that an appendicitis may not as readily result 
from a csecitis as that a choledochitis may be caused by a duodenitis. In 
point of fact we have every reason to believe that the caecum is much 
oftener the seat of inflammation and ulceration than the duodenum. 

1 Talamon, p. 30. ^ Fowler, p. 68. 



EXCITING CAUSES. 285 

llicrobjc Appendicitis. — While it may not be possible to state in 
any given case of appendicitis the exact amount of responsibility which 
the intestinal micro-organisms played in its production, there is no 
longer any doubt that they are in many cases active etiological factors. 
Neither may it be possible to state in any particular case of appendicitis 
which of the many intestinal micro-organisms is the more active de- 
structive agent. The bacterium coli communis is, however, the micro- 
organism that is not only most constantly found, but is present in the 
greatest numbers in the intestinal tract. While a sound intestinal mu- 
cous membrane seems to enjoy an immunity against its presence, it 
becomes an active pathogenic agent to the mucosa whose nutrition or 
physiological function is disturbed. Once the mucous membrane of the 
appendix is denuded of its epithelium, the bacillus coli communis as- 
sumes both pathogenic and pyogenic properties. Not only is this bac- 
terium found in catarrhal inflammation of the caecum and appendix, but 
it is also found in the peritoneal cavity in cases of appendicitis and 
typhlitis, and, too, when no perforation has taken place. It is very 
probable that in addition to catarrhal disturbance of the mucosa any 
atrophic or nutritive lesion of the appendix may subject it to invasion 
of bacteria. While bacteriological appendicitis is no doubt common, it 
must necessarily always be secondary to catarrh or vascular or nervous 
nutritive disturbances. Probably the more acute causes are secondary 
to the former, while the chronic causes are secondary to the latter. 

Barbacci reaches the following conclusions : (1) " In perforative 
peritonitis in man cultures from the exudate yield only one organism in 
the vast majority of cases — the bacillus coli communis. In but a single 
case of the 14 was another micro-organism, the micrococcus lanceolatus 
(Frankel), associated with the bacillus coli communis. (2) Inoculations- 
into the peritoneal cavity of susceptible animals (white mice and guinea- 
pigs) with fresh exudate of peritonitis produce peritonitis, and in 8 
cases out of the 13 the micrococcus lanceolatus was found. (3) The 
micrococcus lanceolatus is present in about 60 per cent, of all cases, but 
is overlooked because it is overgrown by the bacillus coli communis. 
(4) Experiments made on dogs by opening the abdomen, securing a loop 
of intestine, and causing a perforation by the application of caustic 
potash produced a peritonitis exactly simulating, both microscopically 
and bacteriologically, a perforative peritonitis in man. The animals 
died in from twenty to thirty hours, and examination after death 
showed a general fibrinous peritonitis. Enteritis was not found in any 
of the cases. Pure cultures of the bacillus coli communis were obtained 
from the exudate. (5) Marked diiferences exist as to the result when, 
upon the one hand, the examination is made directly from the exudate, 
or by the culture method on the other. Cultures show only bacillus 
coli communis, but by direct examination a number of diiferent organ- 
isms may be found, the latter dying in the exudate in the early stages 
of the inflammation, the bacillus coli communis growing alone in the 
cultures. In dogs killed at intervals of five, five and a half, six, eight, 
and ten hours after perforation examination showed the bacillus coli 
communis mixed mth other organisms up to eight hours ; after this the 
former alone was found. The micrococcus lanceolatus was not found in 
the experimental peritonitis in dogs." 



286 APPENDICITIS. 

Bheumatism and Gout. — There are writers, especially in England, 
who attribvite many cases of appendicitis and typhlitis to rheumatism 
and gout. The physicians of London probably have more experience 
with gout than thoee of any other country. When such a distinguished 
authority as Burney Yeo^ is found adding the weight of his authority 
to the gouty and rheumatic origin of appendicitis and typhlitis, we are 
certainly o])Hged to admit that such cases do probably occur ; and why 
not ? Gout of any other part of the digestive tract is an established 
fact ; gout of the stomach is quite a common expression. 

A gouty enteralgia or diarrhoea is not an unusual occurrence. That 
a g-outy or rheumatic typhlitis or appendicitis or ecphyadalgia should 
occasionally occur is wdiat we might expect. There is no mucous 
membrane or serous tissue exempt from gouty or rheumatic inflamma- 
tion. A boy, now aged fifteen, a patient of mine, had appendicitis 
(parietal) when eight years old, and again when ten ; there was circum- 
scribed peritonitis each time, but no pus and no operation. In the past 
five years he has had two attacks of tonsillitis, which readily yielded 
to salicylate of soda. His mother is a great cripple, and suffered from 
rheumatism since he was five years old. Would the appendicitis have 
yielded so readily to the salicylate ? Its rheumatic origin did not occur 
to me at that time. 

Pathological Anatomy. — The pathology of the appendix or of 
appendicitis is in no sense unique, and for the reason that its anatomy, 
histology, and physiology are quite the same as that of the C£ecum, and 
subject to similar pathological laAvs. The appendix is simply a pouch 
or diverticulum of the caput coli, generally attached to its j^osterior in- 
ternal side. The appendix or its four layers — viz. the serous, muscular, 
submucous, and mucous — is simply a jutting, as it were, of a circum- 
scribed portion of the caput coli (not in an embryological sense, for the 
appendix embryologically is vestigial). " The histology of these four 
tunics is identical with that of the large intestines, with the two excep- 
tions of the greater constancy of the solitary lymph nodes in the mucosa, 
and the complete outer sheath of longitudinal fibres in the muscularis. 
Fowler^ says: "In the appendix Lieberkiihn's glands and solitary 
follicles exist in such profusion that facilities for absorption are even 
greater than in the cfecum. Hence the contents of the appendix are 
always of firmer consistence than those of the cfecum." In applying 
the pathological laws of the colon to the appendix we will find that 
they are to a certain extent modified by the appendicular circulation, its 
anatomical relatious to the intestinal tract, and more especially by the 
calibre of its canal. All narrow mucous canals must necessarily have 
a tendency to strictures and obliteration when the subject of catarrhal 
and ulcerative inflammations. The appendix has but one artery, and 
as about one half of its distal portion is usually free in the abdominal 
cavity without mesentery — that is, it is not attached to any other organ 
— its artery is necessarily terminal. Being thus deprived of anastomoses 
with the terminal branch of any other artery, a thrombosis or obstruc- 
tion of its only artery must result in gangrene, perforation, etc. In 
the case of an appendicular ovarian ligament the artery which it carries 

^ British Medical Journal, June 16, 1894. ^ Ibid., July 14, 1888, p. 43. 



PATHOLOGICAL ANATOMY. 287 

anastomoses with the appendicular artery, and a better blood supply is 
secured and gangrene and ulceration are not so likely to occur. 

The pathology of acute appendicitis may be catarrhal, phlegmonous, 
ulcerative, necrotic, or gangrenous. Appendicitis may or may not ter- 
minate in abscess. Any one of these acute conditions may result in 
circumscribed or general peritonitis, with or without abscess and inde- 
pendent of perforation, the micro-organisms easily traversing the un- 
broken pathological walls. It is not, then, in its pathological laws that 
the appendix differs from any other portion of the alimentary tract, but 
in its greater tendency to pathological conditions, owing to the pecu- 
liarity of its circulation and anatomical relation to the intestinal canal, 
or, in other words, on account of its lower vitality or lesser power of 
resistance, for all vestigiary organs are lacking in vitality. The appen- 
dix is many times more subject to inflammation than the intestines, and 
the acute inflammatory processes are much more rapid and destructive. 
This is well exemplified in the appendicitis that results from scybalum, 
enterolith, or other foreign body impacted in the appendicular opening. 
The obstruction to the circulation of the appendix is at the point of 
impaction, while the ulceration or perforation is likely to be an inch or 
two nearer its terminal extremity, or the very apex is the seat of the 
gangrene. If impaction in any part of the alimentary canal could inter- 
fere with its circulation and nutrition in the same degree, its disturbed 
and disorganized walls would not as readily yield to the destructive 
power of the intestinal micro-organisms. 

The pathology of the appendicitis that results from a torsion or 
stretching of the mesoappendix is about the same as that of obstruction 
from scybala. In the case of scybala the atrophic or nutritive lesion 
is primarily a passive congestion of the appendix, while in torsion of 
the mesoappendix the primary atrophic disturbance is anaemia. In 
either case the destructive agent is undoubtedly the micro-organisms. 

The pathology of appendicitis which accompanies or follows typhoid, 
tubercular, or other infectious or specific diseases is similar to the pa- 
thology of enteritis from the same cause, modified, not from any pecu- 
liarity of the tissue, but on account of its blood-supply and its anatom- 
ical position. If a specific ulcer occurs in the mucous membrane of the 
appendix, it perforates more readily than specific ulcer of the intestinal 
wall. If the inflammation terminates in hyperplasia of fibrous tissue 
of the submucous membrane, a complete occlusion of the appendicular 
canal quickly ensues from cicatricial contraction on account of the 
narrow lumen of the appendix. The pathology of relapsing appendi- 
citis is varied ; repeated attacks occur with nothing more than involve- 
ment of the mucous membrane. AVhen the attacks are catarrhal and 
the submucous tissue becomes involved, hyperplasia of fibrous tissue is 
liable to result in stricture ; when the muscular and serous coats are also 
involved, the termination is often a mere fibrous cord, a cirrhosis, the 
result of fibrous hyperplasia whose contraction has closed the whole 
appendicular canal [appendicitis obliterans). From the mucous or sub- 
mucous tissue the inflammation may involve the muscular and serous 
coats by the second or third day. Should the contraction be irregular, 
producing stricture of the canal, the retained secretions on the distal 
side of the stricture may produce repeated attacks of pain and fever 



288 APPENDICITIS. 

(appendalgia), to be relieved as soon as the accumulation has distended 
the walls and provoked muscular contraction sufficient to force the con- 
tents through the stricture, or to finally end in ulceration and perfora- 
tion, -which is soouier or later likely to be the case if the accumulated 
contents do not find its way into the caecum. 

The same pathological condition may be brought about by a flexure 
of the appendix — that is, if it becomes bent upon itself and perhaps 
adheres in that position. At the point of flexion the canal is as com- 
pletely shut off as it is in stricture or by a foreign body. To be sure, 
recovery may take place after one attack or more ; in fact, patients do 
entirely recover from appendicitis without surgical interference ; too 
often, however, an attack of this disease leaves a pathological volcanic 
focus, not a pleasant thing to carry around in one's abdominal cavity. 
The return to a healthy condition of a once pathological appendix is 
governed to a great extent, no doubt, not by the severity or the pain 
and fever, but by the extent to which the circulation has been impli- 
cated. The condition of the blood supply, and to a less extent the 
nervous impairment, will determine its power of resistance and its 
ability to make for health. 

Ccecitis. — While, clinically, it is not always possible at the present 
time to differentiate between appendicitis and csecitis, pathologically 
they must not be confounded. The fact that appendicitis is a much 
more frequent disease is no reason for ignoring the pathology of csecitis. 
It is very doubtful whether catarrhal inflammation of the csecum is so 
much less frequent than catarrh of the appendix. That ulceration, per- 
foration, and gangrene are less frequent in the csecum is of course well 
established. Ulceration and perforation of the csecum are more likely 
to be specific — tubercular, syphilitic, typhoidal, etc. Probably few per- 
forations of the csecum are due to mere lodgement of foreign bodies (a 
sharp-pointed foreign body may of course readily penetrate the wall), 
while impaction (typhlitis stercoralis) no doubt is responsible for a few 
cases. 

Paratyphlitis. — To attempt to give all the pathological complications 
of paratyphlitis and para-appendicitis would be to write the pathological 
history of each individual case. We may have a matted, adherent, and 
agglutinated condition in one case, or circumscribed or general perito- 
nitis in another. Again, the contents of the appendix or caecum may 
be poured into the abdominal cavity or hemmed in by adhesions, and 
much may depend upon the size, location, and direction of the abscess. 
All these pathological conditions may be modified, determined, or gov- 
erned by the location of the csecum, location or length of the appendix, 
free or adherent condition of the appendix, the portion of the appendix 
or caecum perforated, as well as, to some extent, by the diathesis and 
vitality of the patient. 

While it is not within the scope of this article to give the anomalies 
of form and location of the csecum and appendix, nevertheless a know- 
ledge of these abnormal conditions is necessary in the study of diagnosis, 
symptoms, and pathology of the disease : of course the abscess in the 
great majority of cases is primarily intraperitoneal, but no sooner is 
an abscess formed than it may make toward the surface or above or 
below Poupart's ligament, or escape into the bladder, vagina, or small 



SYMPTOMS. 289 

intestines ob rectum, or, breaking through the iliac fascia, present in the 
lumbar region. When the abscess opens into the bladder, vagina, or 
rectum, it is fair to presume that the position of the caecum and ap- 
pendix may be anomalous. The writer has met with all these unfortu- 
nate terminations, and saw a case recently of recurring appendicitis 
where the abscess was discharging through the bladder. Probably 80 
per cent, of iliac abscesses originate from purulent appendicitis or para- 
appendicitis, and are cases of encysted peritonitis or phlegmonous in- 
flammation of the ileo-psoas cellular tissue. 

Symptoms. — The group of symptoms wliich is now generally de- 
scribed as appendicitis was formerly attributed to lesions of the csecum 
and designated typhlitis, perityphlitis, and paratyphlitis. The word 
typhlitis was used when the lesion was diagnosed as inflammation of the 
mucous membrane of the csecum. Perityphlitis was the term used when 
the inflammation involved the muscular and serous coats as well, and 
paratyphlitis was used to designate inflammation of the connective tis- 
sues behind and surromiding the csecum. It has now been abundantly 
and definitely proved by hundreds of surgical operations and many 
post-mortem examinations made in both this country and Europe — more 
particularly in this country — that this characteristic group of symptoms 
is the expression of pathological changes, which, for the most part, pri- 
marily originate in the appendix and extend to the surrounding serous 
and connective tissues, involving them in inflammation which is fre- 
quently phlegmonous. We say for the most part originated in the ap- 
pendix, for surgical operations and ])ost-mortem examinations on cases 
that have been diagnosed as appendicitis have discovered the appendix 
in a healthy condition, and that the case proved to be one of typhlitis 
or perityphlitis or paratyphlitis. To be sure, these cases are infrequent, 
but they do exist. For instance : " The vermiform appendix was found 
to be normal, while upon the anterior and external surface of the csecum 
there were two gangrenous perforations," etc.^ 

No one who has had much experience with appendicitis will attempt 
to give such a general description of the disease as will apply to all 
varieties. 

Recognizing as we do the great diversity of pathological proceedings 
and terminations, and that symptoms are but expressions of pathological 
conditions, it becomes necessary to describe the symptoms of various 
clinical types as we find them in actual practice. 

(1) We will designate the first form, then, as catarrhal or medical 
appendicitis. In this variety the inflammation confines itself to the 
mucosa. 

(2) The second form we may call mural or parietal appendicitis. 
This form involves all the coats of the appendix, and may assume a 
relapsing or fibrinous or cirrhotic tendency and terminate in a fibrinous 
or cordlike condition of the appendix — appendicitis obliterans. 

(3) A third variets^ may be designated as acute or subacute perfor- 
ating appendicitis. This form might, with great propriety, be called 
surgical or suppurative appendicitis — not that other forms may not be 
suppurative or require surgical aid, but because this variety of the 
disease demands surgical treatment. 

^ McMurtry : Pacific Med. Journal, July 7, 1888. 
Vol. III.— 19 



290 APPENDICITIS. 

(4) The fourth type we may name periappendicitis, which gives us 
circumscribed or general peritonitis without perforation of the appendix 
and non-phlegmonous; and a fifth variety we may desigate as recurrent, 
which is entirely distinct from relapsing. So protean is this abdominal 
disease that we are constantly meeting with cases wdiose symptoms we 
cannot clinically classify under any one of the above varieties ; but even 
this is not so strange when we take into consideration the anomalies of 
position and form of the appendix. The same pathological condition 
of the appendix will manifest itself by entirely different symptoms 
according to its position. 

Among the non-classifiable cases which we occasionally meet is one 
that commences as an acute colic — enteralgia, so considered and treated 
as such — and attributed to catching cold or to errors in diet. These 
attacks may occur at long or short intervals, with quite complete inter- 
missions : each time the attack is attributed to errors of diet or catching 
cold, and each time yields to treatment for colic. Finally, however, 
the attack may cease to occur, or, on the other hand, there suddenly 
develops a well-established attack of appendicitis. 

(1) Catarrhal or Medical Appendicitis. — This is altogether the sim- 
plest form of the disease, and the least likely to require surgical treat- 
ment. Medical appendicitis would, therefore, seem quite an appropriate 
term for this variety of the disease, as distinguishing it from perfora- 
tive or surgical appendicitis. The attacks may be ushered in suddenly 
with a slight chill or recurring chilly sensations, Mdth very acute and 
severe colicky pains concentrating themselves about the umbilicus or 
perhaps radiating over the whole abdomen, and very often attended 
with vomiting and fever. The onset of the disease resembles in every 
way enteralgia, except in most cases there is a temperature. Unlike 
enteralgia, however, it does not pass off in a few hours, but usually 
lasts a few days. At the end of twenty-four or forty-eight hours the 
radiating pains are apt to cease, and from being centred about the 
umbilicus they become concentrated over the csecum. Although there 
is no involvement of the peritoneum, the abdominal muscles are on 
guard, and give a tenderness and rigidity to the walls over the right 
iliac region that might be mistaken for peritonitis. It is well known 
that constipation is sometimes present with catarrhal appendicitis, and 
that the fecal accumulation may be in the csecum ; this being the case, 
an elongated doughy tumor, with dulness on percussion and painful to 
the touch, is readily diagnosed. These cases constituted the stercoral 
typhlitis and perityphlitis of a few years ago. After a brisk cathartic, 
the tumor disappeared, the pain subsided, and the cure of typhlitis was 
attributed to the cathartic. After a few days, whether the stercoral 
tumor be present or not, the symptoms subside and the patient is well, 
having had no parietal or peritoneal involvement. 

Some writers are particular to state that the impaction or stercoral 
tumor is not the cause of appendicitis, but the result, and due to a. 
paresis of the intestines, the paresis being brought about by the severe 
abdominal pains. This, hoAvever, is far from always being the fact. 
In many cases the history goes to show that the patient had been con- 
stipated for several days perhaps before the sudden onset of the appen-. 
dalgia, and should the bowels be moved by enema or cathartic a few 



MURAL OB PARIETAL NON-PERFORATING TYPE. 291 

hours afterxthe pain sets in^ the dried, hard scybalous condition of the 
fecal matter at once indicates that constipation was of several days' 
standing and could not have been the result of a few hours' pain. Tliat 
the stercoral impaction of the caecum is not necessarily the cause or 
result of appendicitis is evident from the fact that it is present in only 
a small percentage of cases. When no impaction and no tumor exists 
the abdominal parietes may be tender and rigid, and a particularly 
localized tenderness can usually be made out over the appendix 
halfway between the umbilicus and the superior spine of the ilium 
(McBurney's point). 

Too much importance must not be attached to this supposed diag- 
nostic point, on account of the anomalies of position and length of the 
appendix. The term '' catarrhal appendicitis " for the past year or two 
is often applied to cases of acute severe abdominal pains accompanied 
by vomiting and with or without fever, when all symptoms subside in 
a few hours. Talamon proposes to call these cases " appendicular colic." 
The expulsion of a foreign body from the appendix is supposed to be 
the etiology in most cases of appendicular colic. They are undoubtedly 
neuralgic, and when the appendix is the seat of the pain I would 
suggest " appendalgia " or " ecphyadalgia " as a more suitable name 
and one more in consonance with the genius of the English language. 

As a matter of fact, these cases may be appendalgic or enteralgic — 
that is, an expulsion of a stercoral or other offending body from the 
appendix, or some indigestible material has irritated the intestinal 
peripheral nerves. 

Mural or Parietal Non-perforating- Type. 
In this variety we have a true appendicitis — that is, the whole four 
coats of the appendix are involved in the inflammation. In every 
case when the walls only are involved, and neither gangrene nor perfora- 
ting peritonitis takes place, the case remains a mural or parietal appen- 
dicitis. The symptoms for the first twenty-four or forty-eight hours 
may not difPer in any way from a catarrhal attack ; the vomiting, 
coated tongue, fever, and pain all correspond ; the pain may be radiated 
over the abdomen or concentrated about the umbilicus (the muscles of 
the walls are particularly on guard) ; instead of subsiding after from 
two to three days, as is usual in catarrhal appendicitis, there is tender- 
ness developed over the right iliac region, and if the caecum and 
appendix are in their normal position, the thickened and rodlike feeling 
of the appendix may mostly be made out by palpation, or a distinct 
tumor may be felt. In catarrhal appendicitis, there being less 
tenderness, swelling, and induration of the appendix, it is not so 
readily felt, though Edebohl and many others claim to locate the 
position of the healthy ap]3endix by palpation. Morris ^ says : " Physi- 
cians must give much more attention to the matter of accurate palpa- 
tion of the appendix." Physicians who palpate ureters and Fallopian 
tubes can readily palpate a normal appendix. The tenderness may 
continue for two or three weeks, with slight exacerbations of pain and 
slight fever, and finally the patient entirely recovers. In many cases, 
however, of the mural type, without gangrene or perforation of the 

^ Lectures on Appendicitis, pp. 166, 167. 



292 APPENDICITIS. 

appendix or circumscribed or general peritonitis, an abscess may super- 
vene. On the other hand, relapses are likely to occur, and the case 
may terminate in appendicitis obliterans — cirrhosis or fibrosis of the 
appendix. 

Ribbert of Zurich has recently advanced the notion that with 
increased age an atrophy of the appendix takes place, and that it 
becomes shorter — that the histological structure of the walls changes and 
the lumen is entirely obliterated. He evidently considers that these 
changes are not the result of previous inflammation, and of course not 
cirrhotic. 

Many of the mural forms that end in appendicular abscess commence 
in catarrh and become relapsing ; each relapse invades more tissue, until 
from catarrhal the case becomes mural, often stretching over a period 
of many months or perhaps several years. In these cases there is not 
a complete intermission, only a remission, of tenderness and freedom 
from pain ; in other words, they are relapsing and not recurrent cases. 
When the appendix is situated behind the csecura and colon it is not 
possible by clinical history or physical examination to differentiate 
between the catarrhal and mural types. In fact, often it is only pos- 
sible to even suspect that the appendix is the seat of the disease. That 
this form of appendicitis may and often does perforate or become gan- 
grenous is as well established as the fact that the catarrhal type may 
take on an ulcerative or fibrinous condition. 

It is not unusual for a patient to have one or more mild attacks of 
catarrhal appendicitis, when perhaps a third or fourth attack is much 
more serious and prolonged, and terminates perhaps in abscess or per- 
foration, and possibly death. Instead of subsiding about the third or 
fourth day, as had previous attacks, the temperature keeps on increas- 
ing, while swelling, tenderness, and inflammation develop in the right 
iliac region, and physical examination reveals a tumor as large or larger 
than a hen's egg ; the first attacks were catarrhal, the latter mural. 

Relapsing- Appendicitis (Remittent Appendicitis). 

This is not a distinct type or variety, but either the catarrhal or 
mural may assume a relapsing phase. A patient has an attack of 
catarrhal appendicitis, or perhaps the submucous tissue is also involved ; 
all the active symptoms subside, and the patient is well excepting for 
some tenderness over the right iliac region. There is evidently a sub- 
acute catarrh left to be lighted up by over-exertion, taking cold, or 
perhaps an error in diet. In the relapse of mural appendicitis, the 
acute symptoms having subsided and the patient being up and about, 
there can still be felt, as a rule, a circumscribed induration of the 
abdominal walls or perhaps a tender tumor or nodule in the right iliac 
region or a tender and perceptibly thickened cordlike appendix. The 
same causes that produced a relapse in the catarrhal variety are in 
operation here. 

Acute Perforative or Surg-ical Appendicitis. 

It is to this acute perforative or surgical variety of appendicitis that 
the disease owes its great present notoriety. This acute surgical type 



ACUTE PERFORATIVE OR SURGICAL APPENDICITIS. 293 

is often called the fulminative variety. We have only to look back at 
the pathology of perforative appendicitis to realize that the clinical 
history of these cases affords a great variety of symptoms, more especi- 
ally up to the time of perforation ; after perforation has taken place 
each case has many symptoms in common. Although the perforation 
in every case is due to the presence of intestinal microbes, the time 
occupied in accomplishing perforation may vary from, say, thirty-six 
hours to as many days. The sufferings of the patient during the time 
may be constant and intense or may be paroxysmal, or the process may 
be painless. 

The clinical history of each case up to the time of perforation is in 
strict accordance with its etiology or pathology. Most of the cases of 
perforation which are caused by obstruction of the appendicular open- 
ing, and probably some of the cases of stricture of the canal, give a 
clinical history of great pain for a few days at least. This may be called 
the appendalgic period. The cases of perforation that result from com- 
plete strangulation of the appendicular artery by twisting, etc. are quite 
free from pain until the perforation has taken place. The sudden in- 
tense pain, collapse, violent peritonitis, phlegmonous inflammation, or 
the death of the patient, as the case may be, follows close upon the per- 
foration. The patient has no warning of the impending intra-abdominal 
storm. The perforation in these cases is gangrenous or necrotic, while 
the perforation in the obstructive tyjae is for the most part ulcerative — 
simply a slower death of the part. Acute perforative appendicitis does 
not necessarily mean that the perforation takes place with the first at- 
tack ; it implies the rapid breaking down of the wall. It may be a 
relapsing or recurrent case, more especially when it is obstructive. 

In following the clinical history of these acute perforative cases we 
divide them into perforative painful cases and perforative painless cases. 
In the former the period of pain before perforation may be from twenty- 
four hours to six days. The perforation, as a rule, takes place within 
the six days. The patient is suddenly seized with severe colicky pains 
of a cramping, twisting nature, extending over the whole abdomen and 
accompanied by severe vomiting or vomiturition, and not infrequently 
high temperature ; the pain and cramps are sometimes quite confined to 
the right side, so much so that appendalgia has been diagnosed as renal 
colic. But more often they radiate over the whole abdomen or may circle 
about the umbilicus ; occasionally the pain is felt more to the left side, 
owing no doubt to an anomalous position or length of the appendix. In 
exceptional cases the perforating period manifests itself by a constant 
dull, deep, heavy ache. The fever in these cases is not usually high 
and the vomiting is not frequent. In a few cases, more especially in 
children, there is catarrhal diarrhoea preceding or accompanying the first 
pains, but more frequently the bowels are constipated. In the cases 
where constipation precedes the attack unless the impaction is in the 
caecum it is in all likelihood purely incidental. Anorexia, coated tongue, 
thoracic breathing, rapid pulse, and rigid and sensitive abdominal walls 
furnish the clinical picture of this acute perforative period. 

The Second Stage. — We recognize the exacerbation of symptoms, 
which are suddenly ushered in by the perforation of the appendicular 
wall and the escape of the contents of the appendix into the peritoneal 



294 APPENDICITIS. 

cavity, as the second stage of this type of appendicitis. We have seen 
that the perforation may appear as early as twenty-four hours or the 
first stage may be of several days' duration. The new exacerbation of 
jDain is usually intense ; the suffering is so intolerable that the patient 
makes no effort to locate it ; in fact, the agony is too often so severe 
that the patient's attention cannot be directed to any one particularly 
tender location. The physician of experience soon realizes that he has 
on his hands a case of diffused peritonitis of intense type. The patient 
assumes the dorsal decubitus position, with his knees drawn up, his head 
thrown a little back, so that the chin is somewhat elevated ; the breath- 
ing becomes rapid, shallow, and thoracic ; the abdominal ■walls are rigid 
and extremely tender to pressure, the weight of the bed-clothes being 
often intolerable ; vomiting is too often an early symptom and one that 
adds to the patient's terrible distress. Every effort to vomit causes an 
agonizing expression, and a look of appeal to the physician for relief that 
is not likely soon to be forgotten. The temperature usually ranges from 
about 101° to 102° F., though sometimes it is subnormal, but occasion- 
ally reaches 105° F. The pulse is frequent and fine or thready. Ob- 
stinate constipation is the rule, due no doubt to a paralysis of the 
muscular structures of the intestines, more particularly of the colon. 
The urine generally contains some albumin, and always indican, and is 
scanty and high colored. Frequent micturition with cystospasmus is a 
distressing feature of many cases, while cystoplegia is the exception. 
The oliguria and albuminuria are by most writers attributed to the 
elimination of ptomaines by the kidneys which have been absorbed by 
the blood from the intestinal tract, or the elimination of microbes which 
the blood has absorbed from the abdominal cavity, or to the heart weak- 
ness or want of arterial force. In many of my own cases the oliguria 
was certainly due to the inability of the stomach to retain fluids. No 
fluid being absorbed from the stomach, very little urine is eliminated. 
And I can see no reason why such a marked change in the functional 
activity of the kidneys — from eliminating fifty or sixty ounces of urine 
daily to, say, five or six ounces or even less — should not disturb and de- 
range the tubular and glomerular epithelium, and hence the albumin. 
The frequent micturition and tenesmus may be the result of pericys- 
titis or a chemical change in the condensed urine. The rigidity of the 
abdominal walls, especially in strong men, is sometimes extreme. The 
walls are very painful to the slightest touch, and the tenseness, rigidity, 
and tenderness preclude all possibility of obtaining any information of 
the abdominal contents by palpation or percussion. There is often no 
great tympanites with this intense rigidity in men, but in women who 
have borne children, whose abdominal walls are weak, the tympanitis is 
frequently extreme. After a few hours of suffering we may expect to 
see the peritoneal facies and pinched expression, dull, sunken eyes, cold, 
clammy extremities, dry lips and tongue, feeble, thready pulse, shallow 
thoracic breathing, with moaning expiration, hiccough, and death. 

At least 80 per cent, of these cases die within the week after per- 
foration. Perforation of the stomach and intestines gives about the 
same clinical history. The immediate shock following perforation 
seems much less in some cases than in others, and the inflammation 
of the peritoneum which follows varies in rapidity and intensity in dif- 



RECURRENT INTERMITTENT APPENDICITIS. 295 

ferent individuals. In peritonitis, as in other septic diseases — diphthe- 
ria, for instance — the patient may die on the second or third day. 
Death may be due to the virulence of the poison absorbed or the greater 
amount absorbed, or to the peculiar susceptibility of the patient to the 
particular poison. Undoubtedly many individuals seem to possess a 
weak hold on life ; occasionally one weathers the first week's storm only 
to die later, apparently from sheer exhaustion. 

Acute Parietal Appendicitis, with Circumscribed or General Peri- 
tonitis, without Perforation or Suppuration. 

The group of symptoms which we now diagnose as acute appendi- 
citis with circumscribed peritonitis that sometimes becomes general, 
and that terminates in resolution, was a few years ago called peri- 
typhlitis ; the probabihty is that an occasional case is that of peri- 
typhlitis without involvement of the appendix. A purely catarrhal 
appendicitis will sometimes very closely assimilate this mural type. 
The tenderness of the right iliac region and an apparent swelling may 
be mistaken for circumscribed peritonitis. A careful examination, how- 
ever,- reveals the fact that the abdominal wall in catarrhal appendicitis 
has not the rigid and indurated feeling that it has in peritonitis. The 
pain is more continuous and less colicky than in catarrh, and the tem- 
perature is more steady, though it may not be very high. In circum- 
scribed peritonitis the rigidity and induration and tenderness of the 
abdominal walls over the swelling are well marked. The right leg (if 
not both legs) is drawn up, more or less fixed, and its motion is painful. 
This variety of appendicitis may be either relapsing or recurrent. A 
patient of mine, a young man about eighteen, had in about one year 
and a half three well-marked attacks of recurrent appendicitis, and with 
each a circumscribed peritonitis. It is now nearly two years since his 
last attack. He determinedly refused an operation. 

The inflammation in these cases is no doubt strictly fibrinous. The 
chances of phlegmonous inflammation, a purulent collection ending in 
resolution, is scarcely possible and surely not probable. We use the 
word " resolution " in its proper sense, for a purulent collection may of 
course be evacuated into the ceecum, for instance, and the patient get 
well. 

The DIAGNOSIS of this form of appendicitis depends entirely upon 
the symptoms of the second or fibrinous stage — that is, the stage of peri- 
toneal involvement. The symptoms of the first stage cannot be differ- 
entiated from appendalgia or the catarrhal form. The difference in the 
duration of the two forms is characteristic, the catarrhal lasting but a 
few days, while the fibrinous exudative variety is seldom fairly conva- 
lescent in less than three weeks. 

Recurrent Intermittent Appendicitis. 

Neither recurrent nor relapsing (remittent) appendicitis is, strictly 
speaking, entitled to be considered a distinct variety or form of the dis- 
ease. The difference between recurrent and remittent appendicitis is 
similar to intermittent and remittent fever : the terms remittent and 
intermittent appendicitis are pathologically more correct and clinically 



296 APPENDICITIS. 

just as imderstandable, and therefore preferable to the terms relapsing 
and recurrent. Either catarrhal or mural appendicitis may become 
relapsing — /.f. chronic; that is, between the acute paroxysmal attacks 
the inflammation almost, but not altogether, subsides. If following the 
attack of appendicitis the tenderness and swelling entirely disappear, a 
subsequent attack is called recurrent. This clinical distinction is useful 
and in a way justifiable, but may not be pathologically correct. We 
stronoly suspect that the inflammation does not entirely subside, though 
the tenderness and swelling do ; if all trace of the inflammation subsides 
and the patient is entirely well after his first attack of appendicitis, why 
should it predispose him to a second attack? In intermittent fever, 
while the patient is apparently well for twenty-four or forty-eight hours 
between the chills, no one for a moment supposes that he is during this 
intermission free from the bacillus malarise. In recurrent (intermittent) 
appendicitis it is not probable that the bacillus coli communis and other 
intestinal micro-organisms are entirely inactive in either the retained 
secretions or in the walls of the appendix during the intermission of all 
tenderness and swelling. 

There is nothing necessarily peculiar in the clinical history of an 
intermittent or remittent attack to distinguish it from a preceding one. 
There is no definite period of time between the attacks, and either the 
relapsing or recurrent may follow the preceding attack in a few weeks 
or a few months : some writers would have it that in return cases there 
is a predisposing condition existing. To sustain their opinion they are 
forced to the supposition, however, that the intervals between the 
attacks were accompanied by complete restoration to health. 

Pus ; Abscess ; Phlegrnonous Appendicitis. 

The character, location, and cpiantity of the pus in appendicular 
abscess vary greatly in accordance with the position of the appendix, 
its adhesion, its length, and the diathesis of the patient. The pus is 
seldom what the old winters call laudable ; usually it is a thin, sero- 
purulent, floccular, and yellowish green liquid, the odor of which is 
extremely offensive. The abscess not infrequently contains offensive 
smelling gas and fecal matter, or perhaps the scybalum, coprolith, or 
other foreign body whose presence in the appendix had given rise to the 
inflammation, and which had escaped from the appendix through the 
perforation. 

Location. — The purulent accumulation must necessarily be intra- 
or extraperitoneal. When the appendix is free in the abdominal cavity 
the abscess is of course intraperitoneal. When the appendix is given 
off from the posterior caecal wall, ascends behind the caecum and ascend- 
ing colon, and is adherent to or surrounded by the cellular tissue of that 
region, the appendicular abscess will be extraperitoneal and may invade 
the lumbar region. Many of the obscure cases of lumbar abscess, as 
well as some of the supposed perinephritic abscesses, are no doubt ap- 
pendicular. Occasionally we find an abscess in the anterior abdominal 
wall extraperitoneal ; pathologically, it is a phlegmonous inflammation 
of the subserous (peritoneal) cellular tissue. Such an abscess occurred 
in the case of a physician upon Avhom the writer operated. As a curious 



COMPLICATIONS AND SEQUELS OF APPENDICITIS. 297 

coincidence^the writer had operated for appendicitis upon three children 
only a few months before for the same physician. There are probably 
other conditions of the appendix which favor extraperitoneal abscess ; 
for instance, some cases of jjelvic inflammations (pelvic cellulitis) are 
the result of inflammations of a misplaced and adherent appendix. The 
inward and downward direction of the appendix may in case of its 
inflammation give rise to a pelvic peritonitis and abscesses that can be 
felt per rectum or per vaginam and behind the bladder. These are the 
cases, no doubt, that evacuate themselves through the rectum, bladder, 
or vagina. The size of the abscess or quantity of pus varies with each 
case from a small pus collection the size of a walnut to that of a quart 
measure. 

Complications and Sequels of Appendicitis. 

Gangrene. — Gangrene and perforation are complications, inasmuch 
as neither of them is a necessary result of appendicitis. A gan- 
grenous termination to appendicitis is usually the result of an impedi- 
ment or an obstruction to the appendicular circulation from a torsion or 
twist or strain upon the artery, or it may be the result of the involve- 
ment of the vessel in the inflammation — thrombosis. The phlebitis or 
endarteritis, or both perhaps, completely occlude the nutrient vessel. 
When the nutrient artery is a terminal one, as is the case in the appen- 
dix, gangrene may be expected as a frequent complication. Gangrene 
has been found to have already taken place within twelve or fifteen 
hours after the clinical history would indicate the commencement of the 
attack. The clinical history of these cases is surely misleading, the 
thrombosis having probably preceded by many hours the appendalgia 
and fever. 

While the appendix is not highly vitalized (no vestigiary organ is) 
the organ will not become gangrenous by twelve hours' deprivation of 
nourishment. Gangrene sometimes invades the neighboring tissue, 
bloodvessels, etc. 

Perforation. — Perforation is a very frequent complication of appen- 
dicitis, an obstruction in the csecal opening causing an accumulation of 
the appendicular secretions, which affords an excellent opportunity for 
the generation of pathogenic bacteria which are doubtless the destruc- 
tive agents. Occlusion of the appendicular canal may occur from an 
impacted foreign body or from stricture the result of inflammation of 
the mucous and submucous membranes. In the case of impaction the 
consequent venous stasis or passive congestion adds to the chances of 
perforation. 

Peritonitis. — So fatal a disease as peritonitis must necessarily be a 
serious complication, and when an accompaniment of appendicitis it 
becomes extremely dangerous. An appendicular peritonitis is neces- 
sarily secondary and septic, and when diffuse, whether phlegmonous or 
not, offers an enormous absorbing surface which is likely to seriously 
tax the strongest constitution. Fortunately, appendicular peritonitis 
is oftener circumscribed than diffused. 

Stomach. — Persistent vomiting is not only a most distressing, but a 
dangerous, complication of appendicitis. The reflex vomiting which 



298 APPENDICITIS. 

for the most part accompanies the onset of the disease, though painful, 
is not dangerous. Determined and persistent vomiting in appendicular 
peritonitis is an alarming symptom, and in most cases, no doubt, is 
caused by gastric peritonitis, the involvement of the serous investments 
of the stomach. 

Hiccough. — Hiccough is particularly painful and exhausting in 
appendicular peritonitis, and as a rule only accompanies the last stage 
of the disease. 

Liver complications are much to be dreaded. Pylephlebitis and 
hepatic abscess constitute the most formidable complications. Fortu- 
nately, they are becoming less frequent, with every prospect of the 
number of cases being still further reduced. It is only in the latter 
stage of the disease, when the mesenteric veins, the highways and 
byways to the portal circulation, become thrombic and embolic, that 
there is danger of pylephlebitis or hepatic abscess. Not only are cases 
of liver complications becoming less frequent, but all the complications 
and sequelae which result from chronic appendicitis are less numerous 
in consequence of timely surgical treatment. 

Lungs and Pleura. — It is safe to say that the lungs are very seldom 
involved. All the thoracic complications or sequelae of appendicitis 
are secondary. I have seen pneumonia and empyema as the result of 
both the appendicular and hepatic and diaphragmatic peritonitis, as 
well as from hepatic suppurations. In exceptional cases the appen- 
dicular hepatic abscess or empyema breaks down the lung tissue and 
is discharged through the bronchi. Septic pneumonia may occur from 
iliac phlebitis, and septic emboli from the thrombic veins act as pneu- 
monic foci. Pulmonary tuberculosis may be complicated with tuber- 
cular appendicitis. 

Heart. — I have never met with a case of pericarditis from appen- 
dicular, hepatic, or diaphragmatic peritonitis, but cases of the kind 
have been reported. 

Phlebitis. — While inflammation of the mesenteric veins is frequent,, 
and of the veins of the liver (pylephlebitis) is not very common, throm- 
bosis of the iliac vein is quite a rare complication. 

Hemorrhage. — Both the iliac veins and arteries may possibly become 
involved in the gangrenous process that sometimes extends to the sur- 
rounding tissue from a gangrenous appendix ; a fatal hemorrhage is the 
result. The same accident may occur when there exists a varicose 
condition of the mesentery or ovarian veins. 

Bowels. — The most frequent intestinal complication is constipation, 
which in a large percentage of cases seems to be the result of a par- 
alysis of the muscular structure. An occasional case of obstinate 
constipation or obstruction occurs from an inflamed, adherent, and 
contracted appendix, Avhich is wound around the intestine. Even a 
circumscribed gangrene of the intestinal wall may occur from an 
adherent gangrenous appendix. The perforation of an abscess into the 
bowels or rectum is an occasional occurrence. The csecum is the por- 
tion of the bowel that is most frequently the subject of this complica- 
tion. This latter accident happens more especially when the abscess 
is situated behind the caecum and ascending colon. Acute appendicitis 
has been found in both inguinal and hernial sacs. 



COMPLICATIONS AND SEQUELS OF APPENDICITIS. 299 

Bladder\. — It is rather a rare occurrence for an appendicular abscess 
to be discharged through the bladder. This complication occurs almost 
exclusively in women, and most probably only when the appendix is 
situated in the pelvis. A few months ago the writer was called to see 
a case where a large quantity of pus and fecal matter was being dis- 
charged from the bladder. On investigation the case was found to be 
one of recurrent appendicitis. The young woman, aged eighteen, had 
had two previous attacks, one of which had resulted in a lumbar 
abscess, and on the other occasion the abscess was evacuated through 
the bowels. She absolutely refused all surgical aid. The pus and fecal 
matter ceased to appear in the urine in about ten days. This might be 
considered a rather remarkable case — three attacks of appendicitis, each 
being phlegmonous with a large collection of pus. The first discharged 
through the lumbar region, the second through the bowel, the third and 
last discharged through the bladder, and the young woman now enjoys, 
apparently, a complete intermission with fair health, but presents a 
tuberculous appearance. In the case of lumbar abscess it is always, of 
course, possible that it may have been the result of perinephritis or 
some spinal disease. The clinical history of each case of lumbar 
abscess demands a very careful investigation. 

Tuberculosis and Syphilis. — Tubercular and syphilitic ulceration of 
the mucosa of the appendix is a frequent occurrence, and probably is, 
for the most part, secondary to tubercular and syphilitic ulceration of 
the caecum or some other portion of the intestinal tract. 

Pregnancy. — Cases of appendicitis are occasionally reported as com- 
plications of pregnancy or the puerperal state. When such cases occur 
they are usually coincident and not complications. A woman might 
have appendicitis while carrying a uterine fibroid or an ovarian tumor. 
A patient of the writer's while the subject of softening of the brain 
had an attack of appendicitis, and a gentleman not long since had an 
attack of appendicitis when convalescing from a gunshot wound of the 
shoulder. Such cases are purely incidental. 

Fallopian Tubes. — We have already seen that the appendix is liable 
to occupy a position in the pelvis, especially in women. It has been 
found attached to the Fallopian tubes, to become gangrenous in this 
position, and thus to implicate the tube in the gangrenous process; and 
pyosalpinx sometimes has its origin in the inflammation of an adherent 
appendix. 

Diagnosis. — One gathers from the vast amount of literature that 
is being published on appendicitis that it is often a very obscure 
disease and extremely difficult of diagnosis. If a physician knew 
nothing of the pathology and symptoms of pneumonia, he would be 
unable to diagnose the disease, and would no doubt think the group 
of symptoms was the expression of an obscure affection. There are no 
doubt general practitioners in active work to-day who do not possess a 
work on the practice of medicine or surgery, or even a dictionary, that 
contains the word " appendicitis." Many general practitioners, it must 
be remembered, are also prone to be negligent in regard to current 
medical literature. To these, and these only, is appendicitis an obscure 
disease and difficult to diagnose. It is only in very exceptional cases 
that the diagnosis of appendicitis presents difficulties. To the physi- 



300 APPENDICITIS. 

cians and surgeons of any considerable medical centre, who keep abreast 
of the medical literature of the day, who attend county. State, and 
national medical societies, the diagnosis of appendicitis is not as dif- 
ficult, is less obscure, and less likely to be overlooked than is either 
tubular or intertubular nephritis. One would also gather from the pro- 
fuse surgical literature on appendicitis in the medical journals that it 
recpiires a surgeon to diagnose and treat every case of appendicitis. 
Except in the large cities the general practitioner is obliged to diagnose 
and treat his surgical as well as his medical cases, and in very many 
instances he is as capable a surgeon as he is physician. As not more 
than 5 to 10 per cent, of deaths occur in appendicitis that are not 
operated upon, it would seem, even in the large cities, that a physician 
might be able to treat the most of them without surgical assistance ; and 
we presume it will be readily granted that a good physician is as ca- 
pable a diagnostician for internal diseases, at least, as a good surgeon, 
yet, according to much of the surgical literature on appendicitis, such 
would seem not to be the case. "I have seen the surgeon forced to 
defer operation in appendicitis because the opinion of the majority of 
the medical attendants was opposed to such a procedure, they holding 
the case to be one of typhoid fever." ^ At most not more than 5 per 
cent, of the cases of appendicitis are very difficult to diagnose, and this 
may be said for almost any other disease ; and any one who has had 
much experience with the diagnosis of abdominal diseases knows that 
nothing short of exploratory incision will clear up the diagnosis of 
some cases, and this applies to diseases of every organ in the abdominal 
cavity. Twenty years of abdominal surgery has taught the writer to 
reserve his diagnosis in some cases of abdominal disease until he gets 
his hand into the cavity ; even then he is occasionally reminded that 
it requires more than the sense of touch and the macroscopic appearance 
of the pathological condition to diagnose the exact pathology of the 
case. As a rule, it is the complications that obscure appendicitis and 
make the diagnosis difficult. There are practitioners who find none of 
the difficulty that so many encounter in the diagnosis of this protean 
abdominal disease. " We do not need exploratory incisions to determine 
whether a patient has appendicitis or not." ^ " The diagnosis can and 
should be made in a few minutes."^ In 90 per cent, of the cases, at 
least, of appendicitis the diagnosis is very readily made by the previous 
history of the case, the acuteness of the attack, the character and loca- 
tion of* the pain, the circumscription of the tenderness, the development 
of dulness or tumor over the csecal region, the rigidity and resistance 
of the abdominal walls, the temperature, the wiry abdominal pulse, 
the decubitus of the patient, the character of the breathing (short and 
thoracic), the age, sex, habits, and occupation of the patient, and the 
accompaniment of nausea and vomiting, with the information obtained 
by a rectal or vaginal examination, which makes the picture unique, 
the diagnosis unmistakable. The nature and location of the pain are 
characteristic. The pain is sudden and colicky, radiating over the 
lower two thirds of the abdomen or circling about the umbilicus. 
Soon, however, the radiating pain becomes less, and, from being more 

^ Deaver on Appendicitis, p. 94. ^ Morris, p. 164. 

'^ Deaver on Appendicitis, p. 123. 



COMPLICATIONS AND SEQUELS OF APPENDICITIS. 301 

severe about the umbilicus, concentrates itself over the ilio-csecal region. 
The pain is now more constant and less violent and colicky. As it con- 
fines itself more particularly to the right iliac region, palpation demon- 
strates that this location is distended, extremely tender, rigid, and 
resistant. The stress laid upon point tenderness is not without its 
value. 

Though the tenderness is not by any means, in every case, on a line 
from the anterior superior spinal process of the ilium to the umbilicus 
(McBurney), a careful palpation does generally elicit a particularly 
tender point, perhaps at the base of the appendix, or may be at the 
extremity or over its anomalous position. In pelvic appendicitis a 
tender point in most cases can be detected by vaginal or rectal exami- 
nation. When the appendix points upward the tender point is usually 
in the location of the gall-bladder. In parietal appendicitis — at least 
after the acute stage of the inflammation has in a measure subsided — 
by a careful examination the swollen and enlarged appendix can gener- 
ally be felt, unless the abdominal wall is too rigid and tender and too 
thick. It is well to bear in mind that palpation and percussion must 
be cautiously done when gangrene or recent perforation of the appendix 
is suspected, and under no circumstances must palpation be done in a 
jerky, punching manner : the palmar surface of the fingers of one hand 
should be placed flatly on the abdomen over the csecal region, and 
steady, firm pressure made while the hand is drawn from near the um- 
bilicus to the crest of the ilium. The fingers must be educated to feel 
what is beneath the abdominal wall with as much accuracy as the blind 
man educates his fingers to read raised letters. It is sometimes w^ell to 
first locate the ascending colon above the most rigid and tumefied por- 
tion of the wall, and by following the colon downward the csecum can 
be distinctly outlined, when the swollen, tender, and enlarged appendix 
can quite readily be located by palpation and percussion when its posi- 
tion is normal. In a case under treatment at present on the third day 
the appendix could be outlined less than halfway from the crest of the 
ilium to the umbilicus, and extending two and a half inches almost 
perpendicularly from a little above Poupart's ligament. A decided dis- 
tention of this region is also manifest with dulness even before a cir- 
cumscribed peritonitis is established. As the disease advances and the 
adhesions form the fulness becomes more pronounced ; the abdominal 
distention and tympanitis are not extreme in the absence of general 
peritonitis, and not always pronounced when it is diffused. 

With the involvement of the visceral layer of the peritoneum and 
with intestinal paresis tympanites is extreme in appendicitis. In dis- 
tention from impaction the rigidity and tenderness are absent and 
borborygmus is usual. As a result, the patient assumes the dorsal 
decubitus position, and by the second or third day draws up the right 
leg, and occasionally finds relief by drawing up both legs. It would 
seem to be traditional that the drawing up of the right knee more par- 
ticularly indicates that the appendix is given off posteriorly, and its 
inflammation involves the cellular tissues of the ilio-psoas. As a rule, 
the knees are flexed when the peritoneum becomes involved. In the 
absence of diffused peritonitis the left leg is moved freely. The right 
leg is flexed and the movements are accompanied with pain whenever 



302 APPENDICITIS. 

the inflammation extends down into the iliac fossa. The respiration is 
usually hurried from the first, and becomes distinctly thoracic, with 
lessened abdominal breathing. There is an anxious and depressed 
look, and the chin ts generally elevated ; 80 per cent, of the cases will 
occur between the ages of ten and fifty years, and will be found four 
times oftener in men than in women. Habits and occupations are re- 
sponsible for the greater frequency of the disease in men than in women. 
The nausea and vomiting in a great measure cease with the first stage 
of the disease, and are evidently reflex — probably leucomainic irritation 
of the sympathetic nerves, as the vomiting does not seem to be induced 
by or depend upon the contents of the stomach. Persistent vomiting 
later in the disease would indicate involvement of the serous coat of 
the stomach. It is the complicated cases and the diseases that may be 
mistaken for appendicitis that give rise to diagnostic difficulties. Tala- 
mon gives hepatic colic, nephritic colic, indigestion, and entero-colitis 
as the conditions most likely to be confounded with or mistaken for 
appendicitis. To be sure, in any of the above conditions it may require 
care to differentiate them from appendicitis. The practitioner who has 
had some experience with abdominal surgery has no doubt met with 
abdominal diseases that are much more difficult to differentiate from 
appendicitis than those mentioned by Talamon. To Talamon's list we 
will add a few more diseases : Acute perforating ulcer of the stomach 
or duodenum or perforation of the ileum or caecum or gall bladder ; 
cholocystitis or intussusception, especially ileo-csecal; internal strangula- 
tion, hernia, volvulus, impaction of faeces or foreign bodies, typhlitis and 
perityphlitis ; movable kidney that has become inflamed and adherent 
behind the caecum ; floating kidney, and diseases of the Fallopian tubes, 
extra-uterine pregnancy, hsematocele, hip-joint disease, lumbar abscess, 
and typhoid fever. Some of these, at least, are of sufficient importance 
to warrant a consideration in detail. 

Liver and Gall Bladder. — Neither pylephlebitis nor abscess of the 
liver is likely to be mistaken for acute appendicitis, but when they are 
secondary to appendicitis the primary disease (appendicitis) may very 
readily be overlooked, unless the history of the case is very carefully 
traced. 

Hepatic Colic (Cholocystalgia). — Great care may be required to differ- 
entiate this condition from appendicitis and appendalgia. They have 
many symptoms in common, such as pain, its sudden commencement, 
its paroxysmal and radiating character, and nausea and vomiting. In 
hepatic colic the pain is felt more in the upper half of the abdomen, 
and gives more of a diaphragmatic restricted feeling and concentrates 
less about the umbilicus. Usually before twenty-four hours the pain 
in hepatic colic is localized over the gall-bladder and above a hori- 
zontal line drawn through the umbilicus, and jaundice begins to mani- 
fest itself. The vomiting is more continuous, and with the jaundice 
the urine becomes porter-like in color. In appendicitis the tender 
point is located below the level of the umbilicus and near the crest 
of the ilium, and occupies the right iliac fossa. The temperature in 
hepatic colic is very irregular, especially if the attack be prolonged, 
often reaching 104° or 105° F., to drop down in a few hours to normal 
or subnormal. In appendicitis the temperature is not so high and is 



COMPLICATIONS AND SEQUELS OF APPENDICITIS. 303 

more steadj. There is an absence of jaundice in appendicitis, and the 
urine is not colored with bile. 

Gall Bladder. — Rupture of the gall bladder simulates rupture of the 
appendix even more closely than does cholocystalgia. An exact diag- 
nosis is impossible when one is called to a patient in great abdominal 
pain, in a condition of collapse, with anxious and sunken expression, 
severe vomiting, and no circumscribed appendalgic peritonitis, no jaundice. 
There are cases of rupture of the appendix without any history of appen- 
dicitis, and rupture of the gall bladder may occur where there is no 
jaundice or previous hepatic colic. In the majority of cases, however, 
previous to the rupture of any of these organs there is an unmistakable 
clinical history that will enable a diagnosis to be made. 

Kidney. — An attack of renal colic of the right kidney on account of 
the location of the pain might possibly be mistaken for appendalgia. 
In nephralgia the pain very generally shoots down the line of the ureter 
or is often felt in the testicle. There often is hypersesthesia of the blad- 
der, with cystospasms and occasionally hsematuria. 

Floating Kidney. — A patient with a floating kidney is often the sub- 
ject of attacks of nephralgia, which may have many symptoms in 
common with appendalgia ; the kidney-shaped movable tumor should 
establish the diagnosis. 

Movable Kidney. — A movable right kidney could only be mistaken 
for an appendicitis when inflamed and fixed in its displaced position, 
but the clinical history of the case, with an intelligent interpretation of 
the objective symptoms, should enable one to make a differential diag- 
nosis. An abscess high up behind the ascending colon, resulting from 
perforation of a posterior ceecal appendix which points upward, might 
very readily be mistaken for abscess of the liver or suppuration of the 
gall bladder or paranephritic abscess or nephrosis or tuberculosis of 
kidney and ureter or psoas abscess. Unless there is permanent obstruc- 
tion to the ureter, pus will be present in the urine in pyonephrosis and 
tubercular kidney. It must be remembered, however, that especially in 
tubercular kidney the lumen of the tubercular ureter is lessened, and 
for several consecutive days there may be nothing escaping from the 
diseased kidney ; in the mean time the healthy kidney is excreting 
normal urine. It is not unusual that the urine must be examined for 
several days before it is found to contain pus. Great difficulty will 
sometimes be encountered in differentiating psoas abscess. The rigidity 
and resistance of the abdominal wall are absent, as is also the enlarged 
and tender appendix. In doubtful cases as to the presence of pus the 
diagnostic value of the needle and aspirator must not be forgotten. By 
resorting to the use of the needle no doubt the operator would gain the 
contempt of some experts, but might confirm his diagnosis and save a 
patient from needless operation, and save his life. Experts who have 
so dogmatically condemned the use of the exploratory puncture do not 
realize how disastrous it w^ould be to the general country practitioner to 
subject a patient to an operation for appendicitis or abscess and have 
to acknowledge that he had made a mistake in his diagnosis. With 
proper aseptic jjrecautions a carefully made exploratory puncture can 
scarcely ever be harmful, and may often be of great assistance in estab- 
lishing a diagnosis and in determining the necessity of operative 



304 



APPENDICITIS. 



measures. An ordinary hypodermic syringe with a rather large-sized 
needle will generally answer the purpose. Notwithstanding all that has 
been said by experts against exploratory puncture, it is not only justi- 
fiable, but often helpful to the general practitioner, who very frequently 
is unable to procure either consultation or assistance, but must deal with 
diseases and conditions with which he is not very familiar and in which 
he has had perhaps little experience. 



Appendicitis. 

Pain. — Colicky, radiating, 
over lower two thirds of 
abdomen, circulating 
about umbilicus, and be- 
coming fixed in right iliac 
fossa. Develops tender 
point (McBurney's). 

Vomiting is usual, but not 
extreme. 

Bladder and testicle symjD- 
toms absent. 

Urine, normal. 

Jaundice, absent. 



D iffe) -ent iation. 
Cholocystalgia. 

Eadiating over upper half 
of abdomen and toward 
right shoulder ; develops 
tenderness over gall blad- 
der. 



Is a pronounced feature, and 
is persistent. 

Bladder and testicle symp- 
toms absent. 

May contain bile. 

Present. 



Nephralgia. 

Kadiating less over abdo- 
men, but down the ureter 
to testicle and head of 
penis, and often irritates 
rectum. Develops ten- 
derness over kidney in 
lumbar region. 

Is pronounced, but not so 
persistent. 

Bladder hyperaesthesia ; 

often cystospasraus. 

May contain blood and 
mucus. 

Absent. 



The above differentiation stands for the rule ; there are exceptions. 
When the appendix, for instance, points upward and the inflammation 
is at the apex, the pain is in the upper portion of the abdomen, with 
great tenderness in the region of the gall bladder or over the right 
kidney. When the appendix is in the pelvis, appendicitis may give 
pain on the left side of the median line, with irritability of the bladder 
or perhaps cystitis. 

Stomach. — It is barely ])ossible that a severe attack of gastralgia 
might be mistaken for appendalgia. Care should be taken with the 
history of the case and attention paid to the subjective symptoms. The 
pain and tenderness should be located over the stomach. The pain does 
not radiate over the whole abdomen, as in appendicitis. As for the 
roimd acute perforating ulcer of the stomach, it is quite impossible to 
differentiate it from sudden perforation of the appendix ; that is, in the 
case of appendicitis where the perforation takes place without being 
preceded by appendalgia or peritonitic symptoms. 

Intestines. — Intussusception, more especially ileo-csecal, gives some 
symptoms in common with appendicitis — viz. the location of the pain 
and fulness or tumor and vomiting. The tenesmus with diarrhceal dis- 
charges containing blood and mucus would, of course, make for intus- 
susception, and the latter disease is most frequent in infancy and childT 
hood, a period of life in which appendicitis is rather uncommon. 

Hernia (internal, abdominal) may readily be confounded with ap- 
pendicitis. The suddenness of the attack, the pain, the vomiting, the 
peritonitis that so often accompanies it, and the obstruction of the 
bowels, are all symptoms in common. In hernia the vomiting is more 
persistent, and soon becomes stercoraceous, while the tympanites is more 
pronounced. 

Volvulus also may be mistaken for appendicitis ; in both of these 



COMPLICATIONS AND SEQVELM OF APPENDICITIS. 305 

diseases it ii\ay be impossible to differentiate them from appendicitis, at 
least during the first twenty-four to thirty-six hours of the attack. If 
by this time there is no indication of pain and tenderness becoming 
located in the right iliac fossa, and no tender point developed, there is a 
strong suspicion that the case may not be appendicitis, and an explora- 
tory incision may be necessary to make a diagnosis. The symptoms of 
perforating ulcer of the duodenum or ileum in no way differ from per- 
forating ulcers of the stomach or rupture of the gall bladder, unless the 
history of the case previous to the rupture w^ould indicate the particular 
accident. Exploratory incision is the only means of making an exact 
diagnosis. 

Typhlitis, peri- and paratyphlitis, are manifested by much the same 
group of symptoms as has been described for diseases of the appendix. 
In typhlitis the tenderness is perhaps not so circumscribed ; there is no 
McBurney point. On pressure the pain seems nearer the surface and 
nearer the crest of the ilium, and the caecum is more often found im- 
pacted — that is, a stercoral tumor is more often present. It is always 
of the greatest importance to cultivate observation and the sense of 
touch, and exercise the best judgment, in order to differentiate diseases. 
But when dealing with a case that might be either perforation of the 
stomach or bowels or gall bladder or appendix, or internal abdominal 
hernia or invagination, a prompt laparotomy is of much more import- 
ance to the patient than an astute guess at differential diagnosis : when 
in doubt, operate. 

Coxitis. — For one who has never seen a case of appendicitis or para- 
typhlitis mistaken for a case of coxitis it may be difficult to imagine its 
possibility. In scrofulous children, more especially, the mistake may 
occur, as one is always on the lookout for coxitis, and might naturally 
fall into the mistake. My own experience furnishes one such case of 
appendicitis. The boy was under treatment for hip-joint disease by a 
distinguished surgeon. Dispensing with his weights and pulleys, the 
evacuation of a perityphlitic abscess resulted in the boy's complete 
recovery. That a para-appendicitis or typhlitis or appendicitis should 
produce pain in the hip or knee is not surprising, since both the obtu- 
rator and anterior crural nerves descend through the fibres of the psoas 
muscle, and both send branches to the hip-joint and knee-joint. 

Extra-uterine Pregnancy, Pelvic Hcematocele, Salpingitis and Pyo- 
salpinx. Pelvic Appendicitis. — It is only in sudden rupture of an ovisac 
that this condition (extra-uterine pregnancy) might be mistaken for 
perforation in appendicitis. The profound collapse that usually follows 
the rupture of the ovisac, on account of the hemorrhage wdiich mostly 
follows, makes against appendicitis. When a history can be obtained 
there have been symptoms of pregnancy previous to the collapse, but 
the puerperal age is to be considered. 

Pelvic Hcematocele. — This condition has many symptoms in common 
with pelvic appendicitis. The symptoms of loss of blood, the sudden 
appearance of tumor, the characteristic feel of a tumor, etc. must assist 
in the differentiation of the disease. But much depends upon the situa- 
tion and size of the blood-clot, whether intra- or extraperitoneal or a 
hsematosalpinx. The sudden appearance of a retro-uterine tumor, with 
symptoms of internal hemorrhage, should not be mistaken. Slow 

Vol. III.— 20 



306 APPENDICITIS. 

hemorrhage from varicose veins of the broad ligament might cause the 
diagnostician very great difficulties. In most cases of haematocele there 
is a history of uterine or ovarian disease. 

Pelvic Appendhitis. — While appendicitis occurs four times more 
often in men than in women, the appendix is found in the pelvis much 
more often in women than in men. The broad, flaring, shallow pelvis 
of the woman offers facilities for the more ready descent of the appen- 
dix. Forcing down the abdominal organs by tight lacing, especially 
where the caecum is loaded (and women are very subject to constipa- 
tion), is another important factor. The weakening of the abdominal 
walls by pregnancy, as Avell as the sudden contracting down of the 
uterus after delivery from its abdominal position during pregnancy into 
the pelvis, also must have an influence in displacing the appendix down- 
ward. It is fortunate that appendicitis is not so frequent in women as 
in men : what with the present chances to lose her ovaries, she would 
be at great disadvantage indeed if in this appendage too the frailty was 
with the woman. Pelvic appendicitis is of the greatest interest to every 
practitioner who has at all to do with the diseases of the female pelvic 
organs. 

Tubes and Ovaries. — The appendix, once in the pelvis, is liable to 
become attached to the Fallopian tubes or ovaries. An inflamed appen- 
dix may adhere to the tubes and result in a salpingitis or a pyosalpinx. 
On the other hand, an infected tube may communicate disease to an 
adherent appendix. Finding the group of symptoms characteristic of 
salpingitis on the right side, it is not always possible by the pain or 
character or shape of the tumor to exclude the possibility of an inflamed 
adherent appendix. Though inflammation of the left tube is much 
more frequent than that of the right when the tenderness, inflammation, 
and tumefaction are on the right, if these symptoms were preceded by 
a gonorrhoea, for instance, it is fair to presume the case is one of sal- 
pingitis ; if preceded by colicky and intestinal disturbances and no 
history of tubo-uterine disease, there would be a strong presumption in 
favor of pelvic appendicitis. In ovaritis or salpingitis there are not the 
rigidity and resistance to the abdominal wall that obtain in appendi- 
citis. A suppurating right ovarian cyst offers even more diagnostic 
difficulties than salpingitis or pyosalpinx. Extensive experience with 
abdominal diseases teaches that, notwithstanding the greatest possible 
care, a diagnosis must be made in many cases with mental reservation, 
lest a laparotomy or autopsy reverses the diagnosis. 

Typhoid Fever. — To mistake the csecal tenderness of typhoid fever 
for appendicitis and to open the abdomen could only occur to one of 
that class of specialists who possesses a strong desire to operate and who 
lacks a knowledge of the clinical history of diseases that even every spe- 
cialist should possess. A careful analysis of the symptoms, with the 
clinical history and the microscopic examination of the fseces, should 
enable one to differentiate between typhoid fever and appendicitis. 
Nevertheless, specialists in abdominal surgery have operated on cases 
of typhoid fever for appendicitis. In one case that came to my know- 
ledge the diagnosis was made after the operation by a microscopic ex- 
amination of the faeces ; the bacillus Eberth was obtained by culture. 

Prognosis. — The friends of a patient are usually more anxious and 



COMPLICATIONS AND SEQUELS OF APPENDICITIS. 307 

much morQ inquisitive and annoying to the medical attendant about the 
prognosis of the attack than the patient. They would not at all be 
satisfied in the case of appendicitis with the statement that about 90 per 
cent, of all the cases of appendicitis get well ; they have no interest 
whatever in the other 99 cases ; their anxiety is for the case in hand. 
In giving a prognosis in an individual case of appendicitis the medical 
attendant must take into consideration the stage of the disease at the 
time, the severity of the attack, the nature of the complications, if any, 
and the possibility of complications. A few points at least are well 
established that will apply in the prognosis of such cases : 

1. If surgical treatment is to be instituted, the earlier in the history 
of the disease that the operation is done the more favorable will be the 
prognosis. 

2. After appendicular suppurative peritonitis is established the prog- 
nosis is bad, with or without surgical treatment. 

3. When medical treatment is being entirely relied upon, the favor- 
ableness of the prognosis is not always in direct proportion to the 
apparent mildness of the attack. 

We have already seen that during the progress of gangrene or per- 
foration of the appendix the patient may have verv little pain or fever 
(page 293). 

4. The complications of ^pylephlebitis, abscess of the liver, or sup- 
purative pleurisy render the prognosis absolutely unfavorable. Even 
in the mildest cases of catarrhal appendicitis an exacerbation of 
symptoms is liable to occur, when the case may assume formidable 
proportions. 

Parietal appendicitis (even non-suppurative) is always serious Avhen 
accompanied with circumscribed peritonitis ; when the peritonitis 
becomes general the prognosis is very unfavorable. Most of these 
cases, however, if non-suppurative, get well without surgical treatment, 
but are liable to relapse. 

Suppuration in every form, whether intra- or extraperitoneal, adds 
to the gravity of the case, and the prognosis is almost hopeless without 
surgical treatment. I am of the opinion, however, that the gravity of 
suppurative peritonitis is over-estimated. Only four weeks ago I was 
called in consultation in a case of appendicitis, and assisted Dr. Wins- 
low Anderson with the operation. There was pus in the peritoneal 
cavity, with gangrene of the appendix, and also a portion of adherent 
omentum, and a necrotic condition of the serous coating of the ileum, 
to which the appendix and omentum were adherent. The appendix 
and the gangrenous portion of the omentum were removed, and 25 per 
cent, solution of peroxide of hydrogen was applied to the suppurating 
surface, and the abdominal cavity was well washed out with sterilized 
water ; a drainage tube was left in, and the patient went out of the 
hospital well in three and a half weeks. 

Occasionally, however, the pus escapes externally or safely through 
the intestines or through the vagina, or it may be absorbed. A case 
illustrating the absorption of pus : Thirteen years ago I attended a boy 
for appendicitis with circumscribed peritonitis and abscess. The father 
refused to allow an operation ; the pus was absorbed ; the boy was well 
for ten years, when he had another attack without peritonitis, and within 



308 APPENDICITIS. 

the past year he has had three more attacks without peritonitis. Having 
arrived at that age, " twenty, Avhen as duteous sons we wish our fathers 
were more wise/' he conchided to part with his appendix. I operated 
May 10, 1897 : the appendix consisted of a stump 1^ inches long; there 
had been a gangrenous destruction of the apex when he suffered from 
the attack thirteen years ago ; it was firmly adherent to the caecum ; there 
was stricture at the orifice ; the cavity was quite distended Avith mucus, 
and the membrane was softened. The last catarrhal attack was three 
weeks before the operation. 

In my own experience one patient recovered after the abscess had 
escaped through the bladder. On account of the great tendency to 
relapse the prognosis may still be unfavorable, as far as the ultimate 
recovery of the patient is concerned, though he may have entirely 
recovered from the attack. This applies even to the mildest form of 
the catarrhal variety. 

In the surgical treatment of appendicitis, aside from the stage and 
gravity of the case, the prognosis will depend to a great extent upon 
the skill and experience of the operator. It is much to be regretted 
that the abdominal cavity is constantly being invaded by those who 
have neither experience nor training in such work ; in consequence 
thereof valuable lives are frequently sacrificed. In the colicky or 
appendalgic variety the subsidence of the pain and fever before the 
expiration of forty-eight hours from the onset is a favorable omen, and 
unless the case relapses within the next forty-eight hours the chances 
for complete recovery are excellent. An attack of appendicitis during 
pregnancy is unfavorable, as abortion and death are apt to result. 

More than half the deaths from appendicitis occur within the first 
eight days. 

Teeatment. — Much extreme writing on the treatment of append- 
icitis has appeared in medical journals of late, or j^erhaps we might 
more properly say writers in medical journals on the treatment of 
appendicitis have been expressing very extreme views on the subject. 
One surgeon declares that appendicitis is a purely surgical disease, and 
that all the physicians in the country and all the medicine in the drug- 
stores are worse than useless ; they only delay surgical treatment and 
thereby jeopardize the life of the patient. Another says that at the 
very first appendicular pain a surgeon should be summoned. Another 
says there must be no hesitation ; operate in every case within the first 
twenty-four hours (one instance, probably, where hesitation on the part 
of the surgeon would prove as disastrous to the man as to the woman). 
Again, another taunts the physician with having done nothing for the 
treatment of appendicitis — that surgeons have done everything ; its 
present treatment is a triumph for surgery. The physician (the extreme 
type, of course) retorts by saying that appendicitis has done a great deal 
for the surgeons, and as for the surgically treated patient, he has lost 
his appendix, paid for the operation, and his life was endangered or 
perhaps lost ; that more patients die when treated surgically than when 
treated medically ; that " meddlesome appendicitis is bad." He (the 
physician) is at a loss to know why appendicitis should be called a purely 
surgical disease, when if all the cases of appendicitis, taken as they 
come, should be treated medically and by the average general practi- 



TREATMENT OF APPENDICITIS. 309 

tioner, not piore than 10 per cent, would die. Guttmann shows that of 
100 cases of typhlitis and perityphlitis treated medically only 4 deaths 
occurred. We have no means of knowing how many of these hundred 
would have died had they been operated upon by the same general 
practitioners ; probably from 20 to 30 per cent. It is not at all certain 
what the percentage of deaths would be should every case of appendi- 
citis be operated upon early ; there are surgeons who do not hesitate to 
assert that the surgical treatment would give the fewer deaths. We 
believe that in the very near future physicians and surgeons will regain 
their mental poise and will treat appendicitis with the same good sense 
and judgment, and with the same conservative regard for the life and 
interest of a patient, as they do every other disease. 

" On the other hand, it is advocated to operate as soon as the diag- 
nosis of appendicitis has been made, whatever its grade of severity. 
Between these extreme views held by those who favor operative meas- 
ures a middle course is usually available. A case demanding operation 
within twenty-four hours from the beginning of the attack is excep- 
tional." 1 

It is the physicians and surgeons who take middle ground in the 
treatment of appendicitis to whom we must look to save every patient 
from being subjected to a serious operation on the one hand, and on the 
other to prevent those who should be operated upon from being allowed 
to die without timely surgical aid. An extremist is seldom right on any 
subject. With a better knowledge of the etiology, pathology, and 
clinical history, and the addition of some experience and common 
sense, it would seem that appendicitis will in the near future be treated 
as rationally as any other disease. 

" ' Perityphlitis belongs to the surgeon' has been until lately an 
assertion defended with emphasis by many surgeons, but which has 
never received the assent of the general practitioner, and never will. 
According to the experience of general practice and the statistical 
results of Sahli, Renvers, Guttmann, Leyden, Fiirbringer, Hollander, 
Rotter, and the majority of French physicians, from 90 to 91 per cent, 
of all cases of perityphlitis, taken in the widest sense, recover without 
any operation. It would therefore smack of insanity to subject every 
case of perityphlitis to the uncertainties of an operation." ? 

It is true that there is a lack of definite knowledge on many points 
in the treatment of appendicitis which, if cleared up, would put the 
treatment on a safer and more rational footing than obtains at present. 
For instance, we can only approximate the average death rate of 
appendicitis under purely medical treatment. Let us call it 10 per 
cent. But we are unfortunate in not being able to know with any 
degree of certainty, before it is too late, which are the 10 of each 100 
that should have been operated upon early. We are at present entirely 
at sea as to what the percentage of deaths would be if every person 
with appendicitis or supposed appendicitis were operated upon wdthin 
the first twenty-four hours of the attack, as advocated by so many 
surgeons. " The diagnosis can and should be made in a few minutes, 

' Fowler : Hare's Practical Therapeutics, p. 598, vol. iv., 1897. 
^ Ewald : Twentieth Century Practice, vol. ix. p. 170. 



310 APPENDICITIS. 

and the operation should follow as soon as possible." ^ The percentage 
would probably be small if every operation could be conducted under 
the very best hygienic and aseptic surroundings and circumstances and 
in the hands of skilted operators ; which is, of course, absolutely impos- 
sible. Hundreds of patients must be treated for appendicitis under the 
worst hygienic surroundings and the most pronounced septic conditions, 
and by medical men unskilled and inexperienced in surgery. Surely 
the writers who so strenuously and unqualifiedly urge surgical treatment 
in every case of appendicitis cannot keep these facts in mind : they 
should at least remember that circumstances govern cases. 

Again, it might be well to inquire if every case diagnosticated as 
appendicitis should be operated upon within the first twenty-four hours, 
what percentage would be found not to have the disease — say 10 per 
cent, in experienced hands and 30 in inexperienced. And what com- 
pensation would these unfortunates receive ? Of course, when the abdo- 
men was open the appendix might be removed, and to be immune there- 
after from appendicitis. would be a consideration. And in case any of 
them die, their friends could be told that they died that others might 
live. A glorious example for their children if they had any ! It is 
also important to inquire what percentage of surgical cases might be 
left with ventral hernia. Ramm ^ " states that it is not infrequent to 
find an apparently healthy appendix at operations in cases in which the 
clinical symptoms have been those of appendicitis." This is quite a 
common experience. 

Nothing more absurd could be proposed for the treatment of appen- 
dicitis than that every case diagnosticated as such should be operated 
upon within the first twenty-four hours, which, every physician and 
surgeon of experience should know, is before the disease can be diag- 
nosticated with any certainty in many cases. It is not possible at 
present to fix the day or hour of the disease when an operation for 
appendicitis is advisable. The proper time to operate after the diag- 
nosis is established and the proper case for operation must be deter- 
mined by the medical man or men in charge of the particular case. 
Not to operate unnecessarily, and not to postpone operation until it is 
too late, will often tax the judgment of the most experienced. How 
early in the disease and what percentage of cases should he operated 
upon should depend largely upon the surroundings of the patient and 
the skill and experience of the operator. Perhaps the best rule that 
can be formulated for operating is — Always operate when serious doubt 
arises as to the necessity for an operation. That skilled and experi- 
enced surgeons are justified in operating earlier and oftener than un- 
skilled and inexperienced operators goes without saying. AVhile sur- 
geons call appendicitis a surgical disease, under some of the circumstances 
already mentioned the surgical treatment should l)e strictly confined to 
opening an abscess when fluctuation can be distinctly made out ; and 
inexperienced practitioners are fully justified in using carefully the ex- 
ploratory needle to diagnosticate the presence of pus. 

A patient with severe colic is likely to send for a physician to be 
relieved of pain. To give the patient a measure of relief, to make a 

^ Deaver on Appendicitis, p. 123. 
2 Qouij . Year-Book, 1897, p. 170. 



TREATMENT OF APPENDICITIS. 311 

diagnosis a^ soon as it is possible, and to inquire into the condition of 
the bowels are the first duties of the physician. The abdomen should 
be carefullj examined for stercoral impaction ; if present in the sigmoid 
or rectum, it should be removed at once by enema — a quart of warm 
water wdth an ounce of glycerin or vinegar or a teaspoonful of salt, 
etc. If in the csecum or in a case of simple constipation, a teaspoonful 
of castor oil, repeated every half hour until the bowels operate, is the 
best and safest of all laxatives in this disease ; no other medicine will so 
thoroughly empty the bowel with as little irritation to the mucous mem- 
brane. The oil may be given in 3j capsules. Small doses of calomel, 
one eighth to one fourth of a grain, repeated every half hour or every 
hour in case the oil is not retained, or one large dose, say of ten to 
twenty grains, will sometimes check vomiting and act as an efficient 
and mild laxative, or a teaspoonful dose every half hour of a saturated 
solution of sulphate of magnesia until the bowels are freed from all 
oifending material. Unfortunately, salts sometimes produce liquid 
passages without emptying the bowels of all impacted fecal matter. It 
is as important to move the bowels freely with mild laxatives or enema 
as it is to avoid active purgation. ]\Iild laxatives assist in relieving the 
pain by clearing the intestines of all irritating material and reducing 
the congestion of the bloodvessels. Active purgation adds fuel to the 
fire. The bowels, once freely relieved by mild laxatives, should sub- 
sequently be kept open by enema every day, consisting of a quart of 
warm water with one half a teaspoonful of lysol or two teaspoonfuls of 
boric acid or a tablespoonful of turpentine emulsion, etc. ; it not only 
prevents intestinal fermentation, but relieves the bowels from accumu- 
lated gases. Hot bottles to the feet and hot applications over the abdo- 
men, with five drops of tincture of aconite in a tablespoonful of whiskey 
and four tablespoonfuls of warm water by injection, afford a measure 
of relief from pain in incipient appendicitis without masking the object- 
ive symptoms, which is a matter of much importance in the early diag- 
nosis of the disease. Half a teaspoonful of compound elixir of chloro- 
form or thirty drops of Hoffman's anodyne in a teaspoonful of syrup 
of codeine is to be preferred to any considerable dose of morphine or 
laudanum when an opiate must be given. Fortunately, patients at the 
present time are likely to escape the torture of blisters, tincture of 
iodine, thermo-cautery, or other relics of barbarous therapeutics. At 
the commencement of circumscribed peritonitis a dozen leeches may be 
applied or the ice-coil may be substituted. Leeching is of no possible 
benefit in catarrhal appendicitis, nor is the ice-coil or bag ; in fact, cold 
generally increases the pain. 

With due deference to the many able and distinguished writers who 
oppose the administration of laxative medicine in appendicitis, I most 
emphatically advise laxatives (castor oil or calomel to be preferred) 
sufficient to very thoroughly unload the bowels. And I am just as 
emphatic in my belief that opium is an objectionable medicine, inas- 
much as it certainly increases the always present difficulties of differ- 
entiating the gangrenous cases. While it allays the patient's pain and 
the physician's anxiety, the fuselike appendix smoulders. The narcotic 
state increases the difficulties of interpreting the pathological progress 
of the disease as expressed by the symptoms. And it is always easier 



312 APPENDICITIS. 

to postpone a seemingly needed operation if the patient is not suffering, 
and too often in appendicitis delays are dangerous. 

Too much care cannot be exercised in regard to diet. Whether it 
be a catarrhal case of three days or a parietal case of three weeks, no 
solid food should be allowed until the patient is well on 'in convales- 
cence, but diet should be confined strictly to cocoa, strained gruel, 
broths made with rice or barley, and strained peptonized milk or whey 
or buttermilk, milk with half a teaspoonful of salt and a large tea- 
spoonful of malted milk to each goblet stirred and sipped slowly. It 
is important that the patient should be kept in bed and not allowed to 
rise under any consideration. The patient should be made to under- 
stand the danger of hasty or violent movements ; he should allow him- 
self to be assisted in turning or moving in bed. A gangrenous appendix 
may give way with very little effort on the part of the patient, or an 
abscess-wall may rupture. Rest as nearly absolute as possible must be 
enjoined. 

To sum up : To evacuate the bowels early by enema or by mild laxa- 
tives by the mouth ; to apply hot applications to the feet and over the 
abdomen ; to relieve the pain, preferably with tincture of aconite and 
whiskey in water by injection, or compound elixir of chloroform, or 
Hoffman's anodyne ; to be exceeding careful with the diet ; to confine 
the patient strictly to bed ; and to exercise the greatest care and best 
judgment in procuring the most skilful surgical aid at the proper time 
for the proper surgical cases, — is the rational treatment for appendi- 
citis. A strictly antiseptic cceliotomy for gangrenous or suppurative 
appendicitis, skilfully performed by an experienced abdominal surgeon, 
in its life-saving results is one of the most necessary, brilliant, and justi- 
fiable operations in the whole range of modern surgery. 

The following case illustrates the extreme surgical view of the 
treatment for appendicitis, and the clinical history of a case of fibrin- 
ous, non-purulent, non-perforative, parietal appendicitis with its medical 
treatment : 

On Thursday, November 29, 1894, I was called to see a patient 
whom I found with characteristic appendicular circumscribed perito- 
nitis ; temperature 102° F., pulse 110 ; extreme tympanites ; breath- 
ing thoracic ; both knees drawn up ; tongue very much furred ; and 
an expression of anxiety and distress. The tender point was well de- 
fined on a line from tiie umbilicus to the inferior spinous process, and 
only one third of the way from the spine to the umbilicus. He had 
been taken ill at half-past 2 a. m. Tuesday, the 27th, fifty-six hours 
before, with intense abdominal pain and vomiting. 

His wife had given him hot water and whiskey, hot ginger tea, and 
had applied hot applications over bowels, all with very little relief. 
Soon after daylight he sent for a doctor who lived in the neighborhood, 
who, though a general practitioner, evidently had extreme surgical views 
on the treatment of appendicitis. He told the patient that he had an 
attack of appendicitis, and unless he submitted to an operation at once 
he would not take charge of the case. The patient, supposing that he 
was only suffering from colic and knowing nothing of appendicitis, 
absolutely refused to be " cut open for colic." The doctor left, and left 
the patient's mind as perturbed as his bowels. The patient took a 



TREATMENT OF APPENDICITIS. 313 

bottle of fli4id citrate of magnesia, and, finding his pain worse by the 
afternoon, sent for another neighboring physician, who prescribed for 
him. Next morning, November 29th, the patient told the doctor that he 
now realized that he was a very ill man, and wished to place himself 
under the care of a physician whom he and his family knew by reputa- 
tion. Fifty-six hours after the commencement of the attack I found 
him as above stated. I explained to him the risks he would have to 
take if not operated upon — that the case might terminate in perforation 
or gangrene or abscess. He was a lawyer and an intelligent man. He 
said, " If you will stand by me and give me relief, and not operate 
until the necessity for an operation is absolutely demanded, I will take 
the risk." He was ordered hot applications to the abdomen, warmth 
to the feet, and the following prescription : 

I^. Spiritus setheris compositi. 

Elixir chloroformi compositi, ad. f^ij ; 

Syrupi tolutani, q. s. ad f^ij. — M. 

Sig. A teaspoonful every hour or two according to pain. 

An enema of warm water was also given. His condition remained 
about the same for the next four days, when the temperature fell to 
100° F., and the tenderness and rigidity of the walls were less. From 
this time until December 20th the swollen and tender appendix could 
be made out distinctly. After about the 25th (Christmas), though the 
tenderness and rigidity had pretty well disappeared, it was barely possible 
to any longer feel the appendix. While it Avas felt distinctly, it could 
be traced for 2.5 inches perpendicularly from Poupart's ligament and 
1.5 inches from the crest of the ilium. The two-ounce mixture was 
repeated once, and part of the second bottle was taken, which was all 
the medicine given, the bowels having been kept open by the enema. 
The temperature was normal after the 15th. December 28, 1894, four 
weeks and three days from the inception of the attack, he was up and 
walking, and would have been out but for the rain, and he seemed per- 
fectly well. The hot applications to the bowels were discontinued on 
the fifteenth day of the disease. 

From the history of this attack it is more than probable that the 
first appendalgic symptoms were the result of strain, as the attack was 
sudden and occurred immediately after he had cohabited. 

When these fibrinous, non-purulent cases are the result of the lodge- 
ment of a foreign body, it is doubtful if they ever terminate in resolu- 
tion while the offending material remains in the appendix. The prog- 
nosis of appendicitis from strain or- injury, as a rule, should be more 
favorable than from lodgement of foreign bodies. 

The differentiation of the medical from the surgical cases demands 
the most careful scrutiny of each case. An appendicitis commencing 
suddenly in the night after several hours' rest in bed would naturally 
suggest the lodgement of a foreign body. It was only by careful 
inquiry that the possible cause was elicited in this case. For my own 
part, I have not the slightest doubt that with increased experience it 
will be possible to differentiate the gangrenous cases that are now the 
bUe noir of the medical attendant. 



INTESTINAL PARASITES. 

By GEORGE DOCK, M. D. 



Protozoa. 



A NUMBER of species belonging to various classes and orders of the 
protozoa occur as parasites of man. Some are pathogenic ; others are 
only occasional parasites ; still others, commensals, living with, but not 
at the expense of, the host, sometimes perhaps even being of advantage 
to him. Some are of great interest and importance, and from the his- 
tory of their discovery we have reason to think that hitherto undiscov- 
ered causes of disease may be found among other species, members of 
these low orders of the animal kingdom. All these organisms are uni- 
cellular and of comparatively simple structure, yet many of them have 
developed organs which make them appear at first glance highly com- 
plicated. One of the most important and one of the lowest of these 
organisms, the amoeba coli, is described in detail in a separate chapter. 
(See Dysentery, Vol. I. p. 364 et seq.) 

The bulk of the body of a protozoon is made up of protoplasm or 
"sarcode," a finely granular-looking, gelatinous substance. Unless 
there are special organs (skeletal) which hinder it, the protoplasm is 
capable of amoeboid motion. It also is capable of differentiation into 
two layers, an " endosarc " and ectosarc " or " endoplasm " and " ecto- 
plasm." These two layers usually have different physical character- 
istics, the endosarc being more granular or less hyaline ; and different 
functions, the ectosarc being the organ of motion, of prehension, and 
excretion, and the endosarc the digestive organ. The ectosarc in many 
species is capable of forming pseudopods, as seen so commonly in 
amoebae ; it also produces in various forms temporary or permanent 
whiplike organs of motion. If short, these are termed cilia ; if long, 
flagella. Occasionally a mouth, oesophagus, and other (excretory) organs 
are present. There is always a nucleus, varying greatly in size, form, 
and affinity to dyes in various species. Reproduction is carried on by 
division, mitotic or more frequently amitotic, by budding, or by spore- 
formation. Division may also take place in an encysted stage or after 
conjugation. In many species tlie mode of reproduction is not known. 

The parasitic protozoa may be endocellular parasites, as in the case 
of the malarial hematozoon, or extracellular. In most cases their origin 
is unknown, though it is most probable that they are derived from forms 
living in water or in or on plants. Among the most important reasons 
for our imperfect knowledge of these parasites are — the small size of 
many of them, about that of red blood corpuscles ; the fact that they 
either have no characteristic form or easily lose it after leaving the host ; 

315 



316 INTESTINAL PARASITES. 

finally, our inability to cultivate tliem as we do bacteria. As in the be- 
ginning of bacteriology, harm is being done by enthusiastic but unskilled 
observers, but we cannot doubt that eventually much progress will be 
made in the investigation of these forms. 

Among the rhizopods the amoeba is the only genus of interest as a 
parasite of man. The next class, the sporozoa, contains a number of 
parasites of great interest in comparative pathology. The order coc- 
cidia is chiefly interesting on account of its connection with the changes 
which follow the infection of the rabbit's liver by that parasite — changes 
early looked on as carcinomatous, and even now claimed by some as of 
that kind. 

The most important species is coccidium oviforme (Leuckart). It 
appears as an oval body, 0.033-0.040 mm. long, 0.015-0.028 mm. 
broad, with a double membrane. The outer membrane is delicate and 
easily lost, and is perhaps the remains of the cell in which the body 
grew. The inner membrane is highly refracting, with a double contour. 
The body itself appears as a coarsely granular mass, later becoming 
round, with a clear spot in the middle in which lies the nucleus. Re- 
production takes place usually by the formation of the so-called sickle- 
shaped spores, though R. PfeifFer has described a process of endogenous 
sporulation. In rabbits the spores are set free in the stomach. 

Coccidia are best known in man, as in lower animals, as parasites 
of the liver or biliary apparatus. Cases in which the intestines have 
been aifected have been reported by Eimer (c. perforans), Kjellberg (c. 
perforans or bigeminum), and by Railliet and Lucet. Grassi and Rivolta 
have described the occurrence of coccidia in human faeces, but in these 
cases it is impossible to know whether the parasites came from the intes- 
tines or the liver. In the cases of Railliet and Lucet, affecting a 
mother and child, there Avas chronic diarrhoea. Diarrhoea was also 
present in a case of coccidiosis of the liver and spleen in a woman re- 
ported by Silcock. There were lesions in the intestines, but it is not 
clear that these contained coccidia.^ 

A number of parasites belonging to the class of infusoria and sub- 
class flagellata have been found in the human intestines or faeces. Or- 
ganisms of this class are unicellular, usually bilaterally symmetrical, 
and with but slight tendency to change of form. They are distinguished 
by the presence of lashlike processes, either short (cilia) or long (fla- 
gella). The species and genera are not yet accurately defined. A very 
common form is the one first described by Davaine and named by him 
cercomonas hominis. This is a parasite of oval or spindle form, with a 
single long flagellum on the broader end and a sharp or taillike process 
at the other end. An undulating membrane has not as yet been demon- 
strated. The bodies are from 0.003 to 0.012 mm. long, though speci- 
mens longer than 0.006 mm. are rare. The broad end usually shows 
with low powers a bright spot which has been taken for the nucleus, 
but the actual nucleus has not been definitely demonstrated. The para- 
sites are characterized by the lively and erratic motion they exhibit in a 
liquid medium. At times they appear to become fast to neighboring 
objects and to keep up an active fluttering motion. These parasites 
have been found in the stomach contents (Osier, Destree) in cases of 

^ Transactions of the Path. Soc. London, xli. p. 320. 



PROTOZOA. 



317 



chronic gastritis, and once by the writer in a case of cancer. They 
have been found very often in the stools in a large number of diseases, 
such as typhoid fever, dysentery, and other diarrhoeal diseases, and even 
in health. Cunningham, Grassi, and Schuberg believe they are constant 
and harmless parasites of the human intestines. In the body of an 
executed felon Miiller found cercomonads in the jejunum thickly cov- 
ering the mucous membrane, without evidences of disease of the latter. 
Following Schuberg, I have found them occasionally in the watery stools 
of persons apparently healthy, after the administration of Carlsbad salt. 
As Perroncito claims, however, that a species of cercomonas produces a 
fatal disease in guinea-pigs, the human parasite deserves further study. 
It is easily found in stools freshly passed by putting a small bit of the 
watery part on a slide and examining with a moderately high power. 
The lively motion makes the parasite easy to recognize. 

In the opinion of the writer the form just mentioned is to be distin- 
guished from other flagellate parasites which have been described under 
various names, such as trichomonas intestinalis (Leuckart), monocercomonas 

Fig. 9. 





Flagellates from the intestine, after various observers. (See American Journal of the Medical 
Sciences, Jan., 1896, p. 1) : a, cercomonas hominis (Davaine) ; b, trichomonas int. (Marchand) ; 
c, cercomonas int. (Zuuker) ; d, trichomonas hominis (Grassi) ; e, the same after May ; / and 
g, after Roos. 

hominis (Grassi), cercomonas coli hominis (May), etc. It is probable that 
most or all of these belong to one genus and species, Avhich at present 
can conveniently be termed trichomonas intestinalis. This parasite is 
somewhat larger than cercomonas, being usually from 0.010 to 0.015 
mm. long. It has the same general shape, but has a number (four ?) of 
flagella and an undulating membrane extending from the insertion of 
the flagella backward along the side of the body. There is a long oval 
nucleus. Small vacuoles can be seen, but there is no pulsating vesicle. 
Mouth, oesophagus, and other internal organs cannot be demonstrated, 
though a mouthlike opening or peristome may sometimes be present. 
Trichomonas intestinalis has been found in faeces in a number of dis- 
eases, with or without diarrhoea, and the prevailing opinion is that it is 
non-pathogenic. May, however, thought it caused a chronic enteritis 
in one case, and Epstein believes it causes a severe diarrhoea in infants.^ 
As to this form, as well as cercomonas, it must be remembered that 
although it may exist in the body without causing inconvenience, it 
may, when present in large numbers, at times cause actual disease. 
This possibility .should be borne in mind in practice, and when discov- 
ered the parasites should be expelled by the administration of cathartics, 
aided if necessary by anthelmintics. 

^ See resume by the author : " Trichomonas as a Parasite of Man," American Journal 
of the Medical Sciences, Jan., 1896. 



318 INTESTINAL PARASITES. 

These organisms can be found by examining feces in a recent condi- 
tion, and can be recognized by the motion of their flagella and undula- 
ting membranes. Staining is unsatisfactory. 

Lamblia intestinaUs, also called cercomonas intesUnalis (Lambl, 1859) 
or megastoma entericum (Grassi), is a common intestinal parasite and 
apparently non-pathogenic. It is oval or pear-shaped, with a hollow 
or excavation in the under and anterior part, the edges of the hollow 
being contractile. Four pairs of flagella rise from the ventral aspect 
of the body and are directed backward. The protoplasm is soft. There 
is a dumbbell-shaped nucleus in the anterior part. The body measures 
from 0.010 to 0.016 mm. in length, 0.005 to 0.0075 mm. in width. 

The sub-class ciliata is represented in human pathology by balanUd- 
ium {paramoeciuvi) coli, discovered by Malmsten in the pus from a 
chronic rectal ulcer. This is an oval parasite, 0.070 to 0.100 mm. long, 
0.050 to 0.070 mm. wide. At the anterior end is a funnel-shaped 
mouth ending in a short oesophagus. The endosarc and ectosarc are 
distinct. The body has parallel longitudinal striations ; the surface is 
covered with short cilia. The nucleus is reniform. There are contrac- 
tile vesicles. Reproduction is effected by transverse segmentation, as 
well as by conjugation and the formation of cysts. Balantidium has 
been observed most frequently in persons with chronic diarrhoea or dys- 
entery, and has been found especially in Northern Europe. It has also 
been found in Italy and China. The parasites occur especially in the 
caecum, appendix, sigmoid flexure, and other parts of the colon. They 
are found in the mucus rather than in the faeces. Leuckart found that 
balantidium coli is common in the rectum of hogs, so that it seems 
probable that the encysted parasites are derived from these animals. 
Grassi and Calandruccio, however, were not able to infect themselves 
with balantidium cysts from the hog. 

Balantidium is affected by acids, so that in case of infection enemata 
of tannic acid or of weak acetic acid should be used, after cleansing the 
colon by copious injections of water or salt water (.7 per cent.). 

Trematodes. 

The trematodes are chiefly important for their infection of the biliary 
apparatus of sheep {distomum hepatienm) and of the abdominal and 
pelvic veins in man (bilharzia hcematobia), but certain species are also 
found in the intestines, lungs, and other organs, and when in the biliary 
apparatus or in the intestines may appear in the faeces. 

The trematodes, plathelminthes, or flukes are bilaterally symmetrical 
parasites, usually flat, tongue-, or leaf-shaped, or elliptical, or in some 
species cylindrical. 

The life history of the flukes is extremely interesting, but cannot 
be described in detail here. The forms which occur in man become 
sexually mature in that host, having been ingested with food or 
water. 

Amphistomum hominis. — This is a short (5 to 8 mm. long, 3 to 
4 mm. broad) reddish worm, with a round or trumpet-shaped sucker at 
the anterior extremity. The eggs are oval, 0.150 mm. long, 0.072 mm. 
broad, and have a lid. This worm has been found in but two cases, in 



CESTODES. 319 

the csecmn and colon, in large numbers, but apparently only as an acci- 
dental parasite. The intestine in the cases observed showed marks like 
leech-bites. 

DistorQum hepaticum, faseiola hepatioa, the liver-fluke, is the cause 
of the " rot " in sheep and has been found in man in the bile-ducts, the 
portal vein and intestine, and occasionally in subcutaneous abscesses. 
It is flat, tongue-shaped, brownish on the sides and yellow in the mid- 
dle, the latter being modified when the intestine is full by the contents 
of the latter ; from 25 to 32 mm. long and 8 to 13 mm. wide. The sur- 
face, especially on the back, is covered with scaly spines. At the end 
of the conical head is a small round (" oral ") sucker, behind this a 
"ventral" sucker, and between the two the genital aperture. The 
eggs, brown or yellow, are usually very numerous. They measure 
0.130 to 0.145 mm. in length, 0.070 to 0.090 mm. in width, and have 
lids. When the parasites are passed by the intestines they can be recog- 
nized without difficulty. The eggs may be passed by the bowel alone, 
and if found might lead to. a diagnosis, though the exact microscopic 
diagnosis is by no means easy. 

The occurrence of distomum hepaticum in the intestines probably 
never comes under observation unless the parasites are present in the 
biliary apparatus. If the parasites or their eggs are recognized in the 
fseces, cathartics and anthelmintics are indicated. 

Distomum Buski, distomum crassum, is the largest of the flukes. 
It measures 4 to 8.5 cm. in length, 1.4 to 2 cm. in width ; is oval, with 
a smooth surface ; the two suckers are close together. The eggs are 
somewhat smaller than those of distomum hepaticum. This worm has 
been found in the fseces of native Chinese or East Indians, or rarely in 
other persons who had long resided in those countries. 

Distomum Rathouisi is a small, long oval fluke, 25 mm. long, 16 
mm. wide. 

Distomum heterophyes is 1 to 1.5 mm. long, 0.7 mm. wide, oval, 
pointed in front, of reddish color, with chitinous spines on the surface. 

Distomum lanceolatum is 8 to 10 mm. long, 1.5 to 2.5 mm. wide, 
long, narrow, pointed in front, broader and pointed behind. The eggs 
are thick-skinned, dark brown, 0.038 to 0.045 mm. long and 0.022 to 
0.080 mm. wide. 

All these forms and their eggs have occasionally been found in the 
fseces or intestines, where, however, they produce no distinct symptoms. 

Cestodes. 

Tape-worms get their name from the long, flat, tape-like body con- 
spicuous in most species. They consist essentially of a head or scolex ; 
-a neck, which at first is narrow and smooth, but gradually becomes 
wider and shows transverse striations ; and the body or strobila, made 
Tip of distinct segments or proglottides. 

The segments become more mature as they become more distant from 
the head. They are hermaphroditic, and capable, when mature, of 
leading for a short time an independent existence. 

There are two views as to the nature of the mature tape-worm. 
According to the older one, the tape-worm is a colony, each proglottis 



320 



INTESTINAL PARASITES. 



Fig. 10. 



being the equivalent of the scolex and formed from it by a budding 
process. According to the other view, the adult worm is an individual 
in which a reduplication of certain organs has taken place. There are 
facts in biology which lend support to both vieM's. 

The tape- worm retains its place in the intestine by means of the 
suckers, assisted, if " armed," by the booklets on the scolex. The worm 
receives its nourishment by imbibition from the nutritive fluids in which 
it lies in the intestine. 

Tape-worms are covered by a more or less thick membrane, pene- 
trated by numerous pores and occasionally having hairlike processes 
on it. This membrane is variously looked on as a basement membrane 
derived from the mesoderm or as an ectodermal epithelium which has 
lost its cell-boundaries and nuclei. The booklets are derived from the 
outer layer, and vary in size and form in different species. 

The parenchyma of the tape-worm is complex in its structure. The 
details need not be mentioned here, but the presence of numerous cal- 
careous bodies in it deserves notice on account of their striking ap- 
pearance in specimens examined microscopically. These are oval 
or ellipsoid, and composed of an organic basis and lime salts, espe- 
cially carbonate of lime. They are looked on as calcified parenchyma 
cells. 

The muscular system of tape-worms is quite extensive. Just beneath 
the outer covering is a thin layer of fibres ; beneath this longitudinal 
and circular or transverse fibres in strong bands ; 
and within these the dorso-ventral fibres. 

The suckers are diiferentiations of the muscu- 
lar system which occur only on the scolex and 
form important organs in the classification of the 
parasites. In some species they are round or disk- 
like, in others grooves. Another muscular struc- 
ture is the '' rostellum," which is present on the 
armed tape-worms and serves to give motion to 
the booklets. In unarmed cestodes the rostellum 
is either absent or appears as a sucker. 

The nervous system of the tape-worm consists 
essentially of two ganglia in the scolex, joined by 
transverse fibres, and peripheral nerves. The 
latter give fibres to the suckers and rostellumj 
and, passing back as lateral nerves, give branches 
to the various organs in the proglottides. 

The tajDC-worm has no alimentary canal, but 
possesses a somewhat complicated excretory organ or system, formerly 
spoken of as the water- vascular system. This begins in so-called term- 
inal or renal cells with a system of capillary and collecting tubes, which 
end in (usually) four longitudinal canals, joined at the back part of each 
proglottis by a transverse canal. At the point where this joins the 
longitudinal canal there is a valve which prevents the contents from 
being forced toward the head during tlie contraction of the body. In 
young or perfect cestodes the longitudinal canals end in a single one, 
usually terminating in a small contractile vesicle. AVhen the worm 
grows older and the oldest proglottis is cast off, the canals open inde- 




Head of tania saginata 
(Erchliorst). 



CESTODES. 



321 



Fig. 11. 



OH 



Proglottis of bothrio- 
cephalus latus ; natu- 
ral size, and enlarged 
three times (after Eich- 
horst). 



Fig. 12. 



pendently. The fluid in the canals is usually clear and watery. It 
contains substances apparently allied to xanthin and guanin. 

In the youngest proglottides no genital organs are present. The 
male organs are formed first. At the time of sexual maturity the gen- 
erative organs often make up the bulk of the pro- 
glottis. The uterus, filled with thick-shelled eggs, 
gives a dark color to the segment, and from its 
form often gives an important clue to the diag- 
nosis of the species. As the segments grow older 
the generative organs become atrophied, the uterus 
being the last to undergo degeneration. The genital 
apertures are sometimes on the sides, sometimes on 
the surface (ventral usually), of the segments. The 
testes, usually numerous, are scattered through the 
parenchyma. Their ducts unite to form a vas deferens, which passes 
out in a spiral manner to the genital sinus, where it ends in the " cir- 
rus," an intromittent organ in some species furnished with barbed 
hooks. This lies in the cirrus-sac. The female genital apparatus 
varies in arrangement in different species. There is usually a bilat- 
eral ovary placed at the posterior end of the proglottis. The oviduct 
soon after leaving the ovar}' unites with the 
yolk-duct, derived from the vitellarium, a 
peculiar organ found in other flat worms, 
consisting of a number of glands scattered 
through the parenchyma. At the point of 
junction of the tAvo ducts the oviduct is en- 
larged, and at this point receives the secre- 
tion from numerous " shell-glands." From 
this point two tubes arise — one the vagina, 
which extends to the genital sinus, the other 
the uterus. This latter either opens on the 
exterior or is blind externally, forming a con- 
voluted or branched system of tubes. In 
some cases a uterus in the ordinary sense is 
absent, the eggs being impregnated and ripen- 
ing in the ovary. When the uterus has no 
external orifice the eggs are only freed by 
the rupture of the proglottis, so that the 
absence of eggs in fseces does not prove the 
non-existence of a tape-worm in the intestine. 

Development of the Tape -worm. — The impregnation of the eggs 
takes place either by the intromission of the cirrus into the vagina of 
the same proglottis, or copulation can take place between the respective 
organs of two proglottides of the same or two different worms. Even 
without intromission the semen can flow from the cirrus into the vagina 
after closure of the genital pore by a contraction of its muscular wall. 
The eggs are impregnated before they receive their outer layers, the 
yolk and shell. The yolk is either cellular (bothriocephalus) or clear 
and albuminous (tsenia). The eggs differ in appearance in different 
species. 

The development of the eggs takes place either in the uterus or out- 
VoL. III.— 21 




Proglottides of (a) tsenia sagi- 
nata and ( b) t. solium ; natural 
size, and enlarged three times 
to show arrangement of uterus 
(after Leuekart). 



322 



INTESTINAL PARASITES. 



Fig. 13. 




Eggs of (a) t. saginata; (6) t. solium; (c) 
bothriocephalus latus; X 300 (after Eicli- 
horst). 



side of it after spontaneous rupture of that organ or after digestion in 
another animal. The embryo, or "■ oncosphere," also called a " six- 
hooked embryo," is a small spherical 
body with six chitinous booklets ar- 
ranged in pairs. The embryos do 
not develop further in the parent 
worm nor in the outer world, but, 
at least in the case of the commonest 
human tape-worms, always require 
the intervention of another host. 
The latter acquires the embryos 
either directly, as in the case of 
dogs and many other animals, or 
indirectly from contaminated food or water. The species of the host is 
not a matter of indifference : certain embryos can only develop in cer- 
tain animals. So the embryo of the taenia solium develops as a rule 
only in hogs, that of taenia saginata in cattle ; that of taenia cucumerina, 
a parasite of dogs and cats, only in parasitic insects of dogs, cats, etc. 
Sometimes young animals are easily infected by a given embryo ; older 
ones of the same species are not. 

When the embryos are swallowed they penetrate the walls of the 
stomach or intestines, and wander or are carried with the blood into 
some organ, occasionally a distant one, as the brain or eye. For a time 
the embryo remains quiet. Its booklets are lost, and it then enters its 
larval stage, and is known as a scolex or cysticercus, the precise cha- 
racters of which vary in different species. In the simplest form the 
scolex resembles the head of the mature worm, with a neck ending in 
a sac or cyst in which the neck and head are inverted. This is soon 
surrounded by a capsule of connective tissue. Such bodies, round or 
oval, and varying in size in different cases, are known commonly as 
" measles." 

In some species of tape-worm compound scolices occur, forming 
groups of cysts containing daughter cysts, each one with its scolex, the 
whole sometimes reaching a large size. 

The time necessary for the development of cysticerci varies in differ- 
ent species from a few weeks to several months. With some exceptions 
the cysticerci do not become sexually mature in the place of their for- 
n^ation, but must enter the "secondary" host. This usually occurs 
after the measles have been eaten, though the cysticerci of certain fish 

sometimes get into the water and 
swim about for some time. 

After the cysticercus enters the 
intestine of the secondary host the 
head is everted from the cyst, the 
latter disappears, and the parasite 
fastens itself to the intestinal wall 
and begins the formation of the tape- 
worm proper. The neck grows, and 
so forms the proglottides. The time 
necessary for the development of the strobila varies somewhat. In 
taenia solium it is about three months. The daily growth of taenia 



Fig. 14. 




Half-grown and mature proglottides of taenia 
solium ; natural size (after Leuckart). 



CESTODES. 323 

saginata h^s been estimated by Perroncito at 3 cm. in the first and 14 
cm. in the second month, the period of maximum development. In 
bothriocephalus latus, with much shorter segments, the growtli has been 
estimated as 8 cm. a day. 

The duration of the life of a single tape-worm varies much. Some 
of those in lower animals live but a short time ; some in man have been 
estimated as living as much as thirty-five years. I have seen a bothrio- 
cephalus removed from a German woman who had been in America fif- 
teen years, so it is safe to assume the worm in that case was at least fif- 
teen years old. The death of the scolex usually leads to the death of the 
proglottides. The latter then break down and putrefy, or occasionally 
become desiccated, forming the so-called mummified worm. But in 
some of the tape-worms of birds the anterior proglottides form organs 
of fixation and so prolong the life of the parasite. 

Tape-worms occasionally show deviations from the normal form, or 
monstrosities. The most important of these, according to the useful 
resum6 of Blanchard,^ are as follows : Discoloration, gray or black, from 
mercury, iron, or bile-coloring matter. Anomalies of the head, such as 
spontaneous separation of the suckers or the complete absence of hook- 
lets in armed tape-worms. Three-sided tape-worms, the cross sections 
of which have the Y shape. These grow from scolices with six suckers. 
Incomplete division of the proglottides. Intercalated proglottides, very 
common abnormalities. Segments without genital apertures ; less fre- 
quently segments with several genital apertures. Fusion of segments, 
sometimes quite extensive. Perforation of segments from fatty degen- 
eration or premature attempts at separation of proglottides. Branching 
of the strobila. 

Of the large number of tape-worms known to zoologists, only two 
genera occur commonly in man, though not always exclusively in him. 
Some of these, as well as others, also occur in the cysticercus stage in 
man. (See Echinococcus.) 

Tsenia Solium. — (The word solium, as shown by Leuckart, appears 
not to be derived from solus, but from a Syrian word meaning " chain.") 
This is also sometimes called the "armed tape-worm," or the "pork 
tape-worm," from the fact that its cysticercus stage occurs in hogs as 
the cysticercus cellulosce. From the time of Linn^us to within a recent 
period the common tape-worm of most countries has been called tsenia 
solium, an error due to an imperfect diagnosis of the species which may 
frequently be seen at the present time. The fashion of calling this the 
solitary tape-worm is perhaps due to an erroneous derivation of the word 
solium. As a matter of fact, the pork tape-worm is said by many to 
occur in numbers more often than the beef tape-worm. Berenger-Feraud 
has found fifteen, Kiichenmeister thirty-three, and Kleefeld forty-one 
in one indi^adual. 

Taenia solium grows to a length of 2 to 3 m. or rarely longer. The 
spheroidal head is 0,6 to 1.0 mm. in diameter. On its summit is a short 
rostellum armed with a circle of twenty-two to thirty-two booklets, of 
two sizes alternating. The booklets are 0.11 to 0.14, and 0.16 to 0.18 
mm. in length. The rostellum is often deeply pigmented. The suckers 
are hemispheroidal, 0.4 to 0.5 mm. in diameter. The neck is thin, from 

^ " Sur quelques Cestodes monstrueus," Progres medicale, 1894. 



324 



INTESTINAL PARASITES. 



Fig. 15. 




Head of taenia solium (after 
Leuckart). 



5 to 10 mm. long. From it the proglottides gradually increases in size. 
At first wider than long, they become quadrate about a metre from the 
head, and from there gradually become longer 
than wide. Sexually mature segments measure 
10 to 12 mm. in length, 5 to 6 mm. in width. 
The genital papillae are on the edges of the 
proglottides, a little behind the middle, and 
alternate irregularly. The fully developed 
uterus consists of a median part, from which 
proceed seven to ten lateral branches, giving oif 
secondary branches as they go out. The de- 
generated segments are usually narrower at the 
ends than in the middle. 

The eggs of the pork tape-worm are oval, 
the outer shell delicate, the shell of the em- 
bryo is thick, with radiating striations, yellow- 
ish, spheroidal, 0.031 to 0.036 mm. in diameter. 
The oncosphere is spheroidal, has six booklets, 
and is about 0.020 mm. in diameter. 

Monstrous specimens are not very common. 
Occasionally fusion of two or more proglot- 
tides is observed, or segments with holes in 
them. Rare monstrosities are those with six 
suckers or those with three-sided proglottides. 
Atrophic specimens are sometimes met with. 

The mature pork tape-worm occurs only in the small intestine of 
man. The head is usually fastened in the anterior part, the mass of the 
worm lying in folds behind it. Kuchenmeister found the head of the 
tape-worm in some cases between the folds of the mucous membrane, a 
position which must render difficult the access of vermifuges to that 
part. The tenacity with which the head is fastened to the intestinal 
wall was well shown in a case mentioned by Hosier and Peiper. In 
this a tsenia in the intestine of a man examined three days post-mortem 
could only be loosened with difficulty. Put into warm water, the worm 
began lively motions. The end of the worm is occasionally found in 
the large intestine. A few loose segments are often to be found lying 
in the intestiiial contents, and indicate the method by which loose pro- 
glottides are expelled with the stools. They sometimes wander out of 
the anus spontaneously. Under exceptional circumstances proglottides 
gain entrance to the peritoneal cavity, to the bladder, or to so called 
verminous abscesses in the abdominal wall. Occasionally the proglot- 
tides have been vomited. 

The larval stage of tsenia solium, the cysticercus cellulosBe, occurs in 
the intermuscular tissues or other organs of the domestic hog, but has 
been found also in some other animals, as the wild hog, cat, rat, ape, 
and in man. It is an elliptical cyst from 6 to 20 mm. long, and 5 to 
10 mm. wide, in which the inverted head can be seen with the naked 
eye as a whitish spot. Feeding experiments showing the relation of the 
larval to the mature stage, and vice versa, have frequently been made. 
The development of cysticercus cellulosse requires from two and a half 
to four months. After some time it undergoes calcification of the cyst 



CESTOBES. 325 

walls. In water the cysticerci die at a temperature of about 120° F. 
In meat at ordinary temperatures they have been known to live twenty- 
nine days. The ordinary methods of smoking and salting meats do not 
kill cysticerci. 

From what has been said it is evident that taenia solium is usually 
acquired by the eating of measly pork which has not been so treated 
as to kill the embryos. The hog in turn acquires the measles from 
the eating of proglottides from the human host, an infection easily 
understood by remembering the eating habits of hogs. The extent 
to which hogs are measly varies much in different countries. Where 
inspection of meat is carried out systematically and the swine prop- 
erly fed the proportion of infected animals is smaller, other things 
being equal. 

Infection with cysticercus in man takes place not only by taking 
embryos into the stomach with food containing measles, bat also with 
food contaminated in various ways, as by washing with infected water, 
or having eggs deposited from feces, or by the use of infected water 
itself, or even by transportation of eggs from the anus to the mouth in 
an accidental way. Should ripe proglottides enter the stomach in vom- 
iting, cysticercus infection may result. 

Taenia saginata ; Taenia mediocanellata ; Beef tape-worm ; Unarmed 
tape-worm. — This is by far the commonest tape-worm in the United 
States, the idea formerly jDrevailing as to the frequency of taenia solium 
having been shown to be erroneous. Taenia saginata reaches a greater 
length than taenia solium. Worms of from 4 to 10 m. in length are not 
uncommon. The enormous lengths reported depend usually on stretch- 
ing the worm in measuring it or in measuring parts of several worms as 
one. Out of 1597 specimens, Berenger-Feraud found only six more 
than 11 m. long. However, in one case he found three taeniae having 
a total length of 154 m. and a combined weight of 922 grammes. In 
measuring tape-worms they should lie flat, never be held up. 

Taenia saginata has a cubical head 1.5 to 2 mm. in diameter. The 
four roundish suckers, 0.8 mm. in diameter, are usually pigmented. 
In the place of the rostellum there is a depression, also frequently pig- 
mented. The neck is long and narrow ; the proglottides gradually in- 
crease in size. The ripe ones are oblong, 16 to 20 mm. long, 4 to 7 
mm. wide. The genital papillae open just behind the middle on the 
edges, and alternate irregularly. The uterus has a narrow median 
trunk and twenty to thirty or more lateral dividing branches. The 
eggs are spherical ; the shell has two or three filaments ; the shell of the 
embryo is oval, thick, with radial striations, transparent and measuring 
0.03 to 0.04 mm. long and 0.02 to 0.03 mm. broad. Taenia saginata is 
usually pale yellow, thick and fat-looking (hence the name, from sagi- 
nare, to fatten), but sometimes it is thin. It may be stained by drugs, 
as already mentioned. Monstrosities occur sometimes, fusion of seg- 
ments being not uncommon. 

Taenia saginata occurs in its mature stage only in the human intes- 
tine. The ripe segments become detached and are expelled with the 
faeces. More frequently than is the case with the preceding species 
such segments have a tendency to wander out of the anus, when they 
travel around in the underclothes, occasionally continuing the migration 



326 



INTESTINAL PARASITES. 



Fig. 16. 



for some time. This worm is usually solitary (in 87 per cent, of cases, 
according to Berenger-Feraud). 

The cysticercus of taenia saginata occurs almost exclusively in cattle. 
It is small, up to 9 mm. long, and 5.5 mm. 
wide, and easily overlooked in the tissue of 
the beef in which it is sparingly distributed. 
From a half to one year is necessary for its 
development. The relation of the cysti- 
cercus bovis to taenia saginata has fre- 
quently been demonstrated experimentally. 
The experimental proof that taenia saginata 
is derived from cysticercus bovis was pro- 
duced by Oliver in 1869 and Perroncito in 
1877, but clinical observations on persons 
fed with raw or rare beef, or the special 
predisposition of certain races, as the Abys- 
sinians, were sufficiently convincing. The 
prevalence of the disease in Abyssinia no 
doubt depends on the custom there of 
whole communities defecating on the 
meadows on which the cattle graze, and 
the use of raw or rare meat. The fact that 
the beef cysticercus is so rarely found de- 
pends partly on the fact that only a few 
cysts are present usually, and these are 
easily overlooked in the great mass of the 
host. Hertwig showed in the Berlin abat- 
toir that the cysticerci are found most fre- 
quently in the internal pterygoid muscles. 
They also occur in the heart and lungs, and 
Avhere these parts are examined the propor- 
tion of infected beeves recognized is much 
larger than otherwise, though varying much 
in different localities. Occasionally, as 
Hosier deinonstrated experimentally, the 
cysticerci grow in enormous numbers in 
cattle, producing the so-called cestodian 
tuberculosis. 

The geographical distribution of taenia 
saginata is worldwide. Not only is it the 
commonest worm in the United States, but 
in some parts of the Southern United States and in Mexico it is extra- 
ordinarily frequent. So Herflf found in Texas that in some localities 
nearly every family was affected. My own experience in that State 
leads me to think that this estimate is not too high. 

The occurrence of cysticercus bovis in the brain and eye of man has 
been claimed in a few cases. 

The other species of taenia found in man are rare and need be only 
briefly described. 

Taenia cucumerina, a common parasite of dogs and cats, has occa- 
sionally been found in human beings, usually in children, explained by 




Taenia saginata ; natural size 
(after Leuckart). 



CESTODES. 



327 




Fig. 18. 



the greater^exposure of these to infection from pet animals. The cysti- 

cercoid of this tape-worm lives in the dog louse (trichodectes canis), as 

shown by Leuckart and Melnikoff, according to Grassi and Rovelli in 

the dog flea (pulex serraticeps), and also in the human flea (pulex irri- 

tans). It does not occur, however, in the larvse of the flea. 

This is a small worm, from 15 to 35 cm. in length. The head is 
small. It has a club-shaped 
rostellum with three or four rows 
of thornlike spines. The suckers 
are large. The neck is short; 
the ripe proglottides are ellip- 
tical or the shape of a cucumber- 
seed, whence the name ; reddish, 
6 to 10 mm. long, 2 to 3 mm. 
wide. There is a genital pore 
ji on each side of a proglottis. 
S M M The eggs are spherical, 0.043 to 
0.050 mm. in diameter, few in 
number. 

The ripe segments frequently 
wander out of the anus, and in 
the case of the dog can some- 
times be seen crawling over the 
backs of their hosts. Then the 
eggs are swallowed by parasitic 
insects and enter the larval stage, 
so making infection in those who 

handle the animals an easy matter. In lower 

animals the worms often occur in numbers, and 

in children as many as forty-eight specimens 

have been observed in one case. 

Taenia nana (von Siebold, 1852) ; Hymeno- 

lepis nana (Blanchard, 1891). — The dwarf tape- 
worm grows to a length of 20 mm., or in rare 

cases 27 mm. It is 0.5 to 0.7 mm. wide. The 

globular head is 0.25 to 0.3 mm. in diameter. The 

rostellum bears a single circle .of twenty-four to 

thirty small booklets. The four suckers are 

round. The neck is rather long, the 150 to 200 

proglottides short, the posterior ones yellow ; the 

genital orifices are all on the same side. The 

oval eggs have three structureless transparent 

shells, and are 0.030 to 0.050 mm. in diameter. 
First discovered by Bilharz in 1859, this 

worm was long considered rare, but within the 

last ten years many cases have been described, 

especially in Italy. Taenia nana has been found 

especially in children, in whom it sometimes 

occurs in enormous numbers (250 in one case, 

more than 370 in a case reported by Mertens, 

more than 2000 at one time in a case observed by Lutz). The develop- 



Taenia cucumerina ; 
natural size (after 
Leuckart). 



Tffinia nana; X 12 
Leuckart). 



(after 



328 



INTESTINAL PARASITES. 



Fig. 19. 




ment of taenia nana is not definitely known. According to Leuckart, 
the larval stage is passed in an insect. The large numbers found 
together lend support to the idea that this species does not require an 
intermediate host, but jievelops from the egg through the cysticercoid 
stage in one and the same host. 

Taenia flavopunctata (Weinland, 1858), or, more properly, taenia 
diminuta (Rudolphi, 1819) is a small tape-worm, 
sometimes reaching a length of 60 cm. and a width 
of 3.5 mm. The head is small, club-shaped, with 
a rudimentary unarmed rostellum and round suck- 
ers. The genital pores are all on one side. This 
worm has been found a few times, especially in 
children. It was first described as a human para- 
site by Weinland, the specimen having been ob- 
tained from a child nineteen months old in Boston. 
Later, Leidy reported the same species in Phila- 
delphia, and since then it has been found in various 
parts of Europe and in Brazil. The same parasite 
is common in mice and rats. The larvae live in 
butterflies and their larvae and in other insects. 
Rudolphi gave the name taenia diminuta to the 
parasite of the rat in 1819. Some specimens de- 
rived from man have, been preserved in the 
museum of the veterinary school at Alfort since 
the end of the last century, though only recently 
recognized by Railliet and Zschokke. 

Taenia Madagascariensis is a worm found in 

only a few cases in persons who were infected in 

various parts of the East. It is an armed worm, reaching a length of 

30 cm. The larval stage is not known, but the larva is supposed to 

live in birds. 

Bothriocephalus latus ; Taenia lata ; Broad tape-worm. — This is the 
largest tape- worm infesting man, and from its history and pathological 
relations is extremely important. The head is 2 to 3 mm. long, clavate, 
with two deep longitudinal, groovelike suckers, one on each side. The 
neck is thin. The proglottides eventually become wide from side to side, 
but are short from before backward, the largest measuring 10 to 18 mm. 
by 5 to 6 mm., and have been found to number as many as 4200 in one 
individual. The uterus forms a rosette-shaped mass in the centre of the 
proglottis ; the cirrus and vagina open j ust behind the uterus. The eggs 
are elliptical, brown, granular, with a lid, and measure 0.068 to 0.071 
mm. long, 0.045 mm. wide. The proglottides are usually grayish yellow 
on the edges, bluish gray in the middle, the rosette yellowish, giving 
the worm a striking appearance. 

The geographical distribution of bothriocephalus is peculiar. In 
Europe it occurs especially in French Switzerland and the German 
Baltic provinces of Russia, and from both of these chief foci it appears 
to have spread out into the neighboring countries, so that Lombardy, 
Germany (Bavaria), Finland, and Sweden are especially affected. It 
also occurs in North Germany and in Holland, and its existence in 
Roumania has been demonstrated by Babes. In Japan the broad tape- 



Tsenia flavopunctata ; nat 
ural size (after Wein- 
land.) 



CEST0DE8. 329 

worm is the^ commonest cestode of man and dogs. In the vicinity of 
the Lake of Geneva the inhabitants are infected to the extent of 20 per 
cent. In Dorpat^ Cruse found 6 per cent, of bodies infected ; in Mos- 
cow eggs were found in 8.9 per cent, of persons examined. The distri- 
bution of the worm varies, however, so that in some countries, especially 
in Germany, where it was formerly rare, it is now becoming common ; 
on the other hand, it was common in Paris in the last century, but is 
now seen there only in imported cases. 

The development of bothriocephalus was worked out by M. Braun. 
The scolices or plerocercoids are 8 to 30 mm. long, with heads that are 
inverted at rest, but can be made to evert by warming them. These 
occur especially in the muscles and intestines of the pike, carp, salmon, 
and many other fish. They are not killed by slight smoking, salting, or 
freezing. Braun was able to infect not only cats and dogs by feeding 
them with larvse from fish, but also three students in Dorpat. Within 
a month the worms developed, and on removal were found to have 
reached a length of from 310 to 450 cm., with ten hundred to thirteen 
hundred proglottides. Similar experiments have since been made by 
others, Avhich not only confirm the mode of infection, but also the great 
rapidity of growth of the parasite. The mode of infection of the fish, 
however, is not known. There may be an intermediate host. It is pos- 
sible also that the embryos of the bothriocephalus may be ingested in 
other ways than by eating fish. Zaeslin claims that in Switzerland infec- 
tion takes place through eating lettuce. This is sometimes raised under 
irrigation from lake-water, which may carry eggs or measles to the 
plants. This would explain the cases of persons who do not eat fish, 
and yet have been infected Avith bothriocephalus. 

In the United States of America bothriocephalus has frequently been 
observed, but, so far as I can learn, only in immigrants. Three hitherto 
unreported cases known to the writer — two in Galveston, Texas, one in 
Leadville, Colorado — were in such people. HerflP, however, believes 
that the parasite is indigenous in Mexico. Bothriocephalus occasionally 
occurs along with other tape-worms. It also occurs sometimes in large 
numbers ; Bottcher found 48 young ones in the intestine of a woman, the 
intestine having been partly washed before the worms were discovered. 

Bothriocephalus cordatus, a parasite of dogs, walrus, and seals in Ice- 
land and Greenland, has been found occasionally in man. 

Bothriocephalus cristatus and bothriocephalus Mansoni have also been 
occasionally found in man. 

Etiology. — The cause of tape-worm disease in man has been almost 
completely elucidated by researches in the development of these worms 
briefly described in the foregoing pages. As a rule, infection takes 
place by the ingestion of meat improperly cooked. The danger of in- 
fection is of course greater in a country where meat (including fish) is 
frequently infected. Accidentally, tape-worms may be acquired by 
handling infected meat, or in some species by handling pet animals 
infested by parasites containing larvse of the worms. 

Tape-worm is most frequent in early middle life, but cases are not 
infrequently seen in the extremes of life. Mensinga found a taenia 
solium in a child ten weeks old. The infant had been infected by con- 
taminated milk when two weeks old. 



330 INTESTINAL PARASITES. 

The disposition of the two sexes is diflPerently stated by authors, 
depending no doubt on peculiarity of clinical material. 

Symptoms. — The symptoms produced by the presence of a tape- 
worm in the intestine varry so widely that while some attribute to these 
parasites an endless array of diseases, others deny them any influence 
on the host. As usual, the truth lies between these extreme views. 
Subjective and objective evidences of tape-worm may be entirely absent, 
and in the experience of the writer usually are with common tape-worm 
in persons of good constitution, and especially those who eat a great 
deal. In one case a perfectly healthy man after eating a quantity of 
raspberry preserve was obliged to defecate in a meadow. He was 
struck by the peculiar appearance of the stool, which contained, accord- 
ing to his description, almost a half pint of tape-worm. Remembering 
the tradition that raspberry preserve is a remedy for tape-worm, he 
suspected he had one and consulted me. A course of treatment insti- 
tuted at once brought away one large beef tape-worm, so that the 
patient must have been the host for at least a number of months with- 
out any symptoms whatever. Another patient, like the first a hon 
vivant, consulted me about some curious bodies which from time to time 
got into his underclothes, and which proved on examination to be sterile 
proglottides of a very large taenia saginata. 

In other cases patients complain of an array of symptoms truly for- 
midable. In this connection " helminthophobia " may be mentioned. 
This is met with frequently in neurasthenic persons, also in men, espe- 
cially men who give no other evidences of neurasthenia, but who either 
from reading or conversation have learned some of the symptoms of 
tape-worm, and imagine they are so afflicted. 

Among the symptoms observed in actual cases disturbances of diges- 
tion are common. The appetite may be voracious, as is believed by the 
laity, but is sometimes poor, at other times capricious. Vomiting, nau- 
sea, and eructations sometimes occur, and, especially in case the worm 
is the pork tape-worm, may have dangerous consequences by reason of 
the proglottides getting into the stomach. 

In some cases colicky pain or pain of a heavy, boring, cutting, or 
tearing character may be felt. These sensations sometimes follow the 
eating of sour or bitter articles of food, or when such things as rasp- 
berries or strawberries have been eaten, and may be easily explained by 
an irritation of the parasite and consequent increased activity, or perhaps 
on account of unusually active efforts on the part of the worm to main- 
tain its hold on the intestinal wall. On the other hand, bland sub- 
stances, and especially milk, often cause cessation of such symptoms. 
There may be constipation or diarrhoea or these may alternate. 

Nervous disturbances sometimes occur in tape-worm disease, espe- 
cially in children. They seem to be more likely to occur in the case of 
infection with taenia cucumerina, nana, and flavopunctata, which so 
especially affect children. Convulsions, chorea, psychic disorders, epi- 
lepsy, aphonia, asthma, palpitation of the heart, fainting, and dizziness 
may also occur with other species of tape-worm, but would appear to be 
relatively more frequent Avith the rarer species. 

Either with or without other symptoms, but especially when these 
are present, patients are prone to become pale and to feel weak and 



CESTODES. 331 

irritable. Part of the cachexia sometimes present may be due to loss 
of nutritive material consumed by the parasite. 

During the last ten years a large amount of evidence has accumu- 
lated tending to show that bothriocephalus may cause a severe anaemia. 
The matter has been ably and apparently conclusively settled by the 
admirable work of Schaumann of Helsingfors.' This author shows that 
the anaemia accompanying the parasites named has all the clinical and 
anatomical features of pernicious anaemia, including all the changes in 
the blood discovered by recent methods of investigation. The condi- 
tion, however, is not so unfavorable as pernicious anaemia of other 
kinds. Concerning the pathology of the disease, Schaumann inclines 
to the view that there must be some other cause present besides the 
tape-worm,. perhaps micro-organisms. Avery curious fact is that in 
some cases eggs of the bothriocephalus have been found in the faeces, 
but treatment showed that either there were no worms present or there 
were dead ones in a state of decomposition — a fact w^hich led Dehio to 
raise the hypothesis that the products of decomposition of the dead 
worms are accountable for the anaemia. Schaumann thinks the blood 
corpuscles are destroyed by pathogenic substances, and the blood-form- 
ing organs afiected secondarily. 

Tape-worm disease is sometimes accompanied by rise of temperature. 
This has also been attributed to tire fact that the tape-worm or segments 
of it have died spontaneously or as the result of treatment, but have not 
been removed from the intestine. 

Of all the symptoms, the passing of the segment is the most certain, 
provided, of course, that the diagnosis of the segments is correct. . Seg- 
ments may be found with the stools or the proglottides may wander out 
by themselves. I have mentioned one example of this. Hosier and 
Peiper mention the case of a student in Giessen whose bed used to be 
filled with proglottides which had escaped in the way described, and 
another case in which the segments escaped in the same way from a 
lady while dancing at a ball. A worm may be present for a long time 
before migration begins. 

The entrance of proglottides into the stomach in vomiting is ex- 
tremely rare. Von Siebert has reported a case in which the worm lay 
in a reversed position, so to speak, with the head down, and it has been 
supposed that this would assist in the passage of the proglottides in 
reverse peristalsis, yet this is by no means necessary, as the worm some- 
times lies in a compact skein, in which the end is not more than a foot 
away from the head, sometimes even at the same level. In a remark- 
able case cited by Leuckart a farmer vomited a worm into his mouth. 
As the physician was carefully extracting the parasite the patient bit 
the latter through, thinking his bowels were being removed ! Franken- 
hausen has reported the case of a patient who had vomited proglottides 
and later acquired cysticerci. 

Diagnosis. — The diagnosis of tape-worm can only be made by find- 
ing the segments or eggs in the stools or after being otherwise evacuated. 
Any other method of making a diagnosis involves so many sources of 
error that it can only be used by charlatans. 

If suspicion of the existence of worms is aroused by any of the nu- 

^ Zur Kentniss der sogenannlen Bothriocephalus-andmie, 1894. 



332 INTESTINAL PARASITES. 

merous symptoms or by a history of exposure, as by eating raw meat, 
etc., a purgative should be given and the stool examined. The stools 
may be examined without this, and in many cases the eggs may give 
the required informaticJli. But as the discovery of proglottides is so 
much easier, and as the purgative may with advantage be followed up 
by the proper treatment, it is on the whole preferable. Moreover, the 
examination of the proglottides gives more certain information as to the 
species, especially as between t£enia solium and taenia saginata ; and this 
knowledge is often of value in treatment, the latter being usually more 
difficult to remove than the former. Prognosis as to removal is usually 
good, especially if the patients can be relied upon to carry out the un- 
pleasant treatment. In the case of taenia solium the danger of cysti- 
cercus should be borne in mind in the prognosis, and in bothriocephalus 
latus the possibility of severe or fatal anaemia. The latter can almost 
certainly be prevented by timely treatment. 

Prophylaxis. — The prophylaxis of the various forms of tape-worm 
appears from a consideration of their natural history. Inspection of 
meat, care in the feeding of animals to be used as food, and disposal of 
excreta of infected persons are