{"1": {"fulltext": "", "height": "3947", "width": "2618", "jp2-path": "diseasesofintes00einh_0001.jp2"}, "2": {"fulltext": "LIBRARY OF CONGRESS.\\nxO%^\u00c2\u00b0\\nChap,..\\\\l__. Copyright No.\\nShelfJ^J^\\nUNITED STATES OF AMERICA.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0002.jp2"}, "3": {"fulltext": "", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0003.jp2"}, "4": {"fulltext": "", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0004.jp2"}, "5": {"fulltext": "", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0005.jp2"}, "6": {"fulltext": "", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0006.jp2"}, "7": {"fulltext": "DISEASES\\nOF\\nTHE INTESTINES\\nA TEXT-BOOK FOR PRACTITIONERS AND\\nSTUDENTS OF MEDICINE\\nMAX EINHORN, M.D.\\nPROFESSOR OF MEDICINE AT THE NEW YORK POST-GRADUATE MEDICAL\\nSCHOOL AND HOSPITAL, AND VISITING PHYSICIAN AT\\nTHE GERMAN DISPENSARY, NEW YORK\\nNEW YORK\\nWILLIAM WOOD AND COMPANY\\nMDCCCC", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0007.jp2"}, "8": {"fulltext": "TWO COPIES RECEIVED.\\nLibrary of Congrft*\\nOffice of tilt\\nMAY 1 6 1900\\nRtglsttr of Copyright*\\n61= //J/ I\\n8KC0ND OOPy,\\n5^ .^,nW\\n~7\\n62607\\nCopyright, 1900\\nBy WILLIAM WOOD AND COMPANY", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0008.jp2"}, "9": {"fulltext": "TO\\nMY ESTEEMED FRIEND AND TEACHER\\nERNST VON LEYDEN, M.D.\\nPROFESSOR OF MEDICINE IN THE UNIVERSITY OF BERLIN\\nTHIS BOOK\\nIS RESPECTFULLY DEDICATED", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0009.jp2"}, "10": {"fulltext": "", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0010.jp2"}, "11": {"fulltext": "PREFACE\\nThis treatise is a continuation of my work on Diseases\\nof the Stomach, the two together comprising the princi-\\npal disorders of the digestive tract. In discussing the\\nsubject of the intestinal affections an effort has been made\\nto follow the same lines laid down in my book on the\\nstomach. The practical points regarding diagnosis and\\ntreatment are always placed in the foreground.\\nAlthough our knowledge of diseases of the intestines has\\nnot made such rapid progress as that of morbid conditions\\nof the stomach, much has likewise been achieved in this\\nfield. Surgery has made many successful advances. The\\nelucidation of the intimate relation existing between func-\\ntional disturbances of the stomach and of the intestines\\nalso marks an important step forward, especially as to\\ntherapy.\\nWhile there are many excellent works on intestinal dis-\\neases by German authors, the more recent English litera-\\nture contains no monographs on this important subject.\\nThe medical encyclopedias, it is true, contain very instruc-\\ntive contributions on this topic, and among these Ewald s", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0011.jp2"}, "12": {"fulltext": "vi PREFACE.\\ntreatise on diseases of the intestines in the Twentieth Cen-\\ntury Practice of Medicine is a most valuable acquisition.\\nThe present volume, it is hoped, will to a certain extent\\nfill the void in American literature of a monograph on the\\naffections of this portion of the digestive tract. The writer\\ndesires to express his indebtedness to Nothnagel, Eosen-\\nheim, Boas, Fleischer, Ewald, Pick, Fowler, Treves, and\\nAllingham, whose works have been frequently consulted.\\nHe trusts that this book will prove of practical utility to\\nthe practitioner, and if it will aid him in more successfully\\ntreating this class of cases, the author s effort will be more\\nthan recompensed. Max Einhorn.\\nNew York, April, 1900.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0012.jp2"}, "13": {"fulltext": "CONTENTS.\\nCHAPTER I.\\nAnatomy and Physiology.\\nAnatomy,\\nThe Intestinal Canal (Intestinum),\\nThe Duodenum,\\nThe Small Intestine,\\nStructure of the Small Intestine,\\nThe Large Intestine or Large Bowel (Intestinum Crassum),\\nHistology of the Large Bowel,\\nPhysiology,\\n1. The Secretory Function or\\nIntestines,\\n2. Absorption.\\n3. Motion,\\nthe Chemical Processes\\nin the\\nPAGE\\n1\\n1\\n1\\n4\\n6\\n11\\n17\\n18\\n18\\n24\\n28\\nCHAPTER II.\\nMethods of Examination and Treatment.\\nExamination,\\nInterrogation,\\nInspection,\\nProctoscopy,\\nPalpation,\\nPercussion.\\nAuscultation,\\nInflation of the Intestine with Carbonic Acid Gas or Air.\\nInjection of Water per Anum\\nLavage of the Bowel,\\nExamination of the Faeces,\\nTreatment,\\nDiet,\\nMechanical Procedures\\nInjections,\\nMassage and Gymnastic Exercises,\\n32\\n32\\n34\\n37\\n40\\n44\\n45\\n45\\n48\\n48\\n49\\n74\\n74\\n78\\n78\\n80", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0013.jp2"}, "14": {"fulltext": "vin CONTENTS.\\nPAGE\\nMechanical Procedures\\nHydrotherapy, 80\\nElectricity, .81\\nCHAPTER III.\\nAcute and Chronic Intestinal Catarrh.\\nAcute Intestinal Catarrh, 83\\nSynonyms,\\n83\\nDefinition,\\n83\\nEtiology,\\n83\\nMorbid Anatomy,\\n85\\nSymptomatology,\\n86\\nGeneral Subjective Symptoms,\\n87\\nObjective Symptoms,\\n88\\nFever,\\n89\\nLocalization of the Catarrhal Process\\n5,\\n89\\nDuration,\\n90\\nDiagnosis,\\n91\\nPrognosis,\\n91\\nTreatment,\\n91\\nChronic Intestinal Catarrh,\\n94\\nSynonyms,\\n94\\nDefinition,\\n94\\nEtiology,\\n94\\nMorbid Anatomy,\\n95\\nSymptomatology,\\n98\\nObjective Symptoms,\\n$9\\nCourse,\\n103\\nDiagnosis,\\n103\\nPrognosis,\\n104\\nTreatment,\\n105\\nHydrotherapeutic Measures,\\n106\\nMineral Waters,\\n107\\nMedicaments,\\n107\\nCHAPTER IV.\\nDysentery.\\nDysentery, f 110\\nSynonyms,\\n110\\nDefinition,\\n110\\nEtiology,\\n110\\nMorbid Anatomy,\\n115", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0014.jp2"}, "15": {"fulltext": "CONTENTS.\\nIX\\nDysentery\\nSymptomatology of Acute Dysentery,\\nSymptomatology of Chronic Dysentery,\\nCourse,\\nComplications,\\nDiagnosis,\\nPrognosis,\\nTreatment of Acute Dysentery,\\nTreatment of Chronic Dysentery,\\nCHAPTER V.\\nPAGE\\n119\\n122\\n123\\n123\\n125\\n125\\n125\\n126\\nUlcers of the Intestines.\\nDuodenal Ulcer, 128\\nSynonyms, 128\\nDefinition, .128\\nEtiology, 128\\nMorbid Anatomy, 129\\nSituation of the Ulcer .130\\nSymptomatology, 131\\nCourse, .133\\nDiagnosis, 133\\nPrognosis, 134\\n.134\\n135\\n135\\n136\\n138\\nTreatment,\\nEmbolic and Thrombotic Ulcers,\\nPathological Changes,\\nSymptoms,\\nPrognosis, 138\\nTreatment, 139\\nAmyloid Ulcers, 140\\nDiagnosis, 141\\nTuberculous Ulcers, 141\\nSyphilitic Ulcers,\\nToxic Ulcers,\\nSymptomatology,\\nDiagnosis,\\nPrognosis,\\nTreatment,\\nCHAPTER VI.\\nNeoplasms op the Intestine.\\nMalignant Growths,\\nCancer,\\n144\\n145\\n145\\n147\\n148\\n148\\n150\\n150", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0015.jp2"}, "16": {"fulltext": "X\\nCONTENTS.\\nPAGE\\nCancer\\nDefinition, .150\\nEtiology, .150\\nLocation, 151\\nMorbid Anatomy, 152\\nSymptomatology, 154\\nCourse, 163\\nDiagnosis 163\\nPrognosis 164\\nTreatment, 164\\nSarcoma and Lympho- Sarcoma, 166\\nBenign Tumors of the Intestine, .167\\nCHAPTER VII.\\nHemorrhoids:\\nHemorrhoids,\\nSynonyms,\\nDefinition,\\nEtiology,\\nMorbid Anatomy,\\nSymptomatology,\\nDiagnosis,\\nPrognosis,\\nTreatment,\\nRadical,\\nComplications,\\nProlapse of the Rectum,\\nFissure of the Anus,\\n169\\n169\\n169\\n169\\n171\\n174\\n179\\n180\\n180\\n185\\n189\\n169\\n193\\nCHAPTER VIII.\\nAppendicitis.\\nAppendicitis, 196\\nSynonyms, 196\\nDefinition, 196\\nGeneral Remarks, 196\\nEtiology, 197\\nMorbid Anatomy, 202\\nSymptomatology, 206\\nCourse, 208\\nDiagnosis, 214\\nDifferential Diagnosis, 215\\nPrognosis, 216", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0016.jp2"}, "17": {"fulltext": "CONTENTS.\\nXI\\nAppendicitis\\nTreatment,\\nMedical,\\nSurgical,\\nCHAPTER IX.\\nIntestinal Obstruction.\\nCHAPTER X.\\nNervous Affections of the Intestines.\\npage\\n218\\n218\\n221\\nIntroductory Remarks,\\n226\\nAcute Intestinal Obstruction,\\n227\\nSynonyms,\\n227\\nDefinition,\\n227\\nEtiology,\\n227\\nCompression of the Intestine,\\n227\\nStrangulation by Adhesions,\\n228\\nStrangulation by Meckel s Diverticulum,\\n230\\nVolvulus,\\n232\\nObturations,\\n233\\nIntussusception,\\n234\\nPathological Changes,\\n236\\nSymptomatology,\\n238\\nObjective Signs,\\n245\\nCourse,\\n247\\nDiagnosis,\\n249\\nPrognosis,\\n258\\nTreatment,\\n258\\nMedical,\\n258\\nSurgical,\\n266\\nChronic Intestinal Obstruction,\\n268\\nEtiology,\\n268\\nSymptomatology,\\n269\\nComplications,\\n276\\nCourse and Prognosis,\\n277\\nDiagnosis,\\n277\\nTreatment,\\n278\\nOperative Intervention,\\n280\\nGeneral Remarks\\nMotor Neuroses of the Intestines,\\nDiarrhoea,\\nEtiology and Symptomatology,\\nDiagnosis,\\n282\\n284\\n284\\n284\\n289", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0017.jp2"}, "18": {"fulltext": "xii CONTENTS.\\nT PAGE\\nDiarrhoea\\nPrognosis, 289\\nTreatment, 289\\nConstipation, 291\\nSynonyms, 291\\nDefinition, 291\\nGeneral Remarks, 291\\nEtiology, 292\\nSymptomatology, 297\\nDiagnosis, 302\\nPrognosis, 304\\nTreatment, 304\\nMoral, 305\\nDietetic, 305\\nMechanical, 306\\nCHAPTER XL\\nNervous Affections of the Intestines.\\nMotor Neuroses (Continued), 314\\nParalysis of the Intestines, 314\\nDiagnosis, 315\\nTreatment, 315\\nProctospasmus, or Spasm of the Rectum, 316\\nDiagnosis, 317\\nTreatment, 317\\nParesis and Paralysis of the Sphincters of the Anus, 317\\nDiagnosis, 318\\nPrognosis, 318\\nTreatment, 318\\nPeristaltic Restlessness of the Intestines, .319\\nDefinition, 319\\nEtiology and Symptomatology, 319\\nDiagnosis, 320\\nPrognosis, 320\\nTreatment, .320\\nMeteorism, 321\\nEtiology, 321\\nSymptomatology, 322\\nDiagnosis, 323\\nPrognosis, 323\\nTreatment, 323\\nSensory Neuroses of the Intestines, 325\\nEnteralgia, 326", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0018.jp2"}, "19": {"fulltext": "CONTENTS.\\nXlll\\nEnteralgia\\nPAGE\\nSynonyms,\\nDefinition,\\n326\\n326\\nEtiology,\\n326\\nSymptomatology,\\nDiagnosis,\\n327\\n329\\nPrognosis,\\n330\\nTreatment,\\n330\\nHypogastric Neuralgia\\nTreatment,\\n332\\n332\\nHyperesthesia, Paresthesia, and Anesthesia c\\nf the\\nIntestine, 333\\nTreatment,\\n334\\nSecretory Neuroses of the Intestines.\\n335\\nMembranous Enteritis,\\n335\\nSynonyms,\\nDefinition,\\n335\\n335\\nHistory,\\n335\\nEtiology.\\n339\\nSymptomatology,\\nDiagnosis,\\nTreatment.\\n.341\\n343\\n344\\nIntestinal Neurasthenia,\\n34?\\nDiagnosis.\\n348\\nTreatment,\\n348\\nCHAPTER XII.\\nIntestinal Parasites.\\nGeneral Remarks.\\n349\\nProtozoa,\\n349\\nAmceba?,\\n349\\nSporozoa\\n350\\nInfusoria\\n350\\nVermes,\\n351\\nCestodes (Tape Worms),\\n351\\nGeneral Remarks,\\n351\\nTenia Solium,\\n354\\nTenia Saginata or Mediocanellata\\n355\\nBothriocephalus Latus. Tenia Lata, or Pig Head.\\n357\\nTenia Nana\\n358\\nTenia Cucumerina,\\n358\\nTenia Flavopunctata or Tenia Diminuta,\\n359\\nTreatment,\\n359\\nTrematodes (Fluke Worms),\\n362", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0019.jp2"}, "20": {"fulltext": "xiv CONTENTS.\\nPAGE\\nTrematodes (Fluke Worms)\\nDistoma Hepaticum or Liver Fluke, 362\\nDistoma Lanceolatum, 363\\nDistoma Haematobium or Bilharzia Haematobia, 364\\nNematodes (Round Worms), 365\\nAscaris Lumbricoides (Common Spool or Kound Worm), 365\\nDiagnosis 367\\nSymptoms, 367\\nProphylaxis, 368\\nTreatment, 368\\nAscaris Mystax, 369\\nOxyuris Vermicularis, Awltail, Seat or Pin Worm, Maggot\\nor Thread Worm, 369\\nSymptoms, 370\\nDiagnosis, 371\\nProphylaxis, 371\\nTreatment, 371\\nAnchylostoma Duodenale, Dochmius Duodenalis, or Stron-\\ngylus Duodenalis, 372\\nSymptoms, 374\\nCourse, 375\\nDiagnosis, 375\\nTreatment, 376\\nAnguillula Stercorals, 376\\nAnguillula Intestinalis, 376\\nTrichocephalus Dispar, Whip Worm, 377\\nSymptoms, 377\\nDiagnosis, 377\\nTrichina Spiralis, 379\\nProphylaxis, 380\\nTreatment, 380", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0020.jp2"}, "21": {"fulltext": "DISEASES OF THE INTESTINES,\\nCHAPTER I.\\nANATOMY AND PHYSIOLOGY.\\nANATOMY.\\nThe Intestinal Canal (Intestinum).\\nThe intestinal canal may be divided into two parts, the\\nsmall intestine and the large intestine (Fig. 1). The small\\nintestine (intestinum tenue) is about seven to eight metres\\nlong, the first portion being called the duodenum, the sec-\\nond the jejunum, and the third the ileum. With the ex-\\nception of the duodenum the small intestine lies for the\\nmost part inside the more fixed portion of the large intes-\\ntine and is connected to the posterior abdominal wall by\\nthe mesentery. This broad membrane extends from above\\ndownward and from left to right, from the end of the duo-\\ndenum above to the ileocecal valve below, enclosing the\\njejunum and ileum along the whole of their extent.\\nThe Duodenum.\\nThe duodenum, so called on account of its length (being\\nabout twelve inches long), is, unlike the other parts of the\\nsmall intestine, very definite in position and extent. It is\\nthat part which is not suspended by the mesentery. It is,\\nfurther, the most fixed as well as the widest part of the\\nsmall intestine, measuring one and one-half to two inches\\n1", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0021.jp2"}, "22": {"fulltext": "DISEASES OF THE INTESTINES.\\nin diameter. It has a curved shape, somewhat resembling\\nthat of a horseshoe. It surrounds the pancreas and is\\ndivided into four parts\\n1. The superior horizontal portion (pars horizontalis\\nsuperior) begins at the pylorus, lying at the level of the\\nfirst lumbar vertebra, and runs slightly upward and back-\\nward toward the right until it reaches the right side of the\\nvertebral column. It ends at the neck of the gall bladder,\\nand is the most movable of the four portions. It is cov-\\nered by the two layers of the peritoneum which are contin-\\nued from the stomach, and by these it is completely sur-\\nrounded. Above it lie the liver (quadrate lobe) and the\\ngall bladder, below it is the pancreas, and behind it are the\\ncommon bile duct and hepatic vessels.\\n2. The descending portion of the duodenum, beginning at\\nthe neck of the gall bladder, is about twice as long as the\\nfirst portion, and runs almost vertically to the second or\\nthird lumbar vertebra. It lies to the right of the lumbar\\nvertebrae, and touches the right kidney. In front of it and\\ncrossing it almost at a right angle, runs the transverse\\ncolon. It is more fixed than the first portion. On its left\\nside is the pancreas, and the common bile duct a little\\nmore posteriorly. Into this part of the bowel, and at its\\ninner and back part, but four inches from the pylorus, the\\ncommon bile duct and pancreatic duct enter. The portion\\nat which these ducts enter, occasionally forms a small sinus\\n(diverticulum or ampulla Yateri).\\n3. The third part or the transverse portion is the longest,\\nmeasuring about five inches. It extends from the base of\\nthe second or third lumbar vertebra on the right side\\nobliquely across the spine to the upper part of the left side,\\nascending a little on its way. In front of it is found the\\nlower layer of the transverse mesocolon. The superior", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0022.jp2"}, "23": {"fulltext": "ANATOMY.\\nmesenteric vessels cross this part of the duodenum, running\\nbetween it and the pancreas in order to reach the mesentery.\\nThis portion is in relation with the pancreas and superior\\nFig. 1.\u00e2\u0080\u0094 The Intestine, as Seen from the Front, after Removing the Omentum (Testut).\\n1, Abdominal wall 2, wall of the thorax 3, oesophagus 3 cardia 4, stomach 4\\npylorus 5, duodenum 6, pancreas 7. liver 8, gall bladder 9, gastrohepatic liga-\\nment 10, right kidney and its suprarenal capsule 11, small intestine 12, terminal\\nportion of the ileum 13, csecum 13 its appendix 14, ascending colon 15, transverse\\ncolon 16, descending colon 17, ileopelvic colon 18, bladder 19, parietal peritoneum\\n20, spleen 21, diaphragm 22, thoracic aorta.\\nmesenteric artery above, with the vena cava, aorta, and\\ncrura of the diaphragm behind. It is the most fixed por-\\ntion of the duodenum.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0023.jp2"}, "24": {"fulltext": "4 DISEASES OF THE INTESTINES.\\n4. The fourth part of the duodenum or second ascending\\nportion ascends vertically at the left side of the spine. It\\nis about one inch long and forms the end of the duodenum.\\nIt is firmly fixed in its place by the musculus suspensorius\\nduodeni, the latter being the name of the fibrous band,\\ncontaining some plain muscular fibres which descend to the\\nvertical part of the duodenum from the left crus of the\\ndiaphragm and the tissues about the coeliac axis. It ter-\\nminates at this point in the jejunum, forming the flexura\\nduodenojejunal at a place situated to the left of the sec-\\nond lumbar vertebra.\\nThe Small Intestine.\\nThe small intestine which forms the continuation of the\\nduodenum is composed of the jejunum and ileum. There\\nis really no marked structural difference between the two,\\nand it is therefore hardly possible to determine where one\\nends and the other begins. As a rule, the upper two-fifths\\nare designated as the jejunum and the lower three-fifths as\\nthe ileum. The jejuno-ileum fills the greater part of the\\nabdomen. It occupies the umbilical, hypogastric, iliac,\\nand lumbar regions, and is more or less encircled by the\\nlarge intestine. The coils formed by the jejunum and\\nileum are very movable and completely invested by the\\nperitoneum. They are supported and attached to the pos-\\nterior parietes by the mesentery. The latter extends from\\nthe end of the duodenum to the ileocecal junction. The\\npoint at which the mesentery is attached above is on a level\\nwith the lower border of the pancreas and just to the left\\nof the vertebral bodies. From this point of insertion the\\nmesentery follows an oblique line running downward and\\nto the right, crossing the great vessels and ending in the\\niliac fossa. The length of the mesentery from the spine", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0024.jp2"}, "25": {"fulltext": "ANATOMY. 5\\nto the intestines varies in different parts of the canal, its\\naverage being eight to nine inches. It soon attains its full\\nlength, and within one inch of the end of the duodenum is\\nalready six inches long. The small intestine hangs on\\nthe mesentery in the form of coils, and the folds which the\\nmesentery forms may be compared to those of a fan.\\nThe small intestine including the duodenum has an aver-\\nage length of about twenty feet. The calibre of the small\\nintestine is larger at its upper end and gradually dimin-\\nishes in size until its entrance into the large boweL Thus\\nat the beginning the jejunum has a calibre of 17.5 cm.,\\nthe ileum at its beginning of 11.5 cm., and at its end 9.5\\ncm. The ileum passes perpendicularly into the ascending\\npart of the larger bowel just above the caecum, its mucosa\\nforming a double valve, called valvula Bauhini. The jejuno-\\nileum is the most movable part of the intestinal tract.\\nWherever a free space is left it occupies it. It is therefore\\nmost often met with in hernias. During gravidity or when\\na tumor or ascites exists in the abdomen the small intes-\\ntine moves up higher and thus escapes compression.\\nThe small intestine receives its blood supply from the\\nabdominal aorta. The arteria gastroduodenalis, a branch\\nof the arteria hepatica, supplies the upper part of the duo-\\ndenum; the lower part of the duodenum and the jejunum\\nand ileum are supplied by the arteria mesenterica superior.\\nThe latter vessel branches off into a fine net of numerous\\nsmall vessels which run through the intestinal wall. The\\nend ramifications penetrate the submucosa and here again\\nform a net. From the latter the finest ramifications pene-\\ntrate the mucosa and form a capillar} system of the villi\\nand glands. The venous blood flows partly into the vena\\ngastrica superior, partly into the vena mesenterica superior,\\nand empties itself into the vena porta. The lymphatics", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0025.jp2"}, "26": {"fulltext": "t DISEASES OF THE INTESTINES.\\nform a continuous series which is divided into two sets,\\nthat of the mucous membrane and that of the muscular\\ncoat. The lymph vessels of both sets form a copious\\nplexus. They run between the two folds of the mesentery\\nand end in the mesenteric lacteals. They are provided\\nwith valves which prevent the current from flowing back-\\nward, the direction of which is into the truncus lymphati-\\ncus intestinalis and finally into the thoracic duct.\\nThe nerves of the small intestine originate principally\\nfrom the plexus mesentericus superior or the sympathetic.\\nThe duodenum is supplied by the plexus hepaticus, a\\nbranch of the plexus cceliacus. The abdominal part of the\\nvagus, namely, the plexus gastricus, anterior and posterior,\\nalso supplies the small intestine with nerves. The nerves,\\nwhich are mostly non-medullary, enter the intestinal wall\\nin connection with the branches of the arteria mesenterica\\nsuperior and form a subserous net. They then penetrate\\nthe long muscular fibres and form between these and the\\ncircular muscular fibres ramifications which consist of nu-\\nmerous groups of multipolar cells (plexus mesentericus\\nseu Auerbachii) fine branches of nerves arising here sup-\\nply the muscularis. Others penetrate the circularis, reach\\nthe submucosa, and form the submucous nerve plexus,\\ncontaining small groups of ganglion cells (Meissner s nerve\\nplexus) fine ramifications also supply the muscularis mu-\\ncosa, the muscles of the villi, and end in the remaining\\npart of the mucosa.\\nStructure of the Small Intestine.\\nThe small intestine is composed of four principal coats\\nthe serous, muscular, submucous, and mucous (Fig. 2).\\nThe serous coat is formed by the visceral layer of the peri-\\ntoneum. The muscular coat consists of an internal circular", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0026.jp2"}, "27": {"fulltext": "ANATOMY. 7\\nand an external longitudinal layer (Fig. 3). The former\\nis usually considerably thicker than the latter. They both\\nFig. 2.- Longitudinal Cross-section through the Wall of the Small Intestine (Ileum).\\nSolitary lymph nodules (nodulus lymphaticus solitarius). Intestinal glands (Lieber-\\nkuehni) (Toldt). a. The mucous layer; ft, the muscularis mucosae; c, ihe submucous\\nlayer r7, the muscular layer e, thesubserosa the serous layer ry, intestinal villi\\nh, intestinal glands (Lieberkuehn) i, blood-vessels fr, a solitary lymph nodule Z, its\\ncentre.\\nconsist of bundles of un striped muscular tissue supported\\nby connective fibres. The submucous coat consists of con-\\nnective tissue in which numerous blood-vessels and lym-\\nd----\\nFig. 3.\u00e2\u0080\u0094 Longitudinal Cross-section through the Wall of the Duodenum. Brunner s\\nglands (glandulae duodenales) (Toldt). o, The mucous layer b, the muscularis muco-\\nsae c, the submucous layer d, the circular muscular layer e, the longitudinal mus-\\ncular layer; intestinal villi g, intestinal glands (Lieberkuehn) 7i, Brunner s duo-\\ndenum glands i, serous layer.\\nphatics ramify. The mucous membrane is the most im-\\nportant coat with regard to the function of digestion. It", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0027.jp2"}, "28": {"fulltext": "8\\nDISEASES OF THE INTESTINES.\\nconsists of a very thin muscular layer (muscularis mucosae)\\ncontaining circular and longitudinal fibres, the tunica\\npropria of the mucosa, a tissue made up principally\\nof reticular connective\\ntissue with numerous\\nleucocytes, glands, and\\nthe epithelial covering.\\nThe mucous membrane\\nof the small intestine is\\nof a grayish-red color\\nand has a velvety ap-\\npearance. It possesses\\ncertain large folds of\\nvalvular flaps (valvulae\\nconniventes Kerkringi)\\n(Fig. 4). These are\\npermanent crescentic\\nfolds of mucous mem-\\nbrane set transversely\\nto the long axis of the\\nintestine. Each one ex-\\ntends from one-half to two-thirds of the distance of the\\nlumen. The largest are more than two inches long and\\nabout one-third of an inch wide. They begin somewhat\\nbelow the pylorus, are very large just below the entrance\\nof the bile duct, remain conspicuous until the middle of\\nthe jejunum is reached, then become smaller and gradually\\ndisappear at the lower part of the ileum. They serve to\\nincrease the surface of the mucous membrane.\\nThe microscopical anatomy of the mucous membrane\\nreveals the following The entire inner surface of the small\\nintestine is composed of villi, certain papilliform processes,\\nand glands an epithelial layer containing columnar epi-\\nFig. 4.\u00e2\u0080\u0094 Jejunum Partly Opened (Toldt). a,\\nSerosa b, mucosa c, circular folds of Ker-\\nkring.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0028.jp2"}, "29": {"fulltext": "ANATOMY\\n9\\nthelial cells with, a striated border, and some goblet cells\\ncover the entire surface. The villi are formed principally\\nby elevations of the tunica propria of the mucous mem-\\nbrane (Fig. 5). They are about 0.5 to 0.7 mm. in height\\nand about 0.1 to 0.2 mm. wide and number almost ten mil-\\nlions. Each villus possesses a centrally located space for\\nchyle which is covered with endothelial cells and connected\\nwith the lymphatics of the intestinal mucosa. Each villus\\ncontains a perfect arrangement of blood-vessels and muscu-\\nlar fibres which originate in the muscularis mucosae. When\\nfilling up with blood each villus expands, while under the\\ncontraction of its muscle it shrinks. Thus it is enabled to\\nperform the function of suction and pumping. The villi\\nform the main organ for\\nthe absorption in the\\nsmall intestine.\\nAround the villi lie\\ntheir glands. First,\\nthere are tubular glands\\n(of Lieberkuhn), and,\\nsecondly, acinous glands\\nof Brunner. The former\\nare similar in structure\\nto the tubular glands in\\nthe stomach. They cover\\nalmost the entire surface\\nof the whole small and large intestine. Each glandular\\ntubule is about 0.3 to 0.4 mm. long and opens without\\nforming any ramifications. They number over forty mil-\\nlions and form the principal organ of intestinal secretion.\\nBrunner s glands are confined to the duodenum. They\\nare most abundant at the commencement of this portion\\nof the intestine, diminishing gradually as the duodenum\\nMM\\nFig. 5.\u00e2\u0080\u0094 Mucous Membrane of the Ileum with\\na Solitary Lymph Nodule (Toldt). a, In-\\ntestinal glands (Lieberkuehn) b, intestinal\\nvilli c, a solitary lymph nodule.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0029.jp2"}, "30": {"fulltext": "10\\nDISEASES OF THE INTESTINES.\\nadvances. They are situated beneath the mucous mem-\\nbrane and embedded in the submucous tissue. Each\\ngland is a branched and convoluted tube lined with col-\\numnar epithelium. In structure they are very similar to\\nthe pyloric glands of the stomach, but are more branched\\nand convoluted, and their ducts are longer. The duct of\\neach gland passes through\\nthe muscularis mucosae\\nand opens on the surface\\nof the mucous membrane.\\nSolitary follicles or\\nglands are found scat-\\ntered throughout the mu-\\ncous membrane of the\\nsmall intestine. They\\nare most numerous in the\\nlower part of the ileum.\\nEach one has a diameter\\nof from 3 to 6 mm. The\\nstructure of the solitary\\nfollicle is similar to that\\nof the lymph nodes and\\nconsists of a dense reti-\\nform tissue packed with\\nlymph corpuscles and\\npermeated by fine capillaries. There are no ducts. The\\ninterspaces of the retiform tissue are continuous with lar-\\nger lymph spaces at the base of the gland, by which they\\ncommunicate with the lacteal system. The base of the\\nnodules is in the submucous tissue. It penetrates the\\nmuscularis mucosae and enters the mucous membrane form-\\ning a slight projection of its epithelial layer. The solitary\\nfollicles are the breeding place of the lymph cells. They\\nFig. 6. \u00e2\u0080\u0094Ileum Partly Opened (Toldt).\\nSolitary lymph nodules; serosa:\\nmucosa.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0030.jp2"}, "31": {"fulltext": "ANATOMY.\\n11\\nare met with in two conditions, namely, either scattered\\nsingly, in which case they are termed glandulse solitarife\\n(Fig. 6), or aggregated in groups varying from one to three\\nFig. 7.\u00e2\u0080\u0094 Peyer s Patch (Noduli Lymphatici Aggregati) in the Ileum (Toldt). a, Peyer s\\npatch 7), solitary lymph nodules.\\ninches in length and about one-half inch in width. The\\nsurface of the solitary follicles is free from villi. Chiefly\\nof an oval form, their long axis is parallel with that of the\\nintestine. In this state they are called glandule agminate\\nor Peyer s patches or plaques (Fig. 7). They are almost\\nalways placed opposite the attachment of the mesentery.\\nPeyer s patches number about twenty to twenty-eight. In\\nsome cases they are already found in. the jejunum, but\\nthey are most prevalent in the ileum.\\nThe Large Intestine or Large Bowel (Intestinum Crassum).\\nThe large intestine extends from the termination of the\\nileum to the anus. It is about five to six feet in length.\\nIts calibre decreases from beginning to end except at the\\nampulla of the rectum where it is larger. It measures\\n28.5 cm. in circumference at the junction of colon and cse-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0031.jp2"}, "32": {"fulltext": "12\\nDISEASES OF THE INTESTINES.\\ncum, 20.5 cm. at the end of the ascending portion, 14.5 cm.\\nin the descending portion. The large intestine is divided\\ninto the caecum, colon, and rectum. With the exception\\nof the rectum\\nit possesses\\nthree taeniae,\\nthese being\\ngroups of non-\\nstriated muscu-\\nlar fibres run-\\nning lengthwise\\nwith the lumen\\nof the intestine.\\nBetween the\\ntaeniae the walls\\nare somewhat\\nsacculated. The\\ncircular muscu-\\nlar fi b r e s are\\nalso accumulat-\\ned in spots,\\nleaving short\\nintervals be-\\ntween each\\nother, thus\\nforming con-\\nstrictions and\\nexpansions (haustra coli) across the intestine (Fig. 8).\\nThe large bowel is further characterized by appendices\\nepiploicae, external pouches, formed by the peritoneal cov-\\nering containing fat. The caecum is the head of the colon\\nor that part of the large bowel situated below the mouth of\\nthe ileum (Fig. 9). It lies in the right iliac fossa and is\\nFig. 8.\u00e2\u0080\u0094 The Large Bowel Partly Opened along the Mesen-\\ntery (Toldt) a, Free taenia b, taenia mesocolica c,\\nappendices epiploicae d, the mucosa e, the semilunar\\nfolds of the colon the mesocolon.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0032.jp2"}, "33": {"fulltext": "ANATOMY.\\n13\\ncompletely covered by the peritoneum. In the filled con-\\ndition it touches the anterior abdominal wall. Starting\\nfrom the inner and back portion of the caecum lies the pro-\\ncessus vermiformis or appendix, forming a narrow, some-\\nwhat bent, blind-ending tube. The appendix is movable\\nand has its own a\\nmesentery (mes-\\nenteriolum).\\nIts length varies\\nbetween 2 and 20\\ncm. and its\\nwidth between\\n0.5 and 1 cm.\\nThe appendix\\nopens into the\\ncaecum (ostium\\nprocessus vermi-\\nformis), occa-\\nsionally form-\\ning a crescentic\\nfold (v a 1 v u 1 a\\nprocessus ver-\\nmiformis) I n\\nman it consti-\\ntutes an entirely\\nfunctionless or-\\ngan which occa-\\nsionally gives\\nrise to manifold\\nailments. The appendix has no fixed position. J. D.\\nBryant 1 found it most often inward, then behind the\\ncaecum, downward and inward, into the true pelvis.\\n1 J. D. Bryant Annals of Surgery, February, 1893, p. 164.\\nFig. 9.\u00e2\u0080\u0094 Section of the Caecum and Ileum, showing the En-\\ntrance of the Latter into the Caecum (Toldt). a, The\\nsemilunar folds of the colon b, c, the ileocaecal valves (b,\\nthe upper, and c, the lower one) d, the end portion of\\nthe ileum e, the posterior ileocaecal valve the appen-\\ndicular valve g, the appendix.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0033.jp2"}, "34": {"fulltext": "14 DISEASES OF THE INTESTINES.\\nWithout distinct demarcation the caecum merges into the\\nascending colon. It passes vertically above the crest of\\nthe ileum and runs along the posterior abdominal muscles\\nand the lower part of the right kidney. At this point just\\nin front of the kidney and immediately beneath the liver\\nthe colon bends toward the left of the flexura coli dextra.\\nThe ascending colon is posteriorly adherent through con-\\nnective tissue with the parts just mentioned, while the\\nperitoneum covers only its anterior and partly also its lat-\\neral surfaces. In close proximity .to its median wall lies\\nthe ascending part of the duodenum. Beginning at the\\nflexura coli dextra the colon runs across the abdominal\\ncavity from right to left (transverse colon), forming the\\nlongest segment of the large intestine. It passes from the\\nhepatic flexure in the right hypochondrium transversely\\nand slightly upward from right to left along the anterior\\nabdominal wall to the splenic flexure in the left hypochon-\\ndrium. This part of the colon is the most movable. It\\nhas a very long mesentery, called the transverse meso-\\ncolon. The usual position of the transverse colon corre-\\nsponds to a line separating the umbilical and epigastric\\nregions. It is in relation by its upper surface with the\\nlower part of the liver and gall bladder, the greater curva-\\nture of the stomach and the lower end of the spleen by\\nits under surface with the small intestine by its anterior\\nsurface with the great omentum and abdominal wall; by\\nits posterior surface with the transverse mesocolon on the\\nright side with the second part of the duodenum, and on\\nthe left besides the latter with some convolutions of the\\nsmall intestine.\\nThe transverse colon does not form a straight line con-\\nnecting the right and left flexures, but is about twice as\\nlong as this line and therefore forms several curves. In", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0034.jp2"}, "35": {"fulltext": "ANATOMY. 13\\nthe left hypochondrium especially, there is an S-shaped\\ncoil. The latter fills out the free space in the left hypo-\\nchondrium which is left by the stomach in its various\\nstates of fulness. Beginning at the flexura coli sinistra\\nthe descending colon runs downward in front of the left\\nkidney and the quadratus lumborum and iliac muscles un-\\ntil it reaches the left iliac fossa. The descending colon\\nruns just in the opposite direction to the ascending colon,\\nand like this is only partly covered by the peritoneum.\\nThe descending colon passes into the sigmoid colon or\\nflexure (S Eomanum), commencing above the iliac crest\\nand ending below in the rectum at the brim of the true\\npelvis opposite the left sacro-iliac articulation. It is gen-\\nerally described as an S-shaped curve having an upper\\ncolic rim turned toward Poupart s ligament and the lower\\nrectal rim, hanging down into the true pelvis. It has a\\ncomplete peritoneal covering or mesentery. This part of\\nthe bowel is very movable, and its calibre is the narrowest\\nof that of the large bowel. The sigmoid flexure continues\\ninto the rectum, forming the terminal portion cf the intes-\\ntinal tube. It runs, coming from the left, in front of the\\nos sacrum down to the bottom of the small pelvis. Only\\nthe upper half of the rectum is invested completely with\\nperitoneum (mesorectum) and is attached to the sacral ver-\\ntebra. The lower half passes between the organs occupy-\\ning the pelvic floor, being adherent to them by connective\\ntissue. It now runs posterior^ along the os coccyx and\\nterminates in the anus. This part has an incomplete peri-\\ntoneal covering (plica Douglasii) lying anteriorly and turn-\\ning backward in order to ascend either over the vagina or\\nthe bladder (excavatio recto-uterina, excavatio recto vesica-\\nlis). Below this point the rectum has very little mobility\\nas it is covered all around by connective tissue. The en-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0035.jp2"}, "36": {"fulltext": "16 DISEASES OF THE INTESTINES.\\ntire rectum is about 18 to 22 cm. long. Its calibre varies.\\nIt is widest at the apex of the prostate, forming the am-\\npulla of the rectum.\\nThe longitudinal muscular fibres of the rectum are not\\narranged in taeniae as in the colon, but pass all around the\\nlumen. The circular muscular fibres become more dense\\nfrom above downward and increase to such a degree at the\\nanal opening that they here form a thick ring (musculus\\nsphincter ani internus). A short distance above this mus-\\ncle there is also an accumulation of circular muscular fibres\\n(musculus sphincter ani tertius). At the anus the walls of\\nthe rectum are connected with striated muscular fibres\\n(sphincter ani externus and levator ani), which are both\\nof importance in the act of defecation.\\nThe colon is supplied by the three arteriae colicae,\\nbranches of the arteria mesenterica superior and arteria\\nmesenterica inferior. The arteria colica sinistra origi-\\nnates from the arteria mesenterica inferior, while the ar-\\nteria colica media and superior are tributaries of the arteria\\nmesenterica superior. The veins accompany the artery and\\nempty partly into the vena mesenterica superior, partly\\ninto the vena mesenterica inferior. The lymphatics of the\\ncolon are numerous and lie below the glands and all\\nthrough the submucosa. The plexus mesentericus supe-\\nrior, a branch of the plexus coeliacus, provides the nervous\\nsupply of the caecum, ascending colon, and the right half\\nof the transverse colon. The plexus mesentericus inferior,\\na branch of the plexus aorticus abdominalis, supplies the\\nleft half of the transverse colon, the descending colon, and\\nthe sigmoid flexure.\\nThe rectum is supplied by the arteriae haemorrhoidales\\nsuperior, media, and inferiores, branches of the arteria\\nmesenterica inferior and arteria pudenda communis. The", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0036.jp2"}, "37": {"fulltext": "ANATOMY. 17\\nvenous blood of the rectum is carried to the venae haemor-\\nrhoidales principally into the vena mesenterica inferior,\\nthus emptying into the vena portarum, partly, however,\\ninto the vena iliaca interna. In this way there is a sepa-\\nrate communication (outside of the portal circulation) with\\nthe remaining vessels of the abdomen. The lymphatics of\\nthe rectum form a wide net, running partly to the glands\\nlying behind the rectum, partly to the plexus lumbalis\\nsinister. The nerves supplying the rectum originate from\\nthe sympathetic, being branches of the plexus mesenteri-\\ncus inferior, the plexus sacralis (nervi haemorrhoidales in-\\nferior and medii) and the plexus hy pogastricus superior.\\nHistology of the Large Bowel.\\nThe large bowel consists, like the small bowel, of four\\ncoats: the serosa, muscularis, submucosa, and mucosa.\\nThe structure of these four coats corresponds to that of\\nthe small intestine, except that the longitudinal muscular\\nfibres are arranged in three groups (taeniae) running along\\nthe wall, as mentioned above. The mucosa of the large\\nbowel differs from that of the small intestine in that there\\nis an absence of the folds of Kerkring and of the villi.\\nLieberkuhn s glands are here somewhat longer and some-\\ntimes curved.\\nThe raucous membrane of the rectum is thicker, more\\nred, and succulent than that of the colon. There are nu-\\nmerous folds. One conspicuous fold is found 6 to 7 cm.\\nabove the anus (plica transversalis recti). In the neigh-\\nborhood of the anus the folds take a longitudinal direc-\\ntion, and are called columnae Morgagnii seu recti. The\\nlower region of the rectum contains the epithelial cells of\\nthe rectum, pavement-like epithelium, forming a gradual\\n2", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0037.jp2"}, "38": {"fulltext": "18 DISEASES OF THE INTESTINES.\\ntransition from the mucous membrane of the digestive\\ntract to that of the external skin. The upper portion of\\nthe rectum corresponds exactly to that of the colon.\\nPHYSIOLOGY.\\nThe intestines are entrusted with the important office of\\ndigesting the food which has not been acted upon by the\\nstomach, of absorbing it, and finally of eliminating the\\nundigested remnants. In order to fulfil this object they\\nhave three functions, the secretory, absorbent, and motor.\\nAll these functions are supervised by ganglionic cells and\\nnerves, the latter also transmitting sensory impressions.\\n1. The Secretory Function or the Chemical Processes in the\\nIntestines.\\nAs is well known, the intestinal secretion consists, first,\\nof the bile; secondly, the pancreatic juice; and thirdly, the\\nintestinal juice proper (succus entericus). The composi-\\ntion of each of these and their properties may be found in\\nthe text-books on physiology, and also briefly in my book\\non The Diseases of the Stomach. It will not be amiss,\\nhowever, to describe here more fully their joint action in\\nthe intestinal canal.\\nThe effect of each of the digestive juices is influenced by\\nthat of the others. For this reason the chemical processes\\nin the intestines are quite complicated. The carbohy-\\ndrates, whose conversion into maltose by the ptyalin has\\nbeen checked in the stomach by the free hydrochloric acid,\\nare now, after reaching the intestines, further changed by\\nthe diastase of the pancreatic secretion into maltose, which\\nis further converted into glucose. Cane sugar is likewise\\nconverted into grape sugar, while milk sugar, according to", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0038.jp2"}, "39": {"fulltext": "PHYSIOLOGY. 19\\nVoit and Lusk, 1 remains unchanged. The finer parts of\\nthe cellulose also undergo some changes, but their ulti-\\nmate products are not known. It is certain, however, that\\nunder the influence of micro-organisms they partly undergo\\nfermentation, giving rise to the formation of marsh gas,\\nacetic acid, and butyric acid.\\nThe pancreatic juice forms the principal factor of all the\\ndigestive processes in the intestinal canal. Besides its ac-\\ntion upon the carbohydrates through its diastatic ferment,\\nit acts upon fats by means of the steapsin and upon al-\\nbuminates by means of the trypsin ferment. According\\nto Nencki 2 and Eachf ord, 3 the fat-splitting action of the\\npancreas is greatly increased by the presence of bile. The\\nsplitting of the fats into fatty acids and glycerin is of\\ngreatest importance for absorption. The fatty acids com-\\nbine with the alkalies of the intestinal and pancreatic\\njuices and form soaps which are either absorbed as such\\nor promote the absorption of fats. There is no doubt\\nthat the greater amount of fats taken in with the nourish-\\nment is absorbed as a fine emulsion in the formation of\\nwhich the soaps take part. These processes of fat emulsi-\\nfication, by the action either of the pancreatic juice or of\\nsoaps, take place only in alkaline media. If the intestinal\\ncontents are acid, emulsification does not occur, or does so\\nonly at those places at which the fat comes in contact with\\nan alkaline secretion covering the mucous membrane. Ac-\\ncording to Claude Bernard 4 and Dastre, 5 the action of bile\\ngreatly increases the emulsifying property of the pancre-\\n1 Lusk Zeitschr. f. Biologie, Bd. 28, p. 275.\\nlJ Nencki Arch. f. experimentelle Path. u. Pharm. Bd. 20.\\n3 Rachford Journal of Physiology, vol. 12.\\n4 Ciaude Bernard Lecons de physiologie experimentale, 2d edi-\\ntion, 1865.\\n5 Dastre Arch, de Physiologie, Tome 2, p. 315.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0039.jp2"}, "40": {"fulltext": "20 DISEASES OF THE INTESTINES.\\natic juice. While the bile exerts a deleterious influence\\nupon the action of pepsin in artificial solutions, its pres-\\nence in the stomach does not seem to have any inhibitory\\neffect. The bile exerts an influence upon the digestion of\\nthe albuminates in the intestines by precipitating the pep-\\nsin in tho acid gastric contents. It thus destroys the ac-\\ntion of the pepsin. This precipitate, formed by the gas-\\ntric contents and the bile, is soon dissolved, partly through\\nthe intervention of freshly secreted bile in abundance,\\npartly through the sodium chloride which arises after the\\nneutralization of the gastric juice by the alkalies present.\\nThe action of the bile upon the pancreatic digestion of al-\\nbumin is not deleterious, and may have a beneficial effect\\nin the presence of organic acids which, as a rule, exist in\\nthe upper parts of the small intestine.\\nAside from the chemical processes caused b}^ the enzymes\\nin the intestines there also exist fermentative and putre-\\nfactive changes produced by micro-organisms. These are\\nbut very slight in the upper part of the intestine and\\nincrease in intensity toward the end of the small intestine\\nand in the greater part of the large bowel, while they again\\ndecrease in the lower part of the bowel and in the rectum.\\nAccording to Macfadyen, Nencki, and Sieber, 1 who have\\nrepeatedly analyzed the intestinal contents of a man with\\na fistula situated near the end of the ileum, only fermen-\\ntative processes take place within the small intestine. The\\ncontents obtained in this case had a golden-yellow color\\nand showed an acid reaction, the acidity amounting to one\\nper mille. As a rule, they were odorless. The principal\\nelements of the acidity consisted of acetic, lactic, and\\nparalactic acids, volatile fatty acids, succinic acid, and\\n1 Macfadyen, M. Nencki und N. Sieber Arch. f. experimentelle\\nPathol, u. Pharm., Bd. 28, p. 311.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0040.jp2"}, "41": {"fulltext": "PHYSIOLOGY. 21\\nbiliary acids; albumin, peptone, mucin, dextrin, sugar,\\nand alcohol were present; leucin and ty rosin, however,\\nwere absent. Thus, according to these authors, fermenta-\\ntive processes in the small intestine result merely from\\nthe action of microbes upon carbohydrates, which ac-\\ntion ultimately leads to the formation of ethyl alcohol\\nand the organic acids just mentioned. The latter pre-\\nvent the putrefaction of albuminates within the small in-\\ntestine and also partly check the decomposition of the\\ncarbohydrates.\\nThe putrefaction of the albuminates takes place in the\\nlarge intestine, the contents there having an alkaline reac-\\ntion. The decomposition of the albuminates by the putre-\\nfactive processes caused by micro-organisms goes much\\nfurther than that by the pancreatic digestion. The pan-\\ncreatic digestion of the albuminates gives rise to albumoses\\nand peptones, lysin, lysatinin, proteinchromogen, amido-\\nacids, and ammonia. In the jmtrefaction of the albumin-\\nates at first the same products are formed, but the decom-\\nposition advances still further and generates a host of new\\nproducts: indol, skatol, paracresol, phenol, phenyl-propi-\\nonic acid and phenyl-acetic acid, para-oxyphenyl-acetic\\nacid, hydroparacumaric acid, volatile fatty acids, carbon\\ndioxide, hydrogen, marsh gas, methyl mercaptan, and sul-\\nphuretted hydrogen. In the putrefaction of gluten neither\\nty rosin nor indol is formed while glycocoll is developed.\\nOf the products of decomposition just named some are of\\ngreat importance, as they are eliminated by way of the urine\\nafter their absorption from the intestinal wall. Some of\\nthem, as for instance the oxy-acids, appear unchanged in\\nthe urine, others (like the phenols) after further oxidation,\\nand still others (like indol and skatol) after combination\\nwith ethereal sulphuric acids. The presence of ethereal", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0041.jp2"}, "42": {"fulltext": "22 DISEASES OF THE INTESTINES.\\nsulphuric acids in the urine is thus to a certain extent an\\nindication of the amount of putrefaction going on in the\\nintestine. The putrefactive processes in the intestine relate\\nnot only to the ingested food but also to the secretions\\nrich in albuminates. Thus Miiller 1 observed that Cetti\\nduring his fasting period first showed a diminution of the\\namount of indican in the uriue which entirely disappeared\\non the third day The phenol elimination was also at first\\ndiminished, but beginning from the fifth day of fasting it\\ncommenced to increase, and on the eighth or ninth day\\nreached an amount which was three to seven times that of\\na man under ordinary conditions.\\nThe putrefactive processes within the intestines, how-\\never, do not reach that height which they attain outside\\nof the body. Thus, for instance, the fresh contents of the\\nlarge bowel do not present so fetid an odor as a pancreatic\\ninfusion or decomposing albumin would reveal after long\\nstanding. The putrefaction within the intestine is partly\\nchecked by several factors\\n1. Carbohydrates as such exert an inhibitory influence\\nupon putrefaction (Hirschler 2 the organic acids which\\ndevelop during their fermentation also partly check putre-\\nfaction. Of other foods, milk and kumyss, according to\\nSchmitz, 3 likewise lessen the processes of bacterial de-\\ncomposition, this effect being due to the presence of lactose\\nand also of lactic acid.\\n2. The bile exerts a decidedly anti-putrefactive action.\\nAs shown by Lindberger 4 and Limbourg, 5 albumin to\\nwhich bile is added does not decompose so thoroughly as\\n1 Miiller: Berl. klin. Wochenschr., 1887, No. 24.\\n2 Hirschler Zeitschr. f. physiol. Chemie, Bd. 10, p. 306.\\n3 Schmitz Zeitschr. f. physiol. Chemie, Bd. 17, p. 401.\\n4 Lindberger Maly s Jahresber. Bd. 14, p. 334.\\n5 Limbourg Zeitschr. f. physiol. Chemie, Bd. 13.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0042.jp2"}, "43": {"fulltext": "PHYSIOLOGY. 23\\nwithout it. The biliary acids, moreover, inhibit putrefac-\\ntion through their acid elements.\\n3. Absorption. The rapid absorption of fluids from the\\nintestinal wall and the forward motion of the contents do\\nnot permit the putrefactive processes to get the upper hand.\\nThese fermentative and putrefactive processes taking\\nplace within the intestines serve to augment the various\\nmeans at the disposal of the organism to utilize or to break\\nup into simpler components the more complex groups of\\nvarious food substances. In the normal state these putre-\\nfactive processes are most probably checked before any\\ndeleterious substances can be developed.\\nThe intestinal contents on their long way from the duo-\\ndenum to the anus show the presence of different gases.\\nThese consist of traces of oxygen and a larger amount of\\nnitrogen; the latter is derived either from swallowed air\\nwhich has come from the stomach, or from pure nitrogen\\nwhich has been diffused from the tissues through the in-\\ntestinal walls. Carbonic-acid gas is present which has been\\ndeveloped through neutralization of the acid gastric con-\\ntents by the pancreatic and intestinal juices, and also from\\nthe butyric and lactic acid fermentation of the carbohy-\\ndrates. Hydrogen is found in larger amounts after a milk\\ndiet and only in small quantities after a pure meat diet.\\nMethyl mercaptan and sulphuretted hydrogen are present\\nin traces, and undoubtedly owe their origin to the albumin.\\nMarsh gas likewise results from the decomposition of\\nalbumin, but it is also evolved from the fermentation of\\ncarbohydrates, especially of cellulose. These different\\ngases are formed and absorbed all along the intestinal\\nwalls, and most probably help to mix the contents and\\nthus facilitate absorption. If present in too large quanti-\\nties, they are easily passed through the rectum occasion-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0043.jp2"}, "44": {"fulltext": "24 DISEASES OF THE INTESTINES.\\nally some of the gases contained in the upper part of the\\nsmall intestine may be eructated by way of the stomach\\nthrough the mouth.\\nIn passing through the large bowel the intestinal con-\\ntents become thickened through the rapid absorption of\\nthe fluids, and at last are eliminated as fecal matter. This\\n(faeces) comprises the remnants of the undigested material,\\nexcretory products of the intestines, and a host of micro-\\norganisms. The quantity of fecal matter within twenty-\\nfour hours varies greatly according to the mode of nourish-\\nment. Thus after a mixed diet it amounts usually to from\\n120 to 150 gm. After a vegetable diet, however, the quan-\\ntity, according to Voit, 1 reached 333 gm. The reaction of\\nthe faeces is varied. Often it is found acid in their inner\\nparts, while the outer surface shows an alkaline reaction.\\nTheir peculiar odor is principally due to Brieger s skatol,\\nbut also to indol and other substances. Their color is\\nusually of a light or dark brown, according to the charac-\\nter of the nourishment.\\n2. Absorption.\\nThe object of digestion is to dissolve and partially\\nchange the food substances into such combinations as can\\nbe assimilated by the blood. Before assimilation can be\\neffected absorption must take place. The main place for\\nthe absorption of nutritive material is the small intestine.\\nIt will be best to describe the process of absorption of the\\ndifferent food materials separately.\\n(a) The proteids are usually changed into albumoses\\nand peptones before their absorption. Albumen as such,\\nhowever, is also liable to be absorbed, although not so\\nquickly as when its change into peptone has been accom-\\n1 Voit Zeitschr. f. physiol. Chemie, Bd. 13.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0044.jp2"}, "45": {"fulltext": "PHYSIOLOGY. 25\\nplished. The absorption of albumoses and peptones takes\\nplace through the intestinal wall by way of the capillaries\\nof the blood-vessels and not through the lacteals. Thus\\nMunk and Eosenstein 2 observed in a patient with a lymph\\nfistula that after a meal rich in albuminous food the lymph\\ndid not contain more proteids than before the meal. The\\npeptones and albumoses do not reach the blood current as\\nsuch, but are previously reconverted into albumin. This\\nfact has been clearly shown by the experiments of Ludwig\\nand Salvioli. 2 These investigators tied a resected intesti-\\nnal coil at both ends and injected into its lumen a solution\\nof peptone, while the coil was kept alive with defibrinated\\nblood. Although the peptone entirely disappeared from\\nthe intestinal coil, the blood did not contain even traces\\nof peptone. It therefore must have become changed into\\nanother substance. This change of the peptones into al-\\nbuminates before reaching the blood is of teleological im-\\nportance. For, as has been shown by Schmidt-Muhlheim 3\\nand others, peptone introduced into the circulating blood\\nis soon eliminated with the urine. Where the change of\\nthe peptones into albuminates takes place and by what\\nmechanism are not as yet certain. Some seem to believe\\nthat the epithelial cells of the intestinal walls perform this\\noffice, others that the leucocytes are the means of its con-\\nversion.\\nThe absorption of the albuminates appears to be more\\ncomplete as regards animal than vegetable food. The\\nreason for this is that the cellulose surrounding the legu-\\nmen partly renders its absorption more difficult. Again,\\nthe peristalsis being greater after vegetable food, the intes-\\n1 Munk and Rosenstein Virchow s Arch., Bd. 123.\\n2 Ludwig and Salvioli Du Bois-Reymond s Arch., 1880, Suppl.\\n3 Schmidt-Muhlheim Du Bois-Reymond s Arch., 1880.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0045.jp2"}, "46": {"fulltext": "26 DISEASES OF THE INTESTINES.\\ntinal contents pass through the canal quicker, and thus\\nless of the albumen is utilized. And again, according to\\nHammarsten, 1 a part of the nitrogenous substances of the\\nplant proteids appears to be indigestible.\\n(b) The carbohydrates are absorbed principally as mono-\\nsaccharides. Glucose, leevulose, and galactose are absorbed\\nas such. Cane sugar and maltose are ordinarily changed\\nfirst into glucose and lsevulose. According to Yoit and\\nLusk, sugar of milk is not converted, and is either partly\\nabsorbed as such or else undergoes lactic-acid fermenta-\\ntion. The different kinds of sugar are absorbed through\\nthe capillaries of the villi and thus reach the circulation.\\nThey enter the liver through the vena porta and are here\\nretained in great part as glycogen. In case, however, a\\nlarge quantity of sugar is at once absorbed, it may occa-\\nsionally reach the lacteals and thus enter the blood current\\noutside of the liver. In such instances sugar appears in\\nthe urine, a condition which is known as alimentary glyco-\\nsuria. The introduction of larger quantities of sugar into\\nthe intestinal tract occasionally gives rise to diarrhoea.\\nCarbohydrates, however, even in large amounts in the form\\nof starch, will be absorbed without difficulty and without\\ngiving rise to any trouble.\\n(c) The fats. In the absorption of fats their emulsifica-\\ntion seems to be of greatest importance. Although a small\\npart is absorbed in the form of soaps, the greatest quan-\\ntity of fat is taken up in the form of an emulsion. The\\nlatter comprises not only neutral fats but also fatty acids.\\nThese, however, undergo a change into neutral fats after\\ntheir absorption from the intestinal walls. It is generally\\naccepted that fats after their absorption from the intestinal\\n1 Olof Hammarsten Lehrbuch der physiologischen Chemie, Wies-\\nbaden, 1895, p. 293.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0046.jp2"}, "47": {"fulltext": "PHYSIOLOGY. 27\\nwall directly reach the lymphatics and thus enter the tho-\\nracic duct, whence they afterward find their way into the\\nblood current. In a girl with a lymph fistula Munk and\\nKosenstein found that sixt} T per cent of the ingested fat\\nappeared in the lymph. After giving the patient erucic\\nacid (a fatty acid foreign to the organism) they could dis-\\ncover thirty -seven per cent of this particular substance in\\nthe form of neutral fats. Thus it appears to be proven\\nthat while the proteids and carbohydrates after their ab-\\nsorption directly reach the blood current, as mentioned\\nabove, the fats are an exception and directly enter the lac-\\nteals. The ultimate way in which absorption takes place\\nis not as yet known. It must, however, be accepted that\\nthe epithelial cells of the intestinal wall cause this process\\nby some specific action. The absorptive property of the\\nsmall intestine for fat is very great. According to Rub-\\nner, 1 a man can absorb over 300 gm. of fat per day. Not\\nall kinds of fat, however, have the same coefficient of as-\\nsimilation. Thus fats with a low melting-point (olive oil,\\ngoose fat, butter, etc.) are absorbed more quickly than\\nthose with a high melting-point (mutton fat and stearin).\\nMoreover, free fats, like butter and lard, are assimilated\\nmore quickly and thoroughly than bacon, in which the fat\\nis surrounded by connective tissue.\\nBesides the above-named three groups of food sub-\\nstances, water and different salts which are kept in solu-\\ntion are very quickly and thoroughly absorbed all along\\nthe intestinal tract. Aside from the salts, other soluble\\nsubstances of the secretory juices are also absorbed. Thus\\nthe urine contains traces of pepsin and also urobilin,\\nwhich shows that the biliary products must have been\\nabsorbed and eliminated through the urine. According\\n1 Rubner Zeitschr. f. Biologie, Bd. 15.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0047.jp2"}, "48": {"fulltext": "28 DISEASES OF THE INTESTINES.\\nto Schiff, 1 the bile is absorbed from the small intestine\\nand reaches the liver with the blood current in order to be\\neliminated again by this organ from the blood.\\nThe pancreatic juice being the principal factor in the di-\\ngestion of the different kinds of food, it appears of interest\\nto ascertain how much of these foods will be absorbed after\\nthe pancreas has been excluded from participation in the\\nact of digestion. Minkowski and Abelmann 2 experimented\\non dogs by extirpating the pancreas, and found that forty-\\nfour per cent of the proteids and from fifty -seven to seventy-\\none per cent of carbohydrates (amylaceous food) were ab-\\nsorbed, while the fats remained totally unabsorbed. The fat\\ncontained in milk, being emulsified, however, was absorbed\\nto the extent of from twenty-eight to fifty -three per cent.\\nWhile the main place at which the absorption occurs is\\nthe small intestine, the large bowel is also able to serve* in\\nthis capacity. Thus aside from the absorption of fluids\\nand salts which normally takes place in this organ, albu-\\nminates and carbohydrates can be absorbed in consider-\\nable amounts, and fats in small quantities. This function\\nof the large bowel is of great practical importance* as it is\\nutilized in some conditions for nourishing purposes (rectal\\nalimentation).\\n3. Motion.\\nThe motor function or peristalsis of the intestine has\\nfor its objects the thorough mixture of the contents and\\ntheir propulsion through the entire canal until their final\\nexit through the anus. Nothnagel 1 and Braam-Houk-\\n1 Schiff Pfliiger s Arch., Bd. 3.\\n2 Abelmann Ueber die Ausnutzung der Nahrungsstoffe nach Pan-\\nkreasexstirpation. Inaug. Dissert. Dorpat, 1890.\\n3 H. Nothnagel Beitrage zur Physiologie und Pathologie des\\nDarms, Berlin, 1884.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0048.jp2"}, "49": {"fulltext": "PHYSIOLOGY. 29\\ngeest have studied the process of intestinal peristalsis in\\nanimals. After laparotomy the latter were kept in a bath\\nof physiological salt-water solution of 38\u00c2\u00b0 C, and the mo-\\ntions of the intestines were investigated.\\nThree types of intestinal peristalsis were discerned: 1.\\nThe ordinary peristaltic motion. The intestinal tract con-\\ntracts at a certain point and thereafter relaxes. The con-\\ntraction is carried with moderate rapidity for a certain\\nlength contiguously in the direction toward the anus and\\nthe contents are pushed forward. 2. Oscillating motions.\\nAn intestinal coil is here moved to and fro all along its\\nmesentery without any particular contraction at any point.\\nThe contents are not propelled, but simply mixed up dur-\\ning these motions. 3. Kotary motions. A filled intesti-\\nnal coil experiences a circular constriction which is rapidly\\ncarried over the intestine for the length of about 20 cm.\\nThis is exactly the same process as described under 1, but\\nexecuted in a violent manner.\\nWhile the first two types of intestinal peristalsis are\\npurely physiological, the third type is partly pathological.\\nIt is met with only when the contents are mixed with a\\ngreat deal of gas. Thus, after indiscretions in diet, we\\noften feel this kind of rapid motion going along with a\\ngurgling sound (tormina intestinorum) This type is ob-\\nserved only in the small intestine, but never in the large\\nbowel.\\nThe small intestine manifests much quicker peristalsis\\nthan the large bowel, the motions of which are very slow.\\nHere the haustra during the act of peristalsis contract and\\nthen protrude in regular order. The small intestine while\\nempty does not show any motion whatever, but after the\\nentrance of chyme into the duodenum intestinal peristalsis\\n1 Braam-Houkgeest Pfliiger s Arch., Bd. 7, p. 266.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0049.jp2"}, "50": {"fulltext": "$0 DISEASES OF THE INTESTINES\\nbegins. It is not, however, transmitted down bo t ho Bau-\\nhinian valve without interruption, but stops as a rale .-it a\\noertain distance Erom its starting-point (about 20 cm.),\\nAfter ;m intermission of some duration it begins again.\\nThus one or more intestinal segments nun be in a state of\\nperistalsis while other parts of the Intestine in between are\\nat ivst. The time for the arrival o( the tirst particles o(\\nchyme from the duodenum into the ctecum is about two\\nhours. But, of course, the intestinal peristalsis must oon-\\ntinue until the stomach has expelled the last portions of\\nthe eh\\\\ me, that is to sa_\\\\ within about two hours after tho\\nstomach has become empty tho small intestine as a rule\\nwill also be found free of contents. The forward motion\\nof the contents in the Large bowel is a ver\\\\ slow one in-\\ndeed. It takes as a rule from twenty io twont v-four hours\\nfor the fecal matter to move from tho eavum to the ree-\\ntum.\\nAntiperistalsis, or reversed motion of t\\\\\\\\o Large bowel\\nand the small intestine, beginning at the anus ami extend-\\ning upward, has never been seen bv Nothnagel in phvsio-\\nLogiqal conditions.\\nThe process of peristalsis is controlled bv nervous influ-\\nences. Auerbaeh s and Moissnor s plexus most probably\\ncontain automatic aerve centres for this aot. Bui there\\naie also other centrally Located nervous agenoies. Thus\\nafter great mental excitement diarrhoea ver\\\\ often results.\\nshowing that the intestinal peristalsis must have been\\ngreatly increased through the influence o( the brain.\\nThere are also numerous nerves which supervise the motor\\nfunction of the entire intestinal tract. Pfluger 1 has shown\\nthat the splanchnic nerve contains inhibitor? fibres for the\\n1 Pfltlger: Uebei das Hemnrangs- and Nervensystem fttrdi* peri\\nstaltischec Bewegungen der Gedftrme, Berlin, L857.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0050.jp2"}, "51": {"fulltext": "PHYSIOLOGY. 31\\nintestinal peristalsis. According to Ehrmann, 1 accelerat-\\ning and inhibitory fibres supervising intestinal peristalsis\\nare contained in the vagus as well as in the splachnicus,\\nbut they have a varied function according to the way they\\nend, whether in the longitudinal or in the circular muscles.\\nThe longitudinal muscles are stimulated by the splanchnic\\nand paralyzed by the vagus. The circular muscles, on the\\nother hand, are stimulated by the vagus and paralyzed by\\nthe splanchnic.\\nNormally the chyme acts as a stimulus on the intestinal\\ncanal and provokes peristalsis (through the influence of the\\nnerves). Too cold drinks, indigestible food, organic acids\\n(present in too large amount) may often cause an increased\\nperistalsis and thus produce diarrhoea. Toxic substances\\nwhich are ingested or developed from unwholesome food\\nmay have the same effect.\\n1 Ehrmann Wiener med. Jahrbucher, 1885.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0051.jp2"}, "52": {"fulltext": "CHAPTER II.\\nMETHODS OF EXAMINATION AND TREATMENT.\\nEXAMINATION.\\nInterrogation.\\nThe examination begins with a thorough interrogation\\nof the patient. Before starting with the narration of the\\npresent ailment a general outline of previous sicknesses is\\nof value. Diseases which involve the intestinal canal, like\\ntyphoid fever, dysentery, and the like, are of special impor-\\ntance, as they are liable to be etiological factors in the de-\\nvelopment of consecutive ailments. The mode of living,\\nwith regard to habits (drinking, smoking, etc. should also\\nbe inquired into.\\nThe patient is then asked to describe his present com-\\nplaint. He should state the time when the trouble began\\nand its nature. If the chief complaint refers to pains, it\\nis necessary to inquire as to their location and character.\\nPains felt in the neighborhood of the navel usually origi-\\nnate in the small intestine those experienced in the right\\niliac region often emanate from the appendix while those\\nin the left iliac region and in and about the rectum have\\ntheir starting-point in the sigmoid flexure and in the lower\\nportion of the rectum. Are the pains of long duration or\\ndo they last only a very short while, a few seconds or min-\\nutes? The former variety is usually caused either by an\\naffection of the sensory nerves of the intestines or by some\\norganic lesion, like ulcers, etc. The latter variety, to which", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0052.jp2"}, "53": {"fulltext": "EXAMINATION. 33\\nthe name colic is applied, is due to a strong spasmodic\\ncontraction of a certain part of the bowel. Colicky pains\\nare often followed and relieved by the passing of flatus or\\nof fecal matter. Occasionally these pains also shift from\\none place of the abdomen to another, and the route of their\\ntravel is distinctly felt by the patient.\\nAbnormal sensations, a feeling of heat or cold may also\\nbe experienced over a certain area of the abdomen. A fre-\\nquent or constant desire for an evacuation (tenesmus) is\\nencountered in dysentery and in many affections of the\\nrectum. It is also advisable to inquire whether the pains\\nand abnormal sensations appear at a certain period of the\\nday or at a certain time after meals (soon after eating or\\nthree to four hours later), or whether they are experienced\\nat night or especially in the early morning hours.\\nThe condition of the bowels should always be described\\nin detail. Do the bowels act regularly and is the evacua-\\ntion of sufficient quantity What is its consistency Is\\nthe stool of sausage-shape and pliable, or is it hard or very\\nsoft, mushy, watery? What is its color? Is it dark brown\\nor light yellow or clay-colored or black? Is there an ad-\\nmixture of mucus or blood? If there is constipation, in-\\nquire whether the bowels move without any cathartics after\\na period of constipation of a few days, and if not, whether\\nmild aperients are sufficient to cause an evacuation, or\\nwhether a strong drastic remedy is necessary. Does the\\nconstipation alternate with periods of normal movements\\nor with periods of diarrhoea? Are the periods of constipa-\\ntion, if cathartics are not resorted to, accompanied by any\\nmarked symptoms (headaches, dizziness, anorexia, etc.)\\nor not? If there is diarrhoea, the patient should state how\\nmany movements a day he has. Is he disturbed during\\nthe night, or is the diarrhoea confined principally to the\\n3", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0053.jp2"}, "54": {"fulltext": "34 DISEASES OF THE INTESTINES.\\nmorning hours? Does the diarrhoea alternate with periods\\nof constipation does it disappear after a change of climate,\\nor is it aggravated by mental excitement? Is there a feel-\\ning of exhaustion in connection with it? Is the abdomen\\nfilled up with gas (meteorism) Does this phenomenon\\npertain to a special part of the abdomen (the upper or\\nlower region, right or left side), or does it extend over the\\nentire abdomen? A feeling of tension in the abdomen\\nwith frequent passing of wind, belching, and flatus, is com-\\nmonly designated as flatulency. It is necessary to inquire\\nwhether this symptom is present principally at a certain\\ntime of the day or continuously. Absence of flatus is of\\nsignificance if it occurs in conjunction with obstinate con-\\nstipation, otherwise it is of no consequence.\\nIn all intestinal disorders it is necessary to inquire as\\nto the state of the stomach. The latter organ being in\\ndirect communication with the intestines, it will often be\\nsubject to disturbances in intestinal affections. Com-\\nplaints of a bad taste and smell in the mouth are often\\nmade, principally in constipation. Anorexia and nausea\\nare present in the most varied intestinal disorders. Vom-\\niting frequently occurs in intestinal obstruction.\\nInspection.\\nInspection of the abdomen is best made in good daylight\\nwith the patient in the recumbent posture, but should also\\nbe completed by inspection in the standing position. The\\ncondition of the skin of the abdomen is first examined.\\nSometimes striae or scar-like lines running parallel to each\\nother over some part of the abdomen (especially the lower\\npart) and presenting either a silvery hue or, if not old, a\\nrather reddish tinge, are observed; these are always signs\\nof a very marked former distention of the abdominal pari-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0054.jp2"}, "55": {"fulltext": "EXAMINATION. 35\\netes. Thus they are found after frequent pregnancies, also\\nafter the removal of rapidly developing abdominal tumors,\\nor after tapping for ascites. These striae persist long after\\nthe disappearance of the conditions which caused their\\ndevelopment.\\nDistention of the abdominal veins, giving them a bluish\\nhue, is observed whenever the return flow of the venous\\nblood of the lower extremities is retarded either by in-\\ncreased intra-abdominal pressure (ascites, tumors of the\\nabdomen) or by thrombosis or compression of the iliac\\nvein or of the vena cava inferior. Cirrhosis of the liver\\nand compression of the portal vein often produce the same\\nresult. In the latter condition there is an extensive forma-\\ntion of veins over the navel which is commonly called caput\\nMedusae. After observing the appearance of the skin, the\\nshape of the abdomen is then minutely considered. In\\nnormal conditions, in grown people, the abdomen and the\\nchest are on the same level in the recumbent position. In\\nsmall children the abdomen as a rule is somewhat more\\nprominent than the thorax. In very old age the abdomen\\nappears somewhat sunken. The greatest degree of a re-\\ntracted or trough-shaped abdomen is found in stricture of\\nthe oesophagus or cardia, in basilar meningitis, and in\\nlead poisoning. Long-continued inanition, no matter of\\nwhat origin, also causes this phenomenon.\\nProtrusion of the abdomen occurs either over a definite\\narea or over the entire surface. The abdomen may pre-\\nsent the shape of a round hemisphere or of a flattened one\\nif there is an accumulation of air and gas in the intestines\\n(intestinal meteorism). This occurs principally in atonic\\nconditions of the intestines and in hysteria. A uniform\\nprotrusion of the abdomen or a general bloated condition\\nis present in general peritonitis, occasionally also in pro-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0055.jp2"}, "56": {"fulltext": "36 DISEASES OF THE INTESTINES.\\nnounced atony of the intestines. In case of ascites, no\\nmatter to what cause it is due (tumors, cirrhosis of the\\nliver, nephritis, etc.), the abdomen is also more or less\\nevenly protuberant above, while the lower parts bulge out\\nsomewhat in the recumbent position. This is caused by\\nthe accumulation of fluid in the lower portions of the ab-\\ndominal cavity. Change of posture alters the shape of the\\nabdomen. This applies to the early period of ascites,\\nduring which the abdominal cavity is not yet filled to its\\nmaximum later, when this is the case, the abdomen ap-\\npears uniformly enlarged, and there is no bulging out of\\nany particular portion. Change of position then no longer\\nalters its shape.\\nProtrusion of a certain part of the abdomen is noticed\\nin many cases of neoplasm, sometimes in fecal concretions,\\nand occasionally in appendicular abscesses. In umbilical\\nhernia a small, more or less roundish protrusion is noticed\\nin the region of the navel. In diastasis of the rectus ab-\\ndominis muscles there appears in the middle line of the\\nabdomen a long protrusion of sausage shape consisting of\\nprolapsed intestine. Sometimes there is a pronounced\\nprotrusion of this area owing to the escape of a large mass\\nof the bowel through the gap in the muscles.\\nIn patients with thin abdominal walls very small sau-\\nsage-shaped prominences are occasionally visible which\\nquickly change their configuration, appearing now in one\\nplace and now in another. This phenomenon is caused by\\nperistaltic contractions of the small intestine. As a rule,\\nthey are not associated with pain and do not denote a mor-\\nbid condition. Sometimes similar peristaltic waves in the\\nsmall intestine appear periodically and annoy the patient.\\nHere they may be caused by nervous influences. Peri-\\nstaltic contractions of the small intestine appearing in a", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0056.jp2"}, "57": {"fulltext": "EXAMINATION.\\n37\\nviolent manner and caused by a stenosis or an obstruction\\nof the intestinal lumen are usually much more pronounced,\\nthat is, the prominences are much higher and involve\\nlarger areas of intestine, the waves moving with greater\\nrapidity and strength and being accompanied by intense\\npain. Visible peristaltic contractions of the large bowel\\nFig. 10.\u00e2\u0080\u0094 Sims Rectal Speculum.\\nFig. 11.\u00e2\u0080\u0094 Allingham s Rectal Speculum.\\nare ordinarily met with only in cases of partial or total\\nintestinal obstruction.\\nInspection of the anal region is best made when the pa-\\ntient lies on his side with his back toward the examiner.\\nThe buttocks are held apart with the hands, and thus thor-\\nough inspection of the anus is rendered possible. Piles,\\nfissures, fistulae may thus be discovered.\\nProctoscopy. In order to inspect the anus internally and\\nalso the rectum it is necessary to introduce a speculum.\\nThis method of inspecting the rectum is called proctoscopy.\\nOf the many specula devised for this purpose I would\\nmention those of Sims, Allingham, and Kelly as the most\\npractical (see Figs. 10, 11, 12). Kelly s speculum, which", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0057.jp2"}, "58": {"fulltext": "38 DISEASES OF THE INTESTINES.\\nconsists of a hollow metallic tube provided with an obtu-\\nrator, is best suited for this purpose. Before inserting the\\ninstrument it must be thoroughly smeared with sweet oil\\nor vaseline. In cases in which the rectal region is inflamed\\nor ulcerated, it is necessary, in order to avoid too much\\npain, to induce anaesthesia of these parts by painting them\\nwith a ten-per-cent cocaine solution or by the introduction\\nFig. 12.\u00e2\u0080\u0094 Kelly s Rectal Speculum.\\nof a suppository of opium with belladonna or of cocaine.\\nIt is hardly necessary to say that endoscopy of the rectum\\nmust not be performed until after a thorough evacuation of\\nthe bowels. It is best to wash out the gut before examin-\\ning with the speculum. When the speculum is in position\\na portion of the rectal mucosa becomes visible when good\\nlight is thrown into the endoscopic tube. The source of\\nlight is immaterial, although it is best to have electric\\nlight. Usually a small electric lamp with a reflecting mir-\\nror fastened to the head of the examiner best serves the\\npurpose. The higher up the bowel has to be examined the\\nlonger the speculum must be. After the full insertion of\\nthe instrument the highest portion of the bowel is first", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0058.jp2"}, "59": {"fulltext": "EXAMINATION. 39\\nexamined, and while gradually drawing out the speculum\\nthe entire area of the bowel through which it passes will\\nbe brought into view. Small ulcers, atrophic and congested\\nconditions can thus be easily recognized and malignant\\ngrowths detected at an early period.\\nTransillumination. Transillumination of the bowel was\\nfirst suggested by myself and later practised principally\\nby Heryng and Reichmann. 2 After a thorough cleansing\\nof the bowel by means of high irrigation about one quart\\nof water is injected and an electric illuminator (very similar\\nin construction to the gastrodiaphane) is inserted into the\\nrectum. The examination must be made in a dark room.\\nBy gradually pushing up the instrument successive portions\\nof the bowel may be transilluminated. This method, how-\\never, has not as yet proven to be of any practical value.\\nRoentgen Rays.- The examination of the colon by means\\nof Roentgen rays seems to be somewhat more promising.\\nA soft-rubber rectal tube through which a flexible wire\\npasses is introduced into the bowel as high up as possible\\nand the patient exposed to the Roentgen apparatus. The\\nwire within the tube becomes visible as a shadow, and thus\\nmarks the course of the bowel in which it lies. Inasmuch\\nas it is hardly possible to insert an instrument higher up\\nthan the sigmoid flexure, the following procedure for the\\nRoentgen examination appears to be of greater value The\\nbowel is rilled with two quarts of water in which 60 gm. (2\\nounces) of subnitrate of bismuth are suspended by means\\nof a starch solution. This mixture penetrates almost the\\nentire colon, and thus the position of the large bowel can\\nbe determined by the Roentgen rays.\\n1 Max Einhorn Die Gastrodiaphanie. New-Yorker medicinische\\nMonatsschrift, November, 1889.\\n2 Heryng und Reichmann Therapeutische Monatsbefte, 1892.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0059.jp2"}, "60": {"fulltext": "40 DISEASES OF THE INTESTINES.\\nPalpation.\\nPalpation is the most important procedure available\\namong the methods of examination in abdominal diseases.\\nIt is best performed in the recumbent position of the\\npatient, the head being slightly raised and the abdominal\\nmuscles relaxed as much as possible. In order to effect\\nthis the room must be of a comfortable temperature and\\nthe hands of the examiner warm. If the patient is fidgety\\nand contracts his abdominal walls, it is necessary to talk\\nto him and to draw his attention away from the exam-\\nination. I have often noticed a great relaxation of the\\nmuscles during an expiration following a deep inspira-\\ntion. Whenever, therefore, it is difficult to obtain relaxa-\\ntion of the abdomen I tell the patient to take a deep\\ninspiration and then make use of the following period of\\nexpiration for palpation. If all these means fail to relax\\nthe abdominal muscles, palpation may be tried in a warm\\ntub bath, as first recommended by Chlapowski, or under\\nchloroform narcosis. In cases of great diagnostic impor-\\ntance the latter method is certainty preferable. In palpat-\\ning the abdomen it is advisable first to examine with the\\nentire palm of the hand, applying very little pressure, thus\\ndetermining the state and consistency of the abdomen.\\nThe hand may thus be passed over the entire abdominal\\nsurface from one place to another. This having been done,\\npalpation is then performed with a trifle more pressure, the\\nfinger tips being used for this purpose. The latter procedure\\nserves for exploring a more circumscribed area. Finally,\\ndeep palpation is practised for which considerable pressure\\nmay be required.\\nPalpation aids us in discovering the position of some of\\nthe abdominal organs. With regard to the intestine the", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0060.jp2"}, "61": {"fulltext": "EXAMINATION. 41\\nfollowing portions are often accessible to this method of ex-\\namination the caecum and part of the ascending colon, the\\ntransverse colon, and the sigmoid flexure. In some in-\\nstances the descending colon above the sigmoid flexure can\\nalsQ be palpated, especially if it is filled with hard scybala.\\nThe jejunum and ileum filling most of the lower part of the\\nabdominal cavity (from the navel downward) cannot nor-\\nmally be separately outlined.\\nFor the detection of tumors in the abdomen palpation is\\nof great service. By means of it we gain information with\\nregard to their size, shape, and consistency. An uneven\\nprotuberant surface is characteristic of malignant growths,\\nwhile an even surface is more often found in benign neo-\\nplasms or in intussusception. A fecal tumor can be recog-\\nnized by indentations made by pressure with the fingers.\\nSometimes after such pressure it is possible to notice for a\\nmoment, when raising the finger, a slipping off of the in-\\ntestinal wall from the fecal mass. This phenomenon, first\\ndescribed by Gersuny l under the name of Klebesymptom,\\nI have observed quite frequently and consider of practical\\nvalue.\\nAnother important object of palpation is to ascertain\\nwhether there is tenderness or pain on pressure. While\\nstrong pressure exerted upon the intestine through the ab-\\ndominal wall even normally elicits an unpleasant sensation,\\nthere is, however, no distinct pain connected with this act.\\nTenderness on slight pressure is often present in inflam-\\nmatory conditions of the bowels and also in ulcerative\\nprocesses. A circumscribed pain on pressure is present\\nin the appendicular region (McBurney s point) in appen-\\ndicitis, especially in the acute form. In chronic appendi-\\ncitis the pain may be elicited only upon very strong press-\\n1 Gersuny Wiener klinische Wochenschrift, 1896, No. 40.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0061.jp2"}, "62": {"fulltext": "42\\nDISEASES OF THE INTESTINES.\\nFULL SIZE\\nJOHN REYNDERS\u00e2\u0080\u0094CO. NEW YORK.\\nFig. 13.\u00e2\u0080\u0094 Finger Cot.\\nure. In ulcerations of the bowel there may be also one\\nor several circumscribed areas very painful to pressure.\\nIn pains due to a purely nervous affection of the bowel\\npressure may afford\\nrelief. If a mere\\ntouching of the ab-\\ndomen elicits pain,\\nit is a sign either of\\nan extensive inflam-\\nmatory process with-\\nin the bowel or of\\nperitonitis.\\nPalpation in the\\nform of tapping oc-\\ncasionally produces a splashing sound (clapotage) over\\nsome portions of the bowel. The splashing sound can be\\nelicited over the colon only when it is filled with liquid or\\nsemi-liquid matter and gas. It can be discovered off and\\non either in the caecum and in the portion of the bowel im-\\nmediately above it or in the sigmoid flexure. In the small\\nintestine clapotage can be obtained only in the dilated\\nportion of the gut above a stricture. Boas first suggested\\nthe method of filling up the bowel with from 500 to 600\\nc.c. of water and then examining for the splashing sound\\nalong the colon. When the patient has been thus pre-\\npared, clapotage can be produced in the sigmoid flex-\\nure and by having the patient turn on his right side, it\\ncan occasionally be produced in the transverse colon, and\\nfinally in the csecal region. In cases of atony of the bowel\\nBoas was able to evoke the splashing sound even after\\nthe injection of only 200 to 300 c.c. of water. Frieden-\\n1 Boas Diagnostik und Therapie der Magenkrankheiten, Theil i.\\n1897, 4te Auflage, p. 105.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0062.jp2"}, "63": {"fulltext": "EXAMINATION.\\n43\\nwald 1 lias also practised the same method with advan-\\ntage. Whenever the splashing sound can be produced in\\nthe colon it serves the purpose of determining the situa-\\ntion of this organ.\\nThe rectum is best palpated with the index finger well\\noiled or smeared with vaseline or encased in a rubber cot\\n(Fig. 13) and anointed in the same\\nway. The condition of the anus and\\nthe lower portion of the rectum can\\nbe advantageously investigated with\\nthe finger. The examination may be\\nmade either in the recumbent posture\\nof the patient, in the side or knee-\\nelbow position, or in the standing po-\\nsition. In the latter instance it is\\nwell to have the patient exert down-\\nward pressure upon the rectum.\\nHemorrhoids, polj-pi, and malignant\\ngrowths can thus be occasionally dis-\\ncovered. In cases in which there is\\na suspicion of malignant growths in-\\nvolving portions of the colon not ac-\\ncessible either to palpation by the\\nfinger or inspection with the procto-\\nscope, examination with the entire\\nhand in chloroform narcosis can be\\ntried as first practised by Simon. 2\\nAfter dilating the anal sphincters, the\\nentire right hand and the arm are inserted into the bowel\\nthrough the anus, and thus the higher portions of the\\nFig. 14a. Fig. 15. Fig. 14b.\\nFigs. 14a and 14 Cylin-\\ndrical Bougies.\\nFig. 15.\u00e2\u0080\u0094 Olive-Point Bou-\\ngie.\\n1 J. Friedenwald Medical News, 1894.\\n2 Simon Verhandlungen der deutsclien Gesellsck. f. Chirurgie, 1871,\\nand Deutsche Klinik. 1S72.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0063.jp2"}, "64": {"fulltext": "44 DISEASES OF THE INTESTINES.\\ncolon palpated with the fingers. This method can be rec-\\nommended only in cases of extreme importance, as such\\nan examination is liable to produce unpleasant symptoms,\\nas, for instance, incontinence of the rectum, tearing of the\\nmucous membrane, etc.\\nPalpation of the rectum by means of sounds is performed\\nwhenever there is suspicion of a stricture involving por-\\ntions of the bowel not accessible to examination by the fin-\\nger. For this purpose either bougies (see Figs. 14 and\\n15), or, still better, rectal tubes of various calibre may be\\nemployed. Kuhn has recently recommended the use of\\ntubes provided with a metal spiral. He believes that\\nthese penetrate the colon farther up without bending.\\nHis statements have, however, not as yet been corroborated.\\nPercussion.\\nPercussion is of less importance than palpation. In\\nmany instances it serves to confirm the results obtained\\nby the latter. In percussing the intestines it is best to\\nuse the fingers. It should be done rather gently. Mild\\npercussion permits the discernment of slight differences\\nof sound much better than strong percussion. As is well\\nknown, percussion over empty intestinal coils or those\\nfilled with gas or air gives a tympanitic sound which is\\nlouder over the large than over the small bowel. Intestinal\\ncoils filled with liquid or solid substances give dulness.\\nIn meteorism of the intestines percussion will elicit a tym-\\npanitic sound of a deeper pitch than normally, and there\\nwill be besides some areas of dulness over the abdomen.\\nThe region of the liver and spleen will here show normal\\nconditions with regard to the percussion sounds. Meteor-\\nism of the abdomen as a result of perforation will manifest\\n1 Kuhn Deutsche med. Wochenschr. 1897, Nos. 36 and 37.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0064.jp2"}, "65": {"fulltext": "EXAMINATION. 45\\nan evenly diffused tympanitic sound all over the abdomi-\\nnal cavity. Usually the dulness over the region of the\\nliver and spleen will have disappeared. In ascites percus-\\nsion will reveal an area of dulness in the lower parts of the\\nabdomeu, and there will be a change in the character of\\nthe sound on altering the position of the patient. Tumors\\nof the intestine give dulness on percussion. Fecal accu-\\nmulations and appendicular abscesses will also manifest\\ndulness on percussion.\\nAuscultation.\\nAuscultation is not of great significance in diseases\\nof the intestine. Palpation of intestinal coils with the\\napplication of moderate pressure may elicit either a gur-\\ngling noise or a friction sound. The latter was formerly\\nbelieved to be pathognomonic of typhoid fever. Of late,\\nhowever, it has been recognized that this sign is found in\\nmany other conditions. At the time of active peristalsis\\nall kinds of gurgling sounds are heard within the intestine\\n(borborygmi), which, however, are not of much impor-\\ntance. In chronic stenosis of the intestine very loud noises\\nare at times heard, caused by the sudden passage of liquid\\nand gaseous contents through the stricture under great\\npressure. In the latter affection splashing sounds can also\\nbe easily produced over the enlarged bowel above the stric-\\nture. Often a tympanitic sound of a metallic character can\\nbe heard.\\nInflation of the Intestine with Carbonic Acid Gas or Air.\\nInflation of the intestine is one of the most important\\ndiagnostic procedures. Von Ziemssen, 1 who first intro-\\nduced this method of examination, injected successively\\n1 Von Ziemssen Deutsches Archiv f. klinische Medicin, 1883, Bd.\\n33, S. 235.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0065.jp2"}, "66": {"fulltext": "46 DISEASES OF THE INTESTINES.\\ninto the bowel two solutions, one containing tartaric acid,\\nthe other bicarbonate of sodium in water. The carbonic\\nacid gas developing fills the large bowel, which can then\\nbe recognized by the tympanitic percussion sound, or, in\\nrare instances, by inspection. Schnetter, 1 of New York,\\nsuggested filling the bowel with carbonic acid gas by means\\nof a tube attached to an inverted siphon containing soda-\\nwater, the valve of which is pressed. Here the carbonic\\nacid gas runs into the bowel without any admixture of\\nwater. Kosenbach 2 made use of liquefied carbon dioxide\\nfrom a sparklet. Instead of the latter Runeberg 3 recom-\\nmended inflation of the intestines by means of air. This\\nis best done by a rectal tube to which a compressible air\\nsuction bulb is attached. The advantage this method offers\\nconsists in the possibility of regulating the amount of the\\nintroduced air. In order to be able to measure the amount\\nof insufflated air, Damsch 4 has recommended the employ-\\nment of a syringe of known capacity. An ordinary bicycle\\npump can be used for this purpose, the rectal tube being\\nattached to it.\\nInflation of the bowel is of importance in detecting\\na stenosis of this organ. Under ordinary conditions the\\ninjected air evenly distends the entire colon, as can be\\nproven by inspection and percussion. In case there is a\\nstenosis in the large intestine the air will distend prin-\\ncipally that portion of the bowel below the stricture, while\\nthat above will remain unchanged. It is thus possible to\\nrecognize the seat of a constriction. The significance of this\\ndiagnostic means, however, is confined merely to strictures\\n1 Sclmetter Deutsches Archiv f. klinische Medicin, 1884, Bd. 34,\\nS. 638.\\n2 0. Rosenbach: Berliner klinische Wochenschrift, 1889, No. 28.\\n3 Runeberg: Deutsches Archiv f. klinische Medicin, Bd. 34, S. 460.\\n4 Damsch: Berliner klinische Wochenschrift, 1889, No. 75.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0066.jp2"}, "67": {"fulltext": "EXAMINATION. 47\\nof a high degree, while a beginning stenosis of the bowel\\ncannot be thus recognized, as the air will pass through it.\\nThe position of the colon can be ascertained by this pro-\\ncedure. Normally the transverse colon is situated some-\\nwhat above the navel, while in cases of enteroptosis it may\\nbe found about a hand s width above the symphysis.\\nInflation of the colon is also of importance in the\\ndifferential diagnosis of abdominal tumors. As is well\\nknown, tumors of the intestine will become more distinct\\nafter inflation of the bowel with air, while tumors of the\\nkidney, of retroperitoneal glands, and of the spine tend to\\nrecede. According to Minkowski, 1 abdominal tumors after\\nfilling the colon with air or water are usually slightly\\nshifted in the direction of the organ to which they be-\\nlong.\\nInflation of the bowel with air impregnated with ether\\nhas been suggested by Dr. Sutton 2 as a means of recog-\\nnizing intestinal perforation. For this purpose he makes\\nuse of a bottle filled with two drachms of ether. The bot-\\ntle is provided with a perforated rubber cork to which are\\nattached two rubber tubes provided with stopcocks. One\\nof these is then attached to a bicycle pump and the other\\nto an ordinary rectal tube. The air pumped into the bowel\\nmust pass through the bottle containing ether and thus\\ntakes up the ether vapors. In case of perforation of the\\nbowel, the ether quickly escapes through the opening into\\nthe abdominal cavity and equally distends it; while, if\\nthere is no perforation, the bowel, first the large and later\\nthe small intestine, becomes filled with air and ether; ulti-\\nmately the ether reaches the stomach and is usually eruc-\\n1 Minkowski Berliner klinische Wochenschrift. 1888, No. 31.\\n2 E. M. Sutton: Diagnosis of Intestinal Perforations by Means of\\nEther Inflation per Rectum. Journal of the Am. Med. Assn., Decem-\\nber 30th, 1899.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0067.jp2"}, "68": {"fulltext": "48 DISEASES OF THE INTESTINES.\\ntated. The ether can then be recognized by its charac-\\nteristic odor. It seems that this procedure is especially\\nuseful in gunshot wounds of the abdomen.\\nInjection of Water per Anum.\\nThis is done by means of a rectal tube and a fountain\\nsyringe provided with a scale indicating the amount of\\nwater used. In case of stricture, especially of the lower\\nportion of the colon, the quantity of water which can be\\ninjected is not great, while ordinarily from three to five\\nquarts of water can be poured in. Inasmuch as even nor-\\nmally some people are not able to hold large amounts of\\nwater in the bowels without experiencing considerable dis-\\ncomfort, the quantity of fluid which can be injected with-\\nout pain is not of great diagnostic value. Filling up the\\nbowel with water can also be made use of for the determi-\\nnation of the position of the colon, as this organ will then\\ngive a dull sound. For this purpose, however, the proced-\\nure in question is not so good as the above-described method\\nof inflation with air.\\nLavage of the Bowel,\\nLavage of the bowel in a similar manner as performed\\nin the stomach has been recommended by Boas l for di-\\nagnostic purposes. It is best performed in the lateral\\nposture of the patient after an evacuation of the bowels.\\nThe same apparatus as for gastric lavage may be used\\nhere. The rectal tube, which represents the stomach tube\\nemployed in gastric lavage, is attached to a long piece\\nof rubber tubing provided with a big funnel. The rectal\\ntube is inserted as high up in the bowel as possible and\\nthen the water is poured in until the patient begins to\\n1 J. Boas Deutsche Aerzte-Zeitung, 1895, Nos. 2 and 3.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0068.jp2"}, "69": {"fulltext": "EXAMINATION. 49\\nfeel some discomfort. As soon as this is the case the fun-\\nnel is lowered and thus the water returns. The latter is\\nnow subjected to a thorough examination. Normally the\\nreturning water appears pretty clear or slightly turbid by\\nthe admixture of small particles of mucus, epithelial cells,\\nand fecal matter. In catarrh of the large bowel a consid-\\nerable quantity of mucus is found. Ulcerative processes\\naccompanied by hemorrhages or by suppuration are often\\nrecognized by the admixture of either pus or blood in the\\nwash-water. Occasionally exfoliated pieces of intestinal\\nmucosa are found in the wash-water, and a microscopical\\nexamination of them may be of diagnostic importance.\\nExamination of the Faeces.\\nThe examination of the faeces is of much service in dis-\\neases of the intestine. The faeces represent the end pro-\\nduct of the digestive act, consisting of residue unsuitable\\nfor further assimilation. It is evident that a thorough\\nknowledge of the dejecta will throw light upon the nature\\nof the activity of the intestines.\\nThe normal faeces consist of changed and unchanged\\nremnants of food, bacteria, traces of digestive juices, epi-\\nthelial cells, and salts. The quantity of the faeces for\\ntwenty -four hours varies greatly with the kind of food\\ntaken. In a mixed diet it usually amounts to from four to\\nseven ounces. The color of the faeces is usually dark brown\\nowing to changed bile pigment, the bilirubin having be-\\ncome changed in the intestine into urobilin. The diet has\\ngreat influence upon the color of the faeces. Meat pro-\\nduces a dark brown, milk a light 3 r ellow color, cacao a\\nmore or less brownish-red, huckleberries and claret a dirty\\nblack-brown color with a greenish hue. The salts of iron\\nand manganese give rise to a darker color than the usual\\n4", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0069.jp2"}, "70": {"fulltext": "50 DISEASES OF THE INTESTINES.\\none, while bismuth produces a more or less blackish color.\\nAccording to Quincke, 1 all these metals are reduced to\\noxydule combinations which are responsible for these\\ncolors, while the former belief that these metals formed\\nsulphides is not correct. Calomel frequently produces a\\ngreenish hue, while senna, santonin, gamboge, and rhubarb\\ngive rise to an intensely yellow color.\\nThe faeces are normally somewhat soft in consistency and\\nhave a sausage shape. In abnormal conditions the con-\\nsistency may be changed in two directions. The dejecta\\nmay be greatly hardened and appear in small balls, or in\\nthe form of very thin cylinders. On the other hand, the\\nstools may be abnormally mushy or even liquid. The\\nhardened stools which occasionally show grooved impres-\\nsions from the taenia coli bear testimony to their long\\nsojourn in the intestine, thus being exsiccated from the\\ncomplete absorption of water. They are, however, by no\\nmeans characteristic of a stenosis of the intestine. Very\\nsoft dejecta may be either watery, as for instance in\\ncholera nostras or asiatica, or they are mixed with mucus\\nwhich can be easily seen when pouring the dejecta into a\\nglass and inverting it, when the mucus as a rule adheres to\\nthe surface of the vessel.\\nOdor. The characteristic odor of the faeces is normally\\ncaused by skatol and also to a less degree by indol. The\\nfecal odor may be increased whenever the faeces have been\\nretained much longer than normally in the intestine. On\\nthe other hand, faeces occasionally present very little or no\\nodor when their sojourn in the intestine has been very\\nshort. As a good instance of the latter variety the so-\\ncalled rice-water movements in cholera nostras and cholera\\nasiatica may be mentioned. Movements with a fetid odor\\n1 Onincke Munchner medizinische Wochenschrift, 1896, No. 36.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0070.jp2"}, "71": {"fulltext": "EXAMINATION 51\\noccur principally in malignant growths of the large bowel\\naccompanied by ulcerative processes.\\nRemnants of Food in the Faeces. Undigested remnants of\\nfood, macroscopically visible, occur in the faeces. Nor-\\nmally, however, only small particles of vegetable sub-\\nstances, like potatoes, asparagus, spinach, peas, etc., are\\nfound, while remnants of meat can never be discovered with\\nthe naked eye. In case particles of meat are visible, it in-\\ndicates a severe lesion of the intestinal tract. If large\\namounts of undigested food (even vegetable matter) are\\npresent in the faeces, it is also an indication of an existing\\nsevere lesion.\\nAbnormal admixtures frequently occur in the faeces, and\\nare occasionally of great diagnostic importance. Thus,\\nblood may be found either in its fresh condition (red) or it\\nmay be very dark but not coagulated. In both instances\\nthe blood comes from the lower portions of the large bowel.\\nSometimes the blood appears in a more changed and de-\\ncomposed form, giving the faeces the appearance of tar. In\\nthis instance it originates from the higher portions of the\\nbowels or from the stomach.\\nAn admixture of pus in the dejecta which can be macro-\\nscopically recognized occurs only in instances in which pus\\nexists in the lower portions of the large intestine. For if\\nthere is pus present in the higher portions of the bowel, it\\nis usually changed before its exit in such a manner that\\nit cannot be detected unless the amount is very consider-\\nable.\\nFragments of tumor (polypi or torn off particles of can-\\ncer) are occasionally found in the dejecta. A thorough\\nexamination of these may be of great help in the diagnosis.\\nMucus, although a normal constituent of the faeces, can-\\nnot be discovered in large amounts under physiological", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0071.jp2"}, "72": {"fulltext": "52 DISEASES OF THE INTESTINES.\\nconditions. Macroscopically visible mucus may exist in\\nthe following forms: (1) It may surround the fecal matter\\nin the form of a glassy layer. This usually indicates a\\ndiseased condition of the lower portion of the bowel. (2)\\nThe mucus may appear in the form of membranes and may\\nbe evacuated either alone or after a fecal evacuation. This\\noften occurs in membranous enteritis. (3) The mucus may\\nappear in a mushy movement having a yellowish coloration\\nand be well mixed with faeces. If a glass rod is dipped\\ninto such an evacuation the mucus adheres to it. (4) The\\nmucus exists in small particles visible with the naked eye\\nand floating in the watery dejecta. All these varieties of\\nmucus with the exception of (2) indicate the presence of a\\ncatarrhal condition of the intestine.\\nIntestinal parasites also occur in the faeces, and their\\ndiscovery may elucidate the diagnosis.\\nChemical Examination of the Faeces. The reaction of the\\nfaeces is normally neutral or slightly alkaline. Under a\\ndiet rich in vegetables, however, it is slightly acid. In\\ncases in which there is an occlusion of the bile duct so that\\nit does not empty into the intestines the reaction is strongly\\nacid. The test for the reaction is best made by means of\\nlitmus paper. The reaction at the surface of the fecal mat-\\nter may be different from that in the interior. It is there-\\nfore best to test both.\\nThe amount of acidity or alkalinity of the faeces can be\\ndetermined by mixing 10 to 20 c.c. of the fresh fecal matter\\nwith about 100 c.c. of distilled water. A drop of a phenol-\\nphthalein solution is added and as much of a deciuormal\\nsolution of either sodium hydrate or sulphuric acid until\\nthe red color appears, or if the alkalinity has to be deter-\\nmined, disappears. The reaction of the faeces is, however,\\nnot of much diagnostic value.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0072.jp2"}, "73": {"fulltext": "EXAMINATION. 53\\nTests for Mucin. According to Hoppe-Seyler, mucin\\nforms one of the principal constituents of the faeces. In\\norder to test for it the faeces are thoroughly mixed with\\nwater and an equal volume of milk of lime, allowing the\\nmixture to stand for several hours. It is then filtered.\\nAcetic acid is now added to the filtrate. In the presence\\nof mucin a precipitate forms. In case particles of sus-\\npected mucus are visible within the faeces, they can be\\nexamined separately in the following manner A small flake\\nof the mucus is dissolved in a weak solution of potassium\\nor sodium hydrate, and acetic acid added. If the precipi-\\ntate remains undissolved after the addition of the acetic\\nacid in excess, it proves the presence of mucin. Inasmuch\\nas nucleoalbumin also gives the reaction just described,\\nthe positive proof that the precipitate is due to mucin is\\nafforded by heating it in a diluted mineral acid to the boil-\\ning-point. If mucin is present the heated solution will\\ncontain a substance reducing copper oxide. Another very\\nuseful test for the presence of mucin consists in staining\\nthe flake of fecal matter resembling mucus with a weak\\ntriacid solution (Ehrlich). The presence of mucus pro-\\nduces a green color, while if the flake consists of albumin,\\na red color arises. This test, first described by Pariser, 1\\nI have found of practical value.\\nAlbumin.\u00e2\u0080\u0094 In order to examine the faeces for albumin,\\nthey are treated repeatedly with water slightly acidified\\nwith acetic acid. The watery extract is filtered several\\ntimes and the filtrate examined for albumin according to\\nthe methods used in examinations of the urine for this\\nsubstance. The addition of acetic acid and potassium ferro-\\ncyanide, however, is best suited for this purpose. Under\\nnormal conditions there is no albumin present in the faeces.\\n1 Pariser Deutsche meclicinische Wochenschrift, 1893, No. 41.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0073.jp2"}, "74": {"fulltext": "54 DISEASES OF THE INTESTINES.\\nYon Jaksch 1 found it present in typhoid fever, in isolated\\ncases of acute enteritis, and in chlorosis.\\nPropeptone and Peptone.\u00e2\u0080\u0094 After the test for albumin has\\nbeen made with negative result, the watery extract of the\\nfeces is treated with phosphotungstic acid, the precipi-\\ntate diluted with water and sodium hydrate and a small\\namount of a weak solution of sulphate of copper added.\\nA purplish-red color (biuret test) shows the presence of\\nboth propeptones and peptones. If it is desirable to ascer-\\ntain the presence of peptones separately it is necessary to\\nfirst precipitate the propeptone by the addition of a large\\namount of ammonium sulphate. In normal dejecta Von\\nJaksch never encountered peptone. Pathologically he\\nfound it in typhoid fever, dysentery, tuberculous ulcer of\\nthe intestine, and in perforation peritonitis.\\nCarbohydrates. In order to test for the presence of car-\\nbohydrates, the faeces are subjected to distillation. The\\nresidue is extracted with alcohol and ether; the extract is\\nthen boiled with water, filtered, and again boiled with the\\naddition of dilute sulphuric acid. This solution is then\\nsubjected to Trommer s or Nylander s test for the presence\\nof reducing substances.\\nIn order to ascertain whether starch is present the\\nwatery extract of the feces is examined with Lugol s solu-\\ntion, the presence of starch producing a blue color.\\nIf the dejecta be examined for the presence of sugar, then\\na watery extract of the fecal matter can be directly tested\\nwith the usual sugar reagents. Normally neither starch\\nnor its derivatives (sugar) are found.\\nSchmidt 2 suggested testing the watery extract of the\\nfecal matter with regard to the amount of gas developing\\n1 Von Jaksch Klinische Diagnostik.\\n2 Ad. Schmidt Berliner klinische Wochenschrift, 1898, No. 41.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0074.jp2"}, "75": {"fulltext": "EXAMINATION. 55\\nthrough fermentation. For this purpose Schmidt puts the\\nwatery extract of the faeces into fermentation tubes (similar\\nto the fermentation saccharometer) and keeps them at blood\\ntemperature. The greater the amount of gases developing\\nin the cylindrical part of the tube, the greater the evidence\\nof disturbances within the intestine. The greater propor-\\ntion of the gas consists of carbonic acid and is due to its\\nformation from the carbohydrates existing in the fecal\\nmatter. In order to be able to judge more accurately from\\nthis test, Schmidt examined his patients after a certain\\ndiet which they had been taking for several days. It con-\\nsisted of 1,560 c.c. of milk, four eggs, three zwieback, one\\nplate of barley soup, one plate of flour soup, and one cup\\nof bouillon a day. While Schmidt asserts that whenever a\\nconsiderable amount of gas is found in the fermentation\\ntube this indicates a real disturbance of the intestine, S.\\nBasch, 1 who has made a thorough study of Schmidt s\\nmethod in a considerable number of cases, is of the opinion\\nthat on the one hand a considerable amount of gas may be\\nfound in cases without any apparent intestinal lesion, and,\\non the other hand, grave disturbances of the intestine may\\nshow a total absence of gas. Inasmuch as Schmidt s fer-\\nmentation method is certainly complicated and its results\\nare not of great diagnostic value, I do not believe that it\\nwill ever come into practical use.\\nFat. The presence of neutral fat and fatty acids is de-\\ntermined in the following manner The faeces are treated\\nwith a considerable amount of ether; the latter is separated\\nand evaporated in a water bath. The fat if present then\\nremains and is visible. In order to show the presence of\\n1 S. Basch Welche klinische Bedeutung bezeichnet die Schmidt sche\\nGahrungsprobe der Faeces? Zeitschrift f klin. Med. Bd. 37, Heft\\n5 and 6.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0075.jp2"}, "76": {"fulltext": "56 DISEASES OF THE INTESTINES.\\nsoaps which do not dissolve in ether, another portion of\\nfecal matter is iirst treated with acids which split up the\\nsoaps and then extracted with ether. The quantitative de-\\ntermination of the amount of fat and of its different com-\\nponents is somewhat complicated and of not much service\\nclinically. Those interested in the subject may look up\\nVon Noor den s Beitrage zur Lehre vom Stoffwechsel,\\nHeft I., p. 109, Berlin, 1892. Normally fat is never per-\\nceptible macroscopically in the faeces unless after the in-\\ngestion of very large quantities. It may then be visible in\\nsmall portions of pea size. Pathologically fat may exist\\nin very large quantities in the fecal matter and give it\\na grayish silvery appearance, the so-called fatty stools.\\nThis normally occurs in diseases of the pancreas, and also\\nwhenever the absorption by the lymphatics is greatly dis-\\nturbed.\\nBlood. Fresh blood from the lower portion of the intes-\\ntine, and also from the higher portions of the bowel if pres-\\nent in large amount, is easily recognized by its macroscopic\\nappearance. Often the microscope will reveal well-pre-\\nserved red and white blood corpuscles. Sometimes, how-\\never, the blood is changed to such a degree that it is not\\neasily recognized. Here various tests are required in order\\nto prove its existence, the same procedures being used as\\nfor the discovery of blood in the gastric contents. The\\nhsemin test which is chiefly used is made as follows A\\nsmall particle especially suspected of containing blood is\\ndried and powdered and a portion of it put on a slide. A\\ntrace of sodium chloride is now added and a drop of glacial\\nacetic acid poured over it and thoroughly mixed. A cover-\\nglass is now put over it, the specimen is slowly heated, and\\nafter cooling examined with the microscope. The presence\\nof hsematin crystals shows that there was blood.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0076.jp2"}, "77": {"fulltext": "EXAMINATION. 57\\nBile Pigment. Under normal conditions no unchanged\\nbile pigment is found in the faeces. In catarrhal conditions\\nof the small intestine it has been frequently detected. The\\npresence of bile pigment is ascertained in the following\\nmanner A particle of highly colored fecal matter is brought\\ninto contact with a drop of fuming nitric acid. The yellow\\ncolor usually passes through the various colors of the spec-\\ntrum red, violet to green. In some instances a green\\ndiscoloration appears at once. The test for biliary pigment\\nmay also be made as follows: The faeces if liquid are\\nfiltered through filter paper, and if not liquid a watery\\nmixture is made and filtered. When the filter paper is\\ndry a few drops of nitric acid are poured on it. The colors\\njust mentioned appear in the form of rings, if bile pigment\\nis present. Still another test is as follows A small quan-\\ntity of the fluid dejecta is treated with a concentrated\\nwatery solution of sublimate. If the faeces contain biliary\\npigments in considerable quantity, the entire mixture turns\\ngreen. If, however, the biliary pigment is adherent to cer-\\ntain small fecal particles then these alone turn green.\\nBiliary Acids. Whenever biliary pigments appear in the\\ndejecta, biliary acids, as a rule, accompany them. The\\npresence of biliary acids is best revealed by Pettenkofer s\\ntest, and is made as follows: A small quantity of fecal\\nmatter is thoroughly treated with alcohol, which is then\\nevaporated. To the residue a weak watery solution of bi-\\ncarbonate of sodium is added, and to this mixture a small\\nquantity of cane sugar and a few drops of sulphuric acid.\\nWhen biliary acids are present a characteristic red or pink\\ncolor arises.\\nUrobilin. Normally the biliary pigment within the in-\\ntestinal tract becomes changed into urobilin, which is the\\nprincipal factor of the characteristic brownish color of the", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0077.jp2"}, "78": {"fulltext": "58 DISEASES OF THE INTESTINES.\\nfaeces. The best test for the presence of urobilin is\\nFleischer s 2 procedure which is as follows A small quan-\\ntity of faeces is put into a test tube and a small amount of\\nalcohol with a few drops of hydrochloric or acetic acid\\nadded; the mixture is then left undisturbed for a short\\ntime. The presence of urobilin produces a yellow or\\nbrown color, the latter, if present in large amount. If\\nthe alcohol is now poured out and a few drops of sodium\\nhydrate added, as well as a small quantity of a chloride-of-\\nzinc solution, there appears, according to the amount of\\nurobilin, a more or less greenish fluorescence in direct rays\\nof light, while in transmitted light the fluid appears pink\\nor yellowish-red. If the watery extract of faeces to which\\nsome ammonia has been added is filtered and chloride of\\nzinc added, the presence of urobilin produces a pinkish-red\\nprecipitate. If this precipitate is filtered under addition\\nof alcohol containing some ammonia there appears a more\\nor less greenish fluorescence (Schmidt s 2 test). A small\\npiece of fecal matter is treated with a concentrated watery\\nsolution of sublimate and thoroughly mixed with a glass\\nrod. The presence of urobilin gives rise either imme-\\ndiately or a little later to a pinkish-red color, while biliver-\\ndin, if present, produces a greenish color.\\nNormally urobilin is present in the faeces. Its absence\\nis observed only in pathological conditions.\\nAcholic Stool. The acholic stool presents a grayish-\\nwhite, ashy gray, or clay color. It is usually of a soft salve-\\nlike consistency. It occurs (1) in conditions in which\\nthere is a total absence of bile in the intestine, and (2)\\nwhenever the absorption of fat is greatly impaired. Until\\nvery recently the grayish- white color has been generally\\n1 R. Fleischer Krankheiten des Darms, p. 1160, Wiesbaden, 1896.\\n2 A. Schmidt; Verhandlungen des Congresses f. Innere Med., 1895.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0078.jp2"}, "79": {"fulltext": "EXAMINATION. 59\\nascribed to the absence of biliary pigments and their modi-\\nfications (urobilin) but Fleischer and Bunge l have conclu-\\nsively shown that the whitish color may be observed in\\nfaeces containing urobilin, the color being due to the pres-\\nence of large amounts of fat. In the latter instance the\\nstool, after being treated with large amounts of ether, thus\\nseparating the contained fat, assumes a brownish color.\\nThis I can confirm also from my own experience.\\nFerments. In order to ascertain the existence of fer-\\nments in the faeces a glycerin extract of them may be made\\nor the fecal matter may be directly mixed with water con-\\ntaining a small proportion of thymol, and filtered. The\\nfiltrate, or the glycerin extract, can now be directly tested\\nfor the presence or absence of the different ferments, tryp-\\nsin and diastase. In order to test for trypsin the fecal\\nfiltrate is made alkaline by the addition of bicarbonate of\\nsodium and a few flakes of fibrin are added. The solution\\nis kept at blood temperature for a few hours and then tested\\nwith potassium hydrate and a weak solution of sulphate of\\ncopper. If trypsin is present, a pinkish-red color will\\narise in consequence of the peptone which has formed\\n(biuret test). In order to test for diastase, a few cubic\\ncentimetres of the filtrate are mixed with about half the\\namount of a starch solution and kept at blood temperature\\nfor half an hour. The mixture is now subjected to Fehling s\\nor Trommer s test for the presence of sugar. Normally, as\\na rule, these ferments are absent, but in pathological condi-\\ntions, especially in diarrhoea, they are frequently found.\\nConcretions. The faeces occasionally contain concretions\\nwhich may be of diagnostic importance. In order to de-\\ntect them, especially if they are small, the faeces must be\\n1 Bunge Lehrbuch der pbys. u. pathol. Chemie, Leipsic, 1887,\\np. 192.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0079.jp2"}, "80": {"fulltext": "60 DISEASES OF THE INTESTINES.\\nthoroughly mixed with warm water and poured through a\\nlarge sieve. While the fecal matter is on the sieve some\\nmore water is added and the mass constantly stirred with\\na wooden stick. Any concretions present will thus be dis-\\ncovered remaining on the surface of the sieve.\\nThe following different concretions may be met with in\\nthe faeces: (1) Gallstones; (2) pancreatic calculi; (3) en-\\nteroliths (4) coproliths (5) foreign bodies.\\nBiliary calculi are easily recognized when they attain\\nconsiderable size. When they are very small, however,\\ntheir recognition is somewhat more difficult. The princi-\\npal constituents of biliary calculi are cholesterin and bile\\npigment in conjunction with lime.\\nThe small concretions (sand) suspected to be of biliary\\norigin should be examined in the following way About\\n2 gm. of the mass is well powdered and treated with 20\\nc.c. of ether, thoroughly mixed and filtered, the filtrate\\nevaporated and tested for the presence of cholesterin in the\\nfollowing manner (a) Part of the residue is dissolved in\\nhot alcohol and put aside on a porcelain dish for spontane-\\nous evaporation. The precipitate is examined under the\\nmicroscope. Crystals of rhomboid shape with a ragged\\nedge are characteristic of cholesterin. (b) Another por-\\ntion of the residue is directly put on a slide, a drop of\\nconcentrated sulphuric acid added, and covered with a.\\ncover-glass. The cholesterin crystals assume a carmine\\ncolor at their margins. If now a drop of Lugol s solution\\nis added a violet color arises, (c) Another portion of the\\nresidue is treated with hydrochloric acid and a trace of\\nchloride of iron and evaporated. If cholesterin is present\\na blue color arises. The residue of the original ether mix-\\nture is treated with diluted hydrochloric acid, heated, and\\nextracted with chloroform after it has cooled off. The", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0080.jp2"}, "81": {"fulltext": "EXAMINATION. 61\\nchloroform extract is now tested with Mellin s reaction\\n(fuming nitric acid). The presence of bile pigment pro-\\nduces the well-known change of colors.\\nPancreatic Calculi. Pancreatic calculi usually have a\\nrough surface, are brittle, and may be faceted. They are\\nsoluble in chloroform and produce on evaporation an aro-\\nmatic odor (IVIinich 1 Bile pigment and cholesterin are\\nabsent.\\nEnteroliths or calculi formed in the small intestine usu-\\nally consist principally of inorganic salts (lime, magnesia).\\nThey are light in color and ordinarily of small size. They\\noccasionally form after an extensive use of mineral medica-\\nments (lime, magnesia, etc.). They hardly ever give rise\\nto intestinal obstruction.\\nCoproliths or fecal calculi are found in the large bowel,\\nprincipally in places in which there is a retardation in the\\npassage of the faeces. Thus they are encountered in the\\ncaecum, in the appendix, in sacculations of the colon, and\\nin the rectum. The coproliths are of stony hardness and\\nof sausage shape. They usually show on section concen-\\ntric rings. Occasionally they attain considerable size and\\nmay give rise to obstruction of the bowel.\\nForeign Bodies. Foreign bodies which have been swal-\\nlowed may pass through the entire intestinal tract and be\\neliminated in the faeces. Thus pieces of bone, coins, mar-\\nbles, needles, and all kinds of foreign substances may be\\nfound in the stools. In rare instances concretions of shellac\\nare discovered in the stools of patients who have drunk\\nfurniture polish, the shellac forming concretions after the\\nabsorption of the alcohol. Hair balls may be found in\\npatients who habitually bite off and swallow hair.\\n1 Minich Berliner klin. Wochenschrift, 1894, No. 8.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0081.jp2"}, "82": {"fulltext": "62 DISEASES OF THE INTESTINES.\\nMicroscopical Examination.\\nThe microscopical examination of the faeces is occasionally\\nof assistance in establishing the diagnosis. With Ewald 1\\nI do not think it necessary to examine microscopically the\\nfaeces of every patient presenting intestinal symptoms. In\\nFig. 16.\u00e2\u0080\u0094 Normal Faeces, showing a few Fat Crystals and Fat Globules; Digested Muscle\\nand Epithelial Cells Micro-organisms.\\ncases, however, in which the diagnosis is not quite clear\\nand the symptoms point to an intestinal lesion, a micro-\\nscopical examination of the faeces should be made.\\nDiarrhceal stools may be examined under the microscope\\n1 C. A. Ewald: Diseases of the Intestines. Twentieth Century\\nPractice of Medicine, vol. ix., p. 113.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0082.jp2"}, "83": {"fulltext": "EXAMINATION. 63\\nwithout any further preparation. Solid fecal matter is\\nexamined by taking a small particle of the faeces, putting it\\non a slide, and mixing it thoroughly with a drop of physi-\\nological salt solution. In order to avoid the unpleasant\\nodor, a small amount of a watery one-per-cent formalin\\nsolution may be first added to the fecal matter. The micro-\\nFig. 17.\u00e2\u0080\u0094 Normal Faeces showing Detritus, Plant Cells, Digested Muscle Fibres, Bacteria.\\nscopic picture of the normal faeces varies greatly according\\nto the diet. In people living on a meat diet no vegetable\\nresidue will be seen, while there will be no remnants of\\nmeat in people subsisting on an exclusively vegetable diet.\\nIn case of a mixed diet there will be remnants of both in\\nthe stool. A mixed diet will reveal the following appear-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0083.jp2"}, "84": {"fulltext": "64 DISEASES OF THE INTESTINES.\\nances: There will be a large number of plant cells, the\\nremnants of various vegetables and fruits. They are usu-\\nally of considerable size, present peculiar shapes, and can\\nbe easily differentiated from animal cells (Figs. 16, 17, 18,\\n19). The peels of pears and apples and of prunes com-\\nmonly pass out in the stool entirely unchanged. Notwith-\\nFig. 18.\u00e2\u0080\u0094 Different Varieties of Vegetable Cells found in Normal Faeces.\\nstanding the presence of these plant cells in the stools\\nstarch, as a rule, is absent. Thus the microscopical speci-\\nmen when stained with Lugol s solution will show no blue\\ncolor. If, however, starch appears in a stool in well-pre-\\nserved granules, it is always pathological, indicating de-\\nficient digestion. Minute fragments of meat are found", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0084.jp2"}, "85": {"fulltext": "EXAMINATION.\\n65\\nin small quantity in the stools. Although considerably\\nchanged the muscles can be recognized as such, and the\\ntransverse markings can often be noticed. Frequently they\\npresent a yellowish tinge from biliary pigment. Connec-\\ntive-tissue fibres and also elastic fibres are occasionally met\\nFig. 19.\u00e2\u0080\u0094 Stool of an Hysterical Patient who Simulated Passing of Large Quantities of\\nMucous Membranes in the Faeces. The membranes under the microscope showed the\\nstructure of common tissue paper a few plant cells, epithelial cells, and fat crystals\\nwere also present.\\nwith, both being quite resistant to the action of the diges-\\ntive juices. The presence of numerous pieces of meat in\\nthe stool is pathological.\\nFat. Microscopically fat can be detected in the faeces in\\nthe form of colorless small globules which may exist in", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0085.jp2"}, "86": {"fulltext": "66 DISEASES OF THE INTESTINES.\\nlarge numbers after an excessive milk diet or in the shape\\nof small needle-shaped crystals, or again in the form of\\nsheaves. The small crystals of needle shape usually occur\\nsingly, and consist mostly of fatty acids, while the sheaves\\nconsist of fatty soaps. The fatty-acid crystals melt and\\ndisappear when heated, while the soaps remain unchanged.\\nEther likewise causes a disappearance of the fatty acids,\\nwhile the soaps remain unchanged. Eieder suggests the\\nuse of the dye stuff Sudan II. (C 22 H 10 N 4 O) in a concentrated\\nalcoholic solution for the differentiation of the fats. This\\ndye stains plain fat bright red, while crystals of fatty acid\\nand of lime and magnesia soaps remain unchanged. While\\nnormally these different forms of fat appear in very scanty\\namounts in the faeces, they may be found considerably in-\\ncreased under pathological conditions (affections of the\\nliver, pancreas, and acute enteritis).\\nCrystals. Besides the crystals of fatty acids and their\\nsoaps the following crystals are met with in the faeces:\\noxalate of lime appears in the well-known envelope form of\\nvarying size, especially after a diet consisting principally\\nof vegetables. Calcium carbonate occasionally occurs in the\\nform of amorphous granules or dumbbell-shaped crystals.\\nNeutral phosphate of calcium and ammonio-magnesium\\nphosphate crystals are often present and can be readily rec-\\nognized, the former occurring in more or less well-defined\\nwedge-shaped crystals collected into rosettes, the latter pre-\\nsenting the well-known coffin shape. They are soluble in\\nacetic acid. All the crystals just mentioned are found in\\nnormal as well as in pathological faeces, and have no diag-\\nnostic importance. Bismuth crystals: when bismuth is\\ninternally administered it is usually found in the faeces in\\n1 Rieder Deutsches Archiv ftir klin. Med., 1898, Bd. 59, Heft 3 and\\n4, p. 444.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0086.jp2"}, "87": {"fulltext": "EXAMINATION. 67\\nrhomboid crystals of a dark-brown or almost black color\\n(Fig. 20). Ha3matoidin crystals are occasionally encoun-\\ntered in severe catarrhal conditions of the intestines or\\nshortly after intestinal hemorrhages have taken place.\\nThey occur in small amorphous particles of an orange or\\nFig. 20.\u00e2\u0080\u0094 Specimen of Stool of Mrs. W., living on Milk Diet and taking Bismuth and\\nMagnesia. Bismuth and magnesia crystals, some fat globules and detritus. No muscle\\nor plant cells.\\nruby red color, or in crystals of the rhombic system.\\nCharcot-Leyden crystals of spermin phosphate, having\\nthe shape of grains of oats, are occasionally met with in\\nthe faeces and are of diagnostic importance. According to\\nLeichtenstern, these crystals are very frequently found in\\n1 Leichtenstern Deutsche med. Wochenschrift, 1892, No. 25.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0087.jp2"}, "88": {"fulltext": "68\\nDISEASES OF THE INTESTINES.\\nthe faeces whenever intestinal parasites (helminthiasis)\\nexist. These crystals, however, occur also in other patho-\\nlogical conditions as in typhoid fever, dysentery, tubercu-\\nlosis of the lungs. In rare instances the Charcot-Leyden\\ncrystals are absent in cases of helminthiasis. When they\\nFig. 21.\u00e2\u0080\u0094 Specimen of Stool of Mrs. V., with Chronic Intestinal Catarrh. Groups of epi-\\nthelial cells detritus a few muscle cells, partly digested plant cells bacteria yeast\\ncells.\\noccur, however, they are an indication that the stools\\nshould be carefully watched for the presence of intestinal\\nworms.\\nElements Derived from the Intestinal Wall. Epithelial\\ncells and also goblet cells occur occasionally in the faeces,\\nbut only in scanty number (Fig. 21). They are very sel-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0088.jp2"}, "89": {"fulltext": "EXAMINATION.\\n69\\ndom unchanged with a distinctly visible nucleus usually\\nthey appear in a metamorphosed condition without any\\nperceptible nucleus. Larger accumulations of epithelial\\ncells may be found in desquamative catarrhal conditions\\nof the intestines.\\nFig. 22.\u00e2\u0080\u0094 Stool of Patient L., with Acute Dysentery. Pus cells in considerable number;\\noccasional epithelia mucus detritus.\\nBlood. Blood in the faeces is occasionally easily recog-\\nnized under the microscope, both red and white blood cor-\\npuscles being present. This, however, is the fact only in\\nhemorrhages of the lower portion of the rectum. In hem-\\norrhages originating in the upper portion of the large\\nbowel or in the small intestine, the blood cells are usually", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0089.jp2"}, "90": {"fulltext": "70\\nDISEASES OF THE INTESTINES.\\nalready greatly changed and not to be recognized as such\\nmicroscopically\\nPus. Pus corpuscles in the dejecta occur in ulcerative\\nprocesses of the intestines or whenever an abscess has\\ndischarged its contents into the bowel. Besides these\\ntwo conditions, it is also met with in dysentery. The pus\\nFig. 23.\u00e2\u0080\u0094 Stool of Patient H., with Chronic Dysentery, during an Acute Exacerbation.\\nHighly magnified. Amoebae red and white blood cells crystals of fat and ammonio-\\nmagnesium phosphate plant and muscles cells detritus.\\ncorpuscles are then distinctly visible under the microscope\\n(Figs. 22, 23, 24) [For the beautiful execution of the above\\ndrawings I am indebted to Dr. C. A. Elsberg of this city.]\\nMucus. Mucus is frequently seen in the dejecta under\\nthe microscope. It is recognized by its thread-like ap-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0090.jp2"}, "91": {"fulltext": "EXAMINATION.\\n71\\npearance (Fig. 25). Occasionally it is also amorphous,\\nThionin colors mucus reddish-violet, while it stains other\\nproteid substances blue. Mucus is often present in ca-\\ntarrhal conditions of the intestine and also in membranous\\nenteritis.\\nPieces of Tumors. In rare instances a small fragment of\\nFig. 24.\u00e2\u0080\u0094 From the Same Patient, a Few Days Later. Highly magnified. Amoebae fat\\nin globules and crystals a few red and white blood corpuscles muscles cells detri-\\ntus; bacteria.\\ntumor may be found in the dejecta. Under the microscope\\nthe structure of the mass will be seen and its character de-\\ntermined. The result of such an examination may be of\\ngreat diagnostic importance.\\nMicro-organisms. Numerous micro-organisms are found", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0091.jp2"}, "92": {"fulltext": "72 DISEASES OF THE INTESTINES.\\nin the faeces normally as well as pathologically. Their\\nnumber averages in daily evacuations fifty -three milliards.\\nSometimes they may reach as high a figure as four hundred\\nmilliards. Beginning with the stomach the number of\\nmicro-organisms steadily increases all through the intesti-\\nnal tract down to the large bowel, where the maximum is\\nFig. 25\u00e2\u0080\u0094 Specimen of the Stool of Mrs. J. B., Suffering from Intestinal Catarrh. Mucus\\nall over the field of vision a few plant cells and muscle cells, and an occasional fat\\ncrystal.\\nreached. The micro-organisms appear to be intimately\\nconnected with the physiological processes of digestion.\\nThis is true notwithstanding the valuable investigations of\\nNencki, Macfadyen, and Sieber, 1 and Thierf elder and Nut-\\n^encki, Macfadyen, und Sieber: Archiv f. experimentelle Patho-\\nlogie u. Pharmakologie, Bd. 28, S. 301.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0092.jp2"}, "93": {"fulltext": "EXAMINATION. 73\\ntal, 1 which have shown that normal digestion is possible\\neven without bacteria. Pathologically various kinds, of\\nbacteria play a very important part. Besides certain spe-\\ncies of pathogenic bacteria, the micro-organisms normally\\nsojourning in the intestine occasionally assume morbific\\nproperties.\\nThe different varieties of micro-organisms in the intes-\\ntinal tract have been thoroughly studied by Mannaberg, 2\\nwho found fourteen different species of bacilli, nine species\\nof micrococci, and four species of schizomycetes. Of the\\nlatter saccharomyces cerevisiae are most frequently encoun-\\ntered in the faeces. They are found in groups forming\\nthree or four buds, and assume a mahogany color when\\ntreated with Lugol s solution. Of the bacteria and cocci\\nthe following deserve special mention\\nThe bacterium coli commune, first described by Esche-\\nrich, 3 occurs in the form of thin or thick rods being about\\n0.4 fi in length. Some show motile power. They are well\\nstained by the ordinary anilin dyes and decolorized by\\nGram s solution. Their colonies growing upon gelatin re-\\nsemble those of the bacillus of typhoid fever.\\nThe bacterium lactis aerogenes (Escherich) greatly re-\\nsembles the bacterium coli commune. It is frequently\\nfound in the stools of infants, and is now and then met with\\nin those of adults. It is found in thick rods frequently\\nlying in pairs. They are non-motile and have the property\\nof causing fermentation of milk, producing coagulation and\\nformation of gas within sixty hours.\\n1 Thierfelder u. Nuttal Zeitschrift f phys. Chemie, Bd. 21, S. 109,\\nu. Bd. 22, S, 62.\\n2 Mannaberg Die Bacterien des Darms Nothnagel s Erkrankun-\\ngen des Darms, Wien, 1895.\\n3 Escherich Beitrage zur Kenntniss der Darmbacterien. Mimch-\\nener med. Wochenschr. 1886, No i., 43-45.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0093.jp2"}, "94": {"fulltext": "74 DISEASES OF THE INTESTINES.\\nBacillus putrificus coli (Bienstock 1 forms slender rods\\n3 p in length. This bacillus energetically decomposes\\nproteid substances in presence of air under the formation\\nof ammonia, amin bases, fatty acids, tyrosin, phenol, indol.\\nWhile all the above-mentioned micro-organisms give a\\nmahogany or brown color with solutions of iodine, there\\nare a few varieties which give a blue color with this sub-\\nstance. To the latter belongs the bacillus butyricus de-\\nscribed by Nothnagel. 2 It is rod-shaped, 3 to 10 t\u00c2\u00b1 long\\nand 1 p. thick. It is often lemon-shaped. This bacillus\\nis anaerobic and produces fermentation of starch, sugar,\\nand cellulose, forming butyric acid and gas. The bacillus\\nbutyricus is often found in pathological conditions of the\\nintestine, but occurs in small numbers also in normal faeces.\\nOf the pathogenic micro-organisms, cholera, typhoid, and\\ntubercle bacilli are found in the faeces. The cholera and\\ntyphoid bacilli causing infectious diseases do not belong,\\nstrictly speaking, to the micro-organisms producing dis-\\neases of the intestine alone. The tubercle bacilli, occasion-\\nally producing intestinal tuberculosis, are recognized in the\\nfaeces by the same methods which are employed in the\\nexamination of the sputum.\\nTREATMENT.\\nDiet\\nThe principles of diet are fully described in my book on\\nthe stomach. Here I will add a few remarks referring to\\nthe dietetic treatment of intestinal diseases. As in the\\ncase of the stomach, acute intestinal disorders lasting a\\n1 B. Bienstock Ueber die Bacterien der Faeces. Zeitschr. f klin.\\nMed., Bd. 8, 1884.\\n2 H. Nothnagel Die normal in dem Menschendarm vorkommenden\\nniedersten (pflanzlichen) Organismen. Zeitschr. f. klin. Med., Bd. 3,\\n1881.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0094.jp2"}, "95": {"fulltext": "TREATMENT. 75\\nfew days or weeks must be managed according to the prin-\\nciple of rest. Very scanty and light foods (mostly liquid)\\nshould be given. In chronic ailments of the intestines the\\nprinciple of rest may also be utilized occasionally for a\\nshort time, while as a general rule we should bear in mind\\nthe necessity of introducing sufficient quantities of food\\nand gradually accustoming the intestinal tract to the ordi-\\nnary foods.\\nIn some instances it is possible to exert a wholesome\\ninfluence upon the disturbances of the intestine by appro-\\npriate dietetic measures. This applies especially to dis-\\norders accompanied by constipation or by diarrhoea.\\nI. Articles of diet which increase the intestinal peristalsis\\nor laxative foods are the following: Most fruits, both\\nraw and cooked, and fruit juices increase the peristalsis\\nin consequence of the organic acids which they contain, as\\napples, pears, plums, peaches, strawberries, gooseberries,\\ndates, and figs. Most salads and garden vegetables also\\nincrease peristalsis, firstly, owing to the large amount of\\nwater they contain, and secondly, owing to the consider-\\nable residue which is left undigested, as, for instance,\\nmelons, cucumbers, tomatoes, pumpkins, all kinds of cab-\\nbage. By many of the latter foods the peristaltic action\\nof the intestine is also increased on account of the forma-\\ntion of acid and gaseous products. Fresh beer, cider,\\nbonny-clabber, and kumyss act in a similar manner. Cold\\ndrinks of plain water or carbonated water act as mild ape-\\nrients in some instances. Here a reflex action upon in-\\ntestinal peristalsis due to irritation must be assumed, for\\noften a movement of the bowels follows very soon (a quar-\\nter of an hour to one hour) after drinking.\\nII. Articles of diet ivhicli diminish the intestinal peri-\\nstalsis or constipating foods (1) All substances con-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0095.jp2"}, "96": {"fulltext": "76 DISEASES OF THE INTESTINES.\\ntaining a considerable portion of astringent agents, par-\\nticularly tannic acid, as, for instance, dried bilberries,\\nFrench red wines (particularly San Kafael wines), tea, ca-\\ncao, the acorn preparations like acorn coffee, acorn cacao.\\n(2) Foods which have a mucilaginous character and thus\\nsomewhat allay irritation also have a slightly constipating\\neffect sago, tapioca, barley, rice. (3) Foods which leave\\nno residue whatever or very little residue, and thus exert\\nno irritation. To these belong egg water (prepared by dis-\\nsolving the white of an egg in some water), scraped raw\\nmeat, mutton broth.\\nSome foods manifest different action in different individ-\\nuals. Thus, for instance, milk is constipating in one per-\\nson and laxative in another, while in still others it has no\\nspecial effect upon intestinal peristalsis.\\nMost foods have no marked influence upon the intestinal\\nperistalsis. To these belong most kinds of meat and fish\\nnot too highly seasoned, the various meat powders, and\\nmost artificial foods like meat peptone and nutrose, eucasin,\\nsomatose, sanose, eggs prepared in different ways, well-\\nbaked bread, wheaten or rye bread, crackers, zwieback,\\nfats in small amounts, especially butter. The preparation\\nof the foods has an important bearing with regard to its\\naction upon the intestinal peristalsis. The finer the foods\\nare the less irritating they will act, and the coarser the\\nparticles the greater the irritation they produce upon the\\nintestinal muscular layer. Highly seasoned foods also act\\nas a stimulant of the peristalsis.\\nIn some severe conditions of the intestines the ordinary\\nway of ingestion of food must be avoided for a short period.\\nHere artificial feeding is employed. Artificial feeding can\\nbe done in two different ways: rectal alimentation and\\nsubcutaneous alimentation.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0096.jp2"}, "97": {"fulltext": "TREATMENT. 77\\n1. Rectal Alimentation. The rectum and the greater\\npart of the large bowel should be emptied if possible be-\\nfore injecting the feeding enema. The latter is best accom-\\nplished by using a fountain syringe and a soft-rubber tube\\nwhich is introduced for about five to seven inches into the\\nrectum. The quantity of the feeding enema may be be-\\ntween five and ten ounces. As feeding enemas the follow-\\ning substances are used (a) The different kinds of pep-\\ntones and propeptones in the market of which about two\\nto three ounces can be dissolved in six to eight ounces of\\nwater. The different beef juices may also be dissolved in\\nwater and injected in corresponding quantities, (b) The\\nmilk and egg enemas. These are mostly used. Their\\ncomposition is as follows Six to seven ounces of milk,\\none or two raw eggs well beaten up, one teaspoonful of\\npowdered sugar, and the point of a knifeful of salt. The\\naddition of pancreatin (one tube of Fairchild pancreatin\\nto one enema) will facilitate assimilation, (c) Meat-pan-\\ncreas enema. Leube employs enemas consisting of well-\\nchopped meat mixed with fresh pancreas.\\nBesides these food enemas injections of water into the\\nbowel are made in order to increase the amount of fluid in\\nthe system. These injections of water for the purpose of ab-\\nsorption are of great importance. Usually saline solutions\\nare employed in quantities varying from one pint to one\\nquart. The nutritive enema should be given three or four\\ntimes in twenty-four hours, and the water enemas for ab-\\nsorption once or twice a day.\\n2. Subcutaneous Alimentation. In diseases of the intes-\\ntine special conditions are met with in which neither the\\nordinary way of feeding nor rectal alimentation is possible.\\n1 Leube: Leyden s Handbuch der Ernahrungstherapie, Bd. i., p.\\n508, Leipsic, 1897.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0097.jp2"}, "98": {"fulltext": "78 DISEASES OF THE INTESTINES.\\nHere an attempt must be made to introduce nourishment\\nsubcutaneously. Most food substances cannot be intro-\\nduced under the skin without inflicting more or less injury.\\nTwo substances only form an exception and are of practical\\nvalue (a) Olive oil. This can be injected subcutaneously\\nto the amount of one ounce twice or three times a day. It\\nis hardly necessary to say that the oil as well as the syringe\\nused for this purpose should be thoroughly sterilized. A\\nlarge-sized Pravaz syringe is employed, and but little\\npressure exerted while injecting. This precaution is neces-\\nsary in order to obviate any traumatism (tearing) of the tis-\\nsues. The best place for the injection is the thigh, {b)\\nWater. A saline solution is subcutaneously injected in\\namounts varying from one pint to a quart. This serves to\\nincrease the amount of fluid in the system. The injection\\nis made by means of the fountain syringe to the end of\\nwhich an aspirating needle is attached. The same pre-\\ncautions as above are necessary. The saline injection\\nmay be employed twice or three times a day if necessary.\\n31echanical Procedures.\\nInjections. Injections into the bowel in the form of clys-\\nters were used for curative purposes even in old times.\\nThe regular syringe with its stiff end may, if forcibly in-\\nserted, give rise to damage of the rectum. For this reason\\nnowadays a soft-rubber rectal tube is employed, to which\\na fountain or Davidson syringe or any form of syringe can\\nbe attached. The tube being flexible cannot injure the in-\\ntestinal walls. It can also be introduced higher up than\\nthe ordinary hard-rubber end pieces of the fountain syringe.\\nInstead of the fountain syringe a funnel apparatus similar\\nto the one used in gastric lavage may be employed. For\\nwashing out the bowel Leube-Rosenthal s appliance for", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0098.jp2"}, "99": {"fulltext": "TREATMENT. 79\\nwashing out the stomach can be used to advantage. For\\nirrigation of the bowel Kemp s hard-rubber rectal doUble-\\ncurrent irrigator can be conveniently employed (Fig. 26).\\nThese injections into the bowel are made for various\\npurposes\\n1. To produce an evacuation. About a quart of luke-\\nwarm water to which a teaspoonful of salt is added can\\nbe employed, or a piece of soap dissolved in the same\\nFig. 26.\u00e2\u0080\u0094 Dr. R. C.Kemp s Rectal Irrigator (New Model). Outer tube of hard-rubber;\\ncentral tube of metal. Hard-rubber flange, protecting sphincter from transmission of\\nbeat through the metal parts.\\namount of water. As a rule, it is not advisable to intro-\\nduce larger quantities of water than these as they distend\\nthe bowel too much. In greatly atonic conditions, how-\\never, in which a quart of water may be inefficient, an\\ninjection of from two to three quarts will be required. In-\\njections of oil (olive oil or sesame oil) in quantities vaiying\\nfrom half a pint to one pint have been recommended by\\nFleiner. 3 According to this writer the oil should be in-\\njected at blood temperature into the rectum when retiring\\nand be retained over night. While olive oil was used as a\\nlaxative injection long ago by Habershon and others, we\\nowe its methodical use to Fleiner, to whom is also due the\\ncredit for having promulgated the method. Small injec-\\ntions of glycerin (one or two drachms) in about an ounce\\nKleiner: Ueber die Behandlung der Constipation. Berl. klin.\\nWochenschr. 1893, Nos. 3 and 4.\\n2 Habershon Diseases of the Abdomen, London, 1862.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0099.jp2"}, "100": {"fulltext": "80 DISEASES OF THE INTESTINES.\\nof water can also be advantageously employed for produc-\\ning an evacuation of the bowels.\\n2. Injections may be resorted to either to strengthen\\nthe tonicity of the bowel, in which case plain very cold\\nwater in amounts of from one to two quarts can be em-\\nployed, or for medicinal purposes, i.e., for applying cer-\\ntain medicaments directly to the intestioal mucosa. The\\ndrugs most frequently used for this purpose are nitrate of\\nsilver, tannic acid, subnitrate of bismuth, as astringents;\\nthymol, hydrogen peroxide, boracic acid, essence of pep-\\npermint, as disinfectants.\\nMassage and Gymnastic Exercises. Massage is frequently\\nemployed in functional diseases of the intestine. Its field\\nof usefulness lies principally in neurotic and atonic condi-\\ntions. Massage should be applied by well-trained and\\nexperienced persons. Abdominal massage requires great\\ncare, as too rough manipulation is liable to do great harm.\\nGymnastic exercises and sports are well adapted to stimu-\\nlate and strengthen the muscles of the abdomen as well as\\nthose of the intestine. Ewald particularly recommends\\nrowing in boats with sliding seats as an exercise which\\ngives definite results in chronic intestinal torpidity. Golf,\\nbilliards, horseback riding, bicycle riding, walking may\\nalso be included among the exercises coDtributing to a ton-\\ning up of the system.\\nHydrotherapy. Moist applications in the form of either\\nPriessnitz s compresses or poultices are often of benefit.\\nPriessnitz s compresses are stimulating, while the warm\\nfomentations serve as a sedative. The latter are applied\\nto allay pain, the heat producing a temporary paralysis of\\nthe superficial sensory nerves. Instead of either cold or\\nwarm compresses a rubber bag filled with either cold or\\nhot water may be applied. When warm applications are", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0100.jp2"}, "101": {"fulltext": "TREATMENT.\\n81\\nrequired they can also be used in the form of the Japanese\\nbox. Sitz baths of various temperatures may be employed.\\nA shower bath, especially over the abdomen, of cold or\\nwarm water or of alternating cold and warm water, is also\\nof benefit. Many of these procedures may be combined\\nwith massage, and in this\\nway the curative action\\nis enhanced.\\nElectricity. The f ara-\\ndic, galvanic, or frank-\\nlinic currents are em-\\nployed. All these three\\ncan be used percuta-\\nneously; the first two\\nalso intrarectally. The\\nfaradic current is mostly\\napplied in atonic condi-\\ntions of the bowel with\\nthe object of stimulating\\nthe motor function of the\\nintestines. The galvanic\\ncurrent i s principally\\nemployed in painful intestinal affections of neurotic char-\\nacter. The franklinic or static current may be advan-\\ntageously used in both conditions. For the intrarectal\\napplication of the current I use an electrode which in prin-\\nciple is very similar to that of Boudet and consists of a\\nperforated hard-rubber end piece in which is lodged a\\nmetallic button connected by means of a wire with the bat-\\ntery. To the upper end of the hard-rubber piece is at-\\ntached a soft-rubber tube leading to an irrigator and pro-\\n1 Boudet Cited after A. Mathieu Treatment of Diseases of the\\nStomach and Intestines, New York, 1894, p. 171.\\n6\\nFig. 27.\u00e2\u0080\u0094 Rectal Electrode.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0101.jp2"}, "102": {"fulltext": "82 DISEASES OF THE INTESTINES.\\nvided with a stopcock (see Fig. 27). Proceed as follows:\\nThe irrigator is filled with water at blood temperature.\\nThe hard-rubber piece, or the rectal electrode, is smeared\\nwith vaseline and introduced into the rectum. Another\\nplate electrode is moistened and placed over the abdomen,\\nthe stopcock partly opened, and the current applied. The\\nwater running from the end piece of the electrode into the\\nbowel carries the electricity along with it. The electrical\\napplication should last from five to ten minutes, the\\namount of water used varies from ten to fifteen ounces.\\nThe outflow of the water can be regulated by the stopcock\\narrangement. I have applied both the faradic and gal-\\nvanic currents with this apparatus and found it very con-\\nvenient. The faradic current may be applied as strong as\\nthe patient can bear, while the galvanic current should be\\nused with the negative pole in the rectum, the intensity\\nof current ranging from eight to fifteen milliamperes.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0102.jp2"}, "103": {"fulltext": "CHAPTER III.\\nACUTE AND CHRONIC INTESTINAL CATAEEH.\\nACUTE INTESTINAL CATARRH.\\nSynonyms: Enteritis acuta; Catarrh us intestinalis acu-\\ntus; Acute diarrhoea; Cholera nostras.\\nDefinition. An inflammatory affection of the intestines\\ncharacterized. by a sudden development of pains and more\\nor less loose movements.\\nEtiology. Acute intestinal catarrh is one of the most\\nfrequent diseases. While it occurs more often in infants\\nand children it is found in persons of all ages.\\nThe affection may attack the entire intestinal tract or\\nmay be limited to a part of it. Thus we may have a duo-\\ndenitis, jejunitis, ileitis, typhlitis, colitis, and proctitis\\n(inflammation of the rectum) With regard to frequency\\nthe colon is most often affected. According to Woodward,\\nan inflammation of the small intestine alone hardly ever\\nexists, a portion of the large bowel always being affected.\\nIntestinal catarrh is either primary (idiopathic) or second-\\nary when occurring as a sequel of other diseases. Acute\\nenteritis may be due to a number of causes\\n1. It may result from the ingestion of heavy indigestible\\nfood, ice-cold drinks, and tainted meat or fish, unripe fruit,\\nstale or sour beer, bad water.\\n2. Good food and drink taken in unusually large quanti-\\nties may also produce this condition.\\n1 Woodward The Medical and Surgical History of the War of the\\nRebellion, vol. i part 2.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0103.jp2"}, "104": {"fulltext": "84 DISEASES OF THE INTESTINES.\\n3. A host of organic and inorganic substances may chem-\\nically irritate the intestinal mucosa and cause inflammation.\\nAll the drastic remedies, like croton oil, colocynth, jalap,\\netc., belong to these organic irritating substances; of the\\ninorganic may be mentioned tartar emetic, arsenic, lead,\\nsulphate of copper, all the mercurial preparations, concen-\\ntrated acids, and strong, caustic alkalies.\\n4. Enteritis may be caused by mechanical irritants.\\nThus hardened scybala, biliary calculi, enteroliths, or\\nforeign bodies which have been swallowed, like large ker-\\nnels of fruit or coins, may evoke inflammation. The\\ncatarrh accompanying intestinal worms may also be placed\\nin this group.\\n5. Intestinal catarrh is very often due to variations in\\ntemperature or to catching cold. It seems that the dispo-\\nsition to this agent varies in different individuals. Thus\\nsome people get an attack of diarrhoea if they sleep uncov-\\nered during the summer and a drop in temperature occurs,\\nthe colder atmosphere affecting the abdomen. Others,\\nagain, are attacked with diarrhoea whenever they get their\\nfeet wet. How the influence of cold acts in causing the\\nenteritis is difficult to say. Some writers believe that the\\nsudden change in the circulation of the blood caused by\\nthe cold is the principal factor others again explain it on\\nthe ground of a more favorable development of micro-\\norganisms during the change of temperature.\\n6. Auto-intoxication. Poisonous substances may develop\\nin the intestinal tract and cause diarrhoea. The enteritis\\nfollowing large burns of the skin belongs to this group.\\nHere the poisonous substance is probably formed at the\\nsite of the burned skin and carried by the blood current\\ninto the intestinal tract.\\nSecondary catarrh of the intestine occurs in almost all", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0104.jp2"}, "105": {"fulltext": "ACUTE INTESTINAL CATARRH. 85\\nacute infectious diseases in the same way as gastric catarrh.\\nIt is further found accompanying heart, kidney, and liver\\ndiseases, tuberculosis, diabetes, etc. Most organic dis-\\neases of the bowels are associated with intestinal catarrh,\\nas cancer of the intestines, volvulus, invagination, peri-\\ntonitis, thrombosis. In this class of cases, however, the\\nintestinal catarrh is of little importance compared with the\\nprimary affection.\\nMorbid Anatomy. The anatomical changes found in au-\\ntopsies are not always very well marked, and there is cer-\\ntainly no exact relation between the intensity of the clinical\\nsymptoms and the severity of the pathological processes\\ndiscovered. The mucous membrane of the affected part\\nof the intestine appears reddened either over its entire ex-\\ntent or only in spots. This red color is more pronounced\\naround the follicles and patches, at the apex of the folds\\nand of the villi. If the process is intense, extravasations\\nof blood may be found. The mucous membrane appears\\nswollen, sometimes cedematous, often it is covered with\\ntenacious mucus. The villi and the solitary follicles are\\nsucculent and appear as whitish, small prominences sur-\\nrounded by a red stratum (enteritis follicularis seu nodu-\\nlaris). If the process continues, these gray areas may\\nrupture, and thus give rise to ulcerative lesions (follicular\\nulcers) Catarrhal ulcers also exist, however, caused by\\nthe loss in some places of the protective epithelial covering\\nof the mucosa. Through extension of the inflammation in\\nwidth and depth irregular losses of substance with under-\\nmined edges are produced. Inflammatoiw irritation in the\\nneighborhood of these defects may give rise to polypoid\\ngrowths, especially when the process has run a protracted\\ncourse.\\nMicroscopically the vessels of the mucosa and sub-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0105.jp2"}, "106": {"fulltext": "86 DISEASES OF THE INTESTINES.\\nmucosa appear in a more or less congested state. Small\\nextravasations often exist between the glands of Lieber-\\nkuehn. The spaces between the glands are frequently\\nwidened and filled with an abundant accumulation of round\\ncells. The epithelium of the mucosa has mostly disap-\\npeared, especially in the large bowel. But according to\\nNothnagel this may be a post-mortem phenomenon and not\\nalways the result of inflammation. Desquamative processes\\nin the epithelial layer, however, occur during life caused\\nby the catarrhal affection, for the changed eroded epithelial\\ncells are found in the mucus voided with the stool. The\\nglands often appear altered with regard to their contour,\\nbeing wider at their fundus and much narrower at their\\nmouth, frequently presenting a flask shape. The sub-\\nmucous tissue is usually somewhat hyperplastic, otherwise\\nnot much changed. The muscular and serous coats are\\nnot affected.\\nSymptomatology. Intestinal catarrh usually manifests\\nitself through a feeling of fulness in the lower part of the\\nabdomen, colicky pains appearing from time to time, and\\ndiarrhoea. As a rule, no fever is present except in cases of\\na severe type. The number of the stools and their quality\\nvary a great deal. In mild cases there may be only two or\\nthree movements in twenty-four hours; in severer cases\\nfifteen to twenty diarrhceal evacuations. The first passage\\nas a rule still contains normal fecal matter in its first por-\\ntion, while the second part is of a mushy character. The\\nnext movements are semi-fluid, and at last entirely liquid\\ndejecta may appear. The first stool still has a brown color\\nand the characteristic f eCal odor, while the following evac-\\nuations present a slightly yellowish color or even a grayish\\nappearance, occasionally resembling rice-water. The latter\\nare sometimes devoid of fecal odor, have an acid reaction,", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0106.jp2"}, "107": {"fulltext": "ACUTE INTESTINAL CATARRH. 87\\nand show a foamy surface. Mucus is almost always pres-\\nent. The fecal matter in its yellow parts contains, as a\\nrule, unchanged biliary substances which give a charac-\\nteristic Gmelin reaction. Microscopically undigested food\\nparticles may be discovered in larger than normal amounts;\\nthus meat fibres arid well-preserved granules of starch\\nmay be observed. A host of micro-organisms, epithelial\\ncells, sometimes in contiguous groups, and mucus are\\nfound. Very seldom and only in severer cases small\\namounts of pus and red blood corpuscles may be dis-\\ncovered. Chemically peptones and sugar may be found in\\nthe dejecta.\\nGeneral Subjective Symptoms. Aside from the diarrhceal\\nmovements and the unpleasant sensations consisting in a\\nfeeling of pressure and fulness in the abdomen mentioned\\nabove, there may in light cases be perfect euphoria usu-\\nally a feeling of weakness exists which is especially marked\\nin the lower extremities. A feeling of dizziness and slight\\nnausea often also appear, especially shortly before and\\nduring evacuations. Vomiting may also occur, as a rule, in\\ncases in which the stomach is likewise affected or when the\\nprocess of inflammation is of a severer type (cholera nos-\\ntras). Tenesmus is frequently present, if the process is\\nin the lower part of the colon, even if not especially pro-\\nnounced. This seems to be the result of the irritating\\naction of the dejecta upon the rectum.\\nThe general symptoms above described are much more\\npronounced in children and very old people. Here the\\nappearance of collapse (cold extremities, blue lips, and\\napathy) is not very rare. Marshall Hall has described a\\ncondition under the name of acute hydrocephaloid disease\\n1 Marshall Hall Diseases and Derangements of the Nervous Sys-\\ntem, London, 1841, p. 153.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0107.jp2"}, "108": {"fulltext": "88 DISEASES OF THE INTESTINES.\\nwhich occurs in weak children with acute enteritis. The\\nhydrocephaloid appears in consequence of severe attacks of\\ngastro-enteritis with a temperature of 104\u00c2\u00b0-106\u00c2\u00b0 F. There\\nis sudden collapse. While the body is hot, the extremi-\\nties become ice cold, the fontanelles sink in, the pulse\\nbecomes considerably accelerated, soft, and often irregular.\\nIn this condition the little patient lies apathetic unless\\nsuddenly disturbed with colicky pains when he utters a\\ncry. The pupils do not react alike and the conjunctival\\nreflex may be absent. Sometimes paralysis of the rectum\\nis present, which I have seen in one case. In this condi-\\ntion the patient often dies within a short time from paraly-\\nsis of the heart.\\nObjective Symptoms. The physical examination of the\\nabdomen occasionally reveals on inspection a bloated con-\\ndition and some spots tender to pressure. As a rule, the\\nlower part of the abdomen, particularly the immediate\\nneighborhood of the navel, is slightly painful on palpation.\\nOccasionally there may be found a decided tenderness,\\neither in the right or in the left iliac region. Sometimes\\nthis tenderness may be quite pronounced in a line running\\nacross the abdomen between the margins of the false ribs\\n(transverse colon). Palpation often elicits gurgling sounds\\ncaused by intestinal coils distended with gas and fluid con-\\ntents. This phenomenon is most frequently observed in\\nboth iliac regions.\\nIn patients with thin abdominal walls peristaltic move-\\nments of the small intestines may be visible either sponta-\\nneously or after palpatory examination.\\nThe urine is voided in small quantities, is concentrated,\\nand often shows Kosenbach s reaction (Burgundy red color\\nafter boiling with nitric acid), and also contains indican\\n(this especially if the process involves the small intestine).", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0108.jp2"}, "109": {"fulltext": "ACUTE INTESTINAL CATARRH. 89\\nCasts and small amounts of albumin are sometimes found\\nin the urine, especially in severer cases (Fischl 1\\nFever. In the greater number of instances there is no\\nrise of temperature during the course of this affection. In\\nsome cases, however, fever is quite a prominent symptom,\\nand the disease may commence with violent chills and a\\nmarked elevation of temperature (104\u00c2\u00b0). The temperature\\nmay either fall suddenly on the next day or after the lapse\\nof a few days, but it does not show that regular steady rise\\nwhich is characteristic of typhoid fever. Fever is espe-\\ncially met with in those cases of acute enteritis which are\\ncaused most probably by infection (either pathogenic micro-\\norganisms or tainted food)\\nLocalization- of the Catarrhal Process. In order to find\\nout what part of the bowels is especially affected the fol-\\nlowing points are of value\\nA duodenitis may be recognized if the above symptoms\\nare accompanied by icterus. Intestinal catarrh attended\\nwith a constant painful sensation in the right epigastric\\nregion, which, besides, is also tender to pressure, indicates\\nmore or less a continuation of the catarrhal process from\\nthe stomach to the duodenum. Pains appearing in the\\nsame region after extensive burns of the skin also point to\\na duodenal affection, even if there be no icterus.\\nJejunitis alone or jejuni tis and ileitis without any affec-\\ntion of the large bowel can be diagnosed only with diffi-\\nculty, for the principal symptom of enteritis (namely, that of\\ndiarrhoea) is as a rule absent. Small amounts of mucus well\\nmixed with fecal matter, a considerable quantity of undi-\\ngested food particles, and epithelial cells tinged with yellow\\nbile pigment in the fseces, point to a catarrhal condition\\nof the small intestine. Indicanuria is also often present,\\nfischl: Prager Vierteljahresschr., 1878, Bd. 139, p. 27.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0109.jp2"}, "110": {"fulltext": "90 DISEASES OF THE INTESTINES.\\nAcute colitis is characterized by painful sensations and\\na greater tenderness on pressure over the entire colon.\\nThe stools are diarrhceal and contain large quantities of\\nmucus. The latter as well as the fecal matter may contain\\nundecomposed biliary pigment. Sigmoiditis, described by\\nMayor 1 and later by Boas 2 and Mathews, 3 means an in-\\nflammatory process involving the sigmoid flexure, and is\\nrecognized by special tenderness on palpation of this por-\\ntion of the bowel, intense backache, and a frequent dis-\\nposition to go to stool.\\nProctitis, or inflammation of the rectum, is characterized\\nby severe tenesmus and colicky pains in the left iliac fossa.\\nThe patients have a constant desire to go to the closet, but\\nat each time void only small quantities of fecal matter\\nunder the greatest pains. The scybala are surrounded by\\na layer of mucus which may be tinged with blood. Occa-\\nsionally the mucous membrane of the rectum prolapses\\nduring defecation. It then appears intensely dark red and\\nis extremely painful to the touch. Even if not prolapsed,\\na digital rectal examination is attended with much pain.\\nThe mucous membrane of the rectum feels hot and the ex-\\namining finger on removal sometimes shows traces of blood.\\nDuration. The duration of acute enteritis varies consid-\\nerably. Mild cases improve in about two to five days,\\nwhile those of a severer type may last about two weeks.\\nAfter recovery from acute enteritis the intestinal tract\\nremains quite sensitive for a long time. If no attention is\\npaid to this condition and gross errors of diet are com-\\nmitted, relapses are liable to occur. Several relapses may\\n1 A. Mayor Revue med. de la Suisse Romande, 1893, No. 4.\\n2 J. Boas Krankheiten des Darms, ii., p. 513.\\n3 Mathews Disease in the Sigmoid Flexure. The American Med-\\nical Quarterly, June, 1899.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0110.jp2"}, "111": {"fulltext": "ACUTE INTESTINAL CATARRH.. 91\\nalso follow each other and ultimately cause a chronic en-\\nteritis.\\nDiagnosis. As a rule the recognition of acute enteritis\\nis very easy. The characteristic diarrhoea, the admixture\\nof mucus in the dejecta, the fact that a dietetic error has\\nbeen committed, or that the abdomen (or other parts of the\\nbody) has been exposed to cold, will all indicate the nature\\nof the affection. The localization of the process, whether\\naffecting more or less the entire intestinal tract or only\\ncertain parts, is more difficult, and the important points of\\ndifferentiation have already been given above. Frequent\\nvomiting and very pronounced general symptoms (espe-\\ncially collapse) point to cholera nostras, which is the most\\nsevere form of acute enteritis. If the diarrhoea is accom-\\npanied by high fever, urinary casts, and pains in the mus-\\ncles and joints, then the assumption of an acute enteritis\\nof an infectious type is justified.\\nPrognosis. The prognosis of acute enteritis is, as a rule,\\ngood, the disease tending to recovery in a very short time.\\nIn children, however, and very old and weakened persons,\\nthe course of the disease is sometimes not so favorable and\\nmay lead to collapse and even to death.\\nTreatment. In mild cases of acute enteritis no medicinal\\ntreatment will be necessary. Abstinence from food for one\\nor two days, allowing the patient to take only weak tea, a\\nsmall quantity of bouillpn, and some boiled water may suf-\\nfice to check the attack. Sometimes, however, especially\\nif the attack of enteritis has been caused by dietetic errors,\\nand fulness of the abdomen and frequent colicky pains in-\\ndicating that irritating substances are lodged within the\\nintestines are present, a good old-fashioned drastic is in\\nplace. Thus castor oil about one ounce may be given\\nor calomel 0.6 (gr. x.), the latter being preferable in cases", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0111.jp2"}, "112": {"fulltext": "92 DISEASES OF THE INTESTINES.\\nof a probably. infectious nature. If there is no fever and the\\nsymptoms are mild, then the patients may be up and about,\\nalthough it is always advisable for them to keep quiet more\\nor less. In cases of a severer type, and especially those with\\nfever, the patients should stay in bed until the symptoms\\nare entirely subdued. If the diarrhoea shows no signs of\\nabating after a day or two, or if the symptoms occur so\\nfrequently as to be debilitating, then an opiate is in place.\\nTincture of opium, seven drops every three hours, or co-\\ndeine, 0.02 or 0.03 (gr. -J\u00e2\u0080\u0094 J) also every three hours, may\\nbe given. Frequently the combination of an opiate with\\nsubnitrate of bismuth and chalk or with tannigen may be\\nuseful. Thus I often prescribe the following powders\\n1$ Bism. subnitr 6.0 (3 iss.\\nCret. pulv 3.0 (gr. xlv.)\\nCod. phosph 0.1 (gr. iss.\\nElasosacch. menth. pip 5.0 (gr. lxxv.\\nMisce f. pulv. Div. in p. seq. No. x. S. One powder three or\\nfour times a day.\\nOr-\\n1$ Morph. muriat 0. 1 (gr. iss.\\nTannigen,\\nElasosacch. menth. pip aa 5.0 (gr. lxxv.)\\nMisce f. p. Div. in p. seq. No. x. S. One powder three times\\ndaily.\\nCalumba, cascarilla, catechu, kino, may also be employed,\\ntwenty to thirty drops of the tinctures being given about\\nthree times daily. Another useful remedy is dermatol,\\nwhich may be administered in doses of 0.5 gm. (gr. viii.)\\nthree times daily. In cases in which the entire colon\\nor its lower part is affected, irrigation of the bowels with\\nastringent solutions is of great benefit. This may be done\\nwith a solution containing nitrate of silver, 0.3 (gr. v.)", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0112.jp2"}, "113": {"fulltext": "ACUTE INTESTINAL CATARRH. 93\\nto 1,000 (one quart) water, or tannic acid, 2 to 5 gm.\\n(30 to 80 grains) to 1,000 water, or liquor ferri sesqui-\\nchlor. 2 1,000. It is best to inject these solutions after\\na previous washing out of the bowel with plain water or\\nsoon after a movement. The astringent solution should\\nbe allowed to remain for about five to ten minutes, but in\\ncase the patient is not able to retain it for even so short a\\ntime, fifteen to twenty drops of tincture of opium may be\\nadded to the injection. This, as a rule, lessens the irrita-\\ntion of the rectum and the patient is thus able to hold the\\nenema longer. The temperature of the water should be\\ntepid. All the above-mentioned astringent remedies have\\nalso slight antiseptic qualities. In cases, however, in\\nwhich the fermentative processes within the bowels are\\nespecially pronounced, the following stronger antifermen-\\ntative substances may be used for irrigation salicylic acid,\\n2 1,000 water, or salicylate of sodium, 10.0 (3 iiss.)\\n1,000; boracic acid, 5.0 1,000; creolin, 1.0 (gr. xv.)\\n1,000.\\nIf pains, are present a warm poultice or a hot-water bag\\nover the abdomen is veiw beneficial.\\nCold drinks should be forbidden. Warm teas, fennel or\\ncamomile, are useful; on the second or third day the pa-\\ntient can be nourished with soups or gruels (barley, rice,\\noatmeal soup cooked with or without milk) water soup\\n(stale bread softened in hot water with the addition of a\\nlittle butter and salt) and hot spiced claret are then in\\nplace. A little later toasted bread, crackers, soft-boiled\\neggs may be added to the diet still later, scraped meat,\\nlamb chops, tenderloin steak, bread and butter. As soon\\nas the diarrhoea has entirely stopped we may allow mashed\\nor baked potatoes in addition to the other articles. For\\nquite a while after an attack of enteritis the patient has to", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0113.jp2"}, "114": {"fulltext": "94 DISEASES OF THE INTESTINES.\\nbe careful with vegetables and especially fruits. The first\\nhe may begin to take in small portions soon after an at-\\ntack, while the latter should be avoided for a somewhat\\nlonger time.\\nIn secondary enteritis the principal primary affection\\nmust be considered first. Thus enteritis accompanying\\nmalaria will be best remedied by quinine. Enteritis ac-\\ncompanying affections of the lung, heart, or liver must be\\ntreated after due attention has been given to the primary\\naffection.\\nCHRONIC INTESTINAL CATARRH.\\nSynonyms. Enteritis chronica; Chronic catarrh of the\\nbowels.\\nDefinition.\u00e2\u0080\u0094 An affection characterized by a chronic\\ninflammation of the intestinal mucosa, giving rise to vari-\\nous disturbances in the function of the bowels.\\nEtiology. Chronic intestinal catarrh may arise either\\nfrom a severe acute enteritis which shows no tendency to a\\ncure, or (most often) from repeated attacks of acute enter-\\nitis following each other at short intervals before the bow-\\nels have had a chance to recover fully. This often occurs\\nin patients who do not pay sufficient attention to their\\napparently slight trouble and disregard the dietetic rules\\nprescribed by the physician. The direct factors causing\\nchronic enteritis are the same as those of the acute condi-\\ntion. Like acute enteritis, chronic intestinal catarrh may\\nbe divided into a primary and a secondary form, the pri-\\nmary being idiopathic, while the secondary appears in\\nconnection with affections predisposing to this condition.\\nThus diseases of the lungs, especially tuberculosis, affec-\\ntions of the heart, liver, and kidneys, and diabetes are often\\naccompanied by chronic intestinal catarrh. Intestinal", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0114.jp2"}, "115": {"fulltext": "CHRONIC INTESTINAL CATARRH. 95\\nparasites, round worms, tapeworms, etc., are quite often\\nthe cause of a secondary chronic enteritis, due to the irri-\\ntation of the intestinal mucosa which they evoke.\\nMorbid Anatomy. The anatomical changes in chronic\\nintestinal catarrh are similar to those of the acute condition\\nand are characterized by hyperemia, swelling, and in-\\ncreased secretion of the mucous membrane. However,\\ninstead of the bright red or intensely dark red color seen\\nin acute catarrh, the mucosa in the chronic form presents a\\ngrayish brown-red tint. The blood-vessels are greatly dis-\\ntended, and often curved into a serpentine shape. In cases\\nof long duration the intestinal mucosa frequently appears\\nof a slate color intermingled with black pigment (changed\\nred blood pigment which has escaped from the blood-ves-\\nsels). These black dots are often found accumulated at\\nthe tips of the villi and also in the immediate neighborhood\\nof the lymph follicles and of the glands of Lieberkuehn.\\nThe surface of the mucosa is as a rule covered with a\\nviscid and transparent mucus. The epithelial cells are\\ncloudy, in a condition of fatty degeneration, and partly\\ndesquamated. The interstitial tissue is infiltrated with\\ncellular elements. The glands themselves are of irregular\\nshape, sometimes elongated and tortuous, occasionally\\nmuch smaller than normally. In cases in which there is\\nan interstitial tissue proliferation, a constriction around\\nthe neck of a gland arises. As a consequence there is\\nretention of the glandular secretion, and ultimately a cyst\\nmay develop. Hyperplastic processes around the inflamed\\narea very often lead to the formation of polypi. The latter\\nas a rule consist of muscular and fibrous tissues and con-\\ntain no glands. Exceptionally polypoid excrescences may\\nappear on the intestinal mucosa (especially in the colon),\\nwhich consist of a real proliferation of the intestinal mu-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0115.jp2"}, "116": {"fulltext": "96 DISEASES OF THE INTESTINES.\\ncosa containing glands. An excellent instance of this rare\\noccurrence has been described by Woodward. 1\\nIn some of the most advanced cases, atrophy of the\\nmucosa may be present. As in the stomach, this process\\nmay arise from two entirely different conditions. In the\\none the process originates in the glandular tissue the lat-\\nter becoming inflamed, the seat of fatty degeneration, and\\nultimately atrophied. In the second group the process\\nleading to atrophy originates from an interstitial tissue\\nproliferation; the connective tissue becoming hypertro-\\nphied, compresses the glands, and, gaining the upper\\nhand, ultimately leads to their entire disappearance.\\nThese atrophic processes, as a rule, do not extend over\\nthe entire intestine, but more often involve certain parts.\\nThus, the csecum and its immediate neighborhood have\\noften been found in this state, even in persons who ap-\\nparently during life had no intestinal affection (Noth-\\nnagel). Large portions of the small and large intestines\\nor the entire intestinal tract are but rarely found atro-\\nphied, more often in children than in grown-up persons.\\nEwald 2 mentions that he has observed this rare condition\\nin six autopsies in adults. They all had suffered during\\nlife from pernicious anaemia and gastro-intestinal disturb-\\nances.\\nBoth the hyperplastic and atrophic processes, as a rule,\\nare not limited to the intestinal mucosa alone, but also in-\\nvolve the neighboring structures (the submucosa and the\\nmuscularis). Thus in the hyperplastic form the thickness\\nof the wall of the small intestine may be increased to six\\ntimes its normal size, while the large bowel may become\\n1 Woodward L. c.\\n2 C. A. Ewald: Diseases of the Intestines. Twentieth Century\\nPractice of Medicine, vol. ix. p, 127.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0116.jp2"}, "117": {"fulltext": "CHRONIC INTESTINAL CATARRH. 9i\\nthree times as thick as normally. In atrophy of the intes-\\ntine there is also a degeneration of the muscles. The gan-\\nglionic cells of the Meissner and Auerbach plexus have been\\nfound in a state of fatty degeneration, smaller and lessened\\nin number in the atrophic form Jiirgens and Sasaki 2\\nWhether these changes in the nervous tissue are the cause\\nor the result of this general intestinal atrophy is as yet not\\nknown.\\nSeveral varieties of ulcerative processes exist complicat-\\ning chronic intestinal catarrh. Some ulcerations arise in\\nconsequence of superficial erosions of the mucosa, which\\ndo not heal. The defect, once produced, gradually grows\\ndeeper. Several superficial ulcers adjacent to each other\\nmay grow larger and unite. Thus a considerable irregu-\\nlar ulceration develops. The ulcerative process increasing\\nin depth may lead to a secondary phlegmonous inflamma-\\ntion of the submucosa, and ultimately to perforation of the\\nintestinal walls. Another danger lies in the ulcerative\\nprocess involving a blood-vessel which may cause hemor-\\nrhage. If the perforation through the intestinal walls oc-\\ncurs rapidly, fatal peritonitis results but if the perforative\\nprocess develops slowly, then agglutination takes place\\nand a localized peritonitis with or without the formation\\nof a fecal abscess follows. These eventualities are, how-\\never, rare. Generally the ulcerations either remain un-\\nchanged (not progressing) for a long period of time or they\\ncicatrize. In the latter event strictures of the intestinal\\nlumen may occasionally develop.\\nFollicular enteritis is also occasionally the cause of the\\nformation of an ulcer. The lymph nodules swell up to pea\\nsize, soften, and burst. A small ulcer thus arises. As a\\nJiirgens: Berl. klin. Wochensch., 1892, p. 357.\\n2 Sasaki Virch. Arch., Bd. 96, p. 287.\\n7", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0117.jp2"}, "118": {"fulltext": "98 DISEASES OF THE INTESTINES.\\nrule, healing takes place, the mucosa of the immediate neigh-\\nborhood extending over and gradually overlapping the de-\\nfect. Sometimes, however, the ulcerative area is covered\\nwith a layer of mucus secreted by the goblet cells of the\\nneighboring glands. From time to time the accumulated\\nmucus is removed from the defect and appears in the dejecta\\nin form of particles resembling sago. Extensive ulcerations\\nare seldom met with in chronic enteritis. Most often they\\noccur in the enteritis accompanying pulmonary tubercu-\\nlosis.\\nSymptomatology. Chronic intestinal catarrh may occa-\\nsionally exist without giving rise to any subjective com-\\nplaints. As a rule, however, there is a feeling of discom-\\nfort and sometimes of slight pains in the abdomen. These\\nabnormal sensations may be especially marked some time\\nafter the ingestion of food or shortly before the evacua-\\ntions. In some cases, again, these annoying sensations\\nappear early in the morning, about an hour or two before\\nrising. Borborygmi often occur; occasionally there is a\\nfeeling of tension or of bloating in the abdomen, which\\nmay be relieved by the passing of flatus. The latter symp-\\ntom may be so constant and annoying that the patient is\\nafraid to appear in society or may be hindered in his voca-\\ntion. An accumulation of gases in the intestine, especially\\nin the colon, may sometimes exert pressure upon the dia-\\nphragm and give rise to asthmatic complaints, palpitations\\nof the heart and angina pectoris, congestion of the head\\nand vertigo. Belching or passing of wind alleviates these\\nsymptoms or entirely removes them.\\nColicky pains sometimes appear and are of short dura-\\ntion. Severe pains, however, are almost always ab-\\nsent.\\nIf the catarrh has lasted for some time, then symptoms", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0118.jp2"}, "119": {"fulltext": "CHRONIC INTESTINAL CATARRH. 99\\nrelating to the general state of health often appear. Thus\\nthe patient may feel weak, show a disinclination to work,\\nbe irritable and somewhat melancholic. Some patients\\ngreatly lose in flesh, and present an appearance of suffer-\\ning, have cold extremities and a slow pulse. Headaches,\\nnausea, and anorexia are also often met with.\\nWhether these symptoms are due to auto-intoxication as\\nsome, especially of the French writers, assume (Bouchard\\nis very difficult to state. It is, however, certain that this\\ntheory does not apply to all cases of this kind.\\nGastric symptoms (nausea, anorexia, etc.) are as a rule\\nmet with only in cases in which the small intestine is\\naffected. If the catarrh is limited to the large bowel these\\nsymptoms are usually absent.\\nObjective Symptoms. In some cases the abdomen is\\nbloated, especially shortly after meals, and somewhat ten-\\nder to pressure. There may be tenderness all along the\\ncolon; occasionally the ascending colon can be felt as a\\nsausage-like body containing hard masses, which change\\ntheir shape upon digital pressure, or this part of the colon\\nis filled with gas and liquids and a splashing sound can\\nthen be easily evoked. Similar phenomena may be ob-\\nserved also in the descending part of the colon (S Koma-\\nnum) in the left iliac fossa. Tenderness along the colon\\nupon pressure is often found; usually the pains are felt\\njust beneath the area where the pressure is exerted; some-\\ntimes, however, the pain appears in a more remote spot.\\nThus, for instance, upon pressing upon the ascending co-\\nlon in the right iliac fossa, pain is felt across the abdomen\\nin a line lying horizontally at two fingers width above\\nthe navel (transverse colon). Intestinal peristalsis may be\\nobserved in persons with thin abdominal walls, especially\\nBouchard Leconssur les Auto-intoxications, Paris, 1887.\\ntutro.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0119.jp2"}, "120": {"fulltext": "100 DISEASES OF THE INTESTINES.\\nafter a palpatory examination. All these signs, however,\\nare occasionally absent.\\nIn the symptomatology of the chronic intestinal catarrh\\nthe character and frequency of the stools are of greatest\\nimportance. While in, acute intestinal catarrh diarrhoea is\\nalmost a constant characteristic symptom, there is much\\nvariation in the frequency of the dejecta in the chronic\\nform. With regard to this point Nothnagel divides cases\\nof chronic intestinal catarrh into the four following groups\\n1. Cases characterized by pronounced constipation. An\\nevacuation appears only once in two, three, or four days\\nsometimes only with the aid of cathartics. The fecal mat-\\nter is usually hard. As a cause of the constipation, Noth-\\nnagel assumes a decreased activity of the automatic nervous\\napparatus of the intestines, this being the result of the ca-\\ntarrhal process.\\n2. Cases in which constipation and diarrhoea constantly\\nalternate. For two or three days there may be a daily\\nevacuation of very hard dejecta. On the following day\\nthere may be four to six very thin or mushy movements\\nmixed with mucus, accompanied by violent pains, and then\\nagain constipation for a day or two, etc. Or there may be\\nquite normal evacuations (once daily) for a few days in\\nsuccession and then again four to seven diarrhoeal move-\\nments in one day, and after this constipation. The prin-\\ncipal feature of these cases is the constipation, but the\\nexcitability of the nervous apparatus being quite good,\\nthe decomposed stagnant contents often cause increased\\nperistalsis and diarrhoea. Sometimes these alternating\\nperiods of constipation and diarrhoea continue for a long\\ntime. Thus the patient may be constipated for four or\\nfive weeks, or even for a few months, and then again the\\ndiarrhoea may set in, lasting several weeks or months.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0120.jp2"}, "121": {"fulltext": "CHRONIC INTESTINAL CATARRH. 101\\n3. In a very limited number of cases there is a daily\\nevacuation, which is usually not formed and mushy.\\n4. Cases in which there are for months several diarrhceal\\nevacuations daily. The dejecta as a rule show the biliary\\nreaction, or they may contain yellow fragments of mucus,\\nyellow tinged epithelia, and round cells. In these cases\\nthe catarrhal process affects not only the large bowel but\\nalso the small intestine. The absorption suffers and there\\nare more abnormal products in the contents (acids), which\\ngive rise to increased peristalsis in the small as well as\\nlarge bowel.\\nBesides these typical cases there are some in which the\\nnervous element plays a part in combination with the ca-\\ntarrhal process. Thus there are patients who are molested\\nwith diarrhceal movements only during the night or in the\\nearly morning hours (morning diarrhoea of Delafield 1\\nwhile they feel well during the remainder of the day.\\nThe quality of the dejecta in those cases in which there\\nis constipation is almost normal, with the only exception\\nthat there is an admixture of mucus. Nothnagel considers\\nthis point the most important in the recognition of a\\ncatarrhal condition of the intestine. The mucus may be\\nabsent in rare instances in which the scybala are small and\\nthe layer of mucus within the intestine is very tough and\\nadherent, so that the fecal matter cannot carry it along in\\nits passage.\\nThe quantity of mucus varies greatly. While in most\\ncases only small particles of mucus are found, there are\\nsome in which a considerable amount may be passed.\\nLarge amounts of mucus without fecal matter are often\\nfound in enteritis membranacea, less frequently in chronic\\nenteritis.\\n1 F. Delafield Medical Record, May 11th, 1895.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0121.jp2"}, "122": {"fulltext": "102 DISEASES OF THE INTESTINES.\\nIn cases in which the dejecta are more or less thin,\\nmushy or watery, the fecal matter has a light color, brown-\\nish-yellow or grayish-yellow, and may at times be very\\npoor in biliary matters. In these instances, undigested\\nfood particles are easily found. Thus small particles of\\nmeat or starchy food may be discovered.\\nThe microscopical examination of the dejecta is often\\nvery useful, for even in cases in which macroscopically\\nnothing abnormal can be discovered, the microscope may\\nreveal considerable amounts of undigested meat fibres,\\nstarch granules, and fat globules. Such substances, if fre-\\nquently present, indicate that the catarrhal affection is\\nprincipally within the small intestine. The microscope\\nhere further shows the presence of epithelial cells, some-\\ntimes of a yellow color and mostly in a shrivelled condi-\\ntion and embedded in mucus.\\nAccording to Rosenheim, l chemical examinations of the\\ndejecta have no practical value in this affection. The reac-\\ntion with regard to litmus varies greatly and is dependent\\nupon the frequency of the stools and the quality of the in-\\ngested food. As a rule, however, an alkaline reaction is\\nfound.\\nThe degree of fermentative processes in the intestines\\nmay be gauged by the intensity of the feeling of tension in\\nthe abdomen, the frequency of flatus, and the condition of\\nthe dejecta. The latter may present a very fetid odor and\\na foamy surface. If the movements are diarrhoeal, a fer-\\nmentation tube may be filled with the liquid contents and\\nkept at blood temperature for a few hours the amount of\\ngas developed in the tube will indicate the degree of fer-\\nmentation. The character of the urine is also of impor-\\n1 Theodor Rosenheim Pathologie und Therapie der Krankheiten\\ndes Darms, Wien und Leipzig, 1893", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0122.jp2"}, "123": {"fulltext": "CHRONIC INTESTINAL CATARRH. 103\\ntance with regard to this point. In conditions in which\\nthere is considerable fermentation and absorption of de-\\ncomposed products within the small intestine, it usually\\ngives a more or less strong indican reaction and also a\\ndecided Rosenbach reaction (Burgundy red color after\\nboiling and the addition of nitric acid).\\nChronic enteritis complicated with catarrhal ulcers mani-\\nfests itself by more frequent attacks of diarrhoea, admix-\\nture of blood or pus in the dejecta, and pain. All these\\nsymptoms are especially apt to be present if the lower\\npart of the intestinal tract is affected if the ulcer is in the\\nsmall intestine, diarrhoea is often absent, nor need there\\nbe any signs of blood or pus in the dejecta.\\nAtrophic processes may also accompany the enteritis.\\nIf these involve only a small part of the intestinal tract, no\\nsymptoms whatever may result; if, however, larger parts\\nof the small intestine are affected, the absorption of food\\nis greatly impaired and then severe symptoms occur.\\nDiarrhoea without passage of mucus and accompanied by\\na gradual but steady loss in weight is present, as are oc-\\ncasional symptoms of pernicious amemia. This condition\\nis found much oftcner in infancy than in later life.\\nCoarse. As a rule chronic enteritis is a very tedious\\naffection. It may last many years, even until the end of\\nlife. The intensity of the symptoms varies a great deal,\\nand there may be periods of apparent perfect euphoria.\\nThere always remains, however, a decided weakness of the\\nintestine, which is easily upset by slight errors in diet,\\nwhich in healthy persons would be harmless.\\nDiagnosis.\u00e2\u0080\u0094 The diagnosis of chronic enteritis is made\\nif there are abnormal sensations within the abdomen, ac-\\ncompanied by irregularity of the bowels and the presence\\nof mucus in the stools. Habitual constipation can be ea-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0123.jp2"}, "124": {"fulltext": "104 DISEASES OF THE INTESTINES.\\nsily differentiated from enteritis (1) by the absence of mu-\\ncus (2) by the fact that it does not so easily nor so com-\\npletely respond to mild cathartics. Malignant growths\\nare often accompanied by enteritis, and thus the symp-\\ntoms of the latter often give rise to mistakes. A longer\\nperiod of observation, however, will aid in arriving at a\\ncorrect diagnosis. In case of a neoplasm symptoms of\\ncachexia will not fail to appear nor will the accompanying\\nenteritis be so readily alleviated as if it were the only\\naffection. In ulcer of the intestine pains predominate and\\nare a marked feature. Constipation and diarrhoea depend-\\nent upon disease of the stomach will be recognized (1) by\\nthe absence of mucus in the stools and (2) by an examina-\\ntion of the gastric contents. They will readily yield to\\ntreatment directed toward the gastric disorder.\\nWith regard to the localization of the process, the fol-\\nlowing is of importance: Chronic inflammation confined\\nto the small intestine is usually accompanied by gastric\\nS} r mptoms, constipation, and the presence of small parti-\\ncles of mucus in the stools, having a yellow tinge and being\\nwell mixed with the dejecta. If the large bowel alone is\\ninvolved (colitis), there is constipation with the presence of\\nmore or less mucus of a grayish color, either covering the\\nentire fecal mass or appearing here and there on its sur-\\nface. Occasionally, especially if the lower part of the\\nbowel is affected, the mucus appears at the end of the de-\\nfecation and is then voided without any admixture of fecal\\nmatter. If the inflammatory process involves both the\\nsmall and the large intestines, constant diarrhoea is a pre-\\ndominant feature. The mucus found in the dejecta has a\\nyellowish color; besides considerable quantities of undi-\\ngested food are discovered in the fecal matter.\\nPrognosis. The prognosis of chronic enteritis depends", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0124.jp2"}, "125": {"fulltext": "CHRONIC INTESTINAL CATARRH. 105\\nupon the intensity of the symptoms, the duration of the\\ndisease, and also greatly upon the age and the constitution\\nof the patient. In infancy and in old age chronic catarrh\\nof the intestines must be considered a grave affection.\\nThe same applies to persons with a weakened constitution\\n(tuberculosis, cardiac or other important lesions). A\\nchronic enteritis of intense type which has lasted a long\\nperiod of time is hardly ever cured perfectly. There may\\nbe improvements in the condition of the patient, but re-\\nlapses are sure to follow soon. Cases of a mild nature, how-\\never, often end in recovery, especially under an appropriate\\ntreatment. In old age a complete cure rarely takes place.\\nIf atrophy of the intestines has developed, then the condi-\\ntion is very unfavorable, the patient succumbing after a\\nperiod of about twelve to eighteen months.\\nTreatment. As in the treatment of chronic gastric ca-\\ntarrh, and perhaps in a still greater degree, hygienic and\\ndietetic measures here play the chief part. It will be at\\nfirst important to regulate the mode of living of the patient\\nnot too much work, not too great business strain, plenty\\nof outdoor life and exercise, regularity of meals. Expo-\\nsure to cold should be carefully avoided. The patient\\nshould dress warmly, especially the abdomen and feet (flan-\\nnel bandage around the abdomen), and should be particu-\\nlarly careful not to get his feet wet. In rainy weather shoes\\nwith thick soles or rubbers should be worn. With regard to\\ndiet the following rules are of value: the meals should be\\ntaken frequentlj- and in small portions. Indigestible sub-\\nstances should be avoided. Sufficient nourishment should\\nbe given, and care taken that there is an increase rather\\nthan a decrease in weight. In cases of diarrhoea the fol-\\nlowing should be forbidden acid or sweet wines, all mine-\\nral waters charged with carbonic-acid gas, lemonade, all", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0125.jp2"}, "126": {"fulltext": "106 DISEASES OF THE INTESTINES.\\nkinds of fruits, salads, all kinds of cabbage including cauli-\\nflower, rye bread, and pastries. Give eggs (soft-boiled\\nor scrambled), light meats, especially sweetbread, calf s\\nbrain, spring chicken, steak, lamb chops, oysters, lean fish,\\nwhite bread well baked or toasted, fresh butter, cream\\nsoups, bouillon, rice, sago, macaroni, mashed or baked\\npotatoes, milk, cacao, tea. Kumyss, matzoon, ginger ale,\\ngood claret or Tokay may also be allowed. As a rule noth-\\ning should be taken in large portions, and the drinks should\\nbe warm or cool (temperature of the room), but not cold.\\nLarge amounts of liquids should be avoided. Patient with\\nvery severe symptoms (frequent diarrhoea, intense pains,\\ngreat weakness) must be kept abed for a short time and\\nput on a rigorous diet at first, as in cases of acute ente-\\nritis. Upon improvement of the condition the dietetic\\nrules described above should be followed.\\nIn cases attended with constipation the diet may be more\\nliberal. Besides all the articles of food mentioned in the\\ndiarrhceal group, light fruits, as oranges, grapes, ripe\\npears, and green vegetables, green peas, cauliflower may\\nbe added. The ingestion of large amounts of starchy\\nfoods, easily assimilated fats, butter, cream, and of fluids\\nis very beneficial. The more indigestible articles of food,\\nlike bran breads (pumpernickel) sausages, lobster salad,\\nmayonnaise dressings, cabbage, cucumbers, etc., should\\nbe avoided. Beer, ale, Rhine wine taken moderately are\\npermissible.\\nHydr other apeutic Measures. In cases of diarrhoea warm\\nmineral baths or baths with the addition of pine needle\\nextract and mud and bran baths are favorable. Cold baths\\nshould be avoided. A cold sponge bath, however, or a\\ncold shower on the back may be serviceable in chronic en-\\nteritis with nervous symptoms. A Priessnitz (wet pack)", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0126.jp2"}, "127": {"fulltext": "CHRONIC INTESTINAL CATARRH. 107\\nover the abdomen may be advantageously used over night.\\nCold sitz baths and cold showers over the abdomen are\\nalso often beneficial.\\nMineral Waters. According to Nothnagel chronic enteri-\\ntis is sometimes greatly improved, and even perfectly cured,\\nby a methodical course of drinking certain mineral waters.\\nSuch a cure can best be carried out at the mineral springs\\nthemselves. For here the patients not only take the waters\\nin the right way, but also observe the necessary rules of\\ndiet and are besides kept free from their business cares.\\nCarlsbad is to be regarded as the best place in cases of\\nchronic enteritis in which the diarrhoea is a prominent fea-\\nture; Vichy comes next. For cases of chronic enteritis\\nwith constipation Marienbad seems to be very useful; the\\nsame applies to Saratoga (Hawthorn and Congress\\nSprings). For cases in which neither constipation nor\\ndiarrhoea plays a prominent part Kissingen or Homburg\\nmay be recommended. Chronic enteritis accompanied by\\nanaemia may be benefited at the watering-places of Fran-\\nzensbad and Elster. The Carlsbad water should be taken\\nin small quantities, about a wineglassful twice daily in\\nsome cases even smaller amounts (25 to 50 gm.) three\\nto five times daily. In cases which have been benefited\\nby a drinking cure in Carlsbad, Nothnagel suggests having\\nthese patients use at home the Carlsbad waters in a similar\\nmanner as at this resort, four times a year for an entire\\nmonth. Nothnagel says The chronic condition requires\\na chronic treatment.\\nMedicaments. Strong cathartics should be avoided in\\nthe treatment of the constipation. Here some articles of\\ndiet which moderately increase the intestinal peristalsis\\nmay be first tried buttermilk, a glass of cold water,\\nstewed fruits, and the like. If these fail, small amounts", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0127.jp2"}, "128": {"fulltext": "108 DISEASES OF THE INTESTINES.\\nof rhubarb, fluid extract of cascara sagrada, podophyllin\\nmay be used. Of greater value, however, are rectal injec-\\ntions either of plain water or with the addition of some\\nsoap or salt (a teaspoonful to a quart) or Carlsbad water.\\nEnemas of olive oil, as first recommended by Habershon\\nand later by Kussmaul and Fleiner, may also be advan-\\ntageously used. The oil enemas should, however, be\\ngiven in small quantities (half a pint to a pint) and be re-\\ntained over night in the bowels. The frequent use of calo-\\nmel, castor oil, and jalap should be forbidden.\\nThe diarrhoea is best treated either by large doses of\\nsubnitrate of bismuth or salicylate of bismuth (1 to 2 gm.,\\ngr. xv. -xxx.) three times daily, or some of the drugs con-\\ntaining tannic acid as their principal ingredient (calumba,\\ncascarilla, rhattania, catechu, kino, lig. campechianum,\\nfructus myrtili). Weber J recommends the following pre-\\nscription\\n1$ Extr. monesise,\\nExtr. calumbse aa 15.0 ss.)\\nExtr. gent, et pulv. liq q. s.\\nUt f. pil. cxx. S. Three times daily two to four pills.\\nI very frequently give fluid extract of condurango and\\nfluid extract of calumba of each twenty drops three times\\ndairy. Dermatol (subgallate of bismuth) seems to be\\nquite beneficial in cases in which the formation of gas is\\na predominant feature. It may be given in doses of half a\\ngram (gr. viii.) three times daily. For the same condition\\nsalicylate of bismuth, benzonaphthol, and creosote in small\\ndoses may be given. Tannigen and tanalbin may be used\\nin doses of 0.5 to 1 gm. (gr. viii.-xvi.) three times daily,\\nthe first being preferable. Both substances seem to less-\\nen fermentation, and by their astringent qualities exert a\\n1 L. Weber New-Yorker medicinische Monatsschrift, 1892.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0128.jp2"}, "129": {"fulltext": "CHRONIC INTESTINAL CATARRH. 109\\nbeneficial influence upon the healing-process. They may\\ntherefore be given continuously for a long period of time.\\nCases accompanied by pains will require an opiate (mor-\\nphine, or still better codeine), with or without the addition\\nof belladonna extract. In chronic proctitis suppositories\\nof opium and belladonna extract with cacao butter are indi-\\ncated. Small enemas of starch solution with an opiate are\\nalso useful here. It is of course to be understood that the\\nadministration of opiates will have to be limited to a short\\nperiod of time.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0129.jp2"}, "130": {"fulltext": "CHAPTER IV.\\nDYSENTEKY.\\nSynonyms. Enteritis crouposa et necrotica; Amoebic\\ndysentery.\\nDefinition. An infectious disease characterized by spe-\\ncific ulcerations of the large intestine, giving rise to fre-\\nquent bloody, mucous, or purulent dejections accompanied\\nby tenesmus and general symptoms.\\nEtiology. Dysentery occurs under three different condi-\\ntions (1) As a disease principally during the warm season\\nin temperate climates, appearing in local epidemics; (2)\\nendemic in hot climates (3) epidemic at certain times in\\nall latitudes, being quickly disseminated, and also sporadic.\\nWhile the endemic zone of dysentery is limited to places\\nlying south of the fortieth degree of latitude, epidemics of\\nthe disease have occurred in almost every part of the\\nglobe. Dysentery is one of the oldest diseases known. It\\nwas observed by Hippocrates and well described by Are-\\ntseus and Celsus. Aretseus already recognized the ulcera-\\ntion of the intestines in dysentery.\\nVarious causes have been adduced to explain the origin\\nof the disease, and meteorological influences have been held\\nresponsible for its prevalence in local epidemics. The\\nendemic dysentery of the tropics was generally ascribed to\\nthe combined action of heat and of the miasm of swamps.\\nSudden exposure to cold, eating of bad and spoiled food,\\nand the use of stagnant or marshy water were all believed", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0130.jp2"}, "131": {"fulltext": "DYSENTERY. 111\\nto be factors in producing dysentery. It is only within\\nrecent years that its infectious and also contagious char-\\nacter has been recognized. Sodre says A careful etio-\\nlogical study shows that dysentery in whatever latitude it\\nbe observed is always due to the action of the same exciting\\ncause, that it starts and is propagated always under the\\ninfluence of infection and contagion, and that it should be\\nincluded in the group of parasitic diseases. The exciting\\ncause of dysentery often lies in the soil, in circumscribed\\nfoci of infection. These foci are represented by marshes\\nand bogs which receive the drainage from dung heaps and\\ncesspools, or by a soil impregnated with human dejec-\\ntions. The contagious character of dysentery is best shown\\nby the following report of Dr. Beauchef. This writer\\nstates that the French ship Loreit, anchored on the west\\ncoast of Africa, was in the best possible sanitary condition,\\nnot one of the crew being ill. She was then ordered to\\ntransport to Gorea the sailors of the sloop of war Eagle,\\namong whom were twenty-nine dysenteric patients. A few\\ndays afterward, while on the high sea, dysentery spread\\namong the crew of the Loreit and ceased only after all the\\npatients had been landed at Gorea.\\nAmong the causes which contribute to diffuse the dysen-\\nteric contagion and to produce the disease in an epidemic\\nform the following may be mentioned Crowding together\\nof individuals, the vicissitudes of war, bodily privation,\\nchiefly hunger. These factors are frequently found asso-\\nciated in times of war when epidemics of dysentery have\\noften appeared, causing great ravages.\\nSince bacteria have been found to play an important\\n1 A. Sodre: Dysentery, Twentieth Century Practice of Medicine,\\nvol. xvi., p. 241.\\n1 Beauchef Cited after Sodre, loc. cit.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0131.jp2"}, "132": {"fulltext": "112 DISEASES OF THE INTESTINES.\\npart in the etiology of infectious diseases, many investi-\\ngators have tried to discover the particular micro-organism\\nproducing dysentery. Various bacilli and cocci have been\\ndescribed and held responsible as etiological factors, but\\ntheir relative significance has not been determined. As\\nearly as 1859, however, Lambl called attention to the pres-\\nence of amoebae in the intestinal contents. He found them\\nin the stools of a child suffering from dysentery. Loesch, 2\\nin 1875, observed amoebae in the dejecta of a patient suffer-\\ning from chronic dysentery. He was the first to attribute\\nthe disease to this micro-organism. He also succeeded\\nin experimentally producing a dysentery -like disease in\\na dog to which he had administered rectal injections of\\nfecal matter containing amoebae. The observations of\\nLoesch have been confirmed by Koch, 3 who, while investi-\\ngating dysentery in Egypt, found in post-mortem examina-\\ntions numerous amoebae in the intestine at the base of the\\nulcers. The next important contribution on this subject\\nwas made by Kartulis, 4 who, while practising in Alex-\\nandria, had an opportunity to observe several hundreds of\\ncases of dysentery. In more than Hye hundred post-mor-\\ntem examinations he found the amoebae constantly in the\\nfaeces and on the surface of the ulcers, and in the abscesses\\nof the intestine as well as of the liver. In other affections\\nof the intestines Kartulis failed to detect the amoebae para-\\nsites. He also succeeded in cultivating them in infusions\\nof sterilized dry straw, and twice produced dysentery in\\n1 Lambl Beobachtungen und Studien aus dem Franz- Josef -Kinder\\nSpital, 1860.\\n2 Loesch Massenhafte Entwickelung von Amoeben im Dickdarm.\\nVirch. Arch., Bd. Ixv.\\n3 Koch Cited after Sodre, loc. cit.\\n4 Kartulis Zur Aetiologie der Dysenterie in Aegypten. Virch.\\nArch., Bd. 105, 1885.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0132.jp2"}, "133": {"fulltext": "DYSENTERY. 113\\ncats by inoculation with these cultures. Kartulis, there-\\nfore, declared the amoebae to be the true etiological factor of\\ndysentery.\\nYery soon afterward observations of a similar character\\nwere made both abroad and here. Thus Quincke and\\nKoos, 1 Hlava, 2 Massaiutin, 3 Nasse, 4 and others abroad, and\\nOsier, 5 Stengel, 6 Musser, 7 Eichberg, 8 Stockton, 9 Council-\\nman and Lafleur, 20 and Harris of this country have also\\ndescribed cases of dysentery with the presence of the\\namoebae parasites.\\nThe theory of the amoebic origin of dysentery has been dis-\\nputed by some writers, for they have found this micro-or-\\nganism in the faeces in other intestinal disorders and, in\\nsome instances, even in the stools of healthy persons. Thus\\nSchuberg 12 says The abundance of amoebae in dysentery\\nis the effect and not the cause of the disease, the ulcerative\\nlesions affording this habitual denizen of the intestines\\nmore favorable conditions for its development. The con-\\nsensus of opinion, however, is that while harmless amoebae\\nmay occur in the intestinal tract, there exists a pathogenic\\nvariety of this organism which is specific for dysentery.\\nFor this reason Councilman and Lafleur proposed the name\\n1 Quincke und Roos Berl. klin. Wochenschr. 1893.\\n2 Hlava Centralbl. fur Bacteriologie, 1887.\\n3 Massaiutin Ibid.\\n4 Nasse Deutsche med. Wochenschr., 1891.\\n5 Osier Bulletin of the Johns Hopkins Hospital, 1890.\\n6 Stengel Medical News, November 15th, 1890.\\n7 Musser University Med. Magazine, December, 1890.\\n8 Eichberg Medical News, August 22d, 1891.\\n9 Stockton International Clinics, 1894, i.\\n10 W. J. Councilman and H. A. Lafleur Amoebic Dysentery. Johns\\nHopkins Hospital Reports, vol. ii., Nos. 7-9, 1891, p. 395.\\n11 K. F, Harris: Amoebic Dysentery. American Journal of the\\nMedical Sciences, 1898, p. 384.\\n12 Schuberg Centralbl. fur Bakteriologie, 1893.\\n8", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0133.jp2"}, "134": {"fulltext": "114 DISEASES OF THE INTESTINES.\\nof amoebae dysenteriae for this special variety. The pres-\\nence of the amoebae in the contents of abscesses of the liver,\\nwhich are so often met with in dysentery according to\\nSodre, constitutes a powerful argument in favor of the\\namoebic etiology of the disease.\\nIt is generally believed that the amoebae enter the system\\nalong with the food or drink. Sodre believes that they can\\nbe taken in with the air. Certain waters, however, ap-\\nparently constitute the principal means of propagation of\\nthese amoebae. Thus, Barthelemy l relates that the troops\\nwhen operating on the shore of the Oueme, whose clear run-\\nning water was filtered in Chamberland filters before being\\nused, were in good health and free from dysentery when,\\nhowever, the army moved away from the Oueme in the\\ndirection of Abomey they were compelled to use unfiltered\\nswampy water. From that moment dysentery made its\\nappearance. Fitz and Gerry 2 described a case of dysen-\\ntery with the presence of amoebae in the stools and found\\nthe same micro-organisms in a cistern, the water of which\\nthe patients constantly used.\\nAge does not seem to have any influence upon the disease.\\nStatistically a greater number of cases is found among\\nadults, as these are more exposed to the morbific causes.\\nBoth sexes are equally predisposed to dysentery, and no\\nrace enjoys immunity from it. One attack does not confer\\nimmunity against others. Persons who suffer from want\\nof food or who live on food of bad quality are most liable\\nto contract the disease. Harris says: Dysentery is a\\ndisease pre-eminently of the poor, and is almost always\\nassociated with filth, bad hygienic surroundings, and lack\\nof proper food. This statement, however, is somewhat\\n1 Barthelemy Medical Report of the War of Dahomey.\\n2 Fitz and Gerry Cited after Sodre, loc. cit.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0134.jp2"}, "135": {"fulltext": "DYSENTERY. 115\\ntoo categorical, and I fully agree with Sodre, who remarks\\nthat dysentery is observed also in persons of the wealthier\\nclass, who live on the best food and are surrounded with\\nevery comfort. Nevertheless, it must be admitted that it\\nis most frequent among the poor, and chiefly among people\\nwho live under bad hygienic conditions.\\nMorbid Anatomy. In acute dysentery the large intestine\\nis almost always found in a thickened condition. This\\nthickening involves all the intestinal coats, but is most\\nmarked in the submucosa. Sometimes the latter layer\\nalone is involved. The mucosa, when washed with water,\\npresents a bright red, at some places dark red color. The\\nfolds of the mucosa are much more voluminous than nor-\\nmally, and thus present considerable prominences. Small\\nred nodules of various size are also seen scattered over the\\nmucous membrane. Besides these nodules more or less\\nnumerous ulcers are found. These vary greatly in size\\n(from a pinhead to two inches long) and also in depth,\\nsome being superficial, others quite deep. The ulcers are\\nsituated chiefly on the folds of the mucosa. Ordinarily\\nthey are oblong and lie transversely to the long axis of\\nthe bowel. Sometimes they are circular, sinuous, or ir-\\nregular.\\nCouncilman and Lafleur have described on the surface of\\nthe mucosa sharply outlined projecting nodular thicken-\\nings, in which are observed cavities filled with a gelatinous\\nmass communicating with the surface of the mucous mem-\\nbrane by small openings, frequently not larger than the\\nhead of a pin. These writers have also pointed out as\\ncharacteristic of the dysenteric ulcers their undermined\\nedges. The disease process in dysentery, according to\\nCouncilman and Lafleur, is essentially one of advancing\\ninfiltration and softening of the submucous and intermus-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0135.jp2"}, "136": {"fulltext": "116 DISEASES OF THE INTESTINES.\\ncular tissue with subsequent necrosis of the overlying\\ntissue. The amoebae reach the submucosa without injur-\\ning the mucous membrane. Here the essential changes\\nare first produced, and the mucous membrane is interfered\\nwith later. The mucosa becomes cedematous and ruptures\\nafter a while, forming an ulcer.\\nHarris described two anatomical forms of ulcers found in\\ndysentery. In the first form, which is encountered most\\nfrequently and can be considered as the typical intestinal\\nlesion of the disease, changes in the submucosa iAay be\\ntraced in advance of the surface ulceration for quite a dis-\\ntance, thus undermining the comparatively healthy mucosa\\nabove. In the second form the ulcers increase in size by\\ngradual softening and breaking down at the surface, never\\nby necrosis and sloughing of the underlying tissue.\\nUlcers of the second category occasionally do not penetrate\\ndeeper than half-way through the mucosa. Generally they\\nextend into the submucosa. They never contain amoebae.\\nThe lesions described are usually found throughout the\\nentire large bowel, but as a rule they do not extend beyond\\nthe ileocaecal valve. In a comparatively small number of\\ncases the small intestine is also involved, principally the\\nileum.\\nIn some instances gangrene of the intestine is found.\\nMany authors even describe a gangrenous form of dysen-\\ntery. Sodre, however, does not regard the gangrene as a\\nlesion brought on by the amoebae dysenteriae, but by the\\naction of bacteria foreign to the dysenteric process. Ac-\\ncording to this author gangrene is a complication of dysen-\\ntery, but not a specific lesion. In this complicated form,\\nbesides the ulcers described above, there exist others of a\\ngangrenous character. The gangrenous process may also\\nextend beyond the ulcers. On the brownish-red mucosa", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0136.jp2"}, "137": {"fulltext": "DYSENTERY. 117\\ngangrenous patches of a dark color and of various size are\\nseen. In this condition the mucosa may be detached over\\na considerable area and eliminated with the dejections.\\nIn chronic dysentery the intestine is pale with slate col-\\nored spots. Its walls are thickened. The mucosa presents\\na pale rosy or slate color. Ulcers in different stages of\\ndevelopment are encountered. Often the ulcers occur in\\ngroups separated from each other by more or less extensive\\nhealthy areas of intestine. Sometimes in certain portions\\nof the intestines the ulcers become confluent. Dysenteric\\nulcers may be round, elliptical, or serpentine in form and\\nusually have thickened and callous edges. In the neighbor-\\nhood of the ulcers, there is no hyperemia or oedema, al-\\nthough an increase of fibrous tissue is noted. Undermined\\nulcers undergoing a process of repair are also found. The\\nmucosa glands are found dilated and filled with mucus. In\\nsome places glandular cysts of considerable size are encoun-\\ntered, in others the glands have almost disappeared, and\\nonly traces of them are left. The mucosa is thickened and\\nrilled with round cells. The submucosa is likewise thick-\\nened and in some places cedematous. Dense fibrous tissue\\nis found almost all over in this layer, predominating, how-\\never, at the location of the cicatrices and of ulcers in the\\nprocess of repair.\\nIn both the chronic and the acute form of dysentery, but\\nprincipally in the latter, besides the lesion of the intes-\\ntines described above, the liver is frequently found dis-\\neased. In dysentery complicated with gangrene this organ\\nis usually greatly increased in volume, tumefied, soft, and\\nfriable. The cross-section presents a dark color inter-\\nspersed with yellowish spots. The latter are usually some-\\nwhat raised above the surface. On microscopical examina-\\ntion the hepatic cells show a large amount of fat; besides,", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0137.jp2"}, "138": {"fulltext": "118 DISEASES OF THE INTESTINES.\\nsmall round abscesses are found around the capillaries,\\nwhich are most probably due to emboli.\\nAside from these very small pus collections of pysemic\\norigin, other abscesses are found which differ from these\\nby their size and the nature of their contents. They are\\nthe so-called dysenteric abscesses of the liver, and are most\\noften encountered in acute dysentery without gangrene.\\nThe dysenteric abscesses vary greatly in size from a few\\nlines to several inches. They are situated chiefly in the\\nright lobe of the liver near the surface. Often several are\\nfound together. The contents of these abscesses vary\\ngreatly. In the most recent, the abscess does not empty\\nitself on section. A small amount of glairy, semi-trans-\\nparent fluid exudes and leaves behind an irregular sponge-\\nlike mass, the fluid being apparently held in the meshes.\\nIn the older abscesses the contents are more fluid, the latter\\nhaving a greenish opaque color. In these are suspended\\nsome solid masses of tissue. In some instances the con-\\ntents are brownish or streaked with brownish-red from\\nadmixture of blood. Microscopical examination of the con-\\ntents of the abscesses reveals the presence of a few pus\\ncells, a large quantity of fatty granules, necrotic hepatic\\ncells, a few blood corpuscles, a great number of amoebae\\n(see Fig. 28), and sometimes micrococci and bacilli. Ac-\\ncording to Councilman and Lafleur, there is no definite\\nabscess-wall, the liver tissue passes gradually into the\\nabscess, and the contour of the edge is very irregular,\\nsometimes extending into the liver for a distance of several\\nnodules. The abscess may penetrate the capsule of the\\nliver and either open externally or it may burst into some\\nof the adjacent organs, as, for instance, the lungs, the\\nstomach, the intestines, or the peritoneal cavity. Most\\noften, however, it bursts into the lungs.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0138.jp2"}, "139": {"fulltext": "DYSENTERY. 119\\nSymptomatology of Acute Dysentery.\u00e2\u0080\u0094 -The disease may\\nbegin suddenly without any premonitory symptoms, or\\nafter a few days of general malaise, loss of appetite, and\\nirregularity of the bowels, the patient is attacked with\\nabdominal colic and diarrhoea. These symptoms are\\nusually accompanied by chills, vague pains through the\\nbody, and fever. The stools, at first abundant and watery,\\nvery soon become scanty, mucous, and usually contain\\nn- u\\nkv ^i^rjrk^\\nIB- 1 lllf W\\nFig. 28.\u00e2\u0080\u0094 Amoebae from an Abscess of the Liver. X 750. (Sodre.)\\nblood. Gastric disturbances are present in almost all\\ncases: anorexia, nausea, often vomiting. The principal\\nfeatures of dysentery are the characteristic stools, the\\nabdominal pains, and tenesmus.\\n1. Stools. The evacuations increase in frequency, oc-\\ncurring from twenty to twenty -seven times during the\\ntwenty-four hours. The calls to stool are usually preceded\\nby rumbling and colicky pains, and are followed by strain-\\ning and tenesmus. While during the first and perhaps the\\nsecond day of the disease the motions are copious, they\\nsoon become scanty The patient is then able to expel but\\na small quantity, about a teaspoonful of mucus mixed with\\nblood, after painful efforts. Occasionally a few small\\npieces of fecal matter are passed. The dejecta occasion-\\nally change their character with regard to frequency as", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0139.jp2"}, "140": {"fulltext": "120 DISEASES OF THE INTESTINES.\\nwell as consistency. Intermissions and exacerbations of\\nthe diarrhoea are sometimes observed in the course of the\\ndisease. The mucus in the stools is almost always mixed\\nwith blood. In some cases the dejecta are hemorrhagic,\\nthat is, consist of almost pure blood, either red and fluid\\nor dark and coagulated. In dysentery complicated with\\ngangrene the stools are serous, of a dark reddish-brown\\ncolor, and contain, in addition to finely divided mem-\\nbranous threads, large and thick masses of necrotic tissue\\nof a gray or black color. The gangrenous dejecta have an\\nintensely offensive odor. In many instances the stool con-\\ntains no bile.\\nAmoebae are almost always found in the dysenteric stools,\\nespecially if the lesions are quite extensive. In examining\\nthe faeces for amoebae it is well to use some precaution.\\nIf possible the examination should be made immediately\\nafter the dejecta have been passed. If this be impossible,\\nthe stool should be preserved in a clean vessel and kept in\\na warm place until the examination is made. The amoebae\\nare from 12 to 36 p. in diameter, and when alive frequently\\nchange their shape by contracting some part of their bodies\\nin order to move about. The body of these micro-organisms\\nconsists of an outer clear homogeneous substance or ectosarc\\nand an inner highly refractive mass or endosarc. Within\\nthe latter are usually found some bacteria, sometimes\\nchanged red blood corpuscles, and a few quite large\\nvacuoles. The amoebae, when outside of the intestinal\\ntract, die very quickly, especially if they are kept in a cool\\nplace. When dead, these organisms generally show a\\nround or almost round configuration.\\n(2) Abdominal pain. Abdominal pains exist with greater\\nor less severity in almost every case. The pains may be\\nexperienced continuously, or principally before an evacu-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0140.jp2"}, "141": {"fulltext": "DYSENTERY. 121\\natiou. Most often they are located in the umbilical region\\nand in the left iliac fossa, but sometimes they exist in the\\nright iliac fossa and may then almost simulate an attack of\\nappendicitis. The pains may be so severe that the patient\\nis forced to lie perfectly still for fear of increasing them.\\nPressure exerted on the large intestine as a rule provokes\\nmore or less intense pain. According to Dutrouleau, in\\nsome very grave cases there is a total absence of colic\\nduring the entire course of the disease.\\n(3) Tenesmus. Eectal tenesmus, consisting at first in\\npainful sensations of pressure and constriction and later in\\nan intense desire to go to stool, is encountered very fre-\\nquently. In grave cases of dysentery the tenesmus may\\nexist almost uninterruptedly. Off and on the patient suc-\\nceeds in expelling a small amount of fecal matter or slime or\\nmerely gas, and then feels relieved for a short while. Very\\nsoon, however, the pains in the anal region return with the\\nsame severity. When the tenesmus is very severe it may\\nbe accompanied by dysuria or strangury. In this condi-\\ntion the patient presents a pitiable appearance. His\\nstraining is frequently agonizing and occasionally accom-\\npanied by fainting.\\nBesides the three cardinal symptoms of dysentery just\\ndescribed, other symptoms are often encountered. Fever\\nmay be present, especially in the severer form of the dis-\\nease. It may occur in the form of chills, when the disease\\nis first ushered in. As a rule, the fever is not very high\\nand shows an irregular course. Gastric symptoms are\\noften present. They consist in intense anorexia, nausea,\\nvomiting, and pain in the epigastric region. The general\\ncondition is more or less affected according to the severity\\n1 Dutrouleau Traite des Maladies des Europeens dans les pays\\nchauds, Paris, 1868.\\nI", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0141.jp2"}, "142": {"fulltext": "122 DISEASES OF THE INTESTINES.\\nof the disease. In grave eases prostration is marked, the\\nskin is dry, the features are altered, and the extremities\\nsometimes cold. The pulse is small and rapid. Some-\\ntimes cerebral disorders, stupor, drowsiness, even delirium,\\nare encountered.\\nDutrouleau and others divide cases of acute dysentery\\ninto three groups: Cases of a mild character, those of\\nmedium intensity, and those of a severe type. In the mild\\nform, there exist only local symptoms which are usually\\nnot very intense. In the form of medium intensity, the\\nlocal symptoms are more accentuated and general symp-\\ntoms are encountered. In the severe form, there are fever,\\nintense pain, very bloody stools, great prostration, and in-\\ntolerable tenesmus.\\nSymptomatology of Chronic Dysentery. \u00e2\u0080\u0094Chronic dysen-\\ntery develops either after several attacks of the acute form\\nor directly from the first acute attack, which after some\\nperiods of improvement persists to a greater or less extent.\\nCases of chronic dysentery are also divided into three\\ncategories\\n(1) The mild form. The general nutrition is not inter-\\nfered with. The patients usually complain of slight con-\\nstipation interrupted by light attacks of diarrhoea. Tenes-\\nmus is either entirely absent or present in a very slight\\ndegree. Even during the attacks of diarrhoea the passages\\nare, as a rule, not bloody.\\n(2) Form of medium intensity. Here slight gastric symp-\\ntoms are present, like anorexia, belchiDg, etc. The gen-\\neral condition is interfered with to a considerable extent.\\nThere are almost always periods of intermission and exac-\\nerbation of the disease. The patient may have regular\\nmovements or be slightly constipated, for a period varying\\nfrom a week to ten days, but soon diarrhoea appears and lasts", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0142.jp2"}, "143": {"fulltext": "DYSENTERY. 123\\nfor four or five clays. The stools are then watery, contain\\nmucus, and occasionally a little blood. Slight colicky\\npains are present, as well as moderate tenesmus and a sen-\\nsation of heat or burning in the rectum.\\n(3) The severe form. General nutrition is greatly im-\\npaired. The patient becomes emaciated, pronounced gas-\\ntric symptoms are present: anorexia, a bad taste in the\\nmouth, often nausea, occasionally vomiting. As a rule,\\nthere is persistent diarrhoea, and the dejecta present a mu-\\ncous or muco-sanguineous character. Colicky pains in the\\nabdomen and pronounced tenesmus are present. In some\\ncases, however, the diarrhoea alternates with short periods\\nof constipation lasting two or three days. The patient\\nusually feels very weak and is obliged to stay abed a great\\ndeal of the time.\\nCourse. The course of acute dysenteiw is very indefinite.\\nSometimes the disease terminates in recovery in eight to\\nfifteen days sometimes in one to three months sometimes\\nagain death occurs a few days after the commencement of\\nthe disease. Again, a case of dysentery may at first be mild,\\nbut later assume a dangerous character, and even terminate\\nfatally. Intermissions and exacerbations are often encoun-\\ntered in this disease. When dysentery becomes chronic\\nits duration varies greatly, often depending upon the\\nseverity of each particular case. Thus, it may last five to\\nsix months or many years. Even in the chronic form\\nrecovery is not entirely impossible.\\nComplications. The course of the disease is occasionally\\nmodified by various complications. Peritonitis often re-\\nsults from an extension of the ulcerative process from the\\nintestinal wall to the peritoneum. Perforation of the\\nintestine maj r occur in a similar way, and is observed\\nprincipally in gangrenous dysentery. Sudden death is", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0143.jp2"}, "144": {"fulltext": "124 DISEASES OF THE INTESTINES.\\noccasionally observed in such an event. In acute as well\\nas in chronic dysentery severe hemorrhages from the bowel\\nmay take place. The loss of blood may be so great even\\nas to cause death. Thrombosis of the femoral artery as\\nwell as of the venous sinuses of the brain has been observed\\nby Laveran as a complication of dysentery. A patient of\\nmine with acute dysentery, apparently on the road to im-\\nprovement, suddenly one day developed a paralysis of the\\nupper and lower right extremities. He later lost con-\\nsciousnes and died about forty-eight hours after the first\\nsigns of paralysis. Here most probably thrombosis of\\nsome brain vessels took place.\\nThe most frequent complication of dysentery is abscess\\nof the liver. In the majority of instances it is observed\\nin convalescence from acute dysentery or during the evolu-\\ntion of chronic dysentery. The symptoms of the forma-\\ntion of an abscess in the liver are: fever of an irregular\\ncharacter, occasionally chills and pain in the hepatic region\\nwhich may radiate to the right shoulder. The physical\\nexamination often reveals some enlargement of the liver.\\nIn the event of a liver abscess opening into the lungs,\\nthere is persistent cough and sometimes expectoration of a\\nreddish-brown fluid containing amoebae. Abscess of the\\nliver is more frequently encountered in tropical regions\\nthan here. The course of such an abscess is very irregular.\\nSometimes it progresses rapidly, at other times it shows\\nperiods of intermissions and exacerbations. The large\\nabscesses of the liver, if not operated upon, usually termi-\\nnate in death. Rarely recovery may follow the opening of\\nthe abscess into a neighboring organ.\\n1 Laveran De la phlebite, de la thrombose et des paralysies comme\\ncomplications de la dysenteric Archives de Medecine militaire,\\n1885.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0144.jp2"}, "145": {"fulltext": "DYSENTERY. 125\\nDiagnosis. The diagnosis of acute dysentery is usually\\nvery easy. The symptoms above described, being ordi-\\nnarily present, cannot fail to indicate the disease. The\\nmost reliable evidence is afforded by the character of the\\ndejecta, the presence of mucus, an admixture of blood and\\npus corpuscles. Appendicitis is occasionally simulated by\\ndysentery if the pains involve principally the appendicular\\nregion. Usually, however, it will be found that, besides\\nthe tenderness over the appendix, there are also similar\\nareas of pain over other portions of the large bowel, espe-\\ncially in the left iliac fossa. Besides, the character of the\\nstool will help to reveal the true condition.\\nThe diagnosis of chronic dysentery is usually somewhat\\nmore difficult. Repeated examinations of the faeces will,\\nas a rule, reveal the presence of amoebae at one time or\\nanother and thus aid in discovering the disease. Many\\ndiseases of the rectum, as for instance proctitis, rectal\\npolypus, and cancer, often present symptoms similar to\\nthose of chronic dysentery. A careful local examination,\\nhowever, will clear up the diagnosis without difficulty.\\nPrognosis. Dysentery must always be considered a\\nquite serious disease. Even the mild form is at times\\nliable to assume a dangerous character. On the whole\\ndysentery must be regarded as a treacherous and insidi-\\nous malady. In general it must be said that cases of\\nsporadic dysentery or of the epidemic form appearing in\\nthe cold and temperate zones take a much milder course\\nand thus present a more favorable prognosis than does\\nthe endemic dysentery of hot climates. These remarks\\napply to both acute and chronic dysentery.\\nTreatment of Acute Dysentery. The patient must be kept\\nabed and put on a diet consisting of liquid food (milk and\\nstrained barley water, bouillon, bouillon with egg, egg", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0145.jp2"}, "146": {"fulltext": "126 DISEASES OF THE INTESTINES.\\nwater, tea). Ipecacuanha lias been found of great benefit\\nin this disease. It may be given, according to Sodre, in\\nthe following combination\\nPowdered ipecacuanha 0.1 (gr. ij.)\\nPowdered opium 0.02 (gr.\\nCalomel 0.05 (gr. f)\\nIn capsules, one to be taken every two hours.\\nIn case the evacuations contain very small quantities of\\nfecal matter, it is best to give a cathartic, as a large dose\\nof castor oil (one to two tablespoonfuls) or sodium or mag-\\nnesium sulphate one teaspoonful twice during the day.\\nThe purgative, however, should be administered only on\\nthe first or second day of the disease, and not be kept up\\nfor a long time. In order to allay the pains, hot poultices\\nare applied over the abdomen and opium is administered.\\nThus, Dover s powder may be given in three-grain doses\\nevery two or three hours. This medicament may also be\\ncombined with salol, subnitrate of bismuth, tannigen,\\ntannalbin, etc. The tenesmus, if severe, must be subdued\\nby suppositories containing opium and belladonna, and by\\nwashing out the bowel with a quart of water containing a tea-\\nspoonful of essence of peppermint, which can be done once\\nor twice in twenty -four hours. Astringent solutions have\\nbeen recommended as injections for the large bowel. They\\nare not, however, of great benefit in acute dysentery.\\nBesides the points just mentioned, the condition of the\\npatient must be carefully watched and every complication\\ntreated by itself. The high fever may necessitate the use\\nof an antipyretic the weak action of the heart analeptic\\ndrugs, etc. As soon as the severe symptoms are allayed\\nand the patient is on the way to recovery the diet can be\\ncautiously increased.\\nTreatment of Chronic Dysentery. If the patient is living", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0146.jp2"}, "147": {"fulltext": "DYSENTERY. 127\\nin an endemic centre of dysentery, it is best to send him to\\nanother climate. The hygienic surroundings of the atient\\nshould be carefully selected. The food should be well pre-\\npared. The patient should eat often, not too much at a\\ntime, and should avoid all coarse and highly seasoned sub-\\nstances. Tannigen gr. viii. three times daily or benzo-\\nnaphthol in the same dose, or subnitrate of bismuth gr.\\nxxx. t.i.d., can be advantageously given. Sometimes these\\ndrugs are combined with codeine or opium. Here local\\nremedies play a prominent part. Loesch was the first to\\nrecommend injections into the bowel of solution of quinine\\n(1 5,000) tannic acid, nitrate of silver, permanganate of\\npotassium have also been employed in clysters with good\\nresults. Harris very recently recommended the use of hy-\\ndrogen dioxide. The ordinary commercial hydrogen diox-\\nide is diluted from four to eight times with water and the\\nsolution injected. About a quart is injected twice daily for\\nabout a week and then gradually decreased. Harris has\\nseen very good results from this mode of treatment. In\\ncases in which there is an exacerbation of the disorder, the\\nsame mode of treatment may be required as in acute dys-\\nentery.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0147.jp2"}, "148": {"fulltext": "CHAPTER V.\\nULCEUS OF THE INTESTINES.\\n1. DUODENAL ULCER.\\nSynonyms. Round duodenal ulcer; Ulcus duodeni pep-\\nticum (Leube).\\nDefinition. A defect in the mucous membrane of the\\nduodenum.\\nEtiology. The etiology of duodenal ulcer corresponds\\nwith that of gastric ulcer. It is undoubtedly caused, as in\\nthe stomach, by the action of the acid gastric juice upon\\nthe duodenal mucosa, the vitality and nutrition of which\\nhave been previously impaired. Such conditions occur as\\na result of circulatory derangements of various kinds.\\nThus, affections of the lungs and heart or of the liver, an\\natheromatous state of the duodenal artery may be the\\npositive factors in disturbing the circulation of the mucous\\nmembrane. Burns of the skin are an etiological factor\\nwhich, while not operative in gastric ulcer, is of great im-\\nportance in duodenal ulcer. After extensive scaldings of\\nthe skin, quite often one or several duodenal ulcers ap-\\npear. According to Mayer 1 these ulcers develop from seven\\nto fourteen days after the burn, very seldom much sooner.\\nThe primary cause of these ulcers is not yet known. The\\ntoxic theory which is the most plausible has been discussed\\nabove.\\nDuodenal ulcer is much less frequent than gastric ulcer.\\n1 Mayer Annal. de la Soc. de Med. d An vers, 1865.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0148.jp2"}, "149": {"fulltext": "DUODENAL ULCER. 129\\nWilligk found it twice in sixteen hundred autopsies. Ac-\\ncording to this writer, there are thirty-eight gastric ulcers\\nto one duodenal ulcer. According to Starke, 2 however,\\nthe ratio is twelve to one. Kraus 3 found that the fre-\\nquency of duodenal ulcers varies in different countries in\\na similar manner as does gastric ulcer, the northwestern\\npart of Europe having the highest percentage, while it is\\nbut rarely met with in the eastern part. In Kraus expe-\\nrience duodenal ulcer most frequently occurs in persons\\nbetween thirty and sixty years of age. Next in frequency\\ncomes the very early age (one to ten, and especially in-\\nfancy). This is another point of difference between gas-\\ntric and duodenal ulcers, for the former hardly ever occur\\nin children. With regard to the distribution of duodenal\\nulcer among the sexes, Kraus found it much more preva-\\nlent among the male than among the female sex, the rela-\\ntion being ten to one. According to Lebert, 4 however,\\nthe proportion is only four to one. This again is another\\npoint of difference in the etiology of duodenal and gastric\\nulcers, for the latter, as is well known, are much more fre-\\nquently encountered in women than in men (two to one).\\nMorbid Anatomy. A duodenal ulcer resembles in most\\nparticulars a gastric ulcer. It is a defect of the mucous\\nmembrane having an oblong and oval contour and extend-\\ning into the depth of the mucosa in form of a terrace or\\nfunnel. The ulcer presents an irregular shape only in\\nthose instances in which several ulcers have coalesced, thus\\nforming one large defect. The size of the ulcer varies\\nfrom that of a lentil up to that of a dollar. The margins\\n1 Willigk Prager Vierteljahresschr., 1833.\\na Starke Deutsche Klinik, 1870.\\n3 J. Kraus: Das perforirende Geschwiir des Duodenum, Berlin,\\n1865.\\n4 Lebert Die Krankheiten des Magens, 1878.\\n9", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0149.jp2"}, "150": {"fulltext": "130 DISEASES OF THE INTESTINES.\\nare usually smooth and overlapping, the latter being espe-\\ncially the case in chronic affections.. The base of the ulcer\\nis formed either by thin layers of the remaining intestinal\\nwall, or, if perforation has taken place, by adhesions with\\nneighboring organs.\\nSituation of the Ulcer. Ordinarily the ulcer is found in\\nthe ascending or the upper horizontal part of the duodenum,\\nmuch more rarely in the descending part, and only excep-\\ntionally in the lower horizontal section. As a rule it is\\nsituated immediately behind the pyloric fold, rarely at\\nsome distant point. If the ulcer is situated in the descend-\\ning part of the duodenum, especially in the immediate\\nneighborhood of the diverticulum Yateri, it may cause\\nthrough cicatricial strictures important complications in-\\nvolving the pancreatic and biliary outlets.\\nAs a rule there is one duodenal ulcer, exceptionally there\\nare two or four. In the latter instance the ulcers may be\\nfound in different stages of development in the initial stage,\\nin that of commencing cicatrization, or fully cicatrized. The\\ncicatricial process may lead to manifold complications. A\\nstenosis of the duodenum just behind the pylorus or at\\nsome distance may result, and create exactly the same dis-\\nturbances of the stomach as are found in cicatricial stenosis\\nof the pylorus itself. I had the opportunity of observing\\ntwo cases of this kind. In both the diagnosis of a benign\\nstricture of the pylorus had been made and the patients\\nsubjected to operation. At the laparotomy the stricture\\nwas found in the duodenum, in one case immediately behind\\nthe pylorus and in the other at some distance therefrom.\\nSometimes the ulcer progresses quickly and leads to per-\\nforation into the peritoneal cavity. Death from shock or\\nfrom diffuse peritonitis then occurs. If there is a slow\\nextension of the ulcer, it often gives rise to circumscribed", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0150.jp2"}, "151": {"fulltext": "DUODENAL ULCER. 131\\nperitonitis, usually with adhesions to neighboring organs.\\nIf the ulcer perforates after adhesions have been formed,\\nit usually leads to an eneapsuled purulent peritonitis. The\\nulcerative process may occasionally extend to contiguous\\nparts with the formation of ulcers in the liver, gall bladder,\\nor other neighboring organs. The development of a cancer\\nat the base of a duodenal ulcer has also been observed by\\nEichhorst and Ewald. 2\\nSymptomatology. Occasionally there may be no symp-\\ntoms whatever during life and the duodenal ulcer may not\\nbe discovered until at the autopsy. Sometimes there are\\nno symptoms at first, then suddenly the disease manifests\\nitself by a severe and dangerous hemorrhage or by a fatal\\njjerf oration. In the majority of cases, however, there are\\npronounced manifestations during the existence of a duo-\\ndenal ulcer. Most frequently pains are present, usually\\nto the right of the linea alba, extending up to the right\\nparasternal line in the region below the liver. These pains\\nusually appear from half an hour to two or three hours\\nafter meals as a rule they do not radiate to the back but\\nrather somewhat downward in the abdominal cavity While\\nthe pyloric region is often found slightly painful on press-\\nure, there is no circumscribed area in the epigastrium\\nintensely painful on deep palpation as in ulcer of the\\nstomach. In rare instances the pains are felt by the patient\\nin the epigastric region, which may also show tenderness\\non pressure. Dyspeptic symptoms, as for instance loss of\\nappetite, nausea, fulness in the epigastric region, are as a\\nrule absent. Vomiting is likewise a rare occurrence in\\nsimple duodenal ulcer, which has not gone on to a partial\\nstenosis of the intestinal lumen.\\n1 Eichhorst Zeitschr. f klin. Medicin, Bd. 14, p. 522.\\n2 C. A. Ewald Berl. klin. Wochenschr. 1886.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0151.jp2"}, "152": {"fulltext": "132 DISEASES OF THE INTESTINES.\\nHemorrhages as the consequence of an erosion of a more\\nor less large blood-vessel, through the progressing necrotic\\nprocess, occur in about thirty per cent of duodenal ulcers.\\nThe blood is frequently voided with the stools (melsena)\\nwhich appear dark red or tarry. Occasionally, however,\\nthere may be vomiting of blood (hsematemesis), in connec-\\ntion with the melsena or without it. If the hemorrhage is\\nvery great the patient may bleed to death. This, however,\\nis rare as a rule the patients recuperate from the loss of\\nblood in about the same time as they do from a gastric\\nhemorrhage.\\nConstipation is often present. The general condition of\\nthe patient is usually good and there may be no loss in\\nflesh.\\nPerforation is quite a frequeot event in duodenal ulcer.\\nThe symptoms will differ according to whether perforation\\nhas taken place before or after adhesions have been formed.\\nIn the former instance perforation leads to a general peri-\\ntonitis, ending fatally in eighteen to thirty hours. Rarely\\nthe course is more protracted when the inflammatory proc-\\ness of the peritoneum has not assumed large dimensions\\nand has become quickly localized through the formation of\\nadhesions in the neighborhood. The perforation mani-\\nfests itself by a sudden appearance of intense pains in the\\nabdominal cavity, by the usual signs of a general collapse\\n(cold extremities, very quick pulse), and by a swelling of\\nthe abdomen. The patient presents an expression of ex-\\ntreme anguish and maintains a rigid attitude often with\\nthe legs flexed, being afraid even to stir. The abdomen is\\npainful to the slightest touch. Nausea and constant sin-\\ngultus soon appear. Sometimes the patient is greatly\\ntormented with vomiting. A few hours later, in addition\\nto these symptoms, the area of liver dulness may be found", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0152.jp2"}, "153": {"fulltext": "DUODENAL ULCER. 133\\nabsent in consequence of the escaped gas which has accumu-\\nlated above its surface and has pressed it down. Dyspnoea\\nand coma ultimately set in and the patient succumbs.\\nIf perforation has taken place after adhesions have been\\nformed, the same complications occur as in ulcer of the\\nstomach under similar conditions. The duodenal ulcer\\noften heals and there is a complete disappearance of all the\\nmorbid symptoms. Sometimes the cicatrix leads to a stric-\\nture of the duodenal lumen and then gives rise to ischo-\\nchymia.\\nCourse. The duodenal ulcer has, as a rule, a very pro-\\ntracted course. In some instances a perfect cure may be\\nestablished without any ill consequences. In the majority,\\nhowever, complications are common. Hemorrhages, ob-\\nstruction of the duodenal lumen in consequence of the\\nstenosis and perforation are often observed.\\nDiagnosis. The diagnosis of a duodenal ulcer can be\\nmade with certainty only in a very few instances. Most\\noften only a probable diagnosis will be possible. A duo-\\ndenal ulcer can be diagnosed with certainty if the symp-\\ntoms of ulceration follow within a short period after exten-\\nsive scalding of the skin has taken place. The sudden\\ndevelopment of icterus in a case presenting symptoms of\\ngastric ulcer speaks with a certain amount of probability\\nfor a duodenal ulcer if gall stones can be excluded. The\\npoints which indicate a probable location of the ulcer\\nwithin the duodenum are the following: 1. The pains\\nusually appear from half an hour to three hours after the\\ningestion of food and are situated most often to the right\\nof the linea alba in the pyloric region. They never radiate\\nto the back. 2. Eepeated attacks of melsena, either not as-\\nsociated with hsematemesis or in which the latter was only\\nslight compared with the melsena. 3. Most of the patients", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0153.jp2"}, "154": {"fulltext": "134 DISEASES OF THE INTESTINES.\\nare men presenting a healthy appearance. 4. Perforation\\nis a frequent occurrence in duodenal ulcer, while it is very\\nrare in the course of gastric ulcer. If all these points are\\nfound associated, then a probable diagnosis of duodenal\\nulcer may be made, otherwise it is uncertain.\\nWith regard to the differential diagnosis between ulcer\\nof the stomach and that of the duodenum, Leube stated\\nthat in the latter the gastric contents show a normal degree\\nof acidity, while in gastric ulcer, as a rule, hyperchlorhy-\\ndria prevails. This point, however, is not of much value,\\nfor on the one hand cases of gastric ulcer are found with\\na lessened degree of secretion, and on the other hand\\nduodenal ulcer may be attended with hyperchlorhydria.\\nIn the two cases of duodenal ulcers mentioned above which\\nhad been operated upon, the condition of the gastric juice in\\none was normal, while the other showed intense hyperchlor-\\nhydria. The differential diagnosis between ulcer and can-\\ncer of the duodenum is the same as that between ulcer and\\ncancer of the stomach or pylorus.\\nPrognosis. The prognosis of duodenal ulcer is almost\\nalways quite serious, as complete recovery is very rare.\\nRelapses after apparent perfect recovery often occur. The\\nsequelae to which the cicatrizing process may give rise,\\nnamely, obstruction of the duodenal lumen, must also be\\ntaken into consideration, and the possibility of death from\\nperforation should never be forgotten. Another danger\\nlies in the formation of a cancerous growth on the base of\\nthe ulcer.\\nTreatment. On the whole the treatment must be con-\\nducted on the same line as that of ulcer of the stomach.\\n1 Leube: von Ziemssen s Handbuch der speciellen Pathologie und\\nTherapie, Bd. vii., Abth. 2. Die Krankheiten des Magens und\\nDarms, Leipzig, 1876.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0154.jp2"}, "155": {"fulltext": "EMBOLIC AND THROMBOTIC ULCERS. 135\\nIn some cases the advisability of operative intervention\\nmust be considered. Cases in which a duodenal ulcer can\\nbe diagnosed with great probability and in which hemor-\\nrhages have recurred several times may perhaps be sub-\\njected to a gastroenterostomy during the period of com-\\nparative euphoria. For by this procedure the duodenum\\nis relieved of a great deal of irritation caused by the pas-\\nsage of the chyme, and the ulcer is thus given a better\\nchance to heal. Cases in which the cicatrix has led to a\\npartial stenosis of the duodenal lumen should certainly be\\noperated upon, pyloroplasty or gastroenterostomy being\\nselected.\\n2. EMBOLIC AND THROMBOTIC ULCERS.\\nThis group of ulcers resembles the duodenal ulcer in that\\ndisturbances of the circulation are the exciting causes.\\nThese ulcers are of very rare occurrence. Embolic ulcers\\nwere first described by Parenski. 1 They originate in con-\\nsequence of emboli which are carried into the fine branches\\nof the intestinal arteries, either from some abscess cavity\\nor from a focus of atheroma or endarteritis.\\nThe pathological changes of the intestine after such an\\noccurrence are slight if a very small vessel, a capillary or\\nan arteriole, has been occluded. In case the embolus is of\\nan infectious nature, infiltration and formation of pus soon\\ndevelop, and the process may quickly penetrate down to\\nthe serosa and infect the peritoneal cavity. It may also\\nrapidly reach the intestinal lumen and thus produce an\\nulcer. In the infectious cases the fatal issue often ensues\\nso quickly that there is hardly time for a complete forma-\\ntion of the ulcer. In such instances only the initial stages\\nof the ulcerative process can be discovered. Fine nodules\\n1 Parenski Wiener med. Jahrbticher, 1876, Heft 3", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0155.jp2"}, "156": {"fulltext": "136 DISEASES OF THE INTESTINES.\\nwill be noticed in the intestinal wall originating from the\\nsubmucosa and consisting of accumulations of round cells\\nin the centre of which are very small blood-vessels.\\nThe symptoms of these embolic ulcers are the same as\\nthose caused by other ulcerative processes of the intestines,\\nnamely, severe pain which may be of a colicky nature,\\ntenderness on pressure over the abdomen, and diarrhoea\\nwith more or less bloody admixture. If these symptoms\\nare present and embolic processes can be discovered in\\nother organs, then the diagnosis of embolic ulcer of the\\nintestine is probable.\\nThe clinical symptoms and the anatomical changes re-\\nsulting from the obstruction of a very small blood-vessel of\\nthe intestines are comparatively slight, compared to those\\nwhich rapidly appear if the embolus has entered the\\narteria mesaraica superior. This affection is extremely\\nrare; only nineteen cases have been described in literature.\\nThe emboli which have been found in the arteria mesaraica\\nsuperior itself or in its branches could be traced to the\\nleft heart or, to the aorta, which was the seat of excres-\\ncences due to endocarditis or atheroma. There is either\\na total obstruction of the entire mesaraic artery or several\\nlarger and numerous smaller branches of this vessel are\\noccluded. The changes which frequently result after the\\nembolus has excluded the organ from circulation are hem-\\norrhagic infarcts and necrosis with partial peritonitis.\\nAccording to Litten, 1 after an occlusion of the arteria\\nmesaraica superior or its branches, the intestine is deprived\\nof all arterial blood, there being no vicarious blood current\\nfrom any anastomoses of these vessels. The arteria mesa-\\nraica superior, although it forms anatomical anastomoses,\\n1 Litten Ueber die Folgen des Verschlusses der Arteria mesaraica\\nsuperior. Yirchow s Arch., Bd. 63.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0156.jp2"}, "157": {"fulltext": "EMBOLIC AND THROMBOTIC ULCERS, 137\\nacts functionally like a terminal artery The reason of this\\nis that the anastomosing vessels are of a very small calibre\\nand pursue a very long course, and hence the mesenteric\\narteries are not able sufficiently to supply with blood the\\nregion deprived of its circulatiou.\\nThe pathological changes which appear after the occlusion\\nof this artery consist of venous hyperemia, hemorrhagic\\nextravasations, oedema, and necrosis. In that part of the\\nmesentery and intestine which was supplied by this oc-\\ncluded vessel, the smaller arteries branching off from the\\nlatter are contracted and empty, while the veins of the\\nserosa and mesentery are overfilled with blood. The\\nmucous membrane appears dark red the entire intestinal\\nwall is cedematous and swollen; small hemorrhages exist\\nall over the mucous membrane and in the mesentery and\\nthe intestinal canal contains extravasated blood either fresh\\nor tarry looking. If the process has lasted for some time,\\nnecrotic changes soon appear and the mucosa presents a\\ndirty brownish-green appearance and may be wiped off\\nfrom the other layers like a slimy coating. The serous\\nlayer may be the seat of inflammation not only over the\\ninvolved intestinal segment, but also over other still healthy\\nintestinal coils, the latter being agglutinated and covered\\nwith a deposit of fibrin. In the peritoneal cavity there\\nmay be a bloody fluid or a purulent exudation.\\nThe clinical symptoms of an embolus of the superior\\nmesenteric artery have been best described by Gerhardt J\\nand Kussmaul. They are not always alike, and two\\ngroups of cases may b^e easily discerned. In the one, being\\n1 Gerhardt Embolie der Arteriae mesentericae. Wiirzburger med.\\nZeitschr., 1863, Bd. iv.\\n2 Kussmaul Zur Embolie der Arterise mesentericse. Wiirzburger\\nmed. Zeitschr, 1864, Bd. v.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0157.jp2"}, "158": {"fulltext": "138 DISEASES OF THE INTESTINES.\\nthe larger, an intestinal hemorrhage is the feature most\\nmarked, in the other the affection presents the picture of\\nintestinal occlusion with or without any signs of perito-\\nnitis. As a rule the disease sets in suddenly with violent\\ncolicky pains involving the entire abdomen or some por-\\ntion of it, usually in the neighborhood of the navel.\\nSoon the pains grow diffused and there is an extreme ten-\\nderness on pressure over the abdomen. Sometimes the\\npain is accompanied by vomiting in rare instances, how-\\never, the pain may be entirely absent. Such a case has\\nbeen mentioned by Nothnagel. Intestinal hemorrhage,\\nwhich is the chief symptom, soon occurs. As a rule sev-\\neral bloody stools appear in succession, which have a dark,\\nalmost black, brown or tarry appearance and occasionally\\na very fetid odor. The blood of the hemorrhage, how-\\never, is not always necessarily voided per rectum, for it\\nmay remain in the intestinal canal. The symptoms, how-\\never, which characterize a profuse intestinal hemorrhage\\n(falling of the body temperature and collapse) will never\\nbe missing. In the second group of cases there are merely\\nsigns of an acute intestinal occlusion pains, constipation,\\nand peritonitis being the only symptoms.\\nThe diagnosis of this affection can be made, according to\\nKussmaul and Gerhardt, in cases in which the source of\\nthe embolus can be determined. An intestinal hemorrhage\\noccurs (for which no primary lesion exists), colicky pains\\nof great violence and later a tympanitic swelling of the\\nabdomen and exudations make their appearance. The\\ndiagnosis can be possibly made only if all the just men-\\ntioned points exist. Otherwise, especially if the intestinal\\nhemorrhage is missing, the diagnosis cannot be made\\nduring life.\\nThe prognosis of this affection is very grave. As a rule", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0158.jp2"}, "159": {"fulltext": "EMBOLIC AND THROMBOTIC ULCERS. 139\\nit ends fatally. It appears, however, according to Vir-\\ncliow, that in rare instances a recovery is possible after\\nlong illness, a collateral circulation having slowly devel-\\noped.\\nWith regard to treatment, there is no special indication\\nfor this affection. The symptoms will have to be treated\\nas such.\\nEmbolus of the inferior mesaraic artery is a very rare oc-\\ncurrence. Two cases have been described by Hegar 1 and\\nGerhardt. The prominent symptoms are violent colicky\\npains, tenesmus, and bloody stools. The mucous mem-\\nbrane of the small intestine remains normal, while that of\\nthe colon, S romanum, and rectum becomes intensely red,\\nsucculent, and contains effusions of blood here and there.\\nSevere anatomical lesions of the intestines, however, are\\nabsent, for the circulation is quite quickly re-established\\nthrough anastomosis with the superior mesenteric artery\\nand with the rectal arteries of the hypogastric vessel.\\nSimilar to the lesions of the embolic process of the\\nsuperior mesaraic artery are the consequences which result\\nfrom a thrombus within the mesenteric veins or the portal\\nvein. A few cases of this nature have recently been ob-\\nserved by Pilliet, 2 Grawitz, 3 and Eisenlohr. 4 The clin-\\nical picture of these cases is as follows There appear sud-\\ndenly violent colicky pains in the abdomen. The latter\\nswells up and grows intensely painful on pressure. Often\\nvomiting is present, occasionally haematemesis. There\\n1 Hegar: Embolic der Lungenarterie und der Arteria mesaraica in-\\nferior. Virchow s Arch., Bd. 93.\\n2 Pilliet: Thromboses des veines mesaraiques. Progres med.,\\n1890, No. 25.\\n3 Grawitz Ein Fall von Embolie der Arteria mesaraica superior.\\nVirchow s Arch., Bd. 110.\\n4 Eisenlohr Zur Thrombose der Mesenterialvenen. Jahrbucher\\nder Hamburger Staatskrankenanstalten, 1890.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0159.jp2"}, "160": {"fulltext": "140 DISEASES OF THE INTESTINES.\\nmay be constipation or very frequent diarrhoeal and bloody\\nmovements. Accompanying these symptoms there is al-\\nways collapse. The course is also a very rapid one, the\\nfatal end appearing after two or three days. This affection\\nis liable to occur in advanced pulmonary tuberculosis, in\\nhighly marasmic conditions like the malarial cachexia, then\\nas a consequence of pressure of the portal vein, in cirrhosis\\nand cancer of the liver. All abdominal neoplasms may\\nlikewise produce a thrombotic condition of the veins by\\npressure. The same may happen in chronic peritonitis by\\nthe formation of constricting cicatricial tissue. Similar\\nprocesses also arise whenever the intestine experiences\\npressure or incarceration at a circumscribed spot. The\\nvenous circulation becomes obstructed by the pressure,\\nwhile the arterial blood supply owing to its elastic walls\\nremains undisturbed. In consequence of the lacking oat-\\nflow of the blood, hyperemia appears, then follow hem-\\norrhagic infarcts, and lastly necrosis.\\nAs the symptoms and treatment of the following classes\\nof intestinal ulcers are identical, we shall discuss them\\ntogether later on, after having first given the etiological and\\nanatomical features of each separately.\\n3. AMYLOID ULCERS.\\nAmyloid processes within the intestine were first de-\\nscribed by Virchow 1 in 1855. The amyloid changes start\\nin the walls of the small blood-vessels (capillaries and the\\nfinest arteries, occasionally also the veins).\\nAt first the vessels of the mucosa alone are affected, but\\nafterward the process may extend through the submiicosa\\nand even through the entire intestinal wall down to the\\n1 R. Virchow: Ueber den Gang der amyloiden Degeneration.\\nVirchow s Arch., Bd. 8.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0160.jp2"}, "161": {"fulltext": "TUBERCULOUS ULCERS. 141\\nserous layer. The amyloid degeneration may also involve\\nthe muscularis mucosae, or even the entire muscular layer\\nof the intestinal walls. The amyloid degeneration of the\\nblood-vessels makes them friable, thereby often leading to\\nnecrotic processes with the formation of small ulcers.\\nAmyloid changes are found more often in the small intes-\\ntine than in the large bowel. The mucous membrane of\\nthe affected part has a waxy and pale appearance. The\\nvilli are missing here and there.\\nThe diagnosis can be positively made by means of the\\ncharacteristic color tests. A solution of iodine poured over\\nthe suspected area gives a brownish-red color which be-\\ncomes violet or blue after the addition of sulphuric acid;\\na solution of methyl violet produces a bright pink color.\\nWe have reason to suspect amyloid processes within the\\nintestine in conditions which are known to be often asso-\\nciated with this process, as tuberculosis, syphilis, leukae-\\nmia. Especially is this true if amyloid degeneration is\\ndetected in other organs (spleen and liver) as shown by\\ntheir enlargement, and besides there are signs of chronic\\ndiarrhoea and insufficient intestinal absorption. There are,\\nhowever, no positive means of establishing the diagnosis\\nof amyloid degeneration of the intestine during life.\\n4. TUBERCULOUS ULCERS.\\nTuberculosis of the intestines is of very frequent occur-\\nrence. While it usually appears in phthisical patients,\\nthere are also cases of an undoubted primary intestinal\\ntuberculosis. According to Frerichs, 1 a tuberculous affec-\\ntion of the ileum is found in eighty per cent of the cases\\nof chronic pulmonary phthisis. Bayle in 1810 was the first\\n1 E. Frerichs Beitrage zur Lebre von der Tuberculose, Marburg,\\n1882.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0161.jp2"}, "162": {"fulltext": "142 DISEASES OF THE INTESTINES.\\nto observe the occurrence and frequency of tuberculous ul-\\ncers of the intestine. The seat of these ulcers is princi-\\npally in the ileum, especially in its lower portion. They\\nmay extend from this point downward over the colon to the\\nrectum or upward over the entire ileum, jejunum, and even\\nthe duodenum.\\nThe development of the ulcer takes place in the following\\nway In one of the solitary follicles a miliary tubercle\\nforms by extensive accumulation of cells, the latter swell\\nup; after a time a caseous degeneration appears in the\\ncentre and the swollen follicle bursts; thus a small pea-\\nsized ulcer is formed. In the same way tuberculous proc-\\nesses may develop in the agminated follicles and also lead\\nto the formation of ulcers. But whereas Peyer s patches\\nare equally affected in their entirety in typhoid fever and\\nintestinal catarrh, in tuberculosis the infiltrations are con-\\nfined only to several follicles of the group, while others be-\\nlonging to the same patch remain intact.\\nThe ulcar enlarges either by spreading directly at the\\nperiphery or by the coalition of several defects. As a rule\\nthe extension of ulcers into the deeper layers proceeds in\\na line transversely to the intestinal lumen corresponding\\nto the direction of the vessels supplying the bowels. Thus\\nin the small intestine the ulcer spreads in a line parallel\\nwith the valvule conniventes, and thus may form a circu-\\nlar defect over the entire lumen of the intestine, trans-\\nversely to its longitudinal axis (the so-called tuberculous\\ngirdle ulcer). There exist, however, ulcers of an oblong\\nor entirely irregular shape. With regard to the depth of\\nthe ulcer it usually penetrates to the muscularis and re-\\nmains at a standstill there. Small tuberculous foci, how-\\never, are often met with within the latter, usually connected\\nwith the lacteals. Sometimes a destruction of the mus-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0162.jp2"}, "163": {"fulltext": "TUBERCULOUS ULCERS. 143\\ncular layers is also present and the ulcer may advance\\ndown to the serosa and may even perforate into the peri-\\ntoneal cavity.\\nThe fully developed large tuberculous ulcer has an irreg-\\nular shape, and mostly a bright red margin, being partly\\nsmooth, partly overlapping, sometimes undermined. Its\\nbase is pultaceous, consisting partly of decomposed tissue,\\npartly of swollen remnants of the mucosa. Tuberculous in-\\nfiltrations are noticeable here and there at the base as well\\nas at the margin. The surroundings of the ulcer often\\nshow catarrhal changes. The serosa over it is usually in\\na state of chronic inflammation, being reddened, thick-\\nened, and surrounded with fibrinous exudations. Some-\\ntimes there are agglutinations with other intestinal coils,\\nthe omentum, or other immediately adjacent organs. The\\nfrequency of these peritonitic adhesions explains why per-\\nforations of tuberculous ulcers within the intestine are\\ncomparatively so rare.\\nTuberculous ulcers very rarely show a tendency to heal,\\nthe process as a rule progressing steadily and leading to\\nthe formation of new nodules in the neighborhood of the\\nmargin. In very few instances, however, cicatrization of\\nthe ulcers takes place. The latter, when occurring in ul-\\ncers of girdle shape, may produce a stenosis of the intes-\\ntinal lumen.\\nTuberculous ulcers are very rarely primary, that is to\\nsay, developing in the intestines without a previous tuber-\\nculous affection existing in other organs. In most instances\\nthey are secondary and are met with in patients who are\\nin a more or less advanced stage of pulmonary tuberculosis.\\nThe ultimate cause of tuberculous processes in the intes-\\ntine is Koch s tubercle bacillus. The latter may be car-\\nried into the intestinal canal with the sputum which", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0163.jp2"}, "164": {"fulltext": "144 DISEASES OF THE INTESTINES.\\nphthisical patients swallow, or it may also, in rare in-\\nstances, be ingested directly with the food. Thus, meat\\nand milk of tuberculous cows may cause primary tubercu-\\nlosis of the intestine. This condition is specially frequent\\nin infants on account of their being fed with milk either\\nfrom phthisical nurses or tuberculous cows.\\n5. SYPHILITIC ULCERS.\\nSyphilitic ulcers of the intestines are quite rare. In the\\nsmall intestine they are mostly met with in the new-born.\\nHere the ulcers are found either singly or in great num-\\nbers over the entire small intestine. They originate in the\\nlymphatic apparatus of the mucosa and submucosa, first\\nforming gummata within the intestinal walls, which after-\\nward undergo rupture. Syphilitic ulcers of the small in-\\ntestine have also been observed in adult life (Klebs, 1 Birch-\\nHirschfeld 2\\nOf greater clinical importance are the acquired syphi-\\nlitic ulcers which often occur principally in the lower\\npart of the colon and the rectum, including the anus (most\\nfrequently the lower part of the rectum a few centimetres\\nabove the anus is affected). We may have primary ulcers\\nof the rectum through direct infection after a preternatural\\ncoitus. These are observed principally in men and are\\nlocated in the median line of the anus. They are character-\\nized by a hard base, sharp margins, and bacon-like appear-\\nance. We may also have secondary ulcers due to constitu-\\ntional syphilis. Condylomata and gummata may undergo\\ndegenerative changes and form ulcers, which by their cica-\\ntrization very often give rise to the development of stric-\\n1 Klebs: Handbuch der pathologischen Anatomie. Berlin, 1868.\\n2 Birch -Hirschf eld Lehrbuch der pathologischen Anatomie, Leip-\\nzig, 1887.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0164.jp2"}, "165": {"fulltext": "TOXIC ULCERS. 145\\ntures of the rectum. The latter variety is much more fre-\\nquently found in women than in men. Among two hundred\\nand nineteen patients with constricting rectal ulcers\\nPoelchen found one hundred and ninety women. This\\nauthor, however, correctly remarks that not all these ulcers\\nresulting in stricture are due to syphilis. In a great many\\ninstances their origin is attributable to a gonorrheal affec-\\ntion of the Bartholinian glands which ultimately through\\ninfection leads to destructive processes within the rectum.\\nSome of these ulcers may also result from traumatic causes,\\nsuch as the frequent use of clysters or hard fecal matter\\nirritating the mucous membrane.\\n6. TOXIC ULCERS.\\nUnder the term toxic ulcers of the intestine are under-\\nstood defects which develop in consequence of abnormal\\n(toxic) products contained in the blood. Thus intestinal\\nulcers occur in severe forms of nephritis, especially when\\nthey are complicated with uraemic symptoms. In leukaemia\\nand scurvy such ulcers are also met with. Intestinal ulcers\\narising in cases of poisoning with mercury likewise belong\\nto this group. The ulcerative process in all these cases is\\nbest explained as due to necrosis in consequence of the\\naltered condition of the blood.\\nSymptomatology. The symptoms which accompany\\nulcers of the intestines vary greatly. In the following we\\nshall enumerate all the symptoms which may be met with\\nin these conditions.\\n1. Diarrhcea. Frequent loose movements are often pres-\\nent, especially if the ulcer is situated in the lower part of\\nthe large bowel. Ulcerations of the small intestines,\\n1 Poelchen Zur Aetiologie der stricturirenden Mastdarmge-\\nschwure. Virckow s Arch., Bd. 127.\\n10", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0165.jp2"}, "166": {"fulltext": "146 DISEASES OF THE INTESTINES.\\ncaecum, and the upper end of the large bowel do not cause\\ndiarrhoea, unless there is some other complicating affection\\n(a catarrhal condition of the bowels or an amyloid state).\\nBut even if the ulcer is situated in the lower part of the\\ncolon, diarrhoea may be absent in rare instances.\\n2. The occurrence of blood or pus in the dejecta. Blood\\nmay be voided with the stools in consequence of a small\\nhemorrhage of the ulcerated intestine. If there is no gas-\\ntric ulcer, and other symptoms point toward intestinal ulcer,\\nthe presence of blood will help to make the diagnosis more\\nprobable. But it is by no means a positive sign, for, on\\nthe one hand, an intestinal ulcer may exist without any\\nhemorrhages, and, on the other hand, intestinal hemor-\\nrhages may occur from other causes than ulcer. The\\npresence of pus in the stools seems to have much greater\\nimportance. According to Nothnagel, real pus (numerous\\nround cells) in the faeces is one of the most valuable signs\\nof ulceration of the intestines. It is to be understood that\\npus may also be present in ulcerative processes accom-\\npanying neoplasms of the intestines and in abscesses which\\nopen into the intestine. The latter two conditions will\\nhave to be excluded before we can infer the existence of an\\nintestinal ulcer from this symptom. The amount of pus\\nin true ulcerations of the intestines is, as a rule, very\\nsmall, and it is necessary to examine the dejecta quite\\nthoroughly in order to find it. While the presence of pus\\nis so important a symptom in intestinal ulcer, its absence\\nby no means speaks against it. For there may be no for-\\nmation of pus at the site of the ulcerative spot, or the pus\\nmay be changed to such a degree that it is no longer recog-\\nnizable, especially if the ulcer is situated high up in the\\nintestine.\\n3. The existence of tubercle bacilli in the dejecta is of", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0166.jp2"}, "167": {"fulltext": "INTESTINAL ULCERS. 147\\ngreat importance in cases in which pulmonary tubercu-\\nlosis can be excluded, since they then show primary intes-\\ntinal tuberculosis. The absence of the tubercle bacilli\\ndoes not speak against the presence of ulcerative areas in\\nthe intestines, nor does their presence positively indicate a\\ntuberculous affection of the intestine when pulmonary tuber-\\nculosis exists, for these microbes are then usually derived\\nfrom the sputa which have been swallowed and carried\\ndown with the passages.\\n4. Pains. If pains exist in the abdomen in a more or\\nless circumscribed spot for a long period of time, and\\nif these pains are increased on pressure, they are prob-\\nably due to an ulcer in the intestines. The absence\\nof this symptom, however, speaks in no way against an\\nulcer, nor is its presence an absolute positive symptom for\\nulcer.\\nThe general state of the system need not be disturbed,\\nif the ulcers are only few in number and very small. If\\ntheir number, however, is great and their size extensive,\\nso that a large part of the intestinal tract is involved in the\\nulcerative process, then nutritive disturbances will manifest\\nthemselves and marked emaciation take place.\\nDiagnosis. As may be seen from the description of the\\nsymptoms, the diagnosis of ulcer of the intestines is, as a\\nrule, quite difficult. Their existence may be suspected\\nwhenever there is diarrhoea of a severe nature and more or\\nless intense pain over a certain fixed region of the abdomen\\nextending over a great period of time. A positive diag-\\nnosis can be made only in the following instances\\n1. If necrotic pieces of the intestinal mucosa or pus\\nappear in the stools (in the latter instance the perforation\\nof an abscess into the intestine has to be excluded).\\n2. The more or less frequent appearance of small amounts", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0167.jp2"}, "168": {"fulltext": "148 DISEASES OF THE INTESTINES.\\nof blood quite changed in the stool, if ulcer of the stomach\\nor vicarious bleeding can be excluded.\\n3. Diarrhoea and the constant appearance of tubercle\\nbacilli in the stools, when pulmonary tuberculosis can be\\nexcluded. This points to the presence of tuberculous proc-\\nesses (ulcers) in the intestine.\\n4. If the ulcers are situated in the lower part of the colon\\nor rectum and are accessible to a direct visual examination.\\nx^he nature of the ulcers (whether catarrhal, tuberculous,\\nsyphilitic, or toxic) must be elucidated by a thorough\\nknowledge of the history of the case and the results of an\\naccurate examination of the patient.\\nPrognosis. The prognosis of intestinal ulcers will de-\\npend largely upon their number, size, and nature. A few\\nsmall catarrhal ulcers will heal quickly without any further\\ntrouble. Amyloid ulcers hardly ever show a tendency to\\nheal. Tuberculous ulcerations occasionally are amenable\\nto treatment, still more so are the syphilitic ulcers. Very\\nextensive ulcerations, no matter of what nature, are very\\ndangerous to life.\\nTreatment. In the treatment of intestinal ulcers the\\netiological factors play the greatest part. Thus, in tu-\\nberculous ulcers general hygienic rules will have to be\\nobserved. An out-of-door mode of living, and, if pos-\\nsible, in the mountains, should be recommended. Guai-\\nacol carbonate, creosote, ichthalbin are of value. In\\nsyphilitic ulcers general anti-syphilitic treatment should\\nbe instituted: inunctions with mercury, or injections of\\nsublimate or calomel, or the administration of large doses\\nof potassium iodide. In toxic ulcers (as those due to\\nuraemia and mercurial poisoning) the treatment must be\\ndirected against the primary trouble. Besides the etio-\\nlogical therapy, intestinal ulcers require specific and", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0168.jp2"}, "169": {"fulltext": "INTESTINAL ULCERS. 149\\nsymptomatic treatment. The treatment directed to the\\nhealing of the ulcers is very successful if the latter are situ-\\nated in the rectum or in the lower part of the colon, while\\nthis object can hardly be attained if they exist high up in the\\ncolon or in the small intestine. In the former instance the\\nulcers, if accessible to view, may be directly treated by the\\napplication of a strong solution of nitrate of silver or pro-\\ntargol. If not visible but situated in the colon, injections of\\na 0.2 to 1 per cent, solution of nitrate of silver or of tannic\\nacid of the same strength into the bowels are of value. If\\nthe ulcers are situated in the small intestine, large doses\\nof subnitrate of bismuth (1 to 2 gm. [gr. xv. to xxx.] three\\ntimes a day) may be tried. The symptoms which accom-\\npany the ulcer and vary from time to time will have to be\\ntreated as such. Diarrhoea, hemorrhage, and pain must\\nbe combated with the customary remedies.\\nMost patients should be kept abed for some time. The\\napplication of a hot-water bag or a wet pack over the\\nabdomen is very beneficial.\\nThe diet should contain nourishing but easily digestible\\nand non-irritating food. Thus, milk, kumyss, matzoon,\\neggs beaten up in milk, soft-boiled eggs, farina, oat meal\\ncooked in milk, mutton broth, chicken soup, scraped beef,\\ncalf s brain, sweetbreads, cacao, tea, and toast may be\\ngiven.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0169.jp2"}, "170": {"fulltext": "CHAPTER VI.\\nNEOPLASMS OF THE INTESTINE.\\nMALIGNANT GROWTHS.\\nCancer.\\nDefinition. An epithelial neoplasm of the intestinal\\nwalls.\\nEtiology. The etiology of intestinal cancer, like that of\\ncancerous disease of other organs, is still unknown. The\\ntraumatic theory (repeated irritation of one particular\\narea) appears quite plausible with reference to this organ.\\nAs will be seen later, this malady occurs much more fre-\\nquently in those parts of the bowels in which the passage\\nof fecal matter is more apt to be retarded, and in conse-\\nquence to cause irritation.\\nWith regard to sex, it is generally accepted that intes-\\ntinal cancer occurs somewhat oftener in men than in women.\\nWith reference to age it is chiefly met with during the\\nperiod from forty to sixty-five years. Cancer of the intes-\\ntine is occasionally found also in young people, this hap-\\npening much more commonly than cancer of the stomach\\nor of other organs. Nothnagel has observed cancer of the\\ncaecum in a twelve-year-old hoy, and Schoening 2 reports\\ntwo cases of rectal cancer in girls seventeen years old.\\n1 H. Nothnagel Die Erkraukungen des Darms und des Perito-\\nneum, Wien, 1898.\\n2 Schoening Deutsche Zeitschr. f. Chirurgie, Bd. xxii., 1885.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0170.jp2"}, "171": {"fulltext": "MALIGNANT GROWTHS. 151\\nAccording to Maydl, the total number of intestinal cancers\\noccurring from the first to the thirtieth year amounts to\\none-seventh of the entire number of cases.\\nLocation. With regard to location the frequency of the\\naffection in the different portions of the bowel varies. The\\nfrequency gradually increases the lower down the growth\\nis situated, beginning with the jejunum and ending with\\nthe rectum. Among one hundred and sixty autoj;sies on\\ncases of cancer of the different organs, Maydl found in one\\nhundred cancerous disease of the bowels. In one hundred\\nand ten autopsies of patients suffering from intestinal\\ncancer, Bryant 2 found the neoplasm located six times\\nwithin the small intestine, seven times in the ca3cal and ileo-\\ncecal regions, nineteen times in the transverse colon, includ-\\ning the hepatic and splenic flexures, seventy-eight times in\\nthe sigmoid flexure and rectum. Maydl gives the follow-\\ning locations of the tumor in one hundred autopsies Two\\nin the duodenum, four in the ileum (none in the jejunum),\\nforty-six in the large bowel (in the vermiform process, one;\\ncaecum, nine; ascending colon, six; colon seventeen; sig-\\nmoid flexure, thirteen), and forty-eight in the rectum. As\\nregards cases observed during life, Maydl gives the follow-\\ning figures During twelve years there were in the Wiener\\nAllgemeines Krankenhaus 246,827 patients. Among these\\nthere were 6,287 patients with cancer. Among the latter\\nthere were 254 cases of cancer of the bowels, and in 224 of\\nthese the neoplasm was in the rectum. This certainly shows\\nthe great predilection of intestinal cancer for the rectum.\\nIntestinal cancers are almost always primary. It is\\nexceptional for cancer of the bowels to develop by way of\\nmetastasis. It is obvious, however, that cancer in this\\n1 Maydl Ueber den Darmkrebs, Wien, 1883.\\nJoseph D. Bryant Annals of Surgery, February, 1893.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0171.jp2"}, "172": {"fulltext": "152 DISEASES OF THE INTESTINES.\\nregion may develop secondarily as a result of direct exten-\\nsion of the cancerous process from a contiguous organ.\\nThis often occurs in cancer of the stomach, gall bladder,\\nor pancreas. Intestinal cancer often gives rise to metasta-\\nses in other organs. According to Muller, 1 these are more\\nfrequently met with in cancer of the small intestine than\\nin that of the large bowel. The lymphatic glands are also\\noften secondarily affected. Those in the neighborhood of\\nthe neoplasm show a greater tendency to become cancer-\\nous than those farther off.\\nMorbid Anatomy. All varieties of cancer are found in\\nthe intestines. Most frequently, however, the cylindrical\\nepithelial-celled carcinoma, having a glandular structure\\n(adeno-carcinoma), is encountered. The latter takes its\\norigin in the epithelial cells of the follicles of Lieberkuehn.\\nColloid carcinoma is quite often found in the rectum, while\\nmelano-carcinoma is here quite rare. Occasionally the\\npavement-celled carcinoma (epithelioma cancroid) is met\\nwith, especially in the lower part of the rectum, starting\\nprincipally from the anus. It often involves the perineum\\nand the vagina.\\nThe neoplasm varies in consistency according as connec-\\ntive tissue or cells predominate. If the former is the prin-\\ncipal element, then the tumor presents a hard consistency\\n(as hard as cartilage) and is termed scirrhus. In case the\\nlatter are more abundant, then it is less firm, occasionally\\nsoft and succulent. The colloid cancer as a rule contains\\na brownish, somewhat viscid fluid. The scirrhus shows a\\ngreater tendency toward partial necrosis in its central part.\\nIt often forms a carcinomatous ulcer.\\nThe primary intestinal cancer frequently shows a ten-\\n2 Max Muller Beitrage zur Kenntniss der Metastasenbildung ma-\\nligner Tumoren. Inaugural-Dissertation, Bern, 1892.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0172.jp2"}, "173": {"fulltext": "MALIGNANT GROWTHS. 153\\ndency to extend in a circular direction perpendicularly to\\nthe lumen of the bowel. Stenosis of the intestinal canal\\nis very often the result of this circumstance. In case the\\nstricture is of marked degree, the intestine above the stric-\\ntured spot becomes greatly distended through stagnating\\nfecal matter and gas. The bowels working hard to over-\\ncome the obstacle show thickened walls due to hypertrophy\\nof the muscles. The irritating and stagnating contents in\\nthe dilated part of the intestine give rise to catarrhal in-\\nflammation and also to ulcers. If the stenosis has become\\nstill more pronounced, the dilatation of the intestine above\\nit may be so excessive that a rupture of its walls ultimately\\noccurs. Below the stricture the intestinal wall appears\\nthinner, and if the stricture is so narrow that no contents\\npass downward, it appears empty and contracted. Occa-\\nsionally the neoplasm constricting the intestinal lumen\\nbegins to break down and ulcerate, and this partly removes\\nthe occlusion of the intestinal canal. This, however, does\\nnot last long, for as a rule the cancer shows a tendency to\\ngrow again and to fill up the defect. Thus the free lumen\\nof the bowel is very soon again occluded.\\nThis partial necrotic process will also often cause more\\nor less hemorrhage through erosion of the smaller blood-\\nvessels. In case a larger artery or vein opens, a severe\\nhemorrhage with fatal issue may result.\\nCancer of the bowel often involves, besides the mucosa\\nand submucosa, the muscularis and even the serosa. In\\nthe latter event perforation occurs in rare instances before\\nadhesions have had time to form, and may result in fatal\\ngeneral peritonitis. In most instances, however, adhe-\\nsions have formed around the involved area, and thus the\\nperforation causes merely a circumscribed peritonitis.\\nEven without the occurrence of perforation the cancer may", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0173.jp2"}, "174": {"fulltext": "154 DISEASES OF THE INTESTINES.\\nprogress from the serous layer to the peritoneum and lead\\nto a carcinomatous peritonitis, which is often accompanied\\nby a hemorrhagic exudation. Another series of grave\\ncomplications is caused by the extension of the cancerous\\nprocess to a neighboring organ which has previously be-\\ncome agglutinated to the bowel. The process of disinte-\\ngration in the cancerous growth then often establishes an ab-\\nnormal communication between the bowel and other organs.\\nThus fistulous openings may occur between colon and\\nstomach, between rectum and bladder, between rectum and\\nvagina, between rectum and uterus, between large and\\nsmall bowels, or a direct fistulous opening may form from\\nthe bowel through the abdominal wall.\\nSymptomatology.- Cancer of the bowel develops quite\\nslowly and insidiously, and in most instances at the begin-\\nning gives rise to hardly any symptoms at all. For this\\nreason it can never be detected at this time later, how-\\never, general and local symptoms manifest themselves.\\nWhile the general symptoms are common to all cancers of\\nthe small and large bowels, the local symptoms will differ\\naccording to the location of the tumor, and it will therefore\\nbe necessary to consider the different portions of the intes-\\ntinal tract separately.\\nA. General Symptoms. The general symptoms of cancer\\nof the bowel are those found in malignant growths of other\\norgans. Of these anaemia and cachexia are the most impor-\\ntant. Usually both are present at the same time. Some-\\ntimes one is more pronounced than the other. In some in-\\nstances a general weakness, pallor, and emaciation are the\\nfirst indications of a severe affection. There may be as yet\\nno local symptoms whatever or a very slight degree of con-\\nstipation and scarcely noticeable sensation of discomfort in\\nthe abdomen. Loss of appetite and slight dyspeptic symp-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0174.jp2"}, "175": {"fulltext": "MALIGNANT GROWTHS. 155\\ntoms are often encountered. Fever is occasionally met with,\\nwhich is due to a suppurative process and absorption of\\npyogenic matter into the blood. The neoplasm often gives\\nrise to disturbances in neighboring organs by constricting\\nor dragging upon them. Thus radiating pains from com-\\npression of nerves may arise and in the same manner dis-\\nturbances of circulation. (Edema of the lower extremities\\nis often encountered, which after lasting for weeks and\\nmonths may occasionally disappear shortly before death.\\nSymptoms of chronic intestinal obstruction are often pres-\\nent. They develop either gradually, the constipation in-\\ncreasing more and more, or they may appear more abruptly.\\nThe bowels, while formerly more or less regular, suddenly\\ncease to move, and even strong cathartics are of no avail.\\nThe clinical features of cancerous obstruction of the\\nbowel are not different from stenosis of the intestine caused\\nby other processes, which are described in Chapter IX-\\nSuch a sudden attack of obstruction of the bowel may ter-\\nminate fatally in a few days sometimes, however, after a\\ntotal occlusion of the bowels, life continues much longer.\\nThus fecal retention of forty -four days duration, without\\neven fecal vomiting, is mentioned by Heusgen, 1 and an-\\nother case of eighty-eight days duration has been reported\\nby Cooper-Forster. 2 Diarrhoea is frequently present in\\ncancer of the bowels. This often serves partly to overcome\\nthe beginning obstruction of the intestinal lumen. In some\\ncases diarrhoea alternates with constipation. In the latter\\ninstance the stools often bear signs of having passed a\\nstrictured spot. They may appear in the shape of a tape\\nor in the form of small, hard balls. These characteristics\\nof the evacuation are, however, by no means a positive\\n1 Heusgen Deutsche raed. Wochenschr. 1877.\\n2 Cooper-Forster Medical Times and Gazette, September, 1867.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0175.jp2"}, "176": {"fulltext": "156 DISEASES OF THE INTESTINES.\\nproof of a real stricture, for they are also met with in\\nmerely neurotic conditions. The stools often contain an\\nadmixture of mucus, blood, or pus. In case the progress\\nof the necrosis of the neoplasm is pronounced, the stools\\nduring that period have a very offensive, almost unbear-\\nable odor. In rare instances particles of tumor may be\\ndiscovered in the dejecta, which show under the micro-\\nscope the exact nature of the neoplasm. If these particles\\nare of a large size (cherry or walnut) they will be easily\\ndiscovered in the stools but if they are minute, a thor-\\nough examination of the fecal matter will be necessary in\\norder to find them. Washing out of the bowels will often\\nbe helpful to discover such minute pieces of the growth,\\nin case the latter is situated in the colon.\\nWhile all of the above symptoms are of great value, they\\nare unimportant compared with the physical signs of a\\ntumor. Its presence in a doubtful case in most instances\\nhelps to clear up the diagnosis. The tumor is often easily\\npalpable and bears the general characteristics of a cancer-\\nous growth. It is hard and presents an uneven nodular\\nsurface. Its size varies greatly, being often that of a wal-\\nnut and occasionally that of an apple or still larger. In\\nthe latter instance the mere inspection of the abdomen may\\nalready show the presence of the tumor. In autopsies the\\nneoplasm is frequently found much smaller than it ap-\\npeared to be during life. The cause of this is the hyper-\\ntrophy which occurs in the walls of the bowel above the\\ntumor, together with the accumulation of fecal matter at\\nthe same place. The tumor is usually situated in the\\nlower half of the abdomen, principally in the left iliac re-\\ngion, not only because this part of the intestine is so often\\naffected, but also because a neoplasm of other parts of the\\nbowel, if not fixed by adhesions, is as a rule dragged down", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0176.jp2"}, "177": {"fulltext": "MALIGNANT GROWTHS. 157\\nby its own weight into this region. Intestinal neoplasms\\nas a rule show a high degree of mobility. Often they can\\nbe moved with the hand in all directions in the abdominal\\ncavity. The only exceptions to this rule are tumors of the\\nduodenum, the sigmoid flexure, and the caecum, which are\\nmore or less fixed.\\nWith regard to the detection of the tumor a thorough\\npalpation of the abdomen (if the abdominal walls are very\\nrigid, under ether or chloroform narcosis) is necessary. A\\ndigital examination of the rectum, aud, in women, of both\\nrectum and vagina, will in most instances be required. A\\nbimanual examination will also be found useful. In case\\nthe affected area in the rectum is not accessible to digital\\nexamination, inspection of this organ and in some instances\\na manual examination under anaesthesia with the whole\\nhand must be resorted to.\\nWhen the disease is fully developed, peritonitis (either\\ncircumscribed or general) often appears as a complication.\\nIt may be simply caused by the inflammatory processes\\naccompanying the neoplasm or be of a real cancerous na-\\nture. While at first it is impossible to differentiate these\\ntwo conditions, later on it is as a rule not difficult to deter-\\nmine which of the two is present. The discovery of a\\nhemorrhagic exudation and of a few nodules under the\\nabdominal wall will indicate that a cancerous affection of\\nthe peritoneum is present. An acute perforation peritoni-\\ntis is much more rare and leads to shock and sudden death,\\nor in the presence of adhesions to grave complications in\\nconsequence of fecal abscesses. If the perforation occurs\\ninto adherent neighboring organs, new communications\\nmay be formed between them and the intestine they ag-\\ngravate the condition and are of great clinical importance.\\nThe following communications are frequently met with", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0177.jp2"}, "178": {"fulltext": "158 DISEASES OF THE INTESTINES.\\n1. Fistula between stomach and colon. The fistulous\\nopening may freely communicate with both cavities or only\\nin one direction on account of the formation of a valve.\\nIf the passage has the direction from the stomach into the\\ncolon, symptoms of lientery develop, and undigested and\\nunchanged foods, as for instance pieces of meat, potatoes,\\nspinach, and the like, appear in more or less large quanti-\\nties in the stools often diarrhoea manifests itself shortly\\nafter a meal and examination of the evacuation shows\\nnumerous particles of food from the last meal. Lavage\\nof the stomach performed in such a case will often show\\nthat the liquid has escaped from the stomach in consider-\\nable quantity and may occasionally be voided by the rec-\\ntum. The admixture of some coloring matter to the water\\nused for lavage will facilitate the recognition of this condi-\\ntion. If the communication has a direction in the oppo-\\nsite way, namely, from the colon into the stomach, there\\nwill be an appearance of fecal matter in the latter. In\\nthat event the gastric contents always contain decomposed\\nand fetid material, and vomiting of fecal matter is fre-\\nquently the result. Inflating the colon with air will often\\ncause a filling up of the stomach with this gas, and again\\nirrigation of the bowel with water (either clear or stained)\\nwill be followed by its appearance in the stomach, which\\nmay be easily discovered by introducing a tube into this\\norgan and evacuating the gastric contents. If the fistulous\\nopening has a free communication in both directions, then\\nsymptoms of lientery and fecal vomiting may be present\\nat the same time or they may appear alternately.\\n2. In case of a communication between rectum and blad-\\nder, small particles of fecal matter and gas appear in the\\nlatter organ and may be voided through the urethra. They\\ngive rise to a putrid cystitis. Occasionally urine may pass", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0178.jp2"}, "179": {"fulltext": "MALIGNANT GROWTHS. 159\\nfrom the bladder into the rectum and be discharged with\\nthe stools. The recognition of the latter condition is,\\nhowever, more difficult.\\n3. Communications between the rectum and uterus or\\nvagina are also met with and give rise to the passage of\\nfecal matter through these organs.\\n4. A fistulous opening may exist between the bowel and\\nthe abdominal wall. This fistula may discharge externally\\na putrid secretion having a fetid odor and containing par-\\nticles of fecal matter or chyle, depending upon its location,\\nwhether in the large or small intestine.\\nAll these fistulous communications appear as a rule in\\nthe last stages of the disease. They are, however, by no\\nmeans characteristic of cancer of the intestine, for they\\nmay also, but very rarely, develop in consequence of other\\nulcerative processes in the bowel (tubercles). Again they\\nmay be a result of a cancerous growth in the stomach in-\\nvolving secondarily the intestinal tract.\\nThe urine does not show anything characteristic of can-\\ncer. However, it often contains large amounts of indican\\nacetone and diacetic acid have also been occasionally met\\nwith.\\nB. Symptoms Due to the Location of the Neoplasm. (a)\\nCancer of the duodenum. In the duodenum the neoplasm\\nalmost always causes gastric symptoms similar in nature\\nto those of cancer of the pylorus. Thus anorexia, pains,\\nvomiting, and dilatation of the stomach will be the pre-\\ndominating features. If the tumor is situated near the\\npylorus in the superior horizontal portion of the duode-\\nnum it will be quite movable, and a differential diagnosis\\nbetween cancer of the pylorus and that of the beginning of\\nthe duodenum will hardly ever be possible during life. In\\ncase the neoplasm is situated in the descending part of the", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0179.jp2"}, "180": {"fulltext": "160 DISEASES OP THE INTESTINES.\\nduodenum, in the immediate neighborhood of Vater s\\npapilla, icterus is often encountered. In such cases the\\ninitial symptoms may be jaundice and sometimes chills.\\nThe icterus may remain stationary or vary in intensity\\nfrom time to time according to the degree of the obstruc-\\ntion of the duct caused by the neoplasm. Ulceration of the\\ntumor may for a while open a passage for the bile and the\\njaundice may then temporarily disappear. If the cancer\\nis located below Yater s papilla, especially in the inferior\\nhorizontal part, the gastric contents will frequently show\\nthe presence of a large amount of bile. In the latter two\\ninstances the tumor, if accessible to palpation, is not mov-\\nable. On account of its deep situation it can frequently\\nnot be discovered.\\n(b) Cancer of the small intestine. According to the re-\\ngion in which the neoplasm is situated, whether at the\\nbeginning of the jejunum or in the lower parts of the\\nileum, gastric or intestinal symptoms will predominate.\\nThere may be anorexia and vomiting, or, on the other\\nhand, good appetite and apparently good stomach diges-\\ntion, but obstinate constipation. The tumor is often acces-\\nsible to palpation, and is as a rule very movable.\\n(c) Cancer of the large bowel. Pains are frequently en-\\ncountered at a localized spot in the region of the large\\nbowel. They may exist before a tumor can be palpated\\nand may be felt either in its immediate neighborhood or\\nin almost exactly opposite portions of the colon. Thus\\ncancer of the caecum may give rise to pain in the sigmoid\\nflexure, and vice versa. These pains are rarely severe as\\na rule they consist merely in a sensation of discomfort or\\nin a feeling of tension. Besides these uncomfortable sen-\\nsations of a more or less permanent nature, there may be\\nmore or less frequent attacks of colic. In the latter in-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0180.jp2"}, "181": {"fulltext": "MALIGNANT GROWTHS. 161\\nstance there may be violent excruciating pains in the ab-\\ndomen, which may be relieved after passing of flatus or\\nafter a diarrhceal movement. The attacks of colic are fre-\\nquently caused by the commencing obstruction of the in-\\ntestine, and therefore become gradually aggravated in na-\\nture. They may lead at last to a total obstruction and be\\nthe immediate cause of death. Constipation is one of the\\nforemost symptoms of a neoplasm of the large bowel. It\\nis encountered in the great majority of cases; in some in-\\nstances it forms the first symptoms of the disease; at first\\nit may be slight in nature, but becomes steadily more ob-\\nstinate. Ten or twenty days may pass without a sponta-\\nneous evacuation, and even cathartics are very slow in their\\naction. The constipation as a rule is accompanied by the\\nusual symptoms resulting from it, tension and fulness in\\nthe abdomen, poor appetite, occasionally pains. The con-\\nstipation may at times disappear and give place to a pe-\\nriod of diarrhoea. In some instances diarrhceal evacu-\\nations may exist for many weeks, and they may be the\\npredominating feature of the disease.\\n(d) Cancer of the rectum. The symptoms met with in\\ncancer of the rectum resemble more or less those of a neo-\\nplasm of the upper portion of the large bowel. Here, how-\\never, the diagnosis can be made with greater ease and cer-\\ntainty. In most instances rectal cancer can be discovered\\nby a digital examination of the rectum. By means of the\\nlatter we may discover a mass lying right beneath the mu-\\ncous membrane of the rectum, over which the mucosa can\\nbe slightly moved or not at all if it is adherent. The sur-\\nface may feel uneven and somewhat hard. Sometimes the\\nfinger encounters a constriction through which it cannot\\neasily pass the tissues here present the same character-\\nistics as just described. Occasionally- an ulcerated area\\n11", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0181.jp2"}, "182": {"fulltext": "162 DISEASES OF THE INTESTINES.\\ncan be discovered on the surface of the neoplasm. In can-\\ncer of the rectum situated high up (not accessible to digital\\nexamination), several clinicians have advised examination\\nwith the whole hand passed through the rectum. This,\\nhowever, can be done only under chloroform narcosis and\\nis not free from danger. Such an examination may in rare\\ninstances cause rupture of the intestinal wall as stated by\\nVolkmann. 1 Inspection of the rectum by means of Kelly s\\nspeculum can be easily performed and aids us in discover-\\ning a neoplasm situated quite high up in the rectum, even\\nif not accessible to digital examination. The latter instru-\\nment may also be used in neoplasms of the lowest part of\\nthe bowel, although its use here is not of much impor-\\ntance, as the palpating finger gives us enough certainty in\\nmaking the diagnosis.\\nCancer of the rectum is as a rule accompanied by severer\\npains than that of the large bowel. These as a rule are\\nlocal in character. They often radiate toward the caecum\\nand the lower lumbar region, toward the bladder and geni-\\ntal organs, and sometimes in the direction of the sciatic\\nnerves. In case the neoplasm involves the anus, there is\\nan exacerbation of the pain at each evacuation. Tenesmus\\nis constantly present in the latter instance. If such a neo-\\nplasm of the lower parts of the rectum becomes ulcerated,\\nthe tortures of the afflicted person can hardly be described.\\nThe patient as a rule is afraid of having an evacuation, and\\ntries to keep it back as long as possible. At last there is\\na movement containing fecal matter, mucus, blood, and\\nsometimes pus, under most excruciating pains.\\nLeube has directed attention to the fact that hemor-\\nrhoids are frequently associated with the neoplasm of the\\n1 Volkmann Ueber den Mastdarmkrebs. Volkmann s Sammlung\\nklin. Vortraege, No. 131.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0182.jp2"}, "183": {"fulltext": "MALIGNANT GROWTHS. 163\\nrectum. This is of importance, as it shows that the pres-\\nence of hemorrhoids should not lead one to abstain from\\ndigital rectal examination. If a patient has complained of\\nconstipation for a short period (a few months) and hemor-\\nrhoids have developed during this time, the latter are\\nrather indicative of a more serious condition, and a digital\\nexamination of the rectum should always be undertaken\\nunder such circumstances.\\nCourse. An uncomplicated intestinal cancer may last\\nfor years. Frequently, however, the time is much shorter.\\nMany complications are liable to occur hemorrhages, per-\\nforation peritonitis, rupture of the intestines, ileus, auto-\\nintoxication, extension of the cancer to other organs, and\\nmetastases. On account of these many possibilities the\\nlife of the patient may be shortened, and it is hardly pos-\\nsible to foresee its duration. In some instances a condi-\\ntion of coma (coma carcinomatosum) appears quite early.\\nIt is generally assumed that the latter is due to auto-intoxi-\\ncation, either by the products of decomposition of the in-\\ntestinal contents or by the toxins of the cancer. Ewald in\\nsuch a case succeeded in isolating a body from the urine\\nbelonging to the group of diamins. In cancer of the\\nduodenum the general nutrition suffers very early and ex-\\ntensively, and for this reason the duration of life is short.\\nIn cancer of the rectum nutrition is well maintained for a\\nlong period, and for this reason the duration of life in the\\nabsence of complications is quite long (about four years).\\nIn case anaemia of a high degree supervenes, a marasmic\\nthrombosis may develop and the patient may die in conse-\\nquence of an embolus of the lungs. If intestinal cancer is\\nunattended with complications, death often results in con-\\nsequence of general exhaustion.\\nDiagnosis. The diagnosis of intestinal cancer can be", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0183.jp2"}, "184": {"fulltext": "164 DISEASES OF THE INTESTINES.\\nmade with, certainty in the following instances: 1. If by\\nabdominal or rectal palpation a tumor can be detected\\nwhich is situated in the small or large bowel, and accom-\\npanied by symptoms of cachexia and disturbances of defe-\\ncation. 2. The presence of a tumor as just described, and\\nthe discovery of small particles of the neoplasm in the\\nevacuation giving microscopically the appearance of a can-\\ncerous growth. 3. Gradually increasing disturbances of\\nthe bowel for a few months in a heretofore healthy person,\\naccompanied by cachexia and symptoms of a beginning or\\nalready developed stricture of the bowels and the presence\\nof a small particle of growth in the stools, giving as above\\nmicroscopically the picture of cancer.\\nIf there is no tumor and if nothing cancerous is found\\nin the stools, the diagnosis can never be made with cer-\\ntainty. A probable diagnosis of intestinal cancer will\\nhave to be made if cachexia is present, together with\\nsymptoms of gradually developing intestinal disturbances,\\nindicating the beginning of an obstruction of the bowel, in\\na middle-aged or elderly person who has been well up to a\\nfew months before.\\nPrognosis. The prognosis of intestinal cancer is always\\nunfavorable. Unless an early operation and total ex-\\ncision of the growth is resorted to, a fatal issue is sure to\\nfollow, although the exact duration of life can hardly be\\npredicted, the latter depending upon subsequent complica-\\ntions.\\nTreatment. A cure is possible only by a total and thor-\\nough removal of the growth. We must therefore always\\nendeavor to make the diagnosis as early as possible and\\nadvise an immediate operation whenever feasible. Cancer\\nof the rectum can be recognized quite early and resection\\nof the neoplasm is here followed by brilliant results. If", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0184.jp2"}, "185": {"fulltext": "MALIGNANT GROWTHS. 165\\nthe tumor is located farther up in the large bowel or in\\nthe small intestine, then the results of an operation are not\\nso promising, for here the recognition of the growth is pos-\\nsible only at an advanced period, and by that time often\\nadhesions with other organs and cancerous infection of the\\nglands have already taken place. Excision of the tumor\\nand resection of the intestine in the neighborhood of the\\nneoplasm with an end-to-end anastomosis should be prac-\\ntised whenever feasible. In case, however, total resection\\nis impossible, an entero-enter ostomy or enter o-colostomy,\\nor if the cancer is situated in the rectum, a colostomy (ar-\\ntificial anus) will be of benefit. These operations are pal-\\nliative in nature and prolong life, at the same time making\\nit more comfortable. They are intended to allay the symp-\\ntoms of obstruction and to carry the fecal matter over a\\nnew route, not passing through and thus not irritating the\\ncancerous area. In some instances of inoperable cancer of\\nthe rectum curettage followed by the application of the\\nthermo-cautery is of benefit for a short period.\\nAside from these surgical means the treatment should\\nbe symptomatic. The diet should consist of foods con-\\ntaining plenty of nourishment but very little indigestible\\nresidue, thus forming only a small quantity of fecal mat-\\nter. If there is stagnation of the intestinal contents,\\ncathartics will have to be given in order to liquefy the\\nfecal matter. This can be done by means of castor oil,\\nrhubarb, magnesium sulphate, and so on. If the neoplasm\\nis located in the large bowel, irrigations with warm oil or\\nwater are preferable. The pains should be allayed by\\nmeans of warm baths and cataplasms, but if these fail,\\nby narcotic remedies, such as morphine, opium, codeine,\\nor belladonna; suppositories being here most suitable.\\nEventual complications should be treated as such.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0185.jp2"}, "186": {"fulltext": "166 DISEASES OP THE INTESTINES.\\nSarcoma and Lympho- Sarcoma.\\nSarcoma of the intestine is a much rarer affection than\\ncancer. According to Kundrat, J in the Wiener Allgemeine\\nKrankenhaus between the years 1882 to 1893 there were\\n2,125 autopsies on cases of cancer. Of this number 243\\nwere cancers of the intestines. In the same period of time\\nthere were 274 necropsies on patients with sarcoma, of\\nwhich 3 were located in the intestines. Among 61 lympho-\\nsarcomata 9 were in the intestines. On the whole the\\nsymptomatology of these malignant neoplasms coincides\\nwith that of cancer of the intestines. There are, however,\\na few points in which they differ from intestinal cancer.\\nWhile carcinoma is most frequently found in the lower\\nportions of the large bowel, sarcoma shows a greater predi-\\nlection for the small intestine and the upper portion of the\\nlarge bowel. Thus, according to Nothnagel, among 9 cases\\nof sarcoma of the intestines 1 was located in the duode-\\nnum, 3 in the jejunum, 3 in the ileum, and 2 in the caecum.\\nSarcoma of the intestines shows very rapid progress,\\nand metastases in other organs are very early found. The\\nduration of life is much shorter than in cancer, being in\\nmost cases about but nine months. There is only one in-\\nstance mentioned in literature in which a patient lived one\\nand three-quarter years after the first appearance of symp-\\ntoms. Symptoms of obstruction which are so frequently\\nfound in cancer of the intestines are very rarely if ever met\\nwith in sarcoma. The tumor as a rule extends over a large\\npart of the intestines, but does not occlude the canal.\\nCachexia and anaemia belong to the early symptoms, and\\nare much more pronounced than in cancer. The progno-\\n1 Kundrat Gerhardt s Handbuch der Kinderkrankheiten, Bd. iv.,\\n2te Abtheilung, Tubingen, 1880.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0186.jp2"}, "187": {"fulltext": "BENIGN TUMORS. 167\\nsis of this form of tumor of the intestines is absolutely\\nfatal. Even in cases in which an operation is performed\\nquite early, it is as a rule not of much benefit on account\\nof the numerous metastases which develop so early and\\non this account Madelung even hesitates to advise surgi-\\ncal interference.\\nBENIGN TUMORS OF THE INTESTINE.\\nOf the benignant neoplasms the following forms are\\noccasionally met with in the intestine: adenoma, fibro-\\nma, lipoma, myoma, angioma, arid cyst. These growths\\nare termed polypi if they have a pedicle. Occasionally\\nthey have a large base and form only a small prominence\\nover the surface. The polypi are usually of small size,\\nthat of a cherry or plum rarely they are larger, pear-sized\\nor greater still. As a rule they are covered with normal\\nmucous membrane. Although they are found almost every-\\nwhere in the intestinal tract, they occur most frequently iu\\nthe rectum (according to Rosenheim in eighty per cent).\\nAmong the benign tumors the adenomata are most fre-\\nquently met with. They arise from the mucosa, have a\\ntypical acinous structure, and are attached to the mucous\\nmembrane either by a broad base or by a pedicle. In the\\nlatter instance they form polypoid excrescences which may\\ncover long distances of the intestinal canal, existing in large\\nnumbers. Ewald refers to a specimen in his possession in\\nwhich the inner wall of the colon was covered from the\\nsplenic curvature to the sigmoid flexure with such numer-\\nous polypi that they projected from the mucous membrane\\nlike tassels from a ribbon. The whole specimen looked\\nsomewhat like a gigantic bunch of grapes. The polypi are\\nmost often met with in children from the fourth to the\\n1 Madelung Centralbl. f, Chirursie. 189-2. No. 30.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0187.jp2"}, "188": {"fulltext": "168 DISEASES OF THE INTESTINES.\\nseventh year, although they also occur in grown-up per-\\nsons.\\nWith regard to symptoms the benign tumors located in\\nthe upper parts of the intestinal tract cause hardly any\\ndisturbances at all. Sometimes, however, especially if\\nthey are present in larger numbers, they may give rise to\\nhemorrhages and catarrhal affections. On account of their\\nsmall size and soft consistency it is almost impossible to\\ndiscover them by palpation through the abdominal wall.\\nIn very rare instances they may give rise to serious symp-\\ntoms by occluding the intestinal lumen or by causing in-\\nvagination. The benign tumors located in the rectum\\nmore frequently give rise to disturbances. Thus tenesmus\\nand difficult defecation are often met with; hemorrhages\\nalso occur frequently. Sometimes such a polypus, if situ-\\nated near the anus, may protrude through this openiog\\nduring defecation and give rise to severe pains. Occasion-\\nally a polypus is torn off from the intestinal wall and\\npassed with the stools. In such an event the symptoms,\\nif there have been any, suddenly disappear.\\nWhenever these tumors are situated in the lower rec-\\ntum they are accessible to direct examination and treat-\\nment. The latter consists in removing them by galvano-\\ncautery or by direct surgical measures.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0188.jp2"}, "189": {"fulltext": "CHAPTER VII.\\nHEMOKKHOIDS.\\nSynonyms Phlebectasia hemorrhoidalis. Piles.\\nDefinition. Diffuse or circumscribed varicose dilata-\\ntions of the hemorrhoidal veins situated either in the sub-\\ncutaneous tissue of the external surface of the anus or in\\nthe submucous tissue of the lower portion of the rectum.\\nEtiology. The affection under consideration is quite\\nfrequently met with. It occurs more often in men than in\\nwomen and very rarely in children. While in olden times\\nit was believed that hemorrhoids were due to a faulty state\\nof the general circulation or dyscrasia, it is now generally ac-\\ncepted that they are the result of merely local disturbances.\\nThe development of hemorrhoidal varices takes place in\\nthe same manner as that of varices of other regions of the\\nbody, principally by mechanical influences. The reason\\nwhy these phlebectases are formed so often in the hemor-\\nrhoidal plexus is as follows: 1. The hemorrhoidal veins\\noccupy a low position of the body, no matter whether in\\nthe standing or in the recumbent posture. 2. They are\\noften unduly compressed by the contraction of the muscles\\nsituated in the lower end of the rectum and by fecal masses\\naccumulated here. The circulation is thus at certain times\\nobstructed or altogether arrested. 3. The hemorrhoidal\\nveins are not provided with valves, and thus blood which\\nhas passed through them can be easily forced back. 4.\\nThe rectal veins are the remotest branches of the portal", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0189.jp2"}, "190": {"fulltext": "170 DISEASES OF THE INTESTINES.\\nvein in which there is normally but a low degree of pres-\\nsure, and in which circulation is easily retarded by dis-\\nturbances of the liver. As all these factors exist even\\nunder normal conditions it is readily conceivable that\\nphlebectases are found in the majority of people; usually,\\nhowever, they do not reach a marked development, and\\nfor this reason do not give rise to complaints.\\nAll conditions which tend to produce lasting hyperemia\\nof the lower portion of the rectum give rise to the develop-\\nment of hemorrhoids. Too prolonged sedentary or stand-\\ning occupations predispose to them. In this way hemor-\\nrhoids occur in clerks, students, some artisans, for instance,\\nshoemakers, tailors, and cavalrymen, seamstresses and\\nwashwomen, etc. High livers and people who are used\\nto strongly seasoned or fatty foods also often suffer from\\npiles on account of the great fulness of the portal circula-\\ntion under these conditions. Habitual constipation also\\nfavors their development. The use of strong cathartics\\nlike aloes, colocynth, gamboge, etc., irritates the large\\nbowel in a marked degree and often gives rise to hemor-\\nrhoids. Diseases of the uterus which lead to an enlarge-\\nment of this organ and also pregnancy are predisposing\\ncauses. In a similar way affections of the prostate and\\ntumors of the bladder as well as of other organs situated\\nin the small pelvis often produce hemorrhoids. All dis-\\neases of the liver which are accompanied by a congestive\\nstate of the portal circulation exert a direct influence upon\\ntheir formation. Diseases of the heart and lungs fre-\\nquently cause congestion of the inferior vena cava and\\nindirectly also of the rectal veins, thus predisposing to\\nthe affection under consideration.\\nHemorrhoids are most frequently developed between the\\nages of thirty and fifty years. They are extremely rare", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0190.jp2"}, "191": {"fulltext": "HEMORRHOIDS. 171\\nin infants and children. With regard to frequency the\\nmale sex seems to be more often afflicted than the female.\\nSome races show a special predisposition to this disease,\\ndepending most probably upon their mode of living and\\ntheir diet. Whether heredity plays a part in the develop-\\nment of hemorrhoids is yet unsettled.\\nMorbid Anatomy. In some instances the hemorrhoidal\\nveins are evenly dilated and can be noticed as bluish-red\\nand tortuous vessels encircling the external anal opening.\\nAt the same time there may be no special varicose swell-\\nings; more frequently, however, besides the general con-\\ngested condition of the veins there are isolated varicose\\nprotrusions which may range in size from a pea to a wal-\\nnut. They vary greatly in shape: sometimes they are\\nround, sometimes flat, sometimes again irregular. Their\\nsize greatly changes from time to time in the same person.\\nAfter defecation as a rule they grow smaller. Internal\\nhemorrhoids appear as soft nodules of a bluish hue and\\nhave thin walls. They often develop to a considerable\\nsize and make defecation difficult. As a rule, hemorrhoids\\noccur as multiple nodules, which may cover the mucous\\nmembrane at different places, or they may encircle the\\nexternal surface of the anus, or be situated above the inter-\\nnal sphincter. Internal and external hemorrhoids may\\nalso be present at the same time. Thus Cruveilhier de-\\nscribed a case in which there existed a wreath of external\\nhemorrhoids around the anal opening, another above the in-\\nternal sphincter, and a third a few centimetres farther up.\\nExternal hemorrhoids are at first covered with normal\\nepidermis which can be moved over them. Later, how-\\never, through inflammatory processes the cutis becomes\\nadherent to the varicose nodule. At the same time the\\n1 Cruveilhier Traite d anatomie pathologique generate, 1849.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0191.jp2"}, "192": {"fulltext": "172 DISEASES OF THE INTESTINES.\\nskin covering the nodule grows thinner through the steady\\npressure to which it is subjected, and it may reach a point\\nwhen it breaks open after a forced defecation. The same\\nremarks also apply to internal hemorrhoids in which the\\ncutaneous covering of external hemorrhoids is represented\\nby the mucous membrane of the bowel. This also be-\\ncomes adherent, thinned, and may ultimately rupture.\\nInternal piles are best divided, according to Allingham, 1\\ninto the three following varieties\\n1. Capillary Piles. These present small, florid, rasp-\\nberry-looking tumors or rather vascular areas upon the\\nmucous membrane, having a granular spongy surface and\\nbleeding on the slightest touch; they are often situated\\nrather high in the bowel in structure they consist almost\\nentirely of hypertrophic capillary vessels and. spongy con-\\nnective tissue. They resemble arterial nsevi very closely,\\nindeed, in their microscopical structure, except that they\\nare covered externally by a very much thinner membrane\\nand consequently are readily made to bleed.\\n2. Arterial Piles. These appear as tumors varying in\\nsize, sessile or somewhat pedunculated, attaining sometimes\\nvery considerable dimensions, glistening or slightly villous\\non their surface, slippery to the touch, hard and vascular\\nwith an artery often as large as the radial entering their\\nupper part. When they are villous on their surface, they\\nbleed very freely and for some reason or other have formed\\nand grown very rapidly. On dissecting one of these tumors\\none will find that it consists of numerous arteries and\\nveins frequently anastomosing, tortuous, and sometimes\\ndilated into pouches, and of a stroma of cell growth and\\nconnective tissue, the latter most abundant.\\n1 William Allingham and Herbert W. Allingham: The Diagnosis\\nand Treatment of Diseases of the Rectum. London, 1896, p. 113.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0192.jp2"}, "193": {"fulltext": "HEMORRHOIDS. 173\\n3. Venous Piles. In these the venous system predomi-\\nnates. The tumors are often very large and are sometimes\\nthe size of a hen s egg. They are bluish or livid in color.\\nThe surface may be smooth and shiny or pseudocutaneous.\\nExternal and internal piles often present themselves as\\nnodules situated closely to each other and sometimes coa-\\nlescing thus larger tumors arise. In these hemorrhoidal\\nvarices important structural changes frequently take place.\\nWhile at first soft, they may grow quite hard by the for-\\nmation of blood clots or by a process of calcification. In-\\nflammatory processes in the neighboring tissue have a\\ntendency to increase their size and to make them more\\nfirm.\\nInternal piles are often pushed downward during the act\\nof defecation. In this manner the mucous membrane of\\nthe base of the tumor is subjected to greater traction, and\\nthus ultimately a pedicle is formed. Such nodules pro-\\nvided with more or less long pedicles and situated near\\nthe internal sphincter very frequently slip out from the\\nanus at each defecation. When, however, they are not\\nespecially large, they spontaneously return into the rectum\\nafter defecation is finished. If they are of considerable\\nsize, it sometimes happens that they become incarcerated\\nby the external sphincter, and if not carefully replaced,\\ninflammation may develop and give rise to intense pains.\\nOccasionally they may even become gangrenous and ulti-\\nmately drop off. In some instances hemorrhoids undergo\\nretrograde changes, become smaller, and even disappear\\nentirely. Flaps of skin hanging near the anus and pre-\\nsenting a brownish color are often the remnants of pre-\\nvious piles. External piles sometimes give rise to the\\nformation of warts and their surface assumes an uneven\\nand wrinkled appearance. Internal hemorrhoids are often", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0193.jp2"}, "194": {"fulltext": "174 DISEASES OF THE INTESTINES.\\ncomplicated by inflammatory processes of the neighboring\\ntissues. Such processes give rise to the formation of ul-\\ncers, proctitis, and periproctitis. In the latter instance\\nan abscess may be formed, which may open either exter-\\nnally or internally, sometimes both ways. Thus a com-\\nplete rectal fistula originates.\\nIn internal hemorrhoids the mucous membrane of the\\nrectum almost always exhibits the signs of a chronic ca-\\ntarrh. Its surface is swollen, succulent, and often covered\\nwith a thick layer of mucus. Occasionally there may be\\nsome pus. The proctitis accompanying piles may be either\\nthe cause or the sequel of the latter sometimes, however,\\nboth may be due to some other factor.\\nSymptomatology. Most of the symptoms produced by\\nhemorrhoids are generally of a local character. They\\ngreatly vary in the different varieties of piles. In the\\nearly stage of external pile there occur off and on, espe-\\ncially after indiscretions in eating and drinking (princi-\\npally effervescent wines or strong alcoholic beverages),\\nattacks caused by an increased congestion- of the hemor-\\nrhoids. These attacks may be described as follows: A\\nsensation of fulness or clogging and slight pulsation in the\\nanus are felt by the patient. Moderate constipation exists,\\ncompelling the patient to strain more than ordinarily.\\nItching of the anal region and the perineum frequently\\nannoy the patient, especially soon after retiring, and may\\nkeep him awake for quite some time. On awaking in the\\nmorning the patient finds the anus tender and swollen,\\nand after a movement a few stains of blood are discov-\\nered on the paper. Such an attack will, as a rule, pass off\\nvery quickly if the patient lives rationally and avoids the\\npredisposing causes if not, the attack will quickly recur\\nwith greater intensity and gradually assume a severer type.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0194.jp2"}, "195": {"fulltext": "HEMORRHOIDS. 175\\nExternal piles may become swollen and oeclematous, and\\nare then extremely painful to touch. Sometimes there\\nmay be ulceration, or suppuration may take place and\\nsmall painful fistulse may form. The venous tumors now\\nand then irritate the sphincter and levator ani muscles and\\nproduce spasm of the latter. The piles are then occasion-\\nally drawn up into the anus and pinched by the latter.\\nThis causes a great deal of pain and keeps the patient\\nawake during the night. A feeling of throbbing and a\\nsensation as of a foreign body in the anus exist. A fre-\\nquent desire for defecation is thereby produced and the\\npatient, as a rule, is inclined to attempt to expel the for-\\neign body by forcible straining, which of course only\\naggravates the pain. Under these circumstances the\\npatient can hardly sit down nor can he walk about com-\\nfortably, and on coughing and sneezing experiences great\\nsuffering on account of the constriction of the involved\\ndiseased parts. During a movement of the bowel and for\\nsome hours afterward the pains are greatly increased.\\nThe patient is unable to attend to his daily occupation.\\nGeneral symptoms like fever, anorexia, dizziness, severe\\nconstipation, may accompany the local manifestations.\\nOf the internal hemorrhoids, the capillary variety, being\\nsmall and only slightly elevated above the mucous surface,\\ngives rise to scarcely any trouble. As a rule, there is no\\npain. Occasionally, however, ulceration takes place which\\nmay cause considerable suffering.\\nArterial and venous hemorrhoids give rise to many more\\nsymptoms. In case the sphincter muscles are relaxed, the\\nhemorrhoids often protrude on the slightest exertion.\\nThis also often occurs at stool. At first they spontane-\\nously return within the sphincter after the bowels have\\nmoved or whenever the exertion has ceased. Later in the.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0195.jp2"}, "196": {"fulltext": "176 DISEASES OP THE INTESTINES.\\ncourse of the disease, however, the patient is compelled to\\nreturn them with the finger. In still more advanced cases\\nthey never remain long within the sphincter and pro-\\ntrude very often whenever the least exertion is made. In\\nthis manner the hemorrhoids cause much discomfort.\\nThey also discharge a gummy acrid mucus which keeps\\nthe parts constantly moist and leads to excoriations around\\nthe anus, and also favors the development of cutaneous\\nexcrescences. Patients with fully developed internal hem-\\norrhoids experience a great deal of suffering during defe-\\ncation. They also feel quite uncomfortable for some time\\nafterward, occasionally to such a degree that they have to\\nlie down. When walking they are always conscious of the\\nfact that they have an anus.\\nIn other instances in which the sphincter ani is strong\\nand tight, the piles in coming down become nipped and\\ntheir return is rendered difficult and painful.\\nThe symptom from which the hemorrhoids originally\\nderived their name, namely, hemorrhage, is common to all\\nvarieties of piles, although it is by no means constant. In\\nmany instances it is absent, or it does not play any essen-\\ntial part, especially in external piles. In some patients a\\nmore or less considerable hemorrhage takes place at cer-\\ntain intervals, appearing periodically, occasionally with\\ngreat regularity. A few premonitory signs, consisting in\\npainful sensations in the back and around the anus, con-\\nstipation, and other indefinite nervous symptoms usually\\nprecede for a few days the beginning hemorrhage. The\\nblood as a rule then appears at first in small quantities\\ngradually increases in amount, and the hemorrhage stops\\non the fifth or sixth day after its commencement. Physi-\\ncians in olden times and some of the laity even nowadays\\nlooked upon the hemorrhage as an important event, free-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0196.jp2"}, "197": {"fulltext": "HEMORRHOIDS. 177\\ning the system of vicious material. This is the reason why\\nformerly the hemorrhoidal bleeding was termed the golden\\nflow. Nowadays we do not attach any particular import-\\nance to these hemorrhages. Their regularity or the perio-\\ndicity of their appearance is simply attributable to the\\nfact that the time necesary for the filling up of the nodules\\nuntil they rupture is usually of the same length.\\nIn some instances there are transient hemorrhages, last-\\ning a shorter or longer period. Ordinarily the patients feel\\nrelieved after the bleeding occasionally they remain quite\\nwell for a long time, sometimes for a year or two, until\\nthere is suddenly a new hemorrhage. In the latter case\\nthe hemorrhage is commonly caused by some unusual oc-\\ncurrence thus, a very copious meal, a long ride on horse-\\nback, or an excess in venery may bring it on.\\nIn another class of patients there may be continuous\\nsmall hemorrhages. These occur more frequently in cases\\nof capillary hemorrhoids. The quantity of blood lost at\\neach action of the bowel is small, but being steady it be-\\ncomes a serious strain upon the patient s constitution and\\nmay give rise to severe forms of anaemia and even per-\\nnicious anaemia.\\nThe blood discharged from piles is either of a bright\\nred or a dark brown color, depending upon its origin from\\narteries or veins. It is characteristic of hemorrhoidal\\nhemorrhages that the blood usually appears in a liquid,\\nnon-coagulated state, covering the fecal matter, but not\\nmixed with it. If the hemorrhage is very copious, uncon-\\nsciousness may result combined with symptoms of pro-\\nfound collapse. This, however, happens very rarely. Ac-\\ncompanying the local manifestations, especially if the latter\\nare of a high degree, there may be varied general symp-\\ntoms. Thus dvspncea, palpitations of the heart, angina\\n12", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0197.jp2"}, "198": {"fulltext": "178 DISEASES OF THE INTESTINES.\\npectoris, irregular heart action, hiccough, headaches, gid-\\ndiness, dizziness, buzzing in the ears, and cloudy vision\\nmay be present. Often a despondent feeling and a condi-\\ntion resembling hypochondria is met with. Anorexia,\\nnausea, belching, and constipation also often occur. The\\ngeneral symptoms are especially marked if incarceration\\nof internal piles within the sphincter has taken place. In\\ncase the swelling of the hemorrhoids is so extensive that\\na reposition cannot be quickly effected, there may be pres-\\nent besides the local pains high fever and signs of col-\\nlapse. If the incarceration lasts a long period, the hem-\\norrhoids may become gangrenous and either fall off,\\naccompanied by profuse hemorrhage, or, although rarely,\\ngive rise to septic and peritonitic conditions. In most\\ninstances after a falling off of the hemorrhoid a sponta-\\nneous cure takes place.\\nSome cases of hemorrhoids are complicated with catarrh\\nof the rectum (proctitis). In such instances the stools\\nreveal the presence of a considerable quantity of mucus,\\noccasionally even of pus. Sometimes the mucous or mu-\\nco-purulent fluid admixed with the faeces may be tinged\\nwith blood. These cases are often accompanied by a\\nparetic condition of the sphincters, which allow the secre-\\ntion to dribble from the anus. This gives rise to excoria-\\ntions and inflammation of the anus and the neighboring\\ntissues. In the course of the proctitis prolonged tenesmus\\nmay appear at times. If the inflammation extends into the\\nrectal cellular tissue, it may lead to the formation of ab-\\nscesses which may empty into or outside the bowels. This\\nis the most frequent way in which fistulas are produced.\\nDisturbances of the adjacent organs are also occasion-\\nally met with in cases of piles. Thus ischuria, stranguria,\\nhemorrhages from the bladder, hemorrhages from the va-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0198.jp2"}, "199": {"fulltext": "HEMORRHOIDS. 179\\ngina, and catarrhal conditions of the latter are encoun-\\ntered.\\nDiagnosis. The diagnosis of hemorrhoids as a rule is\\neasy. External piles are found by inspection of the anus,\\nthe patient lying on his side with the thighs drawn up.\\nThe buttocks are pushed aside with the hands, and the\\npatient is instructed to strain in a similar manner as when\\nhaving a stool. Nodules of a reddish-bluish tinge will be\\nnoticed in the immediate vicinity of the anus or partly\\nwithin it. It is characteristic of hemorrhoidal nodules\\nto increase in size during a period of constipation, and to\\ndiminish after an efficient evacuation of the bowels.\\nCondylomata and small skin tags around the anus can be\\neasily differentiated from piles. Condylomata, as a rule,\\nencircle the anus and are present also on other parts of the\\nbody, especially on the scrotum. Besides, there will be\\na previous history of syphilis, and occasionally other lue-\\ntic manifestations. The cutaneous tags present more the\\nappearance of whitish-looking skin, never change in size,\\nand do not bleed when punctured, while hemorrhoids\\nbleed profusely on puncture.\\nThe diagnosis of internal hemorrhoids can be made by a\\ndigital examination or by this in connection with the in-\\nspection of the lower portion of the rectum by means of a\\nspeculum. The characteristics of internal piles are similar\\nto those of external hemorrhoids. They can be easily\\ndifferentiated from polypi by means of puncture with the\\nneedle. Polypi do not bleed when punctured. Besides,\\npolypi are usually found in children, while hemorrhoids\\noccur with greatest frequency in the advanced period of\\nlife.\\nCarcinoma of the rectum will rarely give rise to mistakes,\\nthe tumor usually presenting a much harder consistency", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0199.jp2"}, "200": {"fulltext": "180 DISEASES OF THE INTESTINES.\\nthan hemorrhoids. As a rule, there will also be other\\nsigns of a malignant trouble, cachexia, etc. It is needless\\nto say that cancer of the rectum may be combined with\\nhemorrhoids. As a matter of fact, it very often gives rise\\nto their development, and the discovery of piles which\\nhave formed within a short period of time should indeed\\nrouse the suspicion of cancer of the rectum.\\nPrognosis. The prognosis of external as well as internal\\npiles is as a rule favorable. They generally exist for a\\nlong time, not infrequently throughout life. They hardly\\never endanger life, unless some grave complications (incar-\\nceration of the hemorrhoids or gangrenous processes or\\nvery profuse hemorrhages) supervene. Hemorrhoids are\\nliable to recede or even to disappear entirely, especially if\\nthe factors producing them have been eliminated.\\nTreatment. A rational mode of living is of the greatest\\nimportance. Patients with hemorrhoids should have\\nplenty of outdoor exercise, should partake of food with\\nmoderation, should avoid all excesses in baccho and in\\nvenere, and should endeavor to have a daily evacuation of\\nthe bowels. Any condition causing venous hyperemia of\\nthe rectum must be removed. Thus vocations requiring\\nconstant sitting, or constant standing, or horseback riding\\nshould be entirely or partly given up.\\nWith regard to diet the following general rules may be\\ngiven: Patients with hemorrhoids should avoid copious\\nmeals. They should rather eat often and sparingly. Fish,\\nfresh, well-cooked vegetables, and ripe fruit should form a\\nconsiderable part of their diet. Alcoholic beverages, strong\\ncoffee, and highly seasoned dishes should be avoided. The\\ndifferent kinds of cheese, very coarse brown bread, cabbage,\\npeas, and beans are best eliminated from the diet. Salads,\\npotatoes, beets, spinach, asparagus, cauliflower, are, how-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0200.jp2"}, "201": {"fulltext": "HEMORRHOIDS. 181\\never, rather of benefit if taken in small quantities, as these\\narticles make the intestinal contents more liquid. Stewed\\nfruits and also raw fruit, as for instance apples, pears,\\nprunes, oranges, grapes, are useful. As a beverage, plain\\nwater, best taken between meals in the quantity of a pint,\\nis most beneficial.. In some instances, especially in anae-\\nmic patients, buttermilk in the same quantity may be\\ntaken instead of water. A small amount of light beer is\\npermissible in some cases.\\nWith reference to hygiene or prophylactic measures it\\nis of importance for the patients to have plenty of outdoor\\nexercise, especially walking. The exercise, however, should\\nnot be continued to over-fatigue. Gymnastic exercises at\\nhome, sawing or chopping wood, and the like, and also\\nmassage are best adapted for this purpose. The patients\\nshould wash the affected part in the morning and evening\\nwith cool water. They should sit on caned chairs, not on\\nupholstered ones, and should sleep on a mattress.\\nThe patient should have a good evacuation of the bowels\\ndaily. In case this does not occur, it will be of the great-\\nest importance to secure it by the different therapeutic\\nmeasures at our disposal (see Chapter X., on constipa-\\ntion). As a rule, however, powerful laxative and drastic\\nremedies should be avoided. The frequent use of injec-\\ntions had also best be omitted. The purgatives most\\nadapted for these patients are the saline ones, sulphur and\\nrhubarb drugs. Thus compound licorice powder, a tea-\\nspoonful in the evening, or sulph. depur., potas. bitartrat.\\naa, also one teaspoonful in the evening. Rhubarb in the\\nform of tincture or in substance 0.5 to 1 gm., taken once\\nor twice daily, is also advantageous for a prolonged use.\\nThe waters of Carlsbad, Kissingen, Marienbad, Tarasp,\\nSaratoga, will also be of benefit, especially if taken at the", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0201.jp2"}, "202": {"fulltext": "182 DISEASES OF THE INTESTINES.\\nwatering-places themselves in connection with a prescribed\\ndiet. If the hemorrhoids have already attained consider-\\nable size, local remedies will often be required.\\nLocal Treatment. The irritation or the rubbing of the\\npiles against each other or against the skin must be pre-\\nvented. For this purpose covering the piles with a small\\npiece of smooth and clean cotton is of benefit still better,\\nhowever, for this purpose is cotton moistened in olive oil\\nor covered with vaseline or a soft salve (Hebra s ointment\\nor ointments of zinc, lead, boracic acid) If the piles are\\ninflamed, it is best to first paint them a few times with the\\nfollowing solution:\\nPotas. iodidi 2.0 3 ss.\\nIodi puri 0. 2 (gr. iiiss.\\nGlycerin 40.0 3 x.)\\nbefore applying the ointment. After a movement the anus\\nand the piles should be first washed with cool water and\\nthen wiped off with soft cotton or linen. This must be\\ndone very gently. Persons suffering with annoying tenes-\\nmus after defecation should accustom themselves to go to\\nstool before retiring. The recumbent position which the\\npatients are thus able to assume soon after the passage\\naffords them decided relief.\\nIf there are pains in the rectum caused by a mere hyper-\\nesthesia of the mucous membrane, an injection of one to\\ntwo teaspoonfuls of warm olive oil or of the same quantity\\nof warm water into the bowel will exert a favorable influ-\\nence. If this fails, or in cases in which the pains are\\ncaused by a superficial excoriation of the piles, it is best\\nto apply an ointment containing some narcotic after an\\nevacuation of the bowels, and sometimes even during the\\nintervals. The following salve, recommended by Kosen-\\nheim, is very appropriate", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0202.jp2"}, "203": {"fulltext": "HEMORRHOIDS. 183\\nLanolin 20.0 3 v.\\nBism. subnitr 2.0 3 ss.)\\nExtr. opii 0.3 (gr. v.)\\nM. f. ungt.\\nIn place of the ointment the piles may be painted with a\\nsolution containing equal parts of fluid extracts of opium\\nand belladonna, or with a two-per-cent cocaine solution.\\nSuppositories containing opium, belladonna, or cocaine\\nare also effectual.\\nInternal piles prolapsing through the anus should be\\npushed back by the patient after anointing them with olive\\noil or with vaseline. In case the reposition is not easy,\\npainting of the piles with a two-per-cent cocaine solution\\nwill after a while lessen the sensitiveness and thus make re-\\nposition possible. In some obstinate cases the patient must\\nbe narcotized in order to accomplish this. If the incarcerat-\\ned piles have already become gangrenous, the pains usually\\ngrow less. In order to arrest the necrotic process it is\\nadvisable to dust the affected area with an antiseptic powder\\n(dermatol) and to cover it with dry gauze. The pile usu-\\nally falls off spontaneously and the wound heals of itself.\\nThe inflammatory processes in piles require special\\ntreatment in the stage of exacerbation (general antiphlo-\\ngistic remedies) Thus rest in bed on the side, applica-\\ntion of cold in the form of an icebag or a Priessnitz poultice,\\noccasionally leeches in the neighborhood of the anus, not\\non the piles themselves. Application of cold lead water is\\nalso useful. In case there are signs pointing to the forma-\\ntion of pus or the development of a septic process, surgical\\nintervention is imperative. An incision into the hardened\\npiles followed by thorough extirpation is essential. Inas-\\nmuch as such an operation must be done under chloroform\\nnarcosis, the radical removal of the entire hemorrhoidal\\narea is therefore best performed at the same time.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0203.jp2"}, "204": {"fulltext": "184 DISEASES OF THE INTESTINES.\\nHemorrhoidal hemorrhages, if not extensive, and if occur-\\nring at long intervals, will hardly require any therapeutic\\nmeasures. If, however, the quantity of blood is quite con-\\nsiderable or if the hemorrhage is protracted, the following\\nmeans should be employed An icebag should be applied\\nto the anus for several hours, or in case the hemorrhage\\nresults from internal piles, a cylindrical piece of ice is\\npushed up into the anus and replaced every half-hour.\\nThe rectal refrigerator may likewise be used with benefit.\\nVery cold injections are also useful. In cases with very\\nfrequent hemorrhages injections of water, to which an as-\\ntringent remedy has been added, are beneficial. Thus a\\ntwo-per-cent solution of tannic acid or of alum, or a 0.3-\\nper-cent solution of acetate of lead may be applied. The\\nfollowing ointment, first suggested by Kossobudskj, 1 may\\nalso be applied in these cases\\n1$ Chrysarobin 0.8 (gr. xiij.)\\nIodoform 0. 3 (gr. v.)\\nExtr. bellad 0. 6 (gr. x.)\\nVaselini 15.0 ss.)\\nM. f. ungt.\\nThis salve not only checks the hemorrhage, but has also\\nan excellent effect in reducing the size of the pile. In in-\\nternal hemorrhoids the following suppository may be used\\nfor the same purpose\\n3 Chrysarobin 0. 1 (gr. if)\\nAcidi tannici 0.1 (gr. if)\\nIodoform 0. 2 (gr. iiif)\\nExtr. opii 0.02 (gr. f)\\n01. theobrom 2.0 (3 ss.)\\nM. f. Suppository. S. One suppository in the evening.\\nKossobudskj Centralblatt fur Chirurgie, 1889.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0204.jp2"}, "205": {"fulltext": "HEMORRHOIDS. 185\\nBadical Treatment. 1. Dilatation of the Sphincters.- Ver-\\nneuil l was the first to recommend dilatation of the sphinc-\\nters as a cure for piles. This treatment is based upon the\\nidea that the spasm of the sphincter is thereby stopped,\\nthat the bowels act more freely and the pressure upon the\\nvenous blood-vessels is relieved. The dilatation of the\\nsphincters may be accomplished gradually by introducing\\nspecula into the rectum, taking a larger size each time,\\nwhich procedure occupies several weeks, or it may be done\\nin one sitting (the so-called forcible dilatation). In the\\nlatter instance, however, chloroform narcosis is necessary.\\nComplete dilatation is effected, according to Allingham 5 in\\nthe following way The patient being fully under the influ-\\nence of ether or chloroform, both thumbs must be inserted\\ninto the rectum, which is to be dilated gradually, first in\\nthe antero-posterior and afterward in the opposite direc-\\ntion. The amount of force used must be sufficient to over-\\ncome the spasm thoroughly. This manipulation must be\\ncontinued until the sphincter muscles yield, as if reduced\\nto a really pulpy condition. Care must be taken to act\\nhigh enough up in the rectum so as to include the whole\\nof the sphincter. The result is that the state of contrac-\\ntion is abolished and no spasm can occur. In fact, for the\\ntime being, as in any other stretched muscle, paralysis re-\\nsults. With great gentleness the desired effect may be ac-\\ncomplished without tearing the mucous membrane. But\\nsome extravasation is usually noted around the anus for a\\nfew days. After this an opium suppository is kept in the\\nrectum and the patient is placed in bed in a recumbent\\nposition. Dilatation of the sphincters may be recoup\\nmended in the early stage of hemorrhoids, especially in\\ncases combined with constipation further in hemorrhoids\\n1 Verneuil Gazette des hop., 1884, 1887.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0205.jp2"}, "206": {"fulltext": "186 DISEASES OF THE INTESTINES.\\nduring pregnancy or occurring in persons greatly debili-\\ntated by other grave diseases.\\n2. Carbolic-Acid Injections. Pooley, 1 Kelsey, 2 Roux, 3 and\\nLange 4 have recommended injections of carbolic acid into\\nthe piles in order to produce shrinking. This method is per-\\nmissible only if the hemorrhoids are not inflamed. Proceed\\nas follows: The piles are first thoroughly cleansed and\\ndried, then covered with iodoform salve. In order to\\nlessen the pains a few drops of a one-per-cent cocaine so-\\nlution may first be used subcutaneously. Then three to\\nfive drops of either of the two following solutions are in-\\njected into theceutre of each pile: (1) Carbolic acidl, gly-\\ncerin 3; (2) Carbolic acid 1, glycerin 3, distilled water 3.\\nThe injection is made with the common Pravaz syringe,\\nbut care must be taken that none of the solution drips from\\nthe needle, so as to avoid cauterizing the mucous mem-\\nbrane. Several piles can be treated at the same sitting.\\nIt is advisable, however, not to. make the injections oftener\\nthan about once a week. This procedure if carefully done\\nis not dangerous nor painful, and often effects shrinking\\nor even disappearance of quite considerable hemorrhoidal\\nnodules.\\n3. Cauterization icitli Fuming Nitric Acid. Houston, 5 of\\nDublin, was the first to recommend cauterization of piles\\nwith fuming nitric acid. This may be done in the follow-\\ning manner After thorough cleansing and drying of the\\nanus and the surrounding parts, the entire area is covered\\n1 J. H. Pooley Injection of Carbolic Acid in Hemorrhoids. To-\\nledo Med. and Surg. Journal, November, 1877, No. 11.\\n2 Charles B. Kelsey The Treatment of Hemorrhoids. Medical\\nRecord, 1886, vol. ii., p. 141.\\n3 Roux Behandlung der Hamorrhoiden. Therap. Monatshefte,\\n1895, p. 124.\\n4 F. Lange Centralblatt fur Chirurgie, 1887, No. 25, Beilage, p. 70.\\n5 Houston Dublin Journal of Medicine, 1844.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0206.jp2"}, "207": {"fulltext": "HEMORRHOIDS. 187\\nwith a thick layer of vaseline excepting the pile which is\\nto be treated. The latter is then painted with nitric acid\\nby means of a small stick of wood or a glass rod. Special\\ncare must be taken that the acid reaches no other spot.\\nAfter the nodule has assumed a grayish-green color it is\\ncarefully dried, smeared with vaseline, and pushed back\\ninto the rectum. This method is best adapted for smaller\\nnodules, especially if they have a wide base. Sometimes\\na second cauterization is necessary, which may be done\\nafter an interval of about five days or a week. Instead of\\nnitric acid other cauterizing substances may be used, and\\nAllingham has recommended concentrated carbolic acid as\\nespecially efficient for this purpose.\\n4. Ligature. Cooper J recommended the ligature of hem-\\norrhoids in order to cut them off from the circulation and\\nthus destroy them. Salmon 2 has improved this method\\nby making an incision before applying the ligature. Ac-\\ncording to this writer, the operation is performed in the\\nfollowing manner The patient is placed on the right side\\non a hard couch and is completely anaesthetized. The\\nsphincter muscles are then gently but completely dilated.\\nThe hemorrhoids, one by one, are then drawn down with a\\npronged hook fork by means of sharp scissors the pile is\\nseparated from its connections with the muscular and sub-\\nmucous tissues upon which it rests. The cut is best made\\nin the sulcus or white mark which is seen where the skin\\nmeets the mucous membrane. This incision is made in a\\ndirection parallel to the bowel and carried to such a dis-\\ntance that the pile is left connected by an isthmus of vessels\\nand mucous membrane only. A well-waxed, strong, thin,\\naseptic silk ligature is now placed at the bottom of the deep\\n1 Cited from Allingham, loc. cit.\\n2 Ibid.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0207.jp2"}, "208": {"fulltext": "188 DISEASES OF THE INTESTINES.\\ngroove which has been made, and the ligature is tied right\\nat the neck of the tumor as tightly as possible. When all\\nthe hemorrhoids have thus been ligated, they should be\\nreturned within the sphincter. A small piece of absor-\\nbent cotton saturated with iodoform ointment is now\\nplaced into the bowel and a pad of cotton applied over the\\nanus.\\n5. Crushing. Crushing of piles has been suggested by\\nPollock and the method further improved by Allingham, x\\nwho devised a very ingenious apparatus for this purpose,\\nnamely, the screw-crushing instrument. The operation\\nbegins with the dilatation of the sphincters. The hemor-\\nrhoid is then drawn into the screw-crusher by means of a\\nhook, and this being intrusted to an assistant the bar is\\npushed up and screwed home as tightly as possible. The\\npile should be crushed longitudinally and not transversely.\\nThe projecting portion of the pile is cut off with the knife\\nor scissors and the pressure kept up for about one minute.\\nAccording to Allingham crushing is a very satisfactory\\nmethod of removing internal piles.\\n6. Thermo-cautery (PaqueUn) and Galvano-cautery Lan-\\ngenbeck introduced the method of operating upon piles\\nby means of thermo-cautery. Each pile is seized with a\\nvolsellum forceps and drawn well down. The clamp is\\nthen applied so as to embrace its base. The portion above\\nthe clamp is cut off with a pair of scissors and the cautery-\\niron, heated to a dull red heat, is repeatedly applied to the\\nstump until all the vessels are well seared.\\nInstead of using the Paquelin, galvano-cautery may be\\napplied for the removal of hemorrhoids, the technique\\nbeing identical with the former. Bardeleben and also Ko-\\nsenheim strongly recommend the latter method.\\n1 Allingham Diseases of the Rectum, 1896, p. 153.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0208.jp2"}, "209": {"fulltext": "HEMORRHOIDS. 189\\n7. Extirpation of Hemorrhoids, followed by Sidure. This\\nmethod was first introduced by von Esmarch 1 in Germany\\nand by Whitehead in England. It is not, however, exten-\\nsively used as it is quite complicated, besides giving rise to\\nmany disagreeable complications. Thus Allingham has\\nnoticed the following sequels of such an operation 1. Anal\\nstricture. 2. Loss of sensation and control over the\\nanus. 3. Irritation of the mucous membrane due to fre-\\nquent discharges of mucus and at times accompanied by\\nbleeding.\\nAfter any of the above-named operations it was customary\\nto employ an astringent in order to prevent a movement\\nof the bowels for a few days. Contrary to this method E.\\nGraser 2 is of the opinion that such patients are better off\\nwhen having a free movement shortly after the operation.\\nHe administers soon after its performance a small dose of\\ncastor oil and instructs the patient to have an evacuation\\nwhile in a warm sitz bath. Cleansing of the anus is very\\neasily obtained in this manner. After an antiseptic wash-\\ning a piece of cotton or linen, thickly smeared with an\\nointment, is introduced into the rectum. This procedure\\nhas usually to be performed once daily. According to\\nGraser, the patients if thus treated are almost without pain,\\nand are able to get up and be out of bed five or seven\\ndays after the operation. For some time after its perform-\\nance it is advisable to have the patient introduce bougies\\nof varying size into the rectum in order to prevent the for-\\nmation of a stricture.\\nComplications. Prolapse of the Rectum. Prolapse of the\\nrectum is a frequent complication of hemorrhoids, although\\nWon Esmarch: Die Krankbeiten des Mastdarms und Afters,\\nStuttgart, 1887.\\n2 E. Graser Penzoldt u. Stinzing, Handbuch d. Therapie, Bd. iv.,\\np. 634.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0209.jp2"}, "210": {"fulltext": "190 DISEASES OF THE INTESTINES.\\nit may also occur alone. The prolapse may involve either\\nthe mucous membrane alone or all the coats of the rectum.\\nIn the latter instance this condition is also called proci-\\ndentia recti. Outside of the anus there is a protrusion of\\nthe mucous membrane in its entire circumference. An\\ninternal prolapse of the rectum may also occur, which con-\\nsists in the descent of the upper part of the rectum through\\nthe lower part, but not appearing outside the anus. This\\ncorresponds rather to an intussusception. A relaxation of\\nthe ligaments which serve to keep the rectum in its place\\nis often the cause of this malady. Weakness and paralysis\\nof the sphincter ani muscles are also predisposing factors.\\nProlapse of the rectum is frequently found in debilitated\\nchildren, especially if an intestinal catarrh is present, for\\nthese little patients go to stool too often and usually strain\\ntoo much and for too long a time. These conditions weaken\\nthe muscular apparatus of the anus, and thus a prolapse of\\nthe rectum easily arises. In elderly people, in patients\\nsuffering from affections of the bladder or from severe\\nconstipation and internal hemorrhoids, and in women\\nwho have gone through many pregnancies in quick suc-\\ncession, prolapse of the rectum is also a frequent oc-\\ncurrence.\\nThe symptoms are as follows If the prolapse is only of\\na moderate degree, there appears in the act of defecation a\\nprotrusion of the rectum outside the anus, one or one and\\na half inches in length, the mucosa looking quite red and\\npuckered. In the more advanced stage the bulged out\\nrectum resembles a large tumor with a star-like opening\\nat its centre, while the color is pale or bluish-red. In\\nchildren the mass generally protrudes only on going to\\nstool, but in adults it is constantly down or comes down\\non the slightest exertion, and therefore may become ulcer-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0210.jp2"}, "211": {"fulltext": "HEMORRHOIDS. 191\\nated or inflamed. In old cases of prolapse incontinence\\nof faeces is also frequently present.\\nThe diagnosis of prolapse of the rectum is easily made\\nfrom the above-mentioned appearances. Internal prolapse\\nis net so easily diagnosed, as the mass never appears out-\\nside the anus. This condition can be recognized only by\\nmeans of a digital examination of the rectum. The finger\\nintroduced into the bowel is first kept close to the anterior or\\nposterior wall, and is passed up until it meets with an ob-\\nstruction (i.e., it has passed into the cul-de-sac). Then\\nthe finger is slightly withdrawn and the centre of the gut\\nexamined until an orifice is found into which the finger or\\na bougie may be passed for some inches high up into the\\nrectum. If the intussusception is rather far up in the rec-\\ntum, the patient should bear down during the examination.\\nWith regard to treatment it is of importance to eliminate\\nall the conditions which were predisposing factors for the\\nprolapse. Extreme cleanliness, especially after defecation,\\nshould be observed. The reposition of the prolapse should\\nbe performed in the most careful manner. It is best done\\nin the knee-elbow posture. If a considerable portion of\\nthe bowel has come down, a large flexible bougie may be\\npassed into the bowel in such a manner as to carry before\\nit the upper part of the descended gut. General taxis\\nshould at the same time be used, and in this way the mass\\ncan generally be returned. In cases in which the prolapse\\noccurs quite frequently, even during a walk, a rectal sup-\\nporter, as suggested by von Esmarch, should be worn by\\nthe patient. It consists of a soft-rubber ball attached to\\nthe anus by means of a belt and a T bandage.\\nThe palliative treatment which is especially successful in\\nchildren is as follows All sources of irritation should be re-\\nmoved and the general health strengthened. Straining at", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0211.jp2"}, "212": {"fulltext": "192 DISEASES OF THE INTESTINES.\\nstool should be strongly forbidden and a mild laxative\\nremedy given. After a movement of the bowels the pro-\\ntruded part should be well washed with cold water and\\npushed back into the anus by gentle pressure. After this\\nprocedure the patient should remain in a recumbent position\\nfor half an hour or so, best lying on the abdomen. If these\\nmeans alone are not sufficient, the following more radical\\nmeasures will have to be adopted Cauterization of the pro-\\nlapsed part with fuming nitric acid or with the thermo-cau-\\ntery under chloroform narcosis is often of great benefit.\\nCare should be taken while cauterizing not to touch the\\nverge of the anus or the skin. After this the prolapsed\\npart should be well oiled and returned. Instead of nitric\\nacid Allingham uses the acid nitrate of mercury.\\nThese cauterizing methods have the disadvantage of often\\nproducing strictures of the rectum. For this, reason a num-\\nber of surgical operations have been devised. Thus exci-\\nsion of triangular or elliptical portions of the mucous mem-\\nbrane, bringing the edges together with sutures, has been\\npractised. Extirpation of the entire prolapsed portion was\\nfirst advocated by Treves. 1 F. Lange, 2 of New York, has\\ndescribed a new operation, serving the purpose of reduc-\\ning the calibre of the rectum and at the same time produc-\\ning a narrow muscular ring. The patient is placed in the\\ngenu-pectoral position, an incision is made from the lower\\npart of the sacrum down to the anus, until the posterior\\nwall of the rectum is reached; the coccyx is then removed.\\nThe object in view is to narrow the gut as high as possible\\nand to lessen the impediments to the action of the levator\\nani. The calibre of the rectum is lessened by introducing\\nburied etage sutures of iodoformed catgut, which do not\\n1 Treves Lancet, 1890, vol. 1.\\n2 F. Lange Annals of Surgery, vol. v., p. 497.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0212.jp2"}, "213": {"fulltext": "HEMORRHOIDS. 193\\nperforate the entire thickness of the gut. The first rows\\nare inserted near the middle line and form a fold in the\\nposterior walls which protrudes into the bowel. In this\\nmanner the more lateral portions of the gut are brought\\ninto position without causing too much tension. Similar\\nsutures are applied to unite the cut surfaces of the levator\\nani and sphincter externus, which had been previously dis-\\nsected in order to lay bare the posterior wall of the rectum.\\nThe cavity thus formed is filled up with iodoform gauze\\nand the flaps of integument are united with sutures.\\nAnother very efficient operation has been suggested by\\nAllingham and consists in making a small incision through\\nthe anterior abdominal wall on the left side, just above the\\nouter third of Poupart s ligament, then introducing the\\nfingers into the abdomen, catching hold of the rectum and\\npulling it up. After it has been drawn as high up as pos-\\nsible, silk threads are passed through the mesentery and\\nthe latter is fastened to the abdominal wall.\\nFissure of the Anus. Another affection which very fre-\\nquently occurs in connection with hemorrhoids is anal fis-\\nsure. The latter consists of an oblong tear of the mucosa\\nof the anus and gives rise to severe pain and spasmodic\\ncontractions of the sphincters. Fissures or ulcers of the\\nanus vary in depth and size. Some are mere abrasions of\\nthe mucous membrane, others are quite large and deep so\\nthat the muscular fibres are laid bare. The edges of the\\nfissure may be in a healthy state or they may be inflamed,\\ncallous, and indurated. Fissure of the anus is usually\\ncaused by an injury or tearing of the mucous membrane\\nat the verge of the anus. This may result either from ex-\\ncessive straining or from the passage of very dry hard\\nscybala. The affection is more often found in women than\\nin men. The posterior portion of the anus is the point of\\n13", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0213.jp2"}, "214": {"fulltext": "194 DISEASES OF THE INTESTINES.\\npredilection, although the fissure may occur at any other\\nplace. It is usually situated parallel to the external sphinc-\\nter, although in some instances it may lie higher up, par-\\nallel to the internal sphincter or even above it.\\nThe symptoms consist in intense pains in the rectum on\\ndefecation, sometimes persisting afterward. The pains are\\noften of a very excruciating character. The size of the fis-\\nsure does not seem to be of so much importance with regard\\nto the severity of the pain as its position. A small crack\\nsituated at the anal orifice over the external sphincter and\\ninvolving the skin causes much greater pain than a large\\nulcer situated higher up in the rectum. There may also\\nbe a discharge of blood and pus.\\nThe diagnosis of anal fissure is made by the symptoms\\njust mentioned and by local examinations. The patient\\nlying on his left side should be told to bear down, and the\\nanus opened with forefinger and thumb as gently as pos-\\nsible. An elongated club-shaped ulcer will be seen within\\nthe orifice. Its floor may be very red and inflamed, or if\\nthe ulcer is of long standing, of a grayish color, with well-\\ndefined and hard edges. Often the introduction of the fin-\\nger into the anus is so painful that before making the ex-\\namination a suppository containing one grain of cocaine\\nhas to be applied. Sometimes even this procedure is in-\\nsufficient, and then chloroform anaesthesia will be required.\\nFor a fissure situated higher up above the internal sphinc-\\nter examination with the speculum will have to be made.\\nFissures of recent origin can often be cured without any\\noperation. Best in the recumbent position should be\\nadopted as much as possible. Mild laxatives are to be\\nrecommended, but no drastic remedies employed. If the\\npatient can manage to have a movement at night time be-\\nfore retiring, it will be of advantage. Locally the fissure", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0214.jp2"}, "215": {"fulltext": "HEMORRHOIDS. 195\\nshould be touched off and on with a ten-per-cent solution\\nof cocaine or with a ten-per-cent solution of nitrate of sil-\\nver. Still better is the application of the following salve\\nrecommended by Allingham\\n3$ Hydrarg. subchlor gr. iv.\\nPulv. opii gr. ij.\\nExtr. bellad gr. ij.\\nUng. sambuci 3 i-\\nH. f ung.\\nIf these palliative remedies are not sufficient, a free incision\\nthrough the fissure should be made. The cut should be\\nrather deep and should reach the sphincter muscles.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0215.jp2"}, "216": {"fulltext": "CHAPTER VIII.\\nAPPENDICITIS.\\nSynonyms: Scolecoiditis Perityphlitis; Paratyphlitis;\\nAppendicular inflammation.\\nDefinition. Inflammation of the appendix, characterized\\nby localized pains, commonly fever and digestive disturb-\\nances.\\nGeneral Bemarks. The inflammatory lesions involving\\nthe right iliac region were formerly designated as typhlitis\\n(inflammation of the caecum itself), perityphlitis (inflam-\\nmation of the peritoneal covering of the caecum), and para-\\ntyphlitis (inflammation of the retro-peritoneal connective\\ntissue of the caecum) Grisolle was the first to maintain\\nthat inflammation of the caecum could hardly give rise to\\nsuch grave lesions as are found in the right iliac fossa, for\\neven ulcerations of the caecum and colon do not, as a rule,\\nshow any tendency to extend into the neighboring connec-\\ntive tissue. He ascribed the above conditions to an inflam-\\nmation of the appendix, which organ shows a tendency\\nto perforate and to lead to abscesses in the right iliac fossa\\nas verified by post-mortem examinations. The possibility\\nof a stercoral typhlitis (inflammation of the caecum as the\\nresult of accumulated fecal matter) which was formerly\\ngenerally accepted, is now held by but very few writers,\\n1 Grisolle Tumeurs Phlegmoneuses des Fosses Iliaques. Archives\\nde Medecine, 1839.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0216.jp2"}, "217": {"fulltext": "APPENDICITIS. 197\\nas for instance, Lennander. 1 Sahli, 2 Notlmagel, 3 Fow-\\nler, 4 Sonnenburg, 5 and others deny its existence. The\\nteachings of Grisolle found further support through the\\nbrilliant investigations of Reginald Fitz 6 of Boston,\\nSands, 7 McBurney, 8 Weir, 9 Bull, 10 and Fowler of New\\nYork, were supplemented by the observations of Sonnen-\\nburg, Sahli, Rotter, 11 Roux, 12 Talamon, 13 and others, and\\nare now generally accepted.\\nEtiology. In former years much importance was at-\\ntributed to the occurrence of foreign bodies like cherry\\nstones, grape seeds, lemon and orange pits, date kernels,\\nfish bones, pins, etc., within the appendix as causative fac-\\ntors of the inflammatory suppurative process. According\\nto Fowler, the belief that the disease is frequently due to\\nthe engaging of foreign bodies in the cavity of the organ is\\nbased to a large extent upon purely speculative or imagi-\\nnary conditions or erroneous observations. In a very large\\nnumber of cases of this disease upon which he operated\\nFowler found but in two instances any body other than\\nsoft fecal masses which could be considered as being in\\n1 Lennander Ueber Appendicitis, Wien, 1895.\\n2 Sahli Ueber das Wesen und die Behandlung der Perityphliti-\\nden. Correspondenzbl. f. Schweizer Aerzte, Basel, 1892.\\n3 Nothnagel 4i Krankheiten des Darms, Wien, 1898.\\n4 George R. Fowler A Treatise on Appendicitis, Philadelphia,\\n1894.\\n5 Sonnenburg Pathologie und Therapie der Perityphlitis, Leip-\\nzig, 1895.\\n6 Reginald Fitz American Journal of the Medical Sciences, 1886\\nand New York Medical Journal, 1888.\\nI Sands New York Medical Journal, 1888, p. 197-205, 607.\\n8 Charles McBurney Annals of Surgery, 1891 Medical Record, 1892.\\n9 Robert F. Weir Medical Record and Medical News, 1887-1892.\\n50 W. T. Bull Medical Record, 1894.\\nII Rotter Ueber Perityphlitis, Berlin, 1897.\\n12 Roux Revue de Medecine de la Suisse romande, 1890, 1891, 1892.\\n13 Talamon Appendicite et Perityphlite, Paris, 1892.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0217.jp2"}, "218": {"fulltext": "198 DISEASES OF THE INTESTINES.\\nany sense foreign. The fecal concretions within the ap-\\npendix are now looked upon as of no importance whatever\\nwith regard to the causation of the disease, as they are also\\naccidentally encountered in perfectly normal appendices.\\nThe opinion generally prevails that the inflammation is\\ncaused by micro-organisms which are conveyed to the in-\\nterior of the organ in the fecal matter. According to\\nNothnagel, however, fecal concretions play a prominent\\npart in lesions leading to perforation of the appendix.\\nMovable kidney has been assumed to be a predisposing\\nfactor in the development of appendicitis by Carl Beck l\\nand Edebohls. 2 The much greater frequency of movable\\nkidney in the female and the comparative infrequency of\\nappendicitis in the latter as compared with the male sex\\nseems to speak somewhat against this view.\\nActinomycosis, tuberculous and typhoid ulcers are pre-\\ndisposing causes of the disease. Occlusion of the lumen of\\nthe appendix, either partial or complete, is likewise a pre-\\ndisposing factor. These occlusions may be the result of\\nformer inflammatory lesions, but are most frequently due\\nto the retrograde changes which this organ is gradually\\nundergoing in the process of evolution. According to Eib-\\nbert 3 and Zuckerkandl, 4 the appendix is found obliterated\\nin about twenty -five per cent of all living persons. Both\\nthese writers ascribe this condition not to inflammatory\\ndiseases, but to the progress of evolution which takes place\\nin the appendix. This view is supported by the fact that\\n*Carl Beck: Appendicitis. Volkmann s Sammlung klinischer\\nVortrage, No. 221, Leipzig, 1898.\\n2 George M. Edebohls: Medical Record, 1898.\\n3 Ribbert Beitrage zur normalen und pathologischen Anatomic\\ndes Wurmfortsatzes. Virch. Arch. Bd. 132.\\n4 E. Zuckerkandl: Ueber die Obliteration des Wurmfortsatzes beim\\nMenschen, Wiesbaden, 1894.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0218.jp2"}, "219": {"fulltext": "APPENDICITIS. 199\\nobliteration of the appendix is found with gradually in-\\ncreasing frequency in more advanced age. Thus Eibbert\\nfound obliteration of the appendix in fifty per cent of per-\\nsons above sixty years of age.\\nWhy the appendix should be the seat of disease so very\\nmuch more frequently than other parts of the intestine is\\na question which cannot be so easily answered. The fact\\nthat the appendix is a rudimentary organ in which proc-\\nesses of evolution are even normally discoverable makes it\\nprobable that it is imbued with less resistance against dis-\\nease-producing agents. The comparatively narrow lumen\\nof the appendix and Gerlach s valve make the emptying of\\nthis little canal a difficult matter. This, in connection with\\nthe scantiness of circular muscular fibres in the walls of\\nthe appendix explains the slowness with which substances\\nwithin the appendicular cavity are emptied into the intes-\\ntine. Stagnation of contents in this organ is certainly a\\npredisposing factor for disease. The abundance of ade-\\nnoid tissue in the appendix has been believed by some\\nwriters to be a predisposing cause of disease. Bacterial\\ninfections here take place in a similar manner as in the\\ntonsils, and Sahli speaks by way of comparison of an an-\\ngina of the appendix. Fowler and Van Cott 1 believe that\\nthe vascular arrangement of the appendix (scantiness of\\nblood supply, the. main vessels being almost end arteries)\\nis responsible to a great extent for the frequency of dis-\\nease in this organ. Some of the blood-vessels and nerves\\nare primarily affected, and the nutrition of the appendix\\nbeing thus disturbed, diseases of an infective character\\neasily take place. Another predisposing cause of appen-\\ndicitis is displacement and malformation of the appendix.\\nWhile all the above-mentioned factors may predispose\\n1 Van Cott-Fowler Treatise on Appendicitis.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0219.jp2"}, "220": {"fulltext": "200 DISEASES OF THE INTESTINES.\\nthe appendix to disease, the real cause of the latter must\\nbe looked for in a bacterial invasion. Talamon was the\\nfirst to lay stress upon the importance of microbes in ap-\\npendicitis. Nowadays all writers coincide with this view.\\nThus Tavel, 1 Hodenpyl, 2 Fowler, Wilson, 3 Barbacci, 4 and\\nothers ascribe a very important part to the bacillus coli\\ncommunis (Escherich), which is almost always encoun-\\ntered in lesions of the appendix, either in the exudate, pus,\\nor the walls of the appendix itself. Other micro-organ-\\nisms are, however, frequently found either in connection\\nwith the bacterium coli commune or alone. Thus strepto-\\ncoccus pyogenes, pneumococcus, staphylococcus pyogenes\\naureus, bacterium lactis, bacillus pyocyaneus and pyogenes\\nfcetidus, proteus vulgaris, and others have, been encoun-\\ntered. In most cases probably a mixed infection (several\\nvarieties of micro-organisms) takes place. The bacterium\\ncoli commune, however, is most frequently found, as it has\\na greater resisting-power and in the course of its growth\\nusually causes disappearance of the other micro-organ-\\nisms.\\nSex and age seem to play an important part in regard to\\nthe distribution of the disease. The male sex is much more\\nfrequently affected than the female. Thus,\\nSonnenburg reports 130 cases 77 males, 53 females.\\nRotter 68 44 24\\nNothnagel 130 \u00e2\u0080\u0094105 25\\nBamberger 5 73 54 19\\n1 Tavel und Lanz Ueber die Aetiologie der Peritonitis. Mitthei-\\nlungen aus Kliniken und Instituten der Schweiz, Basel, 1893.\\n2 Hodenpyl On the Etiology of Appendicitis. New York Medi-\\ncal Journal, 1893.\\n3 E. Wilson Cited after Fowler.\\n4 Barbacci Lo sperimentale, 1893, fasc. 4.\\n5 Bamberger Die Entziindungen der rechten Fossa iliaca.\\nWiener med. Wochenschr., 1853.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0220.jp2"}, "221": {"fulltext": "APPENDICITIS.\\n201\\nVolz 1 reports 59 cases\u00e2\u0080\u0094 45 males, 14 females.\\nMatterstock 2 1,030 \u00e2\u0080\u0094733 297\\nThis preponderance of the male sex is already found in\\nearly life. Thus Matterstock observed 72 cases of appen-\\ndicitis in early life (seven months to fifteen years), and\\namong this number were 51 male children and 21 girls.\\nThe greater frequency of appendicitis in the male sex is\\nexplained by Van Cott as due to the circumstance that the\\nappendix of the male has a less abundant blood supply\\nthan that of the female for in the latter there is a col-\\nlateral circulation derived from the sexual apparatus.\\nWith regard to age all writers agree that appendicitis is\\nmost frequently encountered between the tenth and thir-\\ntieth years. It occurs less frequently in the first decade\\nof life and in the thirtieth to fortieth years, and is quite\\nrare in advanced age. The following table is submitted\\nwith a view of showing the frequency of appendicitis in\\nthe different decades of life as recorded by several eminent\\nwriters\\nAges.\\nFitz.\\nMatterstock.\\nNothnagel.\\nTotal number\\n228\\n22\\n86\\n65\\n34\\n8\\n11\\n1\\n1\\n474\\n46\\n143\\n158\\n72\\n30\\n18\\n5\\n2\\n129\\n1 to 10\\n1\\n10 to 20\\n44\\n20 to 30\\n57\\n30 to 40\\n14\\n40 to 50\\n7\\n50 to 60\\n4\\n60 to 70\\n2\\n70 to 80.\\nThe frequency of appendicitis in relation to other dis-\\neases can be studied from the report of the autopsies made\\n1 Ad. Volz Die durch Kothsteine bedingte Perforation des Wurm-\\nfortsatzes, etc. Karlsruhe, 1846.\\n2 Matterstock Perityphlitis. Gerhardt s Handbuch der Kinder-\\nkrank., Tubingen, 1880.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0221.jp2"}, "222": {"fulltext": "202 DISEASES OF THE INTESTINES.\\nin the pathological institute of the WieDer Allgemeine\\nKrankenhaus between 1870 and 1896. According to Noth-\\nnagel, the total number of autopsies was 44,940. Among\\nthese the number of cases dying from appendicitis amounted\\nto 148. The percentage of appendicitis, therefore, was\\n0.32. With regard to sex there were 107 males (72.3 per\\ncent) and 41 females (27.7 per cent). The actual fre-\\nquency of appendicitis among the living, however, is much\\ngreater than appears from these numbers, which relate\\nonly to cases which have resulted fatally.\\nMorbid Anatomy. The pathological anatomy of appen-\\ndicitis has been thoroughly studied recently, not only in\\nautopsies but principally in operative cases. In the latter\\nan insight is permitted into the changes which take place\\nearly in the disease. Fowler distinguishes four stages of\\nanatomical lesions according to the spread of the morbid\\nprocess involving the different tissues of the appendix. In\\nthe first stage (endo-appendicitis) more or less intense in-\\nflammation of the mucous and submucous layers takes\\nplace. The second stage (parietal appendicitis) consists\\nin an inflammatory process involving the interstitial or\\nintermuscular structure of the body of the appendix. The\\nthird stage (peri-appendicitis) means an inflammatory proc-\\ness involving all the layers of the appendix, the peritoneum\\nincluded. The fourth stage (para-appendicitis) consists in\\nlesions involving the appendix and the neighboring tissues.\\nThis process is most often accompanied with suppurative\\ninflammations of the connective tissue adjacent to that por-\\ntion of the appendix which is not covered with perito-\\nneum.\\nAccording to Fowler, the above described stages are not\\nessentially different processes but further developments of\\none and the same lesion.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0222.jp2"}, "223": {"fulltext": "APPENDICITIS. 203\\nRiedel, J Nothnagel, and others distinguish two different\\ntypes of appendicitis which are of great clinical importance.\\nThey are the following\\n1. Catarrhal appendicitis (endo-app)endicitis) Here in the\\nacute form the mucosa of the appendix is swollen and red-\\ndened, the submucosa is engorged and filled with round\\ncells. The follicles are distinctly swollen. The appendix\\nappears swollen and more rigid, and its lumen is filled with\\nthick yellowish contents, mostly mucus; sometimes the\\nlatter may be mixed with fecal matter. Occasionally there\\nare fecal concretions. Often ecchymoses of the mucosa\\noccur, leading sometimes to superficial defects (erosions)\\nAll these lesions may entirely disappear after the acute at-\\ntack is over, and thus a perfect cure may be established.\\nThis, however, is possible only if there is no occlusion of\\nthe lumen of the appendix and the inflammatory products\\ncan be emptied into the caecum.\\nIn the large majority of cases of catarrhal appendicitis\\nthe cure is not a perfect one and chronic appendicitis is\\nthe result. In this stage the mucosa of the appendix\\npresents a slate-gray appearance. It is filled with accumu-\\nlations of round cells at the same time proliferation of\\ncoDnective tissue and occasionally blood pigment are found.\\nThe submucosa and muscularis may show no changes\\nwhatever, although as a rule they are hypertrophied. The\\nlatter condition is probably due to stricture of the lumen\\nof the appendix and consecutive muscular (compensatory)\\nhypertrophy. The chronic form of appendicitis, owing to\\nsuppurative processes of the mucous membrane, occasion-\\nally leads to a total destruction of the mucosa, and an ob-\\nliteration of the lumen of the appendix. This condition is\\n1 Riedel Ueber die Fruboperation bei Appendicitis purulenta seu\\ngangraenosa. Berl. klin. AVocbenscbr. 1899, Nos. 33 and 34.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0223.jp2"}, "224": {"fulltext": "204 DISEASES OF THE INTESTINES.\\nvery similar to obliteration of the lumen due to the involu-\\ntion processes which have been mentioned above. The\\nappendix then forms a solid membranous band of uniform\\nthickness or with a few small protrusions. As a rule it is\\nfound embedded in peritonitic adhesions.\\nSometimes primary slight lesions of the appendix lead\\nto complications, especially if a stricture is present. Thus\\nan accumulation of secretion within the occluded appen-\\ndicular cavity may take place and give rise to the forma-\\ntion of a cyst. Such cj sts occur, varying in size from a\\ncherry to a fist. Guttmann 1 observed a cyst of the appen-\\ndix fourteen centimetres (five and a half inches) long and\\ntwenty-one centimetres (eight and a quarter inches) wide.\\nThe contents of such a cyst are either of a watery mucous\\ncharacter or gelatinous.\\nIf ulceration takes place in the occluded appendicular\\ncavity, it may give rise to the formation of a small abscess\\n(py-appendix or empyema processus vermiformis). In\\nthese cases the purulent process may penetrate the wall\\nof the appendix and lead to perforation. A timely opera-\\ntion in many instances prevents such an outcome.\\n2. The severe form of appendicitis {appendicitis ulcerosa\\net gangrcenosa, appendicitis perforativa) In this group\\nthe bacterial infection is of a much more virulent nature\\nthan in the catarrhal form. The inflammation originating\\nin the mucosa of the appendix at once involves all its lay-\\ners, including the serosa. Necrobiotic processes and for-\\nmation of pus take place quite early. The peritoneum is\\nalso very soon involved, either in the immediate neighbor-\\nhood of the appendix or in its entirety. Ulcerations and\\ngangrenous processes may lead to the destruction of a\\n1 P. Guttmann Verhandlungen des Vereins fur innere Medicin zu\\nBerlin, 1883-84, p. 301.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0224.jp2"}, "225": {"fulltext": "APPENDICITIS. 205\\npart of the appendix, thus causing perforation, or to a total\\nnecrosis of the entire appendix. As a result of this proc-\\ness the latter may be cast off from the caecum and be found\\nfree in the peritoneal cavity or embedded in pus.\\nThe way in which the peritoneum fs involved is quite\\nvariable. There may be an adhesive type of peritonitis\\nleading to a matted and agglutinated condition of the ap-\\npendix, or a circumscribed or diffuse peritonitis without\\nadhesions. The contents of the appendix may be emptied\\ninto the abdominal cavity or hemmed in by adhesions.\\nThe size, location, and direction of the abscess differ\\ngreatly. The location and length of the appendix and the\\nportion perforated play an important part in this respect.\\nIn the great majority of cases the abscess is at first intra-\\nperitoneal, but very soon extends toward the surface or\\nabove or below Poupart s ligament. Again it may pene-\\ntrate into the bladder, vagina, small intestine, or rectum.\\nIn some instances it reaches the diaphragm and from\\nthere perforates into the pleural cavity.\\nIn some very grave cases there is no abscess but a dif-\\nfuse peritonitis. Here we often meet with a paretic con-\\ndition of the intestine, the latter being filled with gas the\\nserous layer is shiny and red, while there is an absence of\\nany exudation. In other cases a small quantity of a purely\\nserous or bloody serous exudation is found. The condi-\\ntion just described may be discovered either in operations\\nundertaken very early or at autopsies in cases which ter-\\nminate fatally at the beginning of the disease. In still an-\\nother group of cases which is a comparatively very small\\none, the general peritonitis may assume a more protracted\\nand chronic form. In these cases mattings and adhesions\\nare formed over more or less large areas of the abdominal\\ncavity, and in these accumulations of pus may be found.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0225.jp2"}, "226": {"fulltext": "206 DISEASES OF THE INTESTINES.\\nAppendicitis due to tuberculosis is of comparatively rare\\noccurrence and shows a great tendency to the formation of\\nfistulse. Recently actinomycosis has been found to be the\\ncause of some cases of appendicitis with the formation of\\nabscesses. In these cases the actinomycosis fungi can\\neasily be demonstrated.\\nSymptomatology In describing the symptomatology of\\nappendicitis it will again be best to differentiate the two\\nforms already mentioned above, namely, the catarrhal and\\nthe severe form.\\n1. Catarrhal or endo-appendicitis. An attack of appendi-\\ncitis is usually characterized by a sudden appearance of\\npain in the abdominal cavity, which at first may be dif-\\nfused or in the region of the navel, but very soon is local-\\nized in the right iliac region. A moderate rise of temper-\\nature is very frequently present. Slight gastric symptoms,\\nnausea, and sometimes vomiting often occur, but are, as a\\nrule, only transient. The pains usually increase in inten-\\nsity, and the patient assumes a fixed position with the legs\\nflexed. Any change in the position or any movement of\\nthe thighs increases the pain. Examination by palpation\\nshows extreme tenderness on pressure of the right iliac re-\\ngion, more especially at McBurney s point, while the rest\\nof the abdomen can be examined by pressure without giv-\\ning rise to the slightest pain. While the pains are gener-\\nally continuous, they may show periods of exacerbation.\\nThe latter, according to Nothnagel, are most probably due\\nto a spastic contraction of the muscles of the appendix.\\nThe term appendicular colic has been given by Tala-\\nmon to the same condition. Talamon, however, assumed\\nthat the colic is always due to an attempt of the appendix\\nto rid itself of a fecal concretion. Inasmuch as operations\\nfor appendicitis have often been performed during the at-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0226.jp2"}, "227": {"fulltext": "APPENDICITIS. 207\\ntack of colic and no fecal concretions whatever found in\\nthe appendix, and inasmuch as coproliths have been found\\nin cases in which no colic whatever existed, this theory\\ncannot be maintained.\\nIn some cases there is an area of resistance in the right\\niliac region. If the latter be due to an accumulation of\\nfecal matter in the caecum, the tumor can be slightly moved\\nand its shape changed by pressure. In a few of the cases\\nof catarrhal appendicitis the resistance is due to an inflam-\\nmatory swollen (serous) condition of the appendix and of\\nthe neighboring organs. In this instance the tumor is not\\ncircumscribed but rather diffuse, immovable, and its shape\\nunaffected by pressure.\\nIn comparatively few cases can the appendix be directly\\npalpated. It then appears as an elongated round body of\\nthe size of the little finger, and is very painful on pressure.\\nThe examination of the appendix itself, whenever this is\\npossible, is certainly of the utmost importance for diagno-\\nsis. Edebohls 1 deserves much credit for having cultivated\\nand perfected the method of examining the appendix by\\npalpation. According to Edebohls, this examination is best\\ndone as follows The patient lies upon his back with the\\nlegs comfortably flexed. The physician standing at the\\npatient s right begins to search for the appendix by apply-\\ning two, three, or four fingers of his right hand, palmar\\nsurface downward, almost flatly upon the abdomen at or\\nnear the umbilicus while now he draws the examining fin-\\ngers over the abdomen in a straight line from the umbili-\\ncus to the anterior superior spine of the right ilium, he\\nnotes successively the character of the various structures\\nas they come beneath and escape from the fingers passing\\nover them. In doing this the pressure exerted must be\\n1 Edebohls American Journal of the Medical Sciences, May, 1894.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0227.jp2"}, "228": {"fulltext": "208 DISEASES OF THE INTESTINES.\\nstrong enough to recognize distinctly along the whole\\nroute traversed by the examining fingers the resistant sur-\\nface of the posterior abdominal wall and of the pelvic brim.\\nOnly in this way can we positively feel the normal or\\nslightly enlarged appendix. Pressure short of this must\\nnecessarily fail.\\nR. T. Morris suggests for Edebohls method of palpating\\nthe use of three right-hand fingers to feel with and three\\nleft-hand fingers placed upon these to press with. The\\nfingers that are to do the feeling are pressed by means of\\nthe three others down to the border of the right rectus ab-\\ndominalis muscle at the level of the navel and slowly drawn\\ntoward the examiner. I have found both these methods\\nvery useful in detecting the position and size of the ap-\\npendix.\\nThe temperature is usually but slightly raised, some-\\ntimes even normal. The pulse likewise is either normal\\nor but moderately accelerated.\\nConstipation is often present, but seems to be rather the\\nresult of the inflammatory condition of the appendix than\\nits cause, as was formerly believed. In a comparatively\\nsmall number of cases diarrhoea is present during the at-\\ntack of appendicitis.\\nCourse. An acute attack of catarrhal appendicitis may\\nlast from two to three days to two to three weeks. After\\nthis variable period of sickness the symptoms either en-\\ntirely disappear or x^ersist in a slight degree. With regard\\nto the further development the following classes must be\\ndistinguished: 1. There may be complete recovery without\\nany further trouble. 2. The patient may entirely recover\\nfrom the present attack, but have a return of the disease\\nafter a variable period of time (from a few weeks, a few\\n1 R. T. Morris Lectures on Appendicitis, New York, 1899, p. 45.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0228.jp2"}, "229": {"fulltext": "APPENDICITIS. 209\\nmonths to a year or two) recurrent appendicitis, 3.\\nThe symptoms may not completely disappear but may\\npersist for many weeks and the patient may remain in a\\nlingering condition subacute or chronic appendicitis.\\nThe first class of perfect recoveries is comparatively small.\\nIn this group there is either an obliteration of the appen-\\ndix or the catarrhal process may have subsided completely\\nwithout having left behind any lesions. The second class\\nof recurrent appendicitis comprises the majority of the\\ncases. In these a chronic catarrhal condition of the mu-\\ncosa of the appendix may persist without manifesting\\nsynrptoms until a new invasion of micro-organisms gives\\nrise to an acute exacerbation of the process, or strictures\\nof the lumen of the appendix may have formed as a conse-\\nquence of the acute attack and thus become the cause of\\nrenewed disturbances later on. In the third categoiy the\\ncatarrhal appendicitis has led to severe anatomical lesions.\\nThere may be a considerable thickening of the appendix\\nwall including the serosa. The appendicular lumen may\\nshow ulcerations, strictures, or bends. There may also\\nbe an accumulation of pus (py-appendix).\\n2. The severe form of appendicitis {appendicitis suppura-\\ntiva or perforans) The disease usually begins quite sud-\\ndenly in the midst of perfect health rarely it is preceded\\nby slight digestive disturbances. The patient is seized with\\nviolent pains in the abdomen. These are felt at first either\\nover the entire abdomen, in the epigastric region, or on\\nthe left side of the abdomen, but very soon they settle in\\nthe right iliac region. The pains are of an intense charac-\\nter, and occasionally are accompanied by paroxysms dur-\\ning which they are almost unbearable. Any motion in-\\ncreases the pain. The patient lies perfectly motionless\\nand breathes superficiallv. The appearance is that of a\\n14", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0229.jp2"}, "230": {"fulltext": "210 DISEASES OF THE INTESTINES.\\nvery sick person, the countenance manifests great suffer-\\ning and anxiety. The temperature is usually considerably\\nincreased and continues so during the first days of the dis-\\nease. The pulse is accelerated. Occasionally it is of\\nsmall calibre, easily compressible, and at times irregular.\\nThe latter phenomena are found principally in critical\\nconditions. A very frequent pulse and a comparatively\\nlow degree of fever are also considered bad omens. There\\nis always complete anorexia and great thirst, the tongue\\nis dry and thickly coated, the bowels, as a rule, are con-\\nstipated. In rare instances there is diarrhoea. Accord-\\ning to Nothnagel, vomiting is present in almost three-\\nquarters of the cases. It usually appears right at the\\ncommencement of the disease and lasts only a short time.\\nIn exceptional instances it persists for several days. The\\nvomited matter consists of gastric contents, mucus, and\\nbile. In very grave cases it exceptionally assumes a fecu-\\nlent character. The vomiting is occasionally accompanied\\nby hiccoughs. Beth these phenomena are very annoying\\nand at the same time increase the pain through the mo-\\ntions evoked by them.\\nIn many of the cases, soon after the commencement of\\nthe disease a tumor begins to form in the right iliac re-\\ngion. At first a rigidity of the muscles in this region is\\nnoted; later on a distinct resistance over an area of egg\\nsize may be found. The tumor is either circumscribed\\nand sharply defined, or it is diffuse and connected with\\nthe neighboring tissues. The skin over the tumor is as\\na rule easily movable, while the latter is immovable. The\\ntumor generally consists of a purulent exudation in and\\naround the appendix and congested portions of the intes-\\ntines, occasionally of the omentum, and of a purulent infil-\\ntration of the abdominal wall itself. In some instances", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0230.jp2"}, "231": {"fulltext": "APPENDICITIS. 211\\nthe size of the tumor is considerably increased by an ac-\\ncumulation of fecal matter in the csecum. The tumor may\\nbe discovered by palpation and sometimes by percussion.\\nFluctuation is present only in very extensive abscesses.\\nIts absence does not signify the absence of pus. The re-\\nsistance as a rule increases either very slowly or quite\\nrapidly. In rare instances, namely in those in which the\\nabscess is surrounded by a firm capsule, it may remain\\nunchanged for a long time. The abscess occasionally in-\\nvolves the muscles and even the skin lying above it. The\\nlatter becomes infiltrated and cedematous, and in rare in-\\nstances the abscess may spontaneously oj^en through the\\nskin. Occasionally the resistance disappears entirely when\\nthe purulent exudation has descended into the deeper parts.\\nIn such an event, by an examination through the rectum,\\nand in females through the vagina, the exudation may be\\ndiscovered filling Douglas space.\\nIn cases in which there is an extensive inflammation of\\nthe peritoneum accompanied by a considerable quantity of\\npus, severe pains in urination appear quite early, after two\\nor three days (Fleischer). On this account the patients are\\noften rather afraid to urinate. In the same cases there\\nmay also be paresthesia and anaesthesia in the limbs, or\\nobstinate erections of the penis, or a drawing up of the\\nright testicle. These symptoms all show that the accumu-\\nlation of pus presses upon the nerves of the sacral plexus.\\nThe further course of the disease will largely depend\\nupon the way in which the newly formed pus around the\\nappendix acts. Often it leads to a perforation of the ap-\\npendix. Sometimes the abscess forms adhesions and is\\nencapsuled. Sometimes, again, the abscess penetrates into\\nthe peritoneal cavity and gives rise to diffuse septic or\\nfibrino-purulent peritonitis.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0231.jp2"}, "232": {"fulltext": "212 DISEASES OF THE INTESTINES.\\nPerforation of the appendix which occurs quite fre-\\nquently in this class of cases is accompanied, according\\nto Sonnenburg, by the following symptoms: The disease\\nbegins with febrile and marked symptoms violent pains\\nin the abdomen appearing either suddenly or after a short\\nperiod of slight uneasiness and concentrating very quickly\\nin the right side vomiting accompanied by diarrhoea and\\nin other cases by constipation small and frequent pulse\\nfever commencing with chills and quickly rising; pro-\\nnounced tympanites; general appearance extremely bad;\\nslight cyanosis and perspiration a distinct area of resist-\\nance over or around the affected spot. While all these\\nsymptoms are certainly found in cases of perforation of\\nthe appendix, they can by no means be absolutely relied\\nupon for they may exist in the same manner without a\\nperforation taking place, and, on the other hand, the lat-\\nter event may occur without any of the above-mentioned\\nsymptoms being present. For these reasons Boas is re-\\nluctant to make the diagnosis of perforative appendicitis,\\nand contents himself with determining the presence of\\npurulent appendicitis.\\nPerforation peritonitis most often appears between the\\nsecond and fourth days of the disease (Fitz). The danger\\nof a penetration of pus into the free peritoneal cavity less-\\nens with the length of time the disease has lasted, on ac-\\ncount of the formation of adhesions. On the other hand,\\nnumerous other perilous events may take place. In some\\ncases a few days after the commencement of the disease\\nthere is a subsidence of the most important symptoms\\n(pains, fever, etc.), while in others they persist with undi-\\nminished severity. Even in the first class, however, the\\n1 J. Boas: Diagnostik und Therapie der Darmkrankheiten, Leip-\\nzig, 1899.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0232.jp2"}, "233": {"fulltext": "APPENDICITIS. 213\\namelioration rarely persists, for pretty soon afterward the\\npains reappear and the fever recurs, and in connection\\nwith these symptoms the inflammation increases and the\\npus augments. Periods of improvement and exacerbation\\nof the condition may alternate for quite a while until at\\nlast either recovery or a fatal issue ensues.\\nA spontaneous cure or recovery without surgical inter-\\nvention may occur in one of the following ways\\n1. The abscess may become encapsulated, the pus losing\\nits virulence and becoming absorbed. In such an event the\\ntumor disappears and the patient is either definitely or ap-\\nparently cured; for dangers to life remain after such a cure\\nin consequence of the remnants of the abscess and of the\\nadhesions formed among the intestines. The occurrence\\nof a sudden bursting of the abscess, using Ewald s words,\\nhangs like the sword of Damocles over the head of the\\npatient as long as there is still pus present. In seemingly\\nperfect health a fatal peritonitis may thus occur in patients\\nwho had previously suffered from an attack of appendicitis.\\n2. A cure may be established by the opening of the\\nabscess into adjacent hollow viscera. Thus the abscess\\nmay open into the caecum, colon, small intestine, bladder,\\nvagina, or pelvis of the kidney. This favorable issue is,\\nhowever, rare.\\n3. The abscess may find its way externally by ruptur-\\ning spontaneously through the skin. Sometimes, however,\\nthe pus burrows into other organs thus it may reach the\\ndiaphragm (subphrenic abscess), and sometimes even force\\nits way through into the pleural cavity and perhaps the\\nlungs. But even from these places the pus may be evacu-\\nated spontaneously, principally through rupture into a\\nbronchus and its expulsion during a coughing spell.\\nIn a large number of cases peritonitis and septicaemia", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0233.jp2"}, "234": {"fulltext": "214 DISEASES OF THE INTESTINES.\\nterminate the life of the patient in others after recovery\\nthere are frequently grave recurrences of the disease.\\nDiagnosis. Catarrhal appendicitis can be diagnosed if\\nthere is a sudden onset of pain in the right abdominal cav-\\nity, principally in the region of the appendix, combined\\nusually with a slight rise of temperature and some light\\ngastric symptoms (nausea, anorexia, vomiting). The\\ngrave form of the disease or purulent appendicitis shows\\nthe same manifestations, only of a much severer type.\\nBesides there are always present signs of serious illness.\\nThe patient is very pale and manifests an anxious ap-\\npearance. Chills are frequent^ present and the tempera-\\nture shows a certain irregularity in its course. There may\\nbe a marked rise in temperature after it has been quite\\nlow or almost normal for a time.\\nThe presence of a tumor in the right iliac region is of\\ngreat importance in the diagnosis of appendicitis, although\\nthis symptom is frequently absent. In order to recognize\\nthe nature of the tumor with regard to its contents, espe-\\ncially whether pus is present or not, Sahli first suggested\\nthe use of an exploratory puncture. If pus can be aspi-\\nrated through the needle, then an abscess is positively\\npresent. Although many* physicians make use of this\\nmethod even nowadays, as for instance Ley den, 1 Noth-\\nnagel, Penzoldt, 2 Fleischer, Boas, and others, most of the\\nsurgeons are decidedly opposed to this diagnostic measure\\n(Fowler, Treves, 3 Sonnenburg, and others). In this coun-\\ntry the consensus of opinion is against the use of explora-\\ntory puncture, for its employment adds a new element of\\n*E. vonLeyden: Berl. klin. Wochenschr., 1889, No. 31.\\n2 Penzoldt: Behandlung der Erkrankungen des Darras. Pen-\\nzoldt- Stintzing s Handbucn der speciellen Therapie innerer Krank-\\nheiten, Jena, 1896.\\n3 Treves On Peritonitis. British Medical Journal, 1894.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0234.jp2"}, "235": {"fulltext": "APPENDICITIS. 215\\ndanger to the case, while its results, especially if negative,\\nare unreliable.\\nWhile appendicitis can usually be diagnosed without\\ndifficulty, in some instances its recognition is quite diffi-\\ncult. In cases in which the appendix is abnormally situ-\\nated, as for instance in the left iliac region or in the upper\\npart of the right abdominal cavity, the diagnosis of appen-\\ndicitis will hardly be possible.\\nDifferential Diagnosis. The following conditions niay at\\ntimes be confounded with appendicitis, namely, biliary,\\nrenal, and intestinal colic. The following points will serve\\nas a guide in making a correct diagnosis. In biliary colic\\nthe pains are referred by the patient to the right abdominal\\ncavity, radiating to the back and up to the shoulders. Pal-\\npation shows a painful area situated immediately below the\\nright margin of the ribs occasionally jaundice is present.\\nIn kidney colic (right side) the pain is felt by the patient\\nin the right lumbar region, radiating toward the bladder.\\nThere is generally a frequent desire for micturition and\\nslight burning in the urethra. The urine may show the\\npresence of mucus, sometimes of blood and pus cells. In\\nintestinal colic the pain may be referred to the right iliac\\nregion, but, as a rule, it is relieved very soon after the\\npassage of flatus. In contradistinction to these three con-\\nditions .the pain in appendicitis is referred to the right\\niliac region, where it remains localized, does not disappear\\nupon passage of flatus, does not radiate to the shoulder\\nand but very rarely to the bladder, while there is also great\\ntenderness and pain upon pressure at McBurney s point.\\nNo jaundice is present and the urine is normal.\\nIn women the differential diagnosis between appendici-\\ntis and a right-sided salpingitis is not always easily made.\\nA thorough examination through the vagina, however, will", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0235.jp2"}, "236": {"fulltext": "216 DISEASES OF THE INTESTINES.\\nin most instances enable us to decide as to tlie true condi-\\ntion. If the appendix is situated in the small pelvis and\\nhas given rise to the formation of an abscess in this local-\\nity the decision of the question whether the abscess is due\\nto appendicitis or to oophoritis is extremely difficult and\\nsometimes even impossible. Typhoid fever in exceptional\\ncases may simulate an appendicitis the presence or absence\\nof Widal s reaction will serve to differentiate the former.\\nPrognosis. Catarrhal appendicitis affords in most in-\\nstances a favorable prognosis as regards to life. With ref-\\nerence to complete recovery, however, the outlook is by no\\nmeans bright, for the liability to recurrence of the disease\\nis very great. Inasmuch as an apparently mild form of\\nappendicitis may all of a sudden change its character and\\nassume alarming features, the prognosis should always be\\nmade with a certain reserve, even in this class.\\nThe purulent form of appendicitis must be regarded\\nas a very serious disease and gives quite an unfavorable\\nl rognosis unless timely surgical intervention is adopted.\\nThe intensity of the symptoms in purulent appendicitis is\\nby no means a correct measure of the gravity of the dis-\\nease. Experience shows that cases with violent symp-\\ntoms, very high fever, and intense pains, etc., occasionally\\nrecover within a few days, the pus rupturing ktto the intes-\\ntine, while apparently mild cases after a few days of sick-\\nness suddenly develop symptoms of a general septic peri-\\ntonitis with a fatal issue. Diffuse peritonitis is liable to\\noccur between the second and fourth days of sickness, but\\neven later the patient is subjected to numerous risks.\\nGrave complications may suddenly develop even in a pa-\\ntient who is apparently progressing nicely and already\\nconvalescent. Thus purulent appendicitis may give rise\\nto pyopneumothorax, empyema, or purulent pericarditis,", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0236.jp2"}, "237": {"fulltext": "APPENDICITIS. 217\\nand these complications may result in a fatal issue. The\\nprognosis of perforating appendicitis is decidedly less fa-\\nvorable than that of a simple empyema of the appendix,\\nas in the former septicaemia is liable to occur.\\nAfter having described the numerous dangers present in\\nthe severe form of appendicitis it is consoling to say that\\nspontaneous recoveries are, notwithstanding this, in the\\nmajority. With regard to the frequency of spontaneous\\nrecoveries Nothnagel gives the following statistics Among\\n130 hospital patients he observed 85 complete recoveries,\\n4 deaths without operation, 30 partial recoveries, and 11\\ncures after operation. The large number of cases reported\\nby Sahli is also very important in this connection. This\\nauthor reports the results in 7,213 cases of appendicitis;\\n473 cases were operated upon, while 6,740 received only\\nmedical treatment. Among the latter 6,194 recovered (91.2\\nper cent) while 591 (8.8 per cent) died. Sahli further\\nstates that of the 4,593 cases which had not been operated\\nupon and in which inquiries had been made with regard\\nto recurrence of appendicitis, 3,635 were cured without\\nany recurrence.\\nNothnagel says that circumscribed appendicitis is cura-\\nble in the large majority of cases, and that about eighty\\nper cent recover under simple medical treatment. Among\\nthe rest there are still some that can be cured by means\\nof operative procedures. Careful watching of the pa-\\ntient and timely surgical intervention in proper cases\\nmay reduce the number of deaths from appendicitis to\\nperhaps five per cent or three per cent. It is, however,\\nimpossible entirely to avoid fatal issues, even with the\\ngreatest and strictest watchfulness. Aside from accidental\\ncomplications and from rare cases in which a correct diag-\\nnosis is hardlv to be made, there remain instances in which", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0237.jp2"}, "238": {"fulltext": "218 DISEASES OF THE INTESTINES.\\nthe peritoneum is diffusely affected quite early without\\npresenting any symptoms. These are the cases which\\nmake the prognosis unfavorable and they form the great-\\nest contingent of deaths among patients with appendicitis.\\nThe acute septic form with perforation of the appendix is\\nthe most dangerous, while the progressive suppurative form\\nis comparatively favorable.\\nTreatment. With reference to prophylaxis the swallow-\\ning of fruit pits, of very small bones, and coarse, indi-\\ngestible matter in the food was formerly strictly forbidden.\\nNowadays, however, we know that the above-named sub-\\nstances play no part whatever in the etiology of appendi-\\ncitis. Regulation of the bowels or, more practically speak-\\ning, correcting constipation has been believed to be of\\nimportance in preventing appendicitis. This maxim can\\nlikewise not be maintained on the ground of recent re-\\nsearches. Regularity of the bowels is in itself of impor-\\ntance, and hence it will be advisable to pay attention to\\nthis factor. The only means we possess of preventing an\\nattack of appendicitis is the removal of the appendix.\\nWhile this suggestion is not generally practicable, for it\\nrequires an operation which is not entirely without risk,\\nit may, however, be carried out in cases requiring a lap-\\narotomy for other diseases, provided that this additional\\noperation does not demand too much time.\\nThe medical treatment of appendicitis consists in abso-\\nlute rest of the entire body, especially of the intestinal\\ntract, and in appropriate diet. The patient must be kept\\nstrictly abed from the commencement of the disease until\\nit is entirely over. He should not be permitted to leave\\nthe bed for a moment. He must lie perfectly quiet even\\nturning from one side to the other should be avoided, or if\\ndone, performed with the greatest care. In taking nour-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0238.jp2"}, "239": {"fulltext": "APPENDICITIS. 219\\nishrnent tlie head may be slightly raised the urine should\\nbe voided in a glass, and an evacuation of the bowels\\nshould take place in a bed-pan. During this act the pa-\\ntient must be forbidden to strain or exert himself in any\\nway. The utensils needed must be handled by the nurse,\\nwho must also attend to the cleansing of the patient.\\nThe principle of rest must also be applied with reference\\nto diet. During the first few days of illness there should\\nbe either total abstinence from food (only small quantities\\nof water being given now and then), or liquid food in small\\nportions. Thus strained barley water, or this with the\\naddition of a little milk, oatmeal water and rice water\\ngiven in the same way, chicken soup, very weak tea. In\\nthe very severe forms of appendicitis, especially when per-\\nforation has taken place, or when symptoms of ileus and\\nfecal vomiting are present, absolute abstinence from food\\nand also drink is necessary. In accordance with Penzoldt,\\nEwald, and Boas, rectal feeding appears to me to be con-\\ntraindicated in these cases and the only way of supplying\\nthe organism with nutritive material is a subcutaneous\\ninjection of saline solutions, sugar solutions, and also per-\\nhaps small subcutaneous injections of olive oil.\\nSmall pieces of ice may from time to time be given to\\nthe patient. He must, however, keep the ice in his mouth\\nuntil it melts before swallowing. This often alleviates the\\nnausea and retching. The first two or three days of sick-\\nness being over, the patient may be allowed to have milk, an\\negg beaten up in bouillon or milk, in addition to the above-\\nnamed food. The diet should be kept up in this way until\\nthe pains and fever have entirely disappeared. At this pe-\\nriod soft-boiled eggs, crackers, small portions of meat\\n(squab) or chopped beef may be given, and still later mashed\\npotatoes, bread and butter, and light vegetables added.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0239.jp2"}, "240": {"fulltext": "220 DISEASES OF THE INTESTINES.\\nMedicaments. The use of cathartics is mentioned here\\nonly in order to condemn it. Even injections into the\\nbowels should not be administered too frequently nor in\\nlarge quantities. A small enema of one-half to one pint of\\nwater or one-half pint of olive oil may occasionally be given.\\nThe remedy par excellence in the treatment of appendici-\\ntis is opium. Its use was originally recommended by Eng-\\nlish physicians (Graves, Stokes) and later by French clin-\\nicians (Petriquin, Grisolle) in Germany this remedy\\nfound a fervent advocate in Yolz and in America in Alonzo\\nClark. During the last decade the administration of opium\\nhas met with great opposition especially ou the part of many\\nsurgeons. Their reasons against the use of this remedy are,\\nfirst, that opium masks the true picture of the disease, and\\nsecondly, that it gives rise to paralysis of the intestines.\\nSome of the foremost clinicians, Nothnagel, Penzoldt,\\nEwald, Sahli, Boas, and others, are even nowadays en-\\nthusiastic admirers of the opium treatment. The prin-\\ncipal element of importance of opium as a remedy is its\\naction in lessening or arresting the peristalsis of the in-\\ntestine, and besides in alleviating pain. I myself have\\nalways used and still use the opium treatment with great\\nsatisfaction. It is of course understood that the opium\\nshould be given only in sufficient amount to allay the pain,\\nwhile excessive doses should be avoided. As soon as the\\nactive stage of the disease is passed, the opium must be\\nentirely discontinued. The best way of administering it\\nis that suggested by Sahli. Ten or fifteen drops of tinc-\\nture of opium are at first given every hour until there is\\na decided subsidence of the pain. Then five to six drops\\nare given every two or three hours until the pains disap-\\npear completely. As soon as there is an exacerbation an-\\nother large dose is administered, but if the patient is entirely", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0240.jp2"}, "241": {"fulltext": "APPENDICITIS. 221\\nfree from pain no opium is given. If the administration\\nof the drug excites nausea or vomiting, it may be given in\\nthe form of a suppository\\n3 Extr. opii 0. 05\\n01. theobrom 1.00\\nM. f. supp. One suppository every four hours until subsi-\\ndence of pain.\\nOr belladonna extract, 0.005-0.01 gin., may be added to\\nthe opium in the same suppository.\\nBoas* recommends the administration of opium subcuta-\\nneously. (Extr. opii aquosi sterilis. 0.3 to 10.0 water; 1\\nPravaz syringe [1 gm.] three times daily.)\\nIn cases in which the pains are very intense and a quick\\naction is desired, morphine may be administered subcuta-\\nneously in doses of gr. to J. The action of this remedy\\nis, however, not so satisfactory as that of opium, as it has\\nbut a very slight influence in diminishing the peristalsis.\\nWhen morphine is used, opiuin should be given in addition.\\nPoultices. The application of ice over the painful area\\nis often beneficial at the beginning of the disease, espe-\\ncially if the temperature is quite high and symptoms of\\nperitoneal irritation are present. If the patient, however,\\ncomplains of great discomfort from the application of ice,\\nit must be discontinued. In the latter instance a cold\\nPriessnitz poultice may be tried. Cases not accompanied\\nby high fever often derive great relief from the application\\nof a hot- water bag or plain warm poultices. The latter\\nare especially to be recommended in that form of appendi-\\ncitis which is called appendicular colic of Talamon.\\nSurgical Treatment. The question of operation in ap-\\npendicitis is a very live one nowadays and is being every-\\nwhere discussed. The medical profession has not yet come\\nto a unanimous conclusion in regard to it. Surgical treat-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0241.jp2"}, "242": {"fulltext": "222 DISEASES OF THE INTESTINES.\\nment of appendicitis originated in this country, Dr. Regi-\\nnald Fitz of Boston having done the first operation for\\nthis purpose, and it has been practised and perfected here\\nmore than anywhere else. It is therefore quite natural\\nthat we find many more advocates of surgical intervention in\\nAmerica than abroad. As a general rule the majority of sur-\\ngeons frequently recommend operative intervention, while\\nthe larger number of physicians reserve the surgical treat-\\nment only for a small number of grave cases of appendicitis.\\nFowler, Morris, Beck, Deaver, Murphy, and others in\\nthis country and Legueu in France urge surgical treat-\\nment in every case of appendicitis. Legueu says: Ap-\\npendicitis belongs to surgery. There is no medi-\\ncal treatment of appendicitis. Every appendicitis\\nmust be operated early. C. Beck 2 expresses himself\\nin the following manner: No matter how mild the clini-\\ncal picture of appendicitis appears, even if it promises a\\nquick temporary recovery, the operation is always justi-\\nfied. Inasmuch as the gravity of infection can never be esti-\\nmated at the beginning, it appears wiser to look upon every\\ncase of appendicitis as serious. Of two evils one should\\nchoose the lesser, and the lesser one here means opera-\\ntion. In his article Beck makes the two following asser-\\ntions 1. Appendicitis is a surgical disease and should be\\ntreated surgically as soon as diagnosed. 2. So long as no\\nphysician is able to estimate the gravity of the bacterial\\ninfection at the commencement of the disease or to foresee\\nthe course which the appendicitis will pursue, whether\\nmild or grave, the safest treatment consists in the early\\nremoval of the appendix.\\n1 Felix Legueu: Traitraent de l Appendicite. Suite de Mono-\\ngraphies Cliniques, 1899, No. 80.\\n2 C. Beck fci Appendicitis. Volkmann s Sammlung klinischer Vor-\\ntrage, No. 221, Sept.. 1898.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0242.jp2"}, "243": {"fulltext": "APPENDICITIS. 223\\nMany surgeons, even in this country, however, do not\\ntake so radical a view as the above writers. Thus Willy\\nMeyer, 1 Charles McBurney, W. T. Bull, A. J. McCosh and\\nF. Hawkes, 2 and others do not recommend the early opera-\\ntion in milder forms of appendicitis. McCosh and Hawkes\\nexpress themselves in the following manner with regard to\\nthe necessity of operative interference When the presence\\nof pus is assured, the sooner operation is done the better.\\nAlso there are cases which begin and continue for twenty\\nfour or forty-eight hours with such severity that a judicious\\nmind must conclude that operation is demanded. So in the\\nchronic and relapsing cases where the symptoms have con-\\ntinued for months with such severity and have recurred\\nso frequently as to subject the patient to a life of semi-in-\\nvalidism, no wise surgeon can counsel any other plan of\\ntreatment than removal of the diseased appendix. Likewise\\nwhen the patient has suffered from three or more attacks\\nthe offending organ should be removed, for other attacks\\nwill in all probability follow. The same indication for\\noperation also exists in our opinion if a patient has suf-\\nfered from two attacks within a year or even two years.\\nThe view which we take is that operation is not\\nnecessary in every case of appendicitis. We believe that\\nnot infrequently patients recover, and recover permanently,\\nfrom one attack of appendicitis, and that in a certain num-\\nber of cases, provided a careful watch is kept, operation is\\nnot necessary. On the other hand, we acknowledge that\\nmany cases which did not appear to be serious have been\\nallowed to die when they might have been saved by opera-\\ntion.\\n1 Willy Meyer M When Shall we Operate for Appendicitis? Medi-\\ncal Record, February 29. 1896.\\n2 A. J. McCosh and F. Hawkes The Surgical Treatment for Appen-\\ndicitis. The American Journal of the Medical Sciences, May, 1897.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0243.jp2"}, "244": {"fulltext": "224 DISEASES OF THE INTESTINES.\\nWilly Meyer, who was among the first to recommend\\nthe removal of the appendix during the free interval, comes\\nto the following conclusions in his paper already men-\\ntioned: 1. In case of diffuse perforative appendicitis the\\noperation must always be done at once. 2. In cases of\\nacute appendicitis the patient always needs careful obser-\\nvation. If the pulse goes above 116 and 120 and has a\\ntendency to stay there, the indication for an operation is\\ngiven. In cases of doubt the operation is better than\\nwaiting. In cases of subacute attacks of appendicitis, also\\nafter the first severe attack from which the patient recovers\\nwithout immediate operation, the appendix should be re-\\nmoved. The appendix once inflamed has to be looked upon\\nas a diseased organ which is very apt to give repeated and\\nmore serious, even fatal, trouble in the future.\\nAmong the German surgeons Sonnenburg, and especially\\nEiedel, 1 are advocates of early surgical intervention in the\\ngrave forms of appendicitis. Biedel says As soon as the\\ntemperature reaches 101\u00c2\u00b0, the pulse 100, the immediate\\nremoval of the appendix is indicated. A tumor which\\nhas developed, accompanied by fever and an acceleration\\nof the pulse, is always an indication for immediate opera-\\ntion. R. Stein 2 and Henry J. Wolf, 3 in papers read quite\\nrecently before the German Medical Society of New York,\\nurged early surgical intervention in all the graver forms\\nof appendicitis.\\nW T ith Penzoldt, Nothnagel, Ewald, Boas, and others I\\nwould give the following indications for surgical interven-\\ntion in this disease\\n1 Riedel Ueber die sog. Friihoperation bei Appendicitis puru\\nlenta resp. gangraenosa. Berliner klinische Wochenschrift, 1899,\\n33 und 34.\\n2 R. Stein Deutsche med. Wochenschr. 1899, p. 440.\\n3 H. J. Wolf: New Yorker medicinische Monatsschrift, 1899.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0244.jp2"}, "245": {"fulltext": "APPENDICITIS. 225\\n1. Diffuse peritonitis in consequence of perforation of\\nthe appendix demands immediate operation. As a rule the\\nfollowing symptoms will be found Sunken and drawn fea-\\ntures, cyanosis, a small and very frequent pulse, an increase\\nof the painful area, often also a bloated condition of the\\nabdomen.\\n2. Whenever an appendicular abscess showing fluctua-\\ntion is present, an operation should be performed.\\n3. If the protracted course of the disease points to the\\nexistence of an abscess, giving rise to slight septic symp-\\ntoms, an operation should be undertaken.\\nWhile in these three groups there can be no hesita-\\ntion in recommending the operation, in the following\\ngroups the necessity of surgical intervention must be con-\\nsidered and decided in each individual case.\\n4. (a) If the rational treatment does not produce any im-\\nprovement in the course of three to five days, the symptoms\\npersisting in undiminished severity or becoming even more\\npronounced, an operation may be resorted to. (b) A sud-\\nden rise of temperature lasting over twenty-four hours,\\nafter the first few days of sickness, is also an indication for\\noperation, (c) A very frequent pulse, not corresponding\\nto the degree of fever, is another symptom which justifies\\nthe consideration of an operation, (c/) If the tumor con-\\ntinues to increase in size after the fifth day of sickness, an\\noperative treatment should be considered.\\n5. The removal of the appendix should be undertaken\\n(a) In all cases of appendicitis in which after recovery the\\npain in the right iliac region persists for a long time (sev-\\neral months) (b) in recurrent appendicitis if the attacks\\nhave been quite severe or if they have followed each other\\nat short intervals.\\n15", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0245.jp2"}, "246": {"fulltext": "CHAPTER IX.\\nINTESTINAL OBSTRUCTION.\\n{Acute and Chronic.\\nIntroductory Remarks. By intestinal obstruction is un-\\nderstood a great variety of conditions which, although\\nunlike in character, have yet the common feature of me-\\nchanically causing an obstruction to the passage of con-\\ntents along the intestine. Leichtenstern l distinguishes the\\nfollowing three groups with regard to the causation of the\\nintestinal obstruction\\n1. Occlusion due to pressure from without or com-\\npression of the intestinal lumen in the full sense of the\\nword. To this group belong incarcerations of the intes-\\ntines in apertures, in slits, and in hernial openings;\\nstrangulation by pseudo-ligaments, the vermiform proc-\\ness, and diverticula compression by tumors, by the mes-\\nentery, or by displaced abdominal organs. Rotations of\\nthe intestinal tube around its axis (torsions) and forma-\\ntion of knots also belong to this category.\\n2. Occlusion from within the intestinal lumen (obtura-\\ntion). The obturation may be produced either by gall\\nstones, enteroliths, foreign bodies, hardened fecal masses,\\nor by neoplasms of considerable size, especially polypi.\\nIntussusception (involution of one coil of the bowel into\\nanother) also belongs to this class.\\n1 Leichtenstern Verengerungen, Verschliessungen und Lagever-\\nanderungen des Darms. Ziemssen s Handbuch der speciellen Patho-\\nlogie und Therapie, Bd. vii., Leipzig, 1878.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0246.jp2"}, "247": {"fulltext": "ACUTE OBSTRUCTION. 22T\\n3. Occlusions which originate from factors within the\\nintestinal wall and causing narrowing of the lumen either\\ndirectly or indirectly. Constriction may occur either in\\ncircular form (strictures) or as a result of flexions. Ob-\\nstructions developing after chronic peritonitis, distortions,\\nand angular bends of the intestine, cicatricial stenoses\\nas well as those produced by neoplasms, belong to this\\nclass.\\nNotwithstanding the diversity and great multiplicity of\\nthe anatomical factors causing stenoses and obstructions of\\nthe intestines, the clinical picture and the consecutive le-\\nsions which they evoke greatly resemble each other. It\\nwill therefore perhaps be practical to give first the clinical\\npicture of complete obstruction of the bowels (ileus) and\\nof stenosis of the intestine, and then to discuss the differ-\\nent anatomical causes and also the differential diagnosis.\\nACUTE INTESTINAL OBSTRUCTION.\\nSynonyms. Ileus, miserere, passio iliaca.\\nDefinition. An acute stoppage of the passage of the in-\\ntestinal contents. This may be caused either by a me-\\nchanical occlusion at a certain part of the intestinal canal\\n(mechanical ileus) or by an entire absence of motor power\\nin a portion of the bowel (dynamic or paralytic ileus) or\\nsometimes by both (mechano-dynamic ileus).\\nEtiology. The etiology of ileus is quite complicated,\\nand it will be best to analyze separately the different factors\\nproducing it.\\nCompression of the Intestines. Compression of the in-\\ntestines can occur (1) by strangulation through adhesions,\\nbends or pseudo-ligaments, by Meckel s diverticulum, by\\nnormal structures abnormally attached, by slits and aper-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0247.jp2"}, "248": {"fulltext": "228 DISEASES OF THE INTESTINES.\\ntures in the mesentery and omentum, and by incarcerations\\ninto hernise; (2) by torsions (volvulus) and (3) by tumors\\nfrom without.\\nThe primary factor in producing isolated adhesions\\n(bands or pseudo-ligaments) is a preceding localized peri-\\ntonitis. In some cases these bands may have been con-,\\ngenital and due to intra-uterine peritonitis. The band\\nmay have the form of a firm fibrous cord or it may be very\\nslender and may appear as a tough, rigid thread. Occa-\\nsionally it may be of comparatively large size. Seldom\\nthe constricting ligament has the appearance of an actual\\nband, having a width of half an inch or more.\\nThe strangulation of the intestine by an isolated peritoneal\\nadhesion takes place in two ways first, the intestine may\\nbe strangulated under the band as beneath a shallow and\\nnarrow arch; secondly, it may become snared and con-\\nstricted by a noose or knot formed by the false ligament\\nitself. Strangulation from bands occurs when these are com-\\nparatively short and tightly stretched over a firm surface.\\nThe arch beneath which the implicated bowel passes is\\nusually large enough to admit one to three fingers. Stran-\\ngulation by a noose or knot requires the presence of a long\\nfalse ligament which must lie loose and free in the abdom-\\ninal cavity, being attached only at its two ends. The most\\ncommon way in which a coil of intestine becomes snared\\nis where a lax band forms a ring or spiral between its fixed\\npoints. Through this ring a loop of the small intestine\\nslips the protrusion becoming larger the implicated coil\\ncannot free itself from the noose and is strangulated.\\nStrangulation by the formation of a knot is described by\\nLeichtenstern in the following manner There are several\\nkinds of this knotting. The most frequent is the follow-\\ning A long and loose ligament is fastened at one end to", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0248.jp2"}, "249": {"fulltext": "ACUTE OBSTRUCTION.\\n229\\na loop of the small intestine, and hangs in the form of a\\nsimple coil (Fig. 29) if the top of the intestinal loop\\npasses directly through the coil a simple knot is formed\\nabout the piece of the intestine, as is shown in Fig. 30.\\nIt is evident that the same result can be produced by the\\nFig. 30.\\nFig. 31.\\nFig. 32. Fig. 29.\\nFigs. 29-32.\u00e2\u0080\u0094 Types of Constricting Peritonitic Bands. (After Leichtenstern and Treves.)\\ncoil being drawn over the top of and around the intestinal\\nloop. Another and rarer form of knot is produced as fol-\\nlows: A long and perfectly loose false ligament forms a\\nsimple coil between its points of attachment. If now one\\nleg of the so-called primary noose passes through it we\\nhave a knot like that shown in Fig. 31, and if now the", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0249.jp2"}, "250": {"fulltext": "230 DISEASES OF THE INTESTINES.\\nintestinal loop passes directly through (Fig. 32), it be-\\ncomes firmly caught and strangulated. A common char-\\nacteristic of all described knots is that when the strangu-\\nlated intestine is freed, the ligament can immediately be\\ndrawn out straight.\\nStrangulation by Meckel s Diverticulum. Meckel s diver-\\nticulum is due to the persistence or incomplete oblitera-\\ntion of the vitelline duct. Most commonly it exists as a\\nblind tube, given off from the ileum. Its length is about\\nthree inches. As a rule, it is cylindrical in shape, with a\\nconical extremity. Occasionally it presents a globular\\nshape and is then called clubbed. Meckel s diverticle\\nis always single and is attached to the ileum one to three\\nfeet above the ileo-csecal valve. As a rule, the end of the\\ndiverticulum is free. In some iustances it is attached to\\nthe umbilicus or to the abdominal wall. Sometimes the\\nend attached to the abdominal jjarietes may give way and\\nform fresh adhesions with some points of the peritoneal\\nsurface. The latter occurrence is of great importance with\\nreference to strangulation of the intestine, which frequently\\ntakes place under these conditions. By means of the new\\nadhesion of the diverticulum a loop is formed in which\\nsome portion of the intestine is liable to engage. Another\\npossibility for strangulation by the diverticulum is afforded\\nwhen its end is free and club-shaped. The diverticulum\\nforms a ring into which its own free end projects. A loop\\nof the intestine entering the centre of this ring may push\\nthe clubbed end of the process before it and so tie the\\nknot, thus leading to obstruction. Again the diverticulum\\nmay surround the pedicle of an intestinal loop in such a\\nway as to encircle it with a single knot (see Figs. 33, 34, 35).\\nIn a similar manner as Meckel s diverticulum some nor-\\nmal structures may act when they are abnormally attached.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0250.jp2"}, "251": {"fulltext": "ACUTE OBSTRUCTION.\\n231\\nThus the vermiform appendix may become adherent to\\nsome point of the neighboring peritoneum and so form an\\narch under which\\na loop of the in- FIG riG M\\ntestine may b e\\nstrangulated.\\nThe Fallopian\\ntube may likewise\\nbecome adherent\\nto the adjacent\\nperitoneum situ-\\nated in the iliac\\nfossa and thus\\nform an arch in-\\nto which a por-\\ntion of the intes-\\ntine may slip and\\nbecome incarcer-\\nated. Other in-\\nternal organs ab-\\nnormally at-\\ntached may form\\nsimilar traps for\\nintestinal stran-\\ngulation.\\nOf great clini-\\ncal importance is\\nthe strangulation\\nof the intestine in slits and apertures of the mesentery or\\nomentum. These may be either congenital or of traumatic\\norigin. Similar to the action of slits in the production\\nof strangulation are also the various internal hernise (her-\\nnia duodeno-jejunalisj hernia retroperitonealis anterior,\\nFIG. 35.\\nFigs. 33-35.\u00e2\u0080\u0094 Knotting of a Meckel s Diverticulum which\\nhas a Button-like Swelling of its Extremity. (Treves.)", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0251.jp2"}, "252": {"fulltext": "232 DISEASES OF THE INTESTINES.\\nhernia intrasigmoida, hernia bursse ornentalis, formed\\nby the foramen of Winslow, diaphragmatic hernia).\\nIn all these cases the mechanism of the obstruction is as\\nfollows A coil of gut may be driven with sudden severe\\nforce beneath the band or through an aperture and become\\npractically strangulated at once, as is often the case in\\nstrangulated hernia. There being no natural force to drive\\nthe coil out of its place of imprisonment, it remains firmly\\ngripped. In other cases the involved intestine may not be\\nstrangulated at first, but the band pressing upon the mes-\\nenteric vessels produces a congestion in the implicated\\ncoils, which become engorged and distended by an in-\\ncreased accumulation of gas, and thus complete strangu-\\nlation is the result. In other cases, again, the final cause\\nof a strangulation is a twisting of the bowel. All the va-\\nrieties of intestinal strangulation just mentioned occur in\\nthe small intestine, the lower portion of the ileum being\\nprincipally affected, less frequently its upper portion or\\nthe jejunum.\\nThe occlusion may in some cases be due to kinking of\\nthe intestine through a band attached to the bowel and\\ndragging upon it. Adhesions may also obstruct the bowel,\\ncompressing its lumen. This occurs when false mem-\\nbranes are situated around the bowel and have undergone\\nshrinking. They then compress the intestine seriously\\nand narrow its lumen. The same process of shrinking\\nmay also effect an obstruction of the bowel if it takes\\nplace in the mesentery after inflammation.\\nVolvulus. By the term volvulus is understood an obstruc-\\ntion of the bowel by a twist about its mesentery, or its own\\naxis, or the intertwining of an intestinal coil within another.\\nTwisting of the bowel occurs most often in the sigmoid\\nflexure. The usual cause of this trouble is chronic consti-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0252.jp2"}, "253": {"fulltext": "ACUTE OBSTRUCTION. 233\\npation, for in this condition the flexure fs more or less\\nconstantly distended. Its walls become partly paralyzed\\nand hang down into the pelvis, like an inert heavy mass,\\nbeing rilled with fecal matter. Traction is thereby exerted\\nupon the mesocolon and a loop is soon formed. A twist-\\ning of the latter is brought about either by some displace-\\nment of the bowel or by a sudden change in the position\\nof the body. The ascending colon, ca3cum, and the small\\nintestine may also be affected in the same manner, al-\\nthough less frequently. Intertwining of the intestine is\\nhere more often met with.\\nObturations of the Intestine. Intestinal occlusion often\\ntakes place in consequence of obturation of the lumen of\\nthe gut through foreign bodies lodging therein. Accumu-\\nlations of fecal matter may give rise to such an occurrence.\\nThe hard fecal tumor is then situated either in the caecum\\nor in the colic or sigmoid flexures. In these cases chronic\\nconstipation has existed for a long time.\\nGall stones, although rarely, give rise to intestinal oc-\\nclusion. In order to do this they must be of considerable\\nsize. The puzzle as to how the camel could go through\\nthe eye of the needle, i.e., how these enormous gall stones\\ncould reach the bowel, has been solved, by the assumption\\non fair evidence that an ulcerative process opens the way\\nfrom the gall bladder to the bowel, though doubtless very\\nlarge stones occasionally find their passage through the\\nducts (E. D. Ferguson 1\\nIn a similar manner enteroliths may also cause obstruc-\\ntion of the bowel. This happens especially if an entero-\\nlith situated in an intestinal diverticulum has been dis-\\nlodged and found its way into the canal of the gut.\\n1 E. D. Ferguson Transactions of the New York State Medical\\nAssociation, 1898, p. 233.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0253.jp2"}, "254": {"fulltext": "234 DISEASES OF THE INTESTINES.\\nForeign bodies which have been accidentally or inten-\\ntionally swallowed may under favorable conditions reach\\nsome part of the bowel and here obstruct the lumen. This\\nwill occur if the foreign body is of considerable size, or if\\nit is not smooth but provided with sharp points. The\\nlatter catch in a fold of mucous membrane and prevent its\\nfurther passage. The most varied substances have thus\\nbeen found to be the cause of intestinal obstruction mar-\\nbles, stones, coins, glass stoppers, corks, spoons, knives,\\nforks, keys, needles, pins, buttons, false teeth with the\\nplate. Kernels of fruit like cherries, prunes, etc., may\\naccumulate in the bowel and by means of fecal matter be\\nkept together, forming a large conglomeration, completely\\nobstructing the canal.\\nRecently Murphy s button has also been found in a few\\ninstances to cause obstruction of the bowel.\\nIntestinal parasites (tapeworms, ascaris lumbricoides) if\\npresent in large numbers, may also form a mass obstruct-\\ning the canal. This occurs especially after a vermifuge\\nhas been administered and the dead parasites have re-\\nmained within the canal.\\nSimilar to the action of foreign bodies are also tumors\\n(polypi, fibroma, myoma, etc.) connected by a pedicle\\nwith the intestinal wall, filling up its lumen.\\nIntussusception. Intussusception or invagination means\\nthe prolapse of one part of the intestine into the lumen of\\nan immediately adjoining part. An intussusception shows\\nin a vertical section six layers of intestine, three on either\\nside of the central canal, which are more or less parallel to\\none another. The arrangement of the layers is such that\\nmucous membrane is in contact with mucous membrane, and\\nperitoneum with peritoneum. On transverse section the\\ninvaginated mass shows three concentric rings of bowel.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0254.jp2"}, "255": {"fulltext": "ACUTE OBSTRUCTION. 235\\nThe external of the three layers is called the intussusci-\\npiens, the sheath, or the receiving layer. The innermost\\ncylinder is called the entering layer and the middle one the\\nreturning layer. The latter two together form the intus-\\nsusceptum. The neck of the intussusceptum is at its up-\\nper part where the returning layer joins the sheath.\\nIn case the intussusception lasts for some time the se-\\nrous surfaces of the gut touching each other may become\\nglued together and ultimately adherent. This will prevent\\nthe disengagement of the invaginated portion, while its fur-\\nther passage into the other bowel will not be interfered\\nwith. The mesentery always participates in the invagina-\\ntion and becomes more or less compressed and wedged in\\nby the sheath. The whole mass of a simple intussuscep-\\ntion may in its turn become invaginated and give five in-\\nstead of three coats, or even seven if the process is re-\\npeated, so that the upper edge of the intussuscipiens is\\nrolled over like a cuff. These double and triple intussus-\\nceptions are comparatively rare.\\nWith regard to the mechanism of intussusception Noth-\\nnagel s experiments on animals have proven of greatest\\nvalue. According to this writer intussusception may be\\ndue either to a localized spastic contraction of a portion\\nof the bowel or to a total paralysis. The normal gut im-\\nmediately below the contracted part slips upward to a slight\\nextent over this strongly contracted and greatly narrowed\\nportion, and invagination is thus produced. Again if a\\nsegment of the bowel is paralyzed, the gut lying immedi-\\nately below it, on contraction will slip into the paralyzed\\nportion and thus an invagination may arise.\\nIntussusception may take place at any point within the\\nentire small and large intestines. Over fifty per cent of\\nthe cases consist of the invagination of the ileum into the", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0255.jp2"}, "256": {"fulltext": "236 DISEASES OF THE INTESTINES.\\ncolon. With regard to the remote cause of intussuscep-\\ntion Treves 1 has examined a number of reported cases and\\nfound it in one hundred examples of intussusception dis-\\ntributed as follows\\n1. No evident exciting cause 62 per cent.\\n2. Diarrhoea, dysentery, enteritis, marked irregularity of\\nthe bowels 8\\n3. Polypi 5\\n4. Ingesta 5\\n5. Injuries and exposure to cold 5\\n6. Certain acute and chronic ailments which may or may\\nnot have had a concern in the etiology, such as\\ntyphoid fever, whooping-cough, measles, scarlet\\nfever, smallpox, cholera, and hernia with these\\nmay be included pregnancy and labor 15\\nTotal 100\\nThis clinical form of intussusception must not be con-\\nfounded with agonal intussusception, which, as the term\\nindicates, occurs shortly before death and is purely of\\nanatomical importance. The agonal form of intussuscep-\\ntion is sometimes found multiple and is met with fre-\\nquently at autopsies of children who have died from affec-\\ntions of the brain.\\nPathological Changes. The lesions which are encountered\\nin acute ileus, no matter what be its origin, are the follow-\\ning: The intestinal coils above the occluded part of the\\nbowels present a quite different appearance from those\\nbelow. The former are distended, rilled with gas and ill-\\nsmelling feculent contents; and this ectatic condition is\\nthe more pronounced the nearer they are situated to the\\noccluded part. If the occlusion lies in the jejunum or\\nileum, the distention will involve the entire upper portion\\nof the small intestine and also the stomach. If, however,\\nthe stoppage is situated within the colon, the dilatation\\nTreves: Intestinal Obstruction, p. 211.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0256.jp2"}, "257": {"fulltext": "ACUTE OBSTRUCTION. 237\\nwill at first occupy that portion of the colon situated be-\\ntween the ileocecal valve and the obtruded spot, while\\nthe small intestine may remain unchanged, the ileocecal\\nvalve acting in its usual way and thus preventing an over-\\nflow of the contents of the colon into the small intestine.\\nUnder such circumstances the dilated portion of the colon\\nmay attain considerable size, resembling almost the stom-\\nach. After the condition has lasted a few days, however,\\nthe ileocecal valve ceases to functionate and now the con-\\ntents of the colon overflow the small intestine and the\\nstomach and these organs become also overfilled and dis-\\ntended. The portion of the intestine situated below the\\nocclusion is empty and contracted.\\nThe intestinal coils above the occluded spot are usually\\nengaged in very active peristaltic movements, which repre-\\nsent an attempt of nature to overcome the obstacle. After\\nthese peristaltic motions have lasted a few days, a paralytic\\nstate of the intestines supervenes.\\nThe intestinal mucosa situated near the occlusion is\\nsubjected to great mechanical and chemical irritations\\ndue to the constant presence of considerable amounts of\\ndecomposed material, and thus grows intensely inflamed.\\nOften ulcers develop which may penetrate the wall of\\nthe bowel and cause fatal peritonitis. In rare instances\\nafter such a perforation, adhesion to neighboring intes-\\ntinal coils may occur and give rise to fecal abscesses\\nand abnormal communications between different intestinal\\nsegments. By means of a similar process an opening may\\nbe established between the intestine and the abdominal\\nwalls in such a manner that the fecal matter finds an exit\\nhere (anus praeternaturalis).\\nLocalized or general peritonitis is thus often present in\\ncases of intestinal obstruction. Serous, bloody, or puru-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0257.jp2"}, "258": {"fulltext": "238 DISEASES OF THE INTESTINES.\\nlent exudation is frequently found in the abdominal cav-\\nity. The anatomical lesions are most pronounced in the\\nimmediate vicinity of the occluded intestine. This is due\\nnot only to the stoppage of the intestinal contents but also\\nto interference with the circulation of the gut produced by\\nthe same factors which have caused the obstruction. Nu-\\nmerous large and small mesenteric veins become com-\\npressed, thus causing congestion and hemorrhages. The\\nintestinal walls appear infiltrated with blood, showing ec-\\nchymoses at various places, and may even appear dark\\nred. In the neighborhood of the occlusion the intestine\\nmay be covered with black curdled blood in the form of\\na membrane. Its walls become brittle and gangrenous.\\nSymptomatology. The symptoms of acute intestinal ob-\\nstruction appear either suddenly or after slight disturb-\\nances have existed for a few days, as for instance diar-\\nrhoea, constipation, feeling of uneasiness. In some\\ninstances the history of an exciting cause is given. Thus\\na severe blow on the abdomen, violent bodily exertion, a\\ncold, a too copious meal, or a strong laxative.\\nThe patients are first seized with violent abdominal\\npains, sometimes of a crampy character. The pain may\\nbe felt at first at a certain definite spot within the abdo-\\nmen, while later it becomes more diffuse. In other in-\\nstances the patient is unable to localize the pains dis-\\ntinctly. Occasionally the area around the navel is given\\nas the seat of the pains, while in other cases they are re-\\nferred to the entire abdomen. The pain usually exists un-\\ninterruptedly, though it may show exacerbations from time\\nto time. Soon after the occurrence of these colicky pains\\neructations of gas and then vomiting appear. At the be-\\nginning gastric contents are ejected, later bile, and finally\\noffensive feculent material is brought up. The latter usu-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0258.jp2"}, "259": {"fulltext": "ACUTE OBSTRUCTION. 239\\nally has a yellowish-brown color, is liquid, and contains\\nonly very fine, small, solid particles suspended in the fluid.\\nAt this period the eructated gases have a fetid odor and\\nhiccough almost constantly distresses the patient. After\\nthe act of vomiting the patient may feel somewhat relieved\\nfor a short while, but soon there is a return of the severe\\nsymptoms.\\nAlmost simultaneously with vomiting, meteorism of the\\nabdomen ensues. The passage from the rectum is entirely\\nstopped and there is no evacuation either of fecal matter\\nor of flatus. The meteorism may involve either a certain\\nregion of the abdomen or the entire cavity. The tympani-\\ntes gradually increases and a feeling of tension becomes\\nmore and more pronounced. The diaphragm is soon\\npushed upward by intestinal coils filled with gas in such\\na manner that the liver dulness may be absent from the\\nentire right thoracic cavity. Dyspnoea supervenes; the\\nbreathing becomes accelerated and superficial, assuming\\nthe thoracic type. The pulse is small and frequent. The\\nextremities are cold, the skin is covered with perspiration,\\nthe face is pale, bearing the expression of utmost anguish,\\nthe eyes are sunken, dryness of the throat and extreme\\nthirst exist, and the patient is barely able to use his voice.\\nThese extremely painful and tormenting symptoms persist\\nand the patient succumbs unless there is a change in the\\ncourse of the disease remaining conscious until the end.\\nAfter having given a general description of the clinical\\npicture of ileus it will not be amiss to discuss each symp-\\ntom separately.\\n1. Pains. Pain, the most constant and conspicuous\\nsymptom of intestinal obstruction, depends upon several\\nconditions. It is usually due, first, to the injury inflicted\\non the peritoneum and the intestinal walls in consequence", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0259.jp2"}, "260": {"fulltext": "240 DISEASES OF THE INTESTINES.\\nof the strangulation; secondly, especially at a somewhat\\nlater .period, to the tumultuous and increased irregular\\nperistaltic movement of the intestines. These movements\\nabove the site of obstruction are of a very intense charac-\\nter and produce colic as well as exacerbations of the\\npains which occur at certain intervals. The intensity of\\nthe pain depends upon the degree of excitability of the\\nindividual, upon the state of the sensorium, upon the ex-\\ntent of the intestine and peritoneum involved, and upon\\nthe severity of the occluding lesion and the rapidity of its\\noccurrence. Later on the pain is influenced by the dis-\\ntention of the gut and by the presence or absence of peri-\\ntonitis.\\nAt the commencement of the disease the pain is fre-\\nquently not aggravated and sometimes relieved by press-\\nure. Later, however, the pain is considerably increased\\nby even slight pressure, the cause of this being the pres-\\nence of peritonitis.\\nAccording to Treves, 1 the pain is constant, although\\nliable to periodical exacerbations in cases of complete ob-\\nstruction. In cases in which the obstruction is but par-\\ntial the pain is distinctly intermittent, and the patient\\nexperiences intervals between attacks of pains during which\\nhe is free from suffering. The i ain as a rule grows more\\nintense with the progress of the disease. There may be,\\nhowever, a diminution in the severity of the pain for a short\\nperiod before a fatal issue, caused by a collapse, paralysis\\nof the intestine, rupture or perforation of the bowel, or by\\na diminished activity of the sensorium.\\nTreves has pointed out that no matter in what part of the\\nsmall intestine the obstruction is situated, the pain arising\\ntherefrom is usually referred to the region of the umbilicus.\\n1 F. Treves: Intestinal Obstruction, Philadelphia, 1884.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0260.jp2"}, "261": {"fulltext": "ACUTE OBSTRUCTION. 241\\nIf the obstruction is localized in the large bowel, then the\\npain may be experienced, especially at the beginning of\\nthe disease, at the seat of the lesion later, however, the\\npain may assume a more diffused character or may be felt\\nat other regions of the abdomen. This is the reason why\\nonly the initial pain is of some diagnostic significance with\\nregard to the seat of the lesion.\\n2. Vomiting. Vomiting is almost always present. At\\nthe beginning of the disease it is of reflex origin due to\\nthe irritation of the peritoneum; later on it must be as-\\ncribed principally to the irregular, strong, peristaltic con-\\ntractions of the intestines. The appearance of fecal vom-\\niting was believed by the old writers to be a sign that the\\nobstruction was situated in the large bowel. Nowadays,\\nhowever, it is generally known that this symptom is often\\npresent in cases in which the obstruction is situated in the\\nileum or even in the jejunum. The reason of absence of\\nputrefactive processes in the intestinal contents normally is\\nthe rapidity with which they are moved farther on along\\nthe canal until they reach the large bowel. In obstruction,\\nhowever, the peristaltic contractions are much slower and\\nthus putrefactive processes develop even in the small bowel.\\nIn order to explain the mechanism of stercoraceous vom-\\niting a reversed peristaltic or antiperistaltic motion of the\\nintestines was formerly assumed. Of late, however, the\\nmechanism of fecal vomiting as expounded by Haguenot\\nas early as 1713, is now generally accepted. According to\\nthis author, stercoraceous vomiting takes place in the fol-\\nlowing manner Above the occluded intestine there is an\\naccumulation of more or less liquid intestinal contents in\\n1 Haguenot Memoire sur les Mouvernents des Intestins dans la\\nPassion Iliaque. Histoire de l Academie Royale des Sciences, Paris,\\n1713.\\n16", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0261.jp2"}, "262": {"fulltext": "242 DISEASES OP THE INTESTINES.\\nconsiderable, quantity the bowels being distended with\\nlarge amounts of gas are under constant pressure, which\\nis increased after each inspiration and especially after\\nenergetic contraction of the abdominal muscles, occur-\\nring for instance during the act of vomiting. Under the\\ninfluence of pressure the stagnant liquid contents are re-\\ngurgitated from above the occluded spot into places in\\nwhich there is less resistance and thus reach the duo-\\ndenum and the stomach. Here they irritate the mucous\\nmembrane and cause vomiting.\\nThis theory is perfectly in accord with the circumstance\\nthat in stercoraceous vomiting mostly liquid or sometimes\\nsemi-liquid contents are evacuated, but never solid fecal\\nmatter; for even in obstruction of the colon the fluid will be\\nmoved farther upward while solid particles will remain in\\nthe lower portion of the bowel. Vomiting of formed fecal\\nmatter is a very rare occurrence, and must be ascribed to an\\nexisting fistulous opening between the colon and stomach.\\n3. Constipation. Constipation almost always exists and\\nis very obstinate. After injections, very rarely spontane-\\nously, there may be a slight movement of the bowel con-\\nsisting of the fecal matter lodged below the occluded spot.\\nIn some rare instances a catarrhal condition may exist\\nin the segment of the bowel below the obstruction, and\\nthe patient then may rather have diarrhoea combined with\\ntenesmus. Of greater significance than the absence of\\nstools is the inability to pass wind through the anus. The\\npassage of flatus is a sure sign that the permeability of the\\nintestine has been re-established.\\n4. Meteorism. Meteorism is the result of increased for-\\nmation of gas developing in consequence of putrefactive\\nprocesses as well as of diminished absorption. According\\nto Zuntz, the absorption of intestinal gases into the blood", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0262.jp2"}, "263": {"fulltext": "ACUTE OBSTRUCTION. 243\\ntakes place only when the circulation is in good working\\norder. Meteorism thus indirectly points to a disturbed\\ncirculation which is often found in cases of incarcerations.\\nIf meteorism is absent the absorption of gases must be\\nassumed to take place as rapidly as their formation. Me-\\nteorism may be at first present at a certain circumscribed\\nspot of the abdomen and later become more diffuse. If\\nthe place at which it first appears can be distinctly defined,\\nthis is of diagnostic importance with regard to the location\\nof the occlusion.\\nIf the occlusion is in the large bowel the portion situated\\nbetween it and the ileocecal valve will become considera-\\nbly distended with gas. Thus a protrusion of the right\\nside of the abdomen will be noticed when the obstruction\\nis at the right flexure. If the obstacle is situated in the\\nrectum there is at first a protrusion of the left side of the\\nabdomen and later the tympanites will involve the portion\\nof the abdomen situated above the navel (course of the\\ntransverse colon) In some instances, however, obstruction\\nof the rectum may be acompanied by more or less general\\nmeteorism. This is especially the case after the disease\\nhas lasted some time for then, as a rule, the resistance of\\nthe ileocecal valve is overcome by the gas pressure and\\nit remains more or less patent in such a way that the gases\\neasily penetrate the small intestine.\\nIn occlusions affecting the duodenum or the upper part\\nof the jejunum the meteorism as a rule involves the upper\\nhalf of the abdomen, and remains confined to this area.\\nAfter vomiting there is usually a perceptible decrease of\\nthe protrusion for a short while.\\nIf the meteorism has lasted for some time and is in-\\ntense, the abdomen assumes a barrel shape. This is espe-\\ncially found in cases in which the distended intestinal coils", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0263.jp2"}, "264": {"fulltext": "244 DISEASES OF THE INTESTINES.\\nare ahead} paralyzed. The accumulation of gas can now\\ngo on without encountering much resistance and thus do\\ngreat harm. The diaphragm is then pushed upward. The\\nlungs as well as the heart become compressed. Stomach,\\nliver, and bladder are compressed by the intestinal coils\\nfilled with gas lying upon them. In a similar manner the\\nlarge veins (vena cava, vena portae, etc.) are subjected to\\nthe same disturbance. Thus the function of many impor-\\ntant vital organs is interfered with and impaired to such a de-\\ngree, if this condition persists, that a fatal issue may occur.\\n5. Collapse. The diverse symptoms of shock which ap-\\npear in a marked degree in cases of ileus must be ascribed\\nto the sudden damage inflicted upon the peritoneum and\\nintestinal wall by the strangulating agent. The mechani-\\ncal irritation involves first the splanchnic nerves, and\\nthrough them the circulatory apparatus. As a conse-\\nquence there are a lowering of the temperature of the sur-\\nface, cold sweats, lividity of the extremities, anaemia of the\\nbrain, and a small and rapid pulse. The degree of the\\ncollapse depends upon the disposition of the patient, upon\\nthe suddenness of the strangulation, and upon the amount\\nof peritoneum or of intestine involved in the lesion.\\nThe gravest amount of shock is met with in cases in which\\na considerable segment of the intestine is suddenly strangu-\\nlated and an injury thus abruptly inflicted upon an exten-\\nsive nerve area. As a rule, the shock met with in cases of\\nobstruction of the small intestine is much more pronounced\\nthan in cases in which the obstruction is situated in the\\nlarge bowel. The reason for this is the greater supply of\\nnerves and the greater activity of the small intestine as\\ncompared with the large bowel. The nerves of the small\\nintestine are also more directly associated with the great\\nsympathetic ganglia of the abdomen.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0264.jp2"}, "265": {"fulltext": "ACUTE OBSTRUCTION. 245\\n6. The Decrease of the Amount of Fluid in the Blood.\\nIn intimate connection with the disturbance of the nerves\\nand circulator} 7 functions just described is the decrease in\\nthe amount of fluid in the blood. This is due to increased\\nsecretion in the intestine with absence of absorption, to\\nvomiting, and to increased perspiration. As a consequence\\nthere exist dryness of the tongue and a tormenting thirst\\nthe urine is also passed only in small quantities, and in\\nsome instances there ma}- even be anuria.\\nCertain symptoms which occur bat rarely and also be-\\nlong more or less to this group are cramps, tetanus, coma,\\ndelirium, fever. Whether these symptoms are due to\\nauto-intoxication or to other factors (especially the dry con-\\ndition of the blood) is as yet not settled.\\nC j-zcibVe Signs. inspection reveals eitner z symmetri-\\ncal fulness of the abdomen (sometimes barrel shaped) or a\\nprotrusion of certain parts. Thus, as mentioned above,\\nthe upper part of the abdomen is protruded when the oc-\\nclusion involves the duodenum or the upper part of the\\njejunum. The right iliac region is intensely tympanitic\\nif the occlusion involves the hepatic flexure, while the left\\niliac region is the seat of the protrusion if the occlusion\\ninvolves some portion of the descending colon. After the\\ndisease has existed for some days there is as a rule a gen-\\neral marked swelling of the abdomen.\\nPalpation reveals in some cases a circumscribed area\\nwhich is painful on pressure and thus serves to localize\\nthe seat of the disease. This is especially the case very\\nsoon after the onset of the symptoms. In the larger num-\\nber of cases, however, there is a special tenderness either\\nin the region of the navel alone or over the entire abdomen.\\nIn comparatively few cases will palpation reveal a tumor\\nsituated deeply within the abdomen and in direct connec-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0265.jp2"}, "266": {"fulltext": "246 DISEASES OF THE INTESTINES.\\ntion with the site of obstruction. This occurs especially\\nin intussusception, strangulation, in occlusions due to com-\\npression by tumors, and in fecal impaction. After a thor-\\nough palpation of the abdomen a digital examination of\\nthe rectum and also of the vagina should be performed.\\nIt is hardly necessary to add that a thorough examination\\nshould be made of any existing hernia which may be the\\nseat of incarceration.\\nBy means of auscultation either from a distance or in\\nthe immediate neighborhood of the abdomen we are often\\nenabled to judge about the state of the intestinal peristal-\\nsis for when the latter takes place in a violent manner\\nsplashing and gurgling noises are always audible.\\nPercussion is usually of great importance. In general\\nmeteorism it permits us to judge of the position of the dia-\\nphragm and liver. If percussion shows a change in char-\\nacter over a certain region of the abdomen during a period\\nof a few minutes, it follows that the condition of an intes-\\ntinal coil lying beneath has undergone some change in its\\nstate of fulness, and thus indicates that the bowel is still\\nin active peristalsis. Auscultation and percussion may be\\nused conjointly and serve the same purpose. In case no\\nchange whatever is noted on percussion for a very long\\nperiod of time, there is a suspicion that paralysis of the\\nbowels exists. The liver dulness will be found either\\npartly or entirely absent in almost all cases of perforation,\\nbut in some rare instances even without perforation. In\\nthe latter event we must assume that intestinal coils filled\\nwith gas are lying above the liver. I have observed such\\na case with recovery during the last year. Sometimes per-\\ncussion may help to discover existing exudation, dulness\\nbeing found in the lower part of the abdomen.\\nExamination of the vomited matter will show the pres-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0266.jp2"}, "267": {"fulltext": "ACUTE OBSTRUCTION. 247\\nence or absence of fecal elements. The urine is scanty,\\nvery concentrated, often contains albumin, and almost al-\\nways shows an increase of indican and phenol. Eosen-\\nbach s reaction is almost always present.\\nCourse. The course of an acute obstruction will depend\\nfirst upon its location, and secondly upon its nature. The\\nhigher up in the intestine the obstruction is situated the\\nmore rapid as a rule is the course of the disease. Volvu-\\nlus and strangulation of the intestine are generally accom-\\npanied by a more violent course than is obturation by for-\\neign bodies. The duration of the disease is not always\\nthe same. In some instances the patient dies very soon,\\na few hours or a day or two after the commencement of\\nthe obstruction, of shock and paralysis of the heart. In\\nother instances the disease lasts several clays or even a\\nweek. In intussusception the duration of the disease is\\nlonger, several weeks, showing periods of exacerbations\\nand remissions.\\nIf the patient recovers from the collapse and there\\nis a spontaneous re-establishment of the patency of the in-\\ntestinal lumen {i.e., the obstruction is relieved, which may\\nhappen in cases of invagination, torsion, and obturation\\nby foreign bodies), there is at first as a rule a passage\\nof flatus, which may be followed by a fecal movement of\\noffensive odor. In case of invagination there is often some\\nblood in the evacuation. All the symptoms which have\\npreviously existed begin to abate, the fecal vomiting ceases,\\nthe meteorism becomes less, and the patient gradually re-\\ncovers from his severe illness. In cases in which the intes-\\ntinal obstruction has led to considerable anatomical changes\\nwithin the lumen of the bowel (ulcers, gangrenous proc-\\nesses, adhesions), after a period of comparative euphoria,\\nsymptoms of chronic intestinal obstruction may develop.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0267.jp2"}, "268": {"fulltext": "248 DISEASES OF THE INTESTINES,\\nIn the greater number of cases of acute intestinal ob-\\nstruction the latter persists, and the patient, if not oper-\\nated upon, generally dies of diffuse peritonitis, with or\\nwithout perforation of the intestines. Even without per-\\nforation, peritonitis may readily develop in consequence of\\nthe paralytic state of the intestine for, according to Bon-\\nnecken, 1 bacteria can easily penetrate the intestinal wall as\\nsoon as the latter is in a paralyzed condition and thus give\\nrise to inflammation of the peritoneum.\\nCircumscribed peritonitis around the occluded part need\\nnot give distinct symptoms. General peritonitis, however,\\nalways enhances the alarming symptoms already existing.\\nThus the meteorism increases; the dyspnoea, hiccough,\\nand vomiting become more violent, the pains unendur-\\nable the heart begins to give out and pronounced collapse\\nappears. Generally there is a rise of temperature and\\nfrequently a fluid exudation within the abdomen is dis-\\ncoverable. If perforation of the intestine has taken place,\\nthe symptoms just described appear still earlier and with\\nmore violence. The abdomen becomes more or less\\nrounded and the diaphragm is pushed upward in the high-\\nest degree. The liver dulness disappears and the pains be-\\ncome excruciating. The shock may be so great that the\\npatient becomes unconscious and remains so until death\\nbrings relief.\\nComplications appearing during the disease may also be\\nthe cause of death. Thus deglutition pneumonia (Schluck-\\npneumonie) which occasionally occurs by aspiration into\\nthe lungs of gastric and intestinal contents during the act\\nof vomiting, or septicaemia in consequence of intestinal per-\\nforation, may develop with embolic processes in the lungs,\\nliver, and other organs. In exceptional cases there occurs\\n1 Bdnnecken Virchow s Archiv, Bd. 120.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0268.jp2"}, "269": {"fulltext": "ACUTE OBSTRUCTION. 249\\nan adhesion of the occluded intestinal coils to the anterior\\nabdominal wall, and after the gangrenous destruction of\\nthe latter as well as of parts of the gut, an anus praeter-\\nnaturalis develops, or a fistulous opening between two por-\\ntions of the intestines, or again a fistula of the intestine\\ninto the bladder, uterus, vagina, or stomach.\\nDiagnosis. The diagnosis must deal with the following\\nthree points A. Recognition of the intestinal obstruction.\\nB. Its seat. C. Its etiological factor.\\nA. Recognition of the Intestinal Obstruction. The recog-\\nnition of an acute intestinal obstruction is not difficult if\\nthe symptoms described above are present in a marked\\ndegree. Thus total absence of passage of fecal matter and\\nflatus combined with symptoms of collapse, meteorism,\\npains, and fecal vomiting will permit a positive diagnosis\\nof intestinal obstruction. In many instances, however, only\\na few of the symptoms mentioned are present, and then\\nthe diagnosis is quite difficult. The symptom of the great-\\nest diagnostic value is fecal vomiting, although even this\\nalone does not always warrant the diagnosis of obstruction,\\nfor it also occurs in intestinal paralysis. The latter con-\\ndition must be especially borne in mind in cases in which\\nthere has been a history either of contusion of the ab-\\ndomen or of a reposition of incarcerated hernia shortly\\nbefore the appearance of the disease. The fecal vomiting\\nof hysterics can also be easily recognized, as there are\\nalways symptoms present which indicate the true condi-\\ntion.\\nThe greatest difficulty in diagnosis lies in the differenti-\\nation between intestinal obstruction and diffuse peritonitis,\\nespecially if the latter accompanies appendicitis. All the\\nsymptoms characteristic of intestinal obstruction may oc-\\ncur also in peritonitis. A thorough consideration of all", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0269.jp2"}, "270": {"fulltext": "250 DISEASES OF THE INTESTINES.\\nthe symptoms and their differentiation in these two dis-\\neases will, however, permit a decision.\\nThe following points will serve as a guide in this connec-\\ntion In acute peritonitis there is a rise of temperature at\\nthe beginning of the disease, while in intestinal obstruction\\nthere is at first no fever or even a subnormal temperature.\\nThere are exceptions, however, and a general peritonitis of\\na grave nature may run its course without any fever but\\nwith symptoms of collapse. The pains on pressure over the\\nabdomen are much more intense in peritonitis in intesti-\\nnal occlusion the spontaneous pain may occasionally even\\nbe relieved by pressure. Fecal vomiting is of compara-\\ntively rare occurrence in peritonitis, and if present it usu-\\nally appears later than in intestinal obstruction. The me-\\nteorism is diffuse in peritonitis right from the start. It\\nthus causes a general distention of the abdominal parietes.\\nIn obstruction the accumulation of gas is at first less pro-\\nnounced, circumscribed, and increases gradually. In peri-\\ntonitis the abdomen becomes tense from the first, while in\\nobstruction, at the commencement at least, it is as a rule\\nsoft. The existence of an exudation speaks in favor of\\ngeneral peritonitis. In peritonitis accompanying appen-\\ndicitis there will be besides the above symptoms the phe-\\nnomena characteristic of the latter disease. In some in-\\nstances, however, the differentiation between peritonitis\\nand obstruction will hardly be possible and mistakes are\\nliable to occur.\\nAcute intestinal obstruction is occasionally simulated by\\npoisoning with arsenic and also by a very severe attack of\\ncholera. In the former condition there will be a history\\nof poisoning, and in the latter the presence of cholera ba-\\ncilli in the dejecta will clear up the diagnosis. In rare\\ninstances a severe attack of biliary colic or of renal colic", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0270.jp2"}, "271": {"fulltext": "ACUTE OBSTRUCTION. 251\\nmay in some respects resemble intestinal obstruction. A\\nthorough examination, however, will always reveal the true\\ncondition. In biliary colic as a rule there is swelling of\\nthe liver and sometimes jaundice; in renal colic the pains\\nradiate from the kidney to the bladder, there is a burning\\nsensation during urination, and the urine often contains\\nmucus and occasionally a few pus corpuscles or blood cells.\\nIntestinal colic resulting from chronic lead poisoning occa-\\nsionally simulates true obstruction of the bowels. The\\nanamnesis, however, will show that we have to deal with\\nlead poisoning. Besides, in these cases there is, as a rule,\\na more or less sunken condition of the abdomen. Simple\\nintestinal colic (of nervous origin) will hardly ever give rise\\nto mistakes in the diagnosis, as the clinical picture is less\\nsevere and the disease quickly subsides.\\nB. Location of the Obstruction. The location of the seat\\nof the obstruction is not merely of theoretical value, but of\\ngreat practical importance, for this decides the question\\nas to where abdominal incision should be made in cases of\\noperation. It will be useful to discuss first at what point\\nof the abdomen the obstruction is situated, and secondly,\\nwhat particular portion of the bowel it involves.\\n1. The point at which the patient first experiences pain\\nis significant in case he is able to locate it definitely. In\\nmany instances, however, the pain is not experienced in\\none circumscribed spot, and is often located diffusely in\\nthe neighborhood of the navel. The presence of a tensely\\ntympanitic intestinal coil, which does not change its con-\\nfiguration and thus makes the abdominal wall protrude\\nasymmetrically, is of great importance; for, according to\\nVon Wahl, such a coil is often found above the occluded\\nsegment of intestine. Strong peristaltic contractions run-\\nning in the same direction over a certain region of the ab-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0271.jp2"}, "272": {"fulltext": "252 DISEASES OF THE INTESTINES.\\ndomen, especially if they return periodically and always\\nin the same area, will serve to locate the place at which\\nthe obstruction is situated. For these peristaltic waves\\npass along the intestine down to the seat of the obstruc-\\ntion, which they are unable to overcome.\\nPalpation of the abdomen occasionally reveals the pres-\\nence of a sausage-like tumor. This occurs especially in\\ncases of intussusception. If such a tumor is present, the\\nlocation of the obstruction is certainly easy. A thorough\\nexamination of all hernial openings will occasionally re-\\nveal an incarceration of the intestine and also show the\\nsite of the lesion. If there is no hernia the examination\\nmust be continued through the vagina and through the rec-\\ntum The exploration through the vagina will show whether\\nthe pelvic organs are normal, and if not, whether a tumor\\norz^i-atiii^ from the genital organs compressing the in-\\ntestines. Digital examination of the rectum will enable us\\nto discover a stricture, an intussusception, or a tumor of\\nthe lower portion of the bowel. In some cases a thorough\\nexamination of the entire rectum and the descending colon\\nmay be undertaken with the whole hand under chloroform\\nnarcosis, according to the method of Simon. In cases of\\nintussusception involving the sigmoid flexure and rectum,\\nthe anus often remains open (paralysis of the sphincters)\\nand there appears an involuntary evacuation of a muco-\\nbloody fluid from time to time.\\n2. Determination of the Portion of the Intestinal Tract in\\nwhich the Obstruction is Situated. Small Intestine. If the\\nobstruction is situated in the small intestine all the symp-\\ntoms (pains, vomiting, collapse) are, as a rule, much more\\nintense and appear sooner than in obstruction of the large\\nbowel. Soon after the commencement of the disease, there\\nis copious vomiting which may become fecal after a short", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0272.jp2"}, "273": {"fulltext": "ACUTE OBSTRUCTION. 253\\nperiod. The meteorism at the beginning is localized in the\\nupper part of the abdomen, while the lower part remains\\nunchanged. Pronounced visible peristaltic waves in the\\nsmall intestine also point to an occlusion situated within\\nthe latter.\\nJarre was the first to show that obstruction of the small\\nintestine gives rise to pronounced indicanuria. As early\\nas the second or third day of the obstruction, indican can\\nbe found in the urine in large quantities. In obstruction\\nof the large bowel there is as a rule no indicanuria, and if\\nit appears it does so only later in the disease, on the sixth\\nor seventh day. The higher up in the intestinal tract the\\nobstruction is situated, the sooner and the more frequently\\nanuria may appear. Injections of water into the bowel\\nmay secure a fecal evacuation. The colon can also be\\nfilled with a large amount of water or gas.\\nIf the obstruction is situated within the duodenum or in\\nthe upper part of the jejunum, it can often be easily recog-\\nnized. Obstruction of the duodenum above Vater s papilla\\nwill manifest the same symptoms as acute dilatation of the\\nstomach in consequence of a stricture. There will be ischo-\\nchymia and continuous vomiting of chyme. An obstruc-\\ntion situated within the duodenum below Vater s papilla\\nwill give rise to vomiting of large quantities of pure bile.\\nThe vomited matter may contain acids from admixture of\\ngastric juice. It is never fecal in character. The gastric\\nregion is protuberant but sinks in after a spell of vomiting.\\nIf the obstruction is situated within the beginning of the\\njejunum the vomiting assumes at first a greenish hue (de-\\ncomposed bile) which may be followed by the vomiting of\\npure unchanged yellow bile. Occasionally the vomited\\nmatter assumes a fecal character. Obstructions situated\\n1 Jaffe Centralbl. f. die med. Wissenschaften, 1872.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0273.jp2"}, "274": {"fulltext": "254 DISEASES OF THE INTESTINES.\\nwithin the duodenum or at the beginning of the jejunum,\\nas a rule, are unaccompanied with indicanuria.\\nObstruction of the Large Bowel. The symptoms here\\nare usually less violent and appear a little later than in\\nthe obstruction of the small intestine. Fecal vomiting\\noften appears long after the establishment of the occlusion,\\nand it may even be absent if the obstacle is situated at the\\nbeginning of the descending colon or lower down. The\\nmeteorism is in most instances limited to the lower parts\\nof the abdomen and also to the lumbar regions. In occlu-\\nsion of the descending colon it may be noticeable that at\\nfirst there is a protrusion in the left iliac region, afterward\\na protrusion of the transverse colon, and ultimately the as-\\ncending colon will also become tympanitic. As mentioned\\nabove, indicanuria will be absent during the first five or six\\ndays of illness.\\nWith regard to the determination of the occlusion within\\nthe lower parts of the colon, Brinton s 1 method, already in\\nuse over fifty years ago, is very valuable. It consists in\\nfilling up the bowel with water through the rectum. If\\nnot more than half a quart can be injected, the obstruction\\nmust be situated in the upper part of the rectum. If one\\nto two quarts can be injected, the obstruction must be situ-\\nated above the sigmoid flexure, in the descending colon,\\nor still higher. In case obstruction is situated in the as-\\ncending colon four quarts or still more can be injected and\\nretained in the bowel. Insufflation of air or carbonic acid\\ngas into the rectum will also occasionally show the seat of\\nthe obstruction, if the latter is situated in the descending\\nor the transverse colon, as there will be a filling up with\\ngas of the free portion of the bowel up to the obstructed\\npoint. When the obstruction is located beyond the trans-\\n1 Brinton On Intestinal Obstruction, London, 1867.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0274.jp2"}, "275": {"fulltext": "ACUTE OBSTRUCTION. 255\\nverse colon, however, it will not permit of distinct recog-\\nnition by this method.\\nC. -Recognition of the Different Forms of Acute Obstruction.\\nIf the diagnosis of acute obstruction of the bowels is not\\nalways easy, the recognition of the special anatomical\\nlesion underlying it is still more difficult. In many in-\\nstances an exact anatomical diagnosis will not be possible\\nand we will have to be satisfied with a probable conjecture.\\nIn some cases, however, the exact determination of the\\netiological factor underlying the obstruction will be possi-\\nble. The following groups of acute obstruction of the\\nbowels can be clinically differentiated\\n1. Acute Incarceration of the bowels in hernias (also in-\\nternal hernias, in slits of the omentum, mesentery, or di-\\nverticula), in strangulation by bands or twists of the bowel,\\nis most frequent between the ages of twenty and forty.\\nIt occurs more often in males than in females. There is\\noften a previous history of peritonitis, of hernia, or of acci-\\ndents (contusions). The onset of the disease is sudden.\\nThe pains are severe. Vomiting is present from the start,\\nbecoming stercoraceous later on. Collapse is marked.\\nTenesmus is absent. Physical examination of the abdo-\\nmen gives, as a rule, negative results.\\n2. Volvulus most often involves the sigmoid flexure and\\ncan then be easily recognized. Volvulus of the small in-\\ntestine, which occurs very rarely, cannot be differentiated\\nclinically from incarceration. The rotation of the bowel\\naround its axis is either complete (360\u00c2\u00b0) or incomplete\\n(half rotation, 180\u00c2\u00b0). In the first instance there is total\\nocclusion, while in the latter the intestinal lumen is at first\\npartially pervious. Volvulus is more common in males\\nthan in females in the proportion of four to one, and occurs\\nprincipally late in life, usually between forty and sixty.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0275.jp2"}, "276": {"fulltext": "256 DISEASES OF THE INTESTINES.\\nThere is usually an antecedent history of chronic constipa-\\ntion. The onset of the disease is sudden. The pain ordi-\\nnarily is intermittent. Vomiting may be absent at first and\\nlater on occurs intermittently. Constipation is almost ab-\\nsolute and grows worse after the use of aperients. There\\nis pronounced meteorism. The sigmoid flexure can oc-\\ncasionally be felt as a tumor. Only moderate amounts of\\nwater can be injected into the rectum.\\n3. Intussusception occurs very frequently in early child-\\nhood. The onset is sudden, the pains appear early, are\\ncolicky in character and come in paroxysms. There are\\nmarked tenesmus and bloody evacuations. The collapse\\nis not pronounced. The invaginated coil may be acces-\\nsible to palpation and then appears in the form of a tumor\\nof egg-size or somewhat larger, this occurring in about\\nfifty per cent of the cases. Meteorism develops in con-\\njunction with peritonitis.\\n4. Obturation of the Intestine by Gall Stones, Enteroliths,\\nor Foreign Bodies. Obstruction by gall stones occurs chiefly\\nin women and is more frequent at an advanced age. A pre-\\nvious history of gall stones or a preceding attack of jaun-\\ndice, pains in the region of the liver, and swelling of this\\norgan are points which aid in the diagnosis. Obstruction\\nby gall stones usually occurs in the small intestine; the\\nsymptoms, as a rule, are less severe than in other forms\\nof ileus. The collapse is not pronounced or may be en-\\ntirely absent. Flatus may occasionally be passed, copious\\nvomiting of bile may be present. If the gall stone is situ-\\nated in the lower portion of the ileum the vomiting may\\nlater become stercoraceous. Occasionally the stones can\\nbe palpated through the abdomen and felt as a hard mass.\\nMeteorism is generally not highly developed. In some\\ninstances there is diarrhoea with admixture of blood, the", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0276.jp2"}, "277": {"fulltext": "ACUTE OBSTRUCTION. 257\\nlatter being due to abrasions of the intestinal mucosa pro-\\nduced by friction of rough gall stones.\\nThe recognition of an enterolith as the cause of obstruc-\\ntion is very difficult and jjossible only when small frag-\\nments of a fecal calculus have previously been found in the\\ndejecta. The seat of obstruction is as a rule then in the\\nlarge bowel, the latter being the place where enteroliths\\ndevelop.\\nObstruction by foreign bodies will be recognized by the\\nprevious history; often also, especially if they are of a\\nmetallic nature, by a Roentgen picture. An accumulation\\nof cherry pits or plum stones may also cause an obstruc-\\ntion and will likewise be recognized by the previous\\nhistory and by the presence of some of them in the de-\\njecta.\\nHardened fecal matter will very rarely give the picture\\nof obstruction. This will occur only in very weakened in-\\ndividuals and in persons with spinal trouble. In these\\ncases the rectum and colon will be found filled with greatly\\nhardened scybala. If a stricture or a tumor exists within\\nthe intestine and narrows its lumen, an accumulation of\\nfecal matter above the stricture gives rise to acute ob-\\nstruction.\\n5. Dynamic Ileus. Obstruction due to paralysis of a\\nsegment of the bowel can be recognized only with great\\ndifficulty. Often there has been a preceding laparotomy\\nor some operation on the genital organs in the female or\\na history of a replaced hernia.\\nWith regard to the recognition of the different forms of\\nintestinal obstruction the following table, which gives the\\nfrequency of the principal symptoms in the various forms\\nof obstruction, may be of assistance.\\nAmong two hundred and niDetv-five cases of acute ob-\\n17", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0277.jp2"}, "278": {"fulltext": "258\\nDISEASES OF THE INTESTINES.\\nstruction of the bowels collected in literature and minutely\\nexamined by R. Fitz 1 of Boston, the symptoms were as\\nfollows with regard to the different groups of obstruction\\nPain\\nNausea and vomiting\\nFecal vomiting\\nTympanites\\nTumor\\nVisible coils\\nStrangu-\\nIntussus-\\nGall\\nlation.\\nception.\\nTwist.\\nStones.\\nPer Cent.\\nPer Cent.\\nPer Cent.\\nPer Cent.\\n82\\n70\\n60\\n83\\n69\\n75\\n37\\n74\\n47\\n13\\n15\\n61\\n56\\n33\\n55\\n56\\n10\\n69\\n13\\n11\\n7\\nStricture\\nor Tumor.\\nPer Cent.\\n60\\n80\\n33\\n66\\n27\\n20\\nPrognosis. The prognosis of acute obstruction of the\\nbowel is very serious. According to Curschmann, 2 only\\nthirty to thirty-five patients out of one hundred recover\\nfrom this disease. As a rule ileus caused by coprostasis\\nor by obturation with gall stones and foreign bodies gives\\nthe best prognosis. Then come volvulus and intussuscep-\\ntion, while incarceration gives the worst prognosis. If in\\nthe course of ileus deglutition pneumonia or diffuse peri-\\ntonitis or perforation of the bowel develops, then the case\\nis well-nigh hopeless. Operative intervention, especially\\nin cases in which the seat of the intestinal occlusion is\\nknown, improves the prognosis considerably, but only if\\nit is resorted to early. Later, when the complications just\\nmentioned arise, not much can be expected from an opera-\\ntion.\\nTreatment.\\nA. Medical Treatment. Absolute rest is of the great-\\nest importance. The patient should be kept in bed and\\ntold to avoid any abrupt motions. He should not be\\n1 R. Fitz Transactions of the Congress of Physicians and Sur-\\ngeons, vol. i., 1888.\\n2 Curschmann: Die Behandlung des Ileus. Congress fur innere\\nMedicin, Wiesbaden, 1889.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0278.jp2"}, "279": {"fulltext": "ACUTE OBSTRUCTION. 259\\nallowed to go to the water-closet, but should use a bed-\\npan. With Treves, Graser, and others I am for absolute\\nrest of the stomach and intestines, i.e., no food whatever\\nshould be given to patients suffering from acute obstruc-\\ntion of the bowels.\\nIf there is .great thirst a teaspoonful of hot water or very\\nweak tea may be given every half-hour or hour or a small\\npiece of ice may be held in the mouth until it melts, but\\nthe water should not be swallowed. Neither should any\\nstimulants like wine, champagne, or whiskey be given by\\nthe mouth. In obstruction of the small intestine small\\nquantities of a saline solution (about seven to twelve ounces)\\nmay be injected into the bowel several times during the\\nday. If the sickness lasts several days, nutritive enemas\\nconsisting of milk and egg or of a peptone solution may\\nbe given in the same way. If, however, the patient is not\\nable to retain the enema, considerable quantities of saline\\nsolution must be injected either subcutaneously or intra-\\nvenously.\\nAll writers agree that no cathartic remedies whatever\\nshould be used, as they increase the peristalsis and there-\\nby may cause great harm. A cathartic should be per-\\nmitted only in cases in which the obstruction is positively\\ndue either to gall stones or hardened fecal masses or in\\ndynamic ileus. It is, however, of benefit to evacuate the\\nlower parts of the bowel by means of an enema. This\\ncleans out the rectum, diminishes the feeling of tension to\\na slight extent, and prepares the bowel for the nutrient\\nenemas.\\nThe administration of opium plays a principal part. It\\n1 Graser Behandlung der Darmverengerung und des Darmver-\\nschlusses. Penzoldt-Stintzing s Handbuch der speciellen Therapie\\ninnerer Krankheiten, Jena, 1896.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0279.jp2"}, "280": {"fulltext": "260 DISEASES OF THE INTESTINES.\\nis indicated not only as a means of allaying pain but for\\nits soothing action upon the intestinal peristalsis. The\\narrest of the latter may have a direct curative effect, since\\nit may promote a return of the partly incarcerated or in-\\nvaginated or slightly twisted coil to its normal position.\\nIn order to secure a prompt action of the drug it is best\\nto first give a hypodermic injection of morphine, one-sixth\\nto one-fourth of a grain. A short time afterward a sup-\\npository of two-thirds of a grain of opium is administered\\nand repeated every three or four hours until the pains are\\nkept in abeyance. In cases in which the vomiting is not\\nso marked, opium may be given in the form of the tincture\\nfifteen to twenty drops every three to four hours. It is\\nhardly necessary to say that the opiates should not be used\\ntoo lavishly. Only so much should be administered as is\\nabsolutely necessary for relieving the pain and quieting\\nthe violent peristalsis of the intestine. Given in this way,\\nopium not only acts as a sedative but also as a stimulant\\non the heart. Patients in deep collapse very soon after an\\ninjection of morphine become warm, show a better pulse\\nand a more normal temperature. The only disadvantage\\nof opium is that it slightly masks the true picture of the\\ndisease. It is therefore best whenever possible first to\\nmake an exact diagnosis by thorough examination of the\\nabdominal viscera by palpation, auscultation, etc., before\\nadministering it.\\nIf the symptoms of the disease persist after the admin-\\nistration of opium, especially if the tension of the abdomen\\nis not relieved and no flatus is passed, it is well to dis-\\ncontinue the remedy for a certain period of time. This\\nwill enable the physician to judge the situation critically.\\nAs a further sedative agent applications of poultices can\\nbe considered. A hot-water bag, a hot plate wrapped up", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0280.jp2"}, "281": {"fulltext": "ACUTE OBSTRUCTION. 261\\nin flannel, or a Japanese warm box, wet packs (Priessnitz)\\nare useful. If there are signs of peritoneal inflammation,\\napplications of ice or of very cold poultices are prefer-\\nable.\\nLavage of the stomach was first recommended in this\\ndisease by Kussmaul and Calm. 1 This procedure is of\\nbenefit if the obstruction is situated high up in the small\\nintestine. It empties the stomach, relieves the vomiting,\\nand also decreases the abdominal tension. There is no\\ndoubt that this therapeutic measure is sometimes crowned\\nwith success in appropriate cases. As a striking instance\\nof the efficacy of this mode of treatment the following case\\nmay be reported\\nE. K., thirty -five years old, had always been well, when\\nhe suddenly became critically ill with violent abdominal\\npains and constant vomiting. For three days there was\\nno evacuation of the bowels nor was the patient able to\\npass any flatus. On examination I found his abdomen\\nconsiderably distended and tense. The stomach could be\\nmapped out and was considerably dilated, the greater cur-\\nvature extending a hand s width below the navel. On pal-\\npation there was considerable tenderness all over the\\nabdomen. The pulse was quite frequent (110) and weak,\\ntemperature 96.5\u00c2\u00b0 in the mouth, the extremities were cold.\\nThe face showed an expression of great suffering. There\\nwere almost continuous hiccough and now and then vomit-\\ning of a watery, turbid, somewhat brownish-looking liquid\\nwith fecal odor. On introducing the tube over a quart of\\nliquid of the same character was obtained. The stomach\\nwas then washed out with several quarts of water until the\\nfluid returned quite clear. The patient felt somewhat re-\\nlieved. The vomiting stopped and on the following day\\nthere was a spontaneous evacuation of the bowels. The\\npatient was now able to pass flatus, the distention sub-\\n1 Kussmaul -Cahn Heilung von Ileus durch Magenaussptilung.\\nBerl. klin. Wochenschr. 1884, Nos. 42 and 43.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0281.jp2"}, "282": {"fulltext": "262 DISEASES OF THE INTESTINES.\\nsided, and he gradually recuperated. For the sake of com-\\npleteness I would add that besides washing out the stomach,\\nthe treatment consisted in the administration of opium\\nsuppositories.\\nLavage of the Boivel. Injections of large amounts of\\nwater into the bowel under considerable pressure are also\\noccasionally of benefit, especially in cases of intussuscep-\\ntion of the colon or when a foreign body or hardened fecal\\nmatter is the cause of the obstruction within the large\\nbowel. According to Treves, it is desirable to use this\\nprocedure after anaesthetizing the patient. A considerable\\nquantity of water (varying according to the age of the pa-\\ntient from half a pint to three quarts) is introduced into\\nthe bowel by means of an ordinary fountain syringe. The\\nfluid is allowed to remain in the colon for at least ten min-\\nutes. While injecting the water it is best to have the pa-\\ntient in such a position that his head is lowered and his\\npelvis is raised. While the irrigation of the bowels is\\ngoing on the physician should hold his hand upon the\\npatient s abdomen and in this way notice any change which\\nmay occur.\\nIn intussusception when the tumor can be felt the\\nlatter will in some instances suddenly disappear, giving\\nway to the pressure of the water. Too great force,\\nhowever, should never be used, as this may bring on rup-\\nture of the bowels. Instead of water, injections of warm\\nolive oil, which were first recommended by Kussmaul and\\nFleiner, may be used in the same way. Dr. Klubbe has\\nrelated three cases of cure by means of this method,\\nInflation of the Bowel with Air or Certain Gases in\\nCases of Invagination. Trastour 2 recommended inflation\\n1 Klubbe British Medical Journal, November 6th, 1897.\\n2 Trastour Bulletin General de Therapie, 1874, p. 107.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0282.jp2"}, "283": {"fulltext": "ACUTE OBSTRUCTION. 263\\nof the bowel with air by means of a common bellows, to\\nwhich an India-rubber nozzle and rectal tube had been\\nattached. The forcible filling up of the bowel with air is\\ncapable of producing the same effect as the injection of\\nwater and may free the invaginated portion. Yon Ziems-\\nsen has recommended the use of carbonic-acid gas, while\\nSenn 2 suggested hydrogen gas. Carbonic-acid gas is best\\nused in the form of sparklets, as suggested by Dr. A.\\nRose 3 of New York. Care must be taken not to fill up the\\nbowel too quickly and too forcibly.\\nMassage. Massage has been recommended by several\\nwriters. Its use, however, is not entirely harmless. It\\ncan be of benefit only in cases of obstruction by gall stones\\nand fecal matter, but even in these cases extreme care in\\nits use is necessary.\\nElectricity. Electricity has especially been recom-\\nmended by Boudet. Among seventy cases of ileus Boudet 4\\nhad fifty -three recoveries by this method. The faradic or\\ngalvanic current may be used. In the application of the\\nfaradic current one metal electrode of cone shape is in-\\nserted into the rectum while another large plate electrode\\nis kept over the abdomen for about ten to twenty minutes.\\nIn using the galvanic current it is necessary to have a\\nspecial rectal electrode, which is constructed in such a way\\nthat water running through it forms the conductor, so as\\nto avoid burning the mucosa. The other electrode is placed\\nover the abdomen. The negative pole should be inside.\\nThe strength of the current should vary from ten to fifteen\\nmilliamperes. The duration of the treatment should be\\ntwenty to twenty -five minutes.\\n1 Von Ziemssen Archiv fur klinische Medizin, Bel. 33, Heft 3 and 4.\\n2 Nic. Senn: Intestinal Surgery, Chicago, 1889, p. 244.\\n3 A. Rose New York Med. Journal, 1900, i., p. 47.\\n4 Boudet Progres Medical, February 7th and 14th, 1885.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0283.jp2"}, "284": {"fulltext": "264 DISEASES OF THE INTESTINES.\\nElectricity will be of special value in obstruction due\\nto hardened fecal matter or in the paralytic form of ileus,\\nwhile in incarceration it is rather contraindicated.\\nPuncture. Puncture of the distended bowel has recently\\nbeen recommended anew by Curschmann, 1 von Ziemssen,\\nand others. According to Curschmann, puncture of the\\nintestine is performed in the following way A long aspi-\\nrator needle of thin calibre (like that of a Pravaz syringe)\\nprovided with a stopcock is thrust into the abdomen over\\na prominent coil of the intestine. A piece of rubber tub-\\ning is then connected with the outer end of the needle\\nthe free end of the latter is inserted into a bottle filled with\\nwater, which is turned upside down in a basin likewise\\nfilled with water. The stopcock of the aspirating needle\\nis now opened and the gas escaping from the intestinal\\ncoil appears in bubbles rising to the upper part of the\\nbottle, displacing the water. There is no doubt that con-\\nsiderable temporary relief can be afforded by this mode of\\nprocedure, as it lessens the feeling of tension. Occasion-\\nally it may also have a direct curative result. Thus\\nCurschmann reports three cures by this method. Punc-\\nture, however, is not entirely free from danger. In cases\\nin which the intestine is already partly paralyzed, the\\nopening after the withdrawal of the needle may not entirely\\nclose and intestinal gases and contents may continue to\\nooze out and cause peritonitis.\\nMost surgeons of note are against this procedure, as it\\nlacks precision and is not free from danger. Thus Treves, a\\nKocher, 3 and Graser i are all opposed to its employment.\\n1 Curschmann Deutsche med. Wochenschrift, 1887, No. 21.\\n2 Treves: Intestinal Obstruction, New York, 1899, p. 471.\\n3 Kocher: Mittheilungen aus den Grenzgebieten der Medizin,\\n1898. Bd. 4, p. 2.\\nGraser; Penzoldt-Stinzing s Handbuch, Bd. 4, p. 562.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0284.jp2"}, "285": {"fulltext": "ACUTE OBSTRUCTION. 265\\nSad experiences with puncture have been reported by\\nFrentzel, 1 Furbringer, 2 Hoffmann, Korte, 3 and Graser.\\nThe latter observed the appearance of fecal matter and\\nconsecutive peritonitis from such an opening. He con-\\nsiders puncture permissible only if the patient absolutely\\nrefuses an operation.\\nMercury (Mercurius Vivus) The internal administration\\nof pure mercury in tablespoonful doses was highly es-\\nteemed as a remedy for ileus by the old physicians. When\\nall resources had been exhausted without success, mercury\\nwas given as an ultimum refugium. Even nowadays many\\nphysicians are convinced of its efficacy. The use of mer-\\ncury in incarceration, strangulation of the bowel by twists\\nor bands, intussusception, is not permissible, as it does\\nreal harm. In ileus in consequence of coprostasis or in\\ndynamic ileus, mercury may be employed if all other rem-\\nedies have proven futile. Its effect consists in the pene-\\ntration of the mercury into the accumulated fecal matter,\\nthus softening it.\\nAll the enumerated internal methods of treatment must\\nbe applied, first, in cases in which the obstruction is due\\neither to gall stones or to foreign bodies or fecal accumu-\\nlation or volvulus of the sigmoid flexure; secondly, in cases\\nin which the exact diagnosis as to the kind of obstruction\\nis not settled, and which are not of a very severe type. In\\nall other varieties of intestinal obstruction and even in the\\ntypes just mentioned, after the failure of the medicinal\\nmeasures at hand, an operation should be resorted to.\\n1 Frentzel Deutsche Zeitschr. f. Chirurgie, Bd. 33.\\n2 Furbringer Verhandl. des 8ten Congresses f. innere Medicin, 1889.\\nD Korte: Ibidem.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0285.jp2"}, "286": {"fulltext": "266 DISEASES OF THE INTESTINES.\\nB. Surgical Treatment,\\nTreves, the greatest authority on intestinal obstruction,\\nsays: There is one measure for the treatment of acute\\nintestinal obstruction, and that is by means of laparotomy.\\nThe operation should be performed at the earliest possible\\nmoment, as soon indeed as the diagnosis is reasonably\\nclear. In case of acute abdominal trouble in which the\\ndiagnosis is not clear, the better and safer course is to\\noperate. This view is now generally accepted by physi-\\ncians as well as surgeons.\\nAs mentioned above, obturation, ileus, and volvulus of\\nthe sigmoid flexure are the only groups of intestinal ob-\\nstruction in which medical treatment plays a prominent\\npart. The importance of an early operation has been\\nshown by Naunyn, who found that among two hundred\\nand eighty-eight cases of ileus operated upon, the results\\nwere the more favorable the earlier recourse was had\\nto surgical intervention. In those cases in which the\\noperation was performed during the first two days of\\nsickness recovery took place in seventy -five per cent.\\nDuring the third day and still later there were only\\nthirty -five to forty per cent of recoveries.\\nA similar view is expressed by Gibson, who dealt par-\\nticularly with acute intussusception. Among one hundred\\nand forty-nine cases of this affection he found an average\\nmortality of fifty -three per cent. The first and second days\\nshowed mortality inferior to the general mortality, while\\nthe four succeeding days showed a steadily increasing mor-\\ntality, in each instance greater than the average. With\\nregard to treatment by inflation of the bowels by enemata\\n1 C. L. Gibson Mortality and Treatment of Acute Intussusception,\\nwith Table of 239 Cases. Medical Record, July 17th, 1897.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0286.jp2"}, "287": {"fulltext": "ACUTE OBSTRUCTION. 267\\nof fluids (or air) Gibson says: It is probably not an ex-\\naggeration to say that if all cases of intussusceptioD were\\ntreated on the onset, or say within forty-eight -hours, by\\nabdominal section, without any previous attempt at re-\\nduction, the mortality, while still considerable, would in all\\nprobability be very much less than the present figures.\\nGibson believes that injections should be tried only on\\nthe first or at the latest on the second day.\\nIn the discussion on intestinal obstruction which took\\nplace at the New York State Medical Association, all the\\nspeakers (Parker Syms, E. D. Ferguson, George D. Stew-\\nart, J. W. Gouley, J. D. Eushmore, LeEoy J. Brooks,\\nJohn F. Erdmann, Fred. H. Wiggin, and H. O. Marcy)\\nwere in favor of surgical treatment and for early interven-\\ntion. J. D. Eushmore says: 2 I have no hesitation in\\naffirming that in competent hands operation for intestinal\\nobstruction would not have a mortality above twenty per\\ncent. In my personal experience, including over one hun-\\ndred and ten operations, the mortality has been nearly forty\\nper cent. In the last thirty cases there have been six\\ndeaths. Wiggin 3 considers that operations performed\\nwithin the first forty -eight hours will give a mortality of\\n22.2 per cent.\\nInasmuch as the question of operation has to be dealt\\nwith in each case of intestinal obstructioD, it is advisable\\nto have the opinion and advice of an expert surgeon right\\nat the start of the disease. The physician and surgeon\\nshould act together, the first watching the symptoms\\ncarefully and making the diagnosis, the second prepared\\nto resort to surgical intervention as soon as it is demanded.\\n1 Transactions of the New York State Medical Association, 1898.\\n2 J. D. Rushmore Ibidem.\\n3 F H. Wiggin; Da Costa s Modern Surgery, p. 644.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0287.jp2"}, "288": {"fulltext": "268 DISEASES OF THE INTESTINES.\\nIn this way the number of recoveries will be greater in the\\nfuture than it has been in the past.\\nThe operation consists in making an abdominal incision,\\nfinding the seat of the lesion, and removing the obstacle if\\npossible. If not, an enterostomy is performed in the most\\ndistended coil of intestine which is then attached to the\\nabdominal wall. The fecal matter and the gases thus find\\nan outlet through this opening. Enterostomy is also re-\\nquired in all cases in which the portions of the intestine\\nare already found gangrenous. Treves says that this oper-\\nation (enterostomy) could be avoided in acute intestinal\\nobstruction if the abdomen were opened at the very earliest\\npossible moment. Every hour delayed adds to the grav-\\nity of the case. The earlier the operation the less the\\nneed for enterostomy. Laparotomy should be performed\\nat an early enough period to render an opening into the\\nbowel unnecessary.\\nCHRONIC INTESTINAL OBSTRUCTION.\\nEtiology. Chronic intestinal obstruction may be caused\\nby the same factors which produce acute ileus if they do\\nnot occlude the entire lumen of the bowel but leave part of\\nthe canal open. Besides, obstruction of the intestine is\\nfrequently occasioned by strictures resulting from preced-\\ning ulcers or from new growths. The latter, benign as\\nwell as malignant, are liable to give rise to occlusion even\\nif they do not occupy the entire circumference of the bowel,\\nby simply obtruding part of the canal at the site of their\\ngreatest development. Strictures caused by ulcers much\\nmore frequently involve the large than the small intestine.\\nAccording to Treves, they are found six times as often in\\nthe large bowel as in the small one.\\nWhile formerly dysentery was believed to be the cause of a", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0288.jp2"}, "289": {"fulltext": "CHRONIC OBSTRUCTION. 269\\nlarge number of these intestinal strictures, Woodward has\\nshown that this view is not supported by facts. Among\\nthe many autopsies on patients with chronic dysentery\\nwhich the latter had an opportunity to observe, there was\\nnot one case of dysenteric stricture of the intestine.\\nNothnagel agrees with Woodward. On the other hand,\\ntuberculous ulcers of the intestine which were regarded\\nas only rare causes of intestinal stricture have recently been\\nfound to produce strictures quite frequently. Koenig 2 laid\\nstress upon the frequency of constricting tuberculosis of\\nthe intestines. The latter may exist even if tuberculosis\\nin other organs is absent. Ulcers of typhoid fever very\\nrarely if ever cause strictures, and this also applies to the\\nsmall follicular ulcers. Syphilitic ulcers on the contrary\\nproduce strictures quite often. All kinds of strictures are\\nmet with most frequently in the lower portion of the colon,\\nprincipally in the rectum. Sometimes they lie just above\\nthe anal region and can then be very easily discovered.\\nSymptomatology The symptoms and the course of the\\ndisease vary considerably, and greatly depend upon the\\ncause of the obstruction. Thus, clinically, the benign\\ngrowths must be differentiated from the malignant ones\\n(in which the obstruction is caused by cancer). The pic-\\nture which the intestinal obstruction as such produces\\nwill, however, be pretty much the same. A stenosis which\\nis not very much pronounced may give rise to no symp-\\ntoms whatever. It is therefore quite evident that the dis-\\nease may exist for some length of time before manifesting\\nits presence.\\nIn typical cases of chronic intestinal obstruction the\\nonset is slow and insidious. The patient at first notices\\n1 Woodward Loc. cit.\\n2 Koenig Deutsche Zeitschrift fur Chirurgie, 1891.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0289.jp2"}, "290": {"fulltext": "270 DISEASES OF THE INTESTINES.\\nslight digestive disturbances, some discomfort in the\\nabdomen which gradually changes into real pain, and\\nslight constipation. The latter as a rule quickly becomes\\nworse. Mild aperients which a short while before were\\nefficient refuse to act, and the patient is obliged to resort to\\nstronger cathartics; at times even these will fail to work.\\nFrequently constipation suddenly alternates with an attack\\nof severe diarrhoea, which may last several days and be\\nfollowed by another period of obstinate constipation. In\\nsome instances the color and form of the fecal matter will\\nbe an indication of the seat of the stenosis. It is gener-\\nally believed that pipestem-like or tape-like motions indi-\\ncate a stricture in the colon. According to Treves, how-\\never, this sign is of very little value, as in the great\\nmajority of cases the sphincter muscle is the originator\\nof these peculiar shapes. Diarrhoea may also occasionally\\noccur. It is sometimes quite obstinate, especially if the\\nstenosis is situated in the large bowel. An admixture of\\nblood or pus in the dejecta is occasionally met with and is\\ndue to ulcerative processes taking place at the seat of the\\nstricture or immediately above it.\\nVomiting is not a very marked feature at first, but later\\non occurs more frequently. When the obstruction, how-\\never, becomes complete, vomiting is a prominent symp-\\ntom and may assume a stercoraceous character.\\nThe situation of the obstruction has much influence upon\\nthe clinical picture of the disease. If the stenosis is situ-\\nated in the duodenum above Vater s papilla, the symptoms\\nwill resemble those of stricture of the pylorus. Ischochy-\\nmia, vomiting, nausea will be the prominent features. A\\nstenosis of the duodenum below Vater s papilla, although\\npresenting symptoms similar to those of stricture of the\\n\u00e2\u0080\u00a2Treves: Loc. cit., p. 395.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0290.jp2"}, "291": {"fulltext": "CHRONIC OBSTRUCTION. 271\\npylorus, will be recognized by the more or less constant pres-\\nence of large amounts of bile in the stomach. The farther\\ndown in the small intestine the obstruction is situated, the\\nless pronounced are the gastric symptoms and the more\\nmarked the intestinal manifestations (less vomiting or\\nnausea, more constipation, colicky pains). If the stenosis\\nis situated in the lower portion of the ileum or in the colon\\nno gastric symptoms are as a rule present. The appetite\\nis good, there is no nausea, and the principal features are\\nobstinate constipation, sometimes alternating with diar-\\nrhoea and frequent attacks of colicky pains.\\nCondition of the Abdomen. The abdomen may present a\\nnormal appearance when the stenosis is situated in the\\nupper portion of the small intestine, although in some of\\nthese cases there may be a protrusion of the upper part\\nof the abdomen. If the site of obstruction is in the lower\\nportion of the small intestine or in the large bowel, then\\nsome distention of the abdomen is usually noticeable, espe-\\ncially after the disease has advanced considerably. Above\\nthe obstruction there is always distention and hypertro-\\nphy of the bowel. The latter is a manifestation of the\\nattempt which nature makes in order to overcome the diffi-\\nculty. The intestines above the stenosis act with greater\\nforce in order to propel the contents through the narrow\\npassage.\\nThe contraction of the bowel above the affected area\\noften assumes a tetanic type and is then painful. Such\\nviolent tetanic contractions are often visible through the\\nabdominal wall, and by propelling large amounts of liquids\\nand gases through the narrowed lumen, give rise to gur-\\ngling and bubbling sounds audible at a distance. Treves\\nthus describes the picture which this violent peristalsis\\nmanifests The surface of the abdomen becomes uneven,", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0291.jp2"}, "292": {"fulltext": "272 DISEASES OF THE INTESTINES.\\na rounded elevation appears in one place and depressions\\nappear in another. They produce an aspect comparable\\nto that of a relief map of a hilly country. Slowly the\\nhill-like elevation sinks and vanishes and out of the\\nshallow valley appear fresh eminences which rise up and\\nmove along beneath the skin. The movements are slow\\nand attended by colicky pains, and by more or less of\\nrumbling and gurgling sounds. The same coil\\nappears again and again and can often be quite definitely\\nrecognized. Although as a rule the contracting coils of\\nthe small intestine are of considerably smaller size than\\nthose of the large bowel, occasionally even the small intes-\\ntine may assume such dimensions that it cannot be differ-\\nentiated from the large bowel.\\nMeteorism is often present. If the obstruction is situ-\\nated in the lower portion of the colon or in the rectum, the\\nmeteorism is at first restricted to the large bowel, the dis-\\ntention then being pronounced along the course of the colon\\nat both sides of the abdominal wall and in the epigastric\\nregion. The lower part of the abdomen and also the re-\\ngion of the navel may be free from meteorism. If the\\nstricture is situated in the lower portion of the ileum or\\ncaecum, the lumbar regions of the abdomen are quite lax,\\nwhile the distention is more or less pronounced in the na-\\nsogastric and hypogastric regions.\\nAfter having described the symptoms of chronic intesti-\\nnal obstruction in a general way it will be useful to point\\nout separately the characteristics of some special forms\\nwhich occur more or less frequently.\\nChronic intussusception may develop either after an acute\\nattack or begin slowly and insidiously without at first giv-\\ning rise to any marked symptoms. It is most frequently\\nfound in the ileo-csecal portion. Pain occurs during the", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0292.jp2"}, "293": {"fulltext": "CHRONIC OBSTRUCTION. 273\\nprogress of the disease and is usually of a paroxysmal\\ncharacter. Attacks of pain may appear several times a\\nday or once in twenty-four hours. Occasionally days and\\neven weeks elapse between the paroxysms. As a rule the\\nintervals between the attacks grow shorter as the disease\\nadvances. In some cases there is almost continuous suffer-\\ning with occasional exacerbations. Yomiting seldom oc-\\ncurs and is certainly not a marked feature. A tendency to\\ndiarrhoea very often exists. The bowels may be normal or\\nconstipated for a while and then become loose, or there\\nmay be persistent diarrhoea. Blood is very often passed\\nwith the stools and tenesmus is occasionally present.\\nOn examination of the abdomen by palpation a tumor is\\nfound in almost half of the cases. The nature of the tumor\\ncorresponds to that found in acute intussusception de-\\nscribed above. Occasionally a tumor can be felt in the rec-\\ntum when the intussusception involves the lower portion of\\nthe large bowel. In rare instances the invaginated portion\\nis separated from the bowel by necrotic processes, and may\\nthen appear in the movement. While this event may in\\nrare instances lead to perfect recovery (the other portions\\nof the bowel growing together and the lumen thus being\\nrestored), in the greater majority it causes death through\\nperforation, rupture of the intestinal walls, and general\\nperitonitis.\\nChronic Obstruction Due to Fecal Accumulation. This\\nvariety of intestinal obstruction is more common in fe-\\nmales than in males and is usually met with in more ad-\\nvanced age and in patients suffering from hysteria and\\nbrain troubles. As a rule, the patients have already long\\nbefore been subject to habitual constipation usually many\\ndays elapse without an evacuation of the bowels. From\\ntime to time enormous quantities of fecal matter are passed\\n18", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0293.jp2"}, "294": {"fulltext": "274 DISEASES OF THE INTESTINES.\\nby artificial means. Later on the symptoms of constipa-\\ntion grow more intense. The abdomen becomes distended\\nand it is much more difficult to secure an evacuation even\\nby artificial means. As a rule the patient is tormented by\\neructations and flatulence. His appetite is poor; he has\\na bad taste in his mouth and frequently his breath has an\\nunpleasant odor. Headache, vertigo, and a general tired\\nfeeling are often encountered.\\nThese symptoms, as well as the marked unhealthy ap-\\npearance of the skin, are most probably due to intestinal\\nauto-intoxication. Certain chromogens, the products of\\ndecomposition, are absorbed from the bowel and give rise\\nto this peculiar discoloration of the skin. The conjunctivae\\nalso are often yellow. A further symptom due most prob-\\nably to the same process of auto-intoxication is the rise of\\ntemperature which is often present. If the distention of\\nthe abdomen is very marked, a feeling of oppression in the\\nchest and palpitations of the heart are experienced.\\nFecal accumulation sometimes causes pressure upon the\\nlumbar or sacral nerves and gives rise to discomfort in\\nthe genital organs or to pain in the thigh radiating down\\nthe entire leg. Distended coils may be visible through\\nthe abdomen and there may be much rumbling and gur-\\ngling heard after constipation has lasted a long period.\\nThis symptom is, however, not so marked here as in cases\\nof stricture of the intestine. Vomiting may occur and even\\nbecome stercoraceous. Slight colicky pains are felt over\\nthe abdomen, but as a rule they are not intense.\\nThe symptoms having advanced to an extreme degree, re-\\nlief may ensue either spontaneously or after resort to differ-\\nent procedures which serve to evacuate the bowels. Occa-\\nsionally, however, an evacuation of the bowel cannot be\\nobtained and the patient develops all the symptoms of an", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0294.jp2"}, "295": {"fulltext": "CHRONIC OBSTRUCTION. 275\\nunyielding obstruction which may be fatal. Often there\\nare attacks of obstruction following each other at certain\\nintervals. The narrowed lumen of the bowel most prob-\\nably becomes entirely occluded or blocked by a piece of\\nhard fecal matter, which completely fills it and cannot\\nmove in either direction. Sometimes the abrupt stoppage\\nmay be due to some bending or kinking of the distended\\nbowel.\\nIn almost all cases of obstruction by fecal masses\\na tumor can be palpated usually in some portion of the\\ncolon. The tumor is caused by the fecal accumulation.\\nThe caecum, the hepatic and the sigmoid flexures are the\\nplaces where the tumor is most often encountered. Such\\na fecal tumor feels hard and uneven sometimes it has a\\nglobular shape. As a rule it is not painful on pressure.\\nSometimes it is possible to change the shape of the\\ntumor by pressure. This is the best proof of its fecal\\ncharacter. Sometimes, however, pressure does not give\\nrise to any change in the configuration of the mass if\\nthe fecal matter is very hard. The best sign of its fecal\\nnature is the change in form after repeated irrigations of\\nthe bowel. In some rare instances the fecal accumulation\\noccupies the greater part of the abdominal cavity and gives\\nthe impression of one immense tumor of very hard consist-\\nency. I have seen two such cases in patients suffering\\nfrom grave melancholia. Here also after repeated irriga-\\ntions of the bowel and administration of cathartics the tu-\\nmor gradually becomes smaller and ultimately disappears.\\nStricture of the Rectum. In this condition as a rule there\\nare at first merely symptoms of constipation later on these\\nbecome more obstinate, requiring stronger cathartics. The\\npatient now begins to complain of congestion of the head,\\nanorexia, nausea, cold feet, and sometimes of disagreeable", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0295.jp2"}, "296": {"fulltext": "276 DISEASES OF THE INTESTINES.\\nsensations in his limbs still later there is diarrhoea which\\nmay persist as such or alternate with constipation. Off\\nand on muco-purulent material appears with the dejecta.\\nA burning sensation is often felt in the rectum, and tenes-\\nmus is frequently present. Hemorrhoids and prolapse of\\nthe rectum often accompany the stricture.\\nDigital examination of the rectum often reveals a ste-\\nnosed area in its lower part. The finger is either not able\\nto pass any farther than a few centimetres (five to six)\\nabove the anus or it meets with a resistance which it can\\novercome. Contrary to spasm of the rectum which yields\\ncompletely after the finger has succeeded in passing the\\nconstriction, in stricture of the rectum the pressure of the\\nnarrowed lumen exerted upon the finger remains constantly\\nthe same.\\nMost of the strictures are situated about Hwe to six centi-\\nmetres above the anus, seldom higher up. In the latter in-\\nstance the examination must be made with a bougie or with\\na rubber tube which is not too soft. In order to determine\\nthe exact nature of the stricture it is always best to make\\na visual examination of the rectum by means of a specu-\\nlum.\\nComplications. No matter to what cause the intestinal\\nobstruction is due, in the protracted course of the disease\\nseveral complications are liable to occur, although here\\nless often than in acute obstruction. Above the stenosed\\narea ulcerations of the bowel may take place and perfora-\\ntion may occur, giving rise to general peritonitis. Occa-\\nsionally circumscribed peritonitis may ensue in a similar\\nmanner and lead to an abscess surrounded by adhesions.\\nSuch an abscess may rupture through the abdominal wall\\nand under favorable conditions (if communicating with\\nthe intestinal lumen) form a fecal fistula. In many in-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0296.jp2"}, "297": {"fulltext": "CHRONIC OBSTRUCTION\\n27\\nr jCFp*\\nstances the patients gradually waste away and die in con-\\nsequence of thrombosis of the crural vein and decubitus.\\nCourse and Prognosis. The\\nduration of chronic intestinal\\nobstruction depends largely\\nupon the nature of the partic-\\nular affection and upon the\\ndegree of the obstruction. If\\nthere are no complications and r\\nthe patients lead a perfectly ra-\\ntional life (with regard to diet I\\nand treatment) the condition\\nmay last a number of years. In j\\nother cases the symptoms of\\nintestinal obstruction rapidly j\\nprogress and life is then of j\\nshort duration unless something\\nradical is done.\\nDiagnosis. The diagnosis of\\nchronic intestinal obstruction is\\nwarranted by the presence of\\ngradually increasing sj mptoms\\nof constipation, and attacks of\\nintestinal colic with a temporary\\nstoppage of the bowels follow-\\ning each other at not too great\\nintervals. The acute attack of\\nobstruction in these cases of\\nchronic intestinal stenosis is as a rule much milder than\\nin acute occlusion of the bowel not due to a chronic con-\\ndition. In the chronic form there is either no collapse at\\nall or it is but slightly marked. Increased intestinal peri-\\nstalsis is often encountered in the chronic form, especially\\nFig. 36.\u00e2\u0080\u0094 Patient M. with Chronic\\nIntestinal Stenosis (Stricture of\\nDescending Colon), Showing the\\nBarrel-shaped Abdomen.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0297.jp2"}, "298": {"fulltext": "278 DISEASES OF THE INTESTINES.\\nduring an attack of obstruction, while in the acute form\\nthis is quite rare and, if present, less pronounced. The\\nbarrel-shape of the abdomen is often present in chronic\\nintestinal stenosis and is of diagnostic value (Fig. 36).\\nThe different forms of intestinal obstruction can be rec-\\nognized by their varied symptoms which have already\\nbeen described above.\\nTreatment. The treatment comprises the management\\nof the disease during the intervals and during the attacks.\\nDuring the intervals the following rules are of importance:\\nThe diet should exclude all substances which give large\\nresidue of fecal matter or which are of an irritating charac-\\nter. Thus green vegetables, salads, fruits, vinegar, mus-\\ntard, pepper, must be strictly forbidden. Milk and milk\\nsoups, eggs, tender meats without too much fat and with-\\nout tendons, butter, toasted bread or plain white bread\\nwell baked, farina, rice and sago, well cooked, are permis-\\nsible. The patients should eat frequently and not too\\nmuch at a time. Cold drinks should be avoided. Atten-\\ntion must be paid to the patient s taking a sufficient quan-\\ntity of food.\\nThe bowels must be kept in working order. It is abso-\\nlutely necessary to secure one evacuation daily. Massage,\\nelectricity, and the usual mild cathartics (like magnesia\\nsulphate, rhubarb, cascara sagrada, syrup of figs) may be\\nused. Injections of water or oil into the bowel are also\\nof benefit. When diarrhoea is present it should not be\\nchecked unless the patient is greatly debilitated. Even\\nthen only mild astringent remedies are permissible. Often\\neven during periods of diarrhoea, when not very large evac-\\nuations take place, a mild cathartic (like castor oil or\\nCarlsbad salts) must be employed in order to assure a\\nthorough cleansing of the bowel.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0298.jp2"}, "299": {"fulltext": "CHRONIC OBSTRUCTION. 2,9\\nDuring the attack of intestinal colic warm fomentations\\nover the abdomen should be applied. If these be insuffi-\\ncient, the narcotic remedies are in place. Opium alone or\\nopium with belladonna maj r be given either by the mouth\\nor in suppositories. Here also it is necessary to produce\\na sufficient evacuation of the bowel, which is best done by\\nrectal injections. If there are great distention of the abdo-\\nmen and vomiting, gastric lavage is beneficial. Cocaine\\nin doses of one-third to one-half grain, or menthol one\\ngrain three times daily, will alla} r the vomiting. If there\\nis a real attack of acute obstruction this must be treated\\nin the same manner as primary acute intestinal obstruc-\\ntion, described above.\\nIf the stenosis involves the upper portion of the small\\nintestine, lavage will play an important part in allaying\\nthe symptoms temporarily. Chronic fecal impaction re-\\nquires the application of massage and also of electricity,\\nas described in the chapter on constipation. Sometimes\\nthe hardened scybala will have to be removed from the\\nrectum by artificial means. For this purpose the sphincter\\nis first dilated and the fecal masses are removed with the\\nfingers or with a spoon-shaped instrument. If there is a\\nblocking of the passage higher up in the colon, strong\\ncathartics (croton oil) may be administered. Metallic\\nmercury has also been advantageously used in these in-\\nstances.\\nStrictures of the rectum, excepting those of a cancerous\\nnature, can first be treated by dilating them gradually with\\nbougies of various size. The rectal bougie of Crede best\\nanswers this purpose. It is advisable to leave the bougie\\nwithin the stricture for at least fifteen minutes and to\\ninsert it once every two to three days. If the stricture is\\nof a very high degree this method of treatment may be", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0299.jp2"}, "300": {"fulltext": "280 DISEASES OF THE INTESTINES.\\ninefficient, and then surgical measures will have to be un-\\ndertaken.\\nOperative Intervention. All types of chronic intestinal\\nobstruction, with the exclusion of those caused by fecal\\naccumulation and strictures of the rectum, gradually grow\\nworse. The above-described modes of treatment are only\\nof a palliative nature. For this reason it must be consid-\\nered as a decided advance that surgical means have been\\nfound fully to remove the obstacle and restore the patient\\nto complete health. The procedures which are resorted\\nto are various and depend upon the anatomical lesion un-\\nderlying the obstruction.\\nMalignant growths must be extirpated as early as pos-\\nsible and an end-to-end anastomosis of the bowel estab-\\nlished. A circular stricture of the bowel (of benign type)\\ncan be removed by enteroplasty in a similar way as pylo-\\nroplasty, namely, by splitting the gut parallel to its axis\\nor vertically to the stricture and uniting the edges of the\\nincision transversely. Pean l has successfully performed\\nsuch operations. Several simple strictures of the bowel\\ncan be treated in the same way, if they are not too close\\ntogether. If the stricture is of a tubular form or if it is\\nof too high a degree, excision of the involved part followed\\nby exact coaptation of the divided ends by sutures is best\\ndone. This operation is greatly facilitated by Murphy s\\nbutton, which makes it possible to unite the two ends of\\nthe severed bowel rapidly without losing too much time\\nin the suturing.\\nIn cases in which the stricture cannot be excised nor\\notherwise remedied, or in any other form of obstruction of\\nthe bowel which cannot be removed, the bowel just above\\nthe stricture is united to the bowel below it and a short\\n1 Pean Bulletin de l Academie de Medecine, 1890, p. 856.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0300.jp2"}, "301": {"fulltext": "CHRONIC OBSTRUCTION. 281\\ncircuit thus established. This is likewise best accom-\\nplished by Murphy s button.\\nIn some strictures of the colon in patients who are already\\nquite prostrated, a complete operation of excision or even\\nof the formation of a new circuit cannot be performed with-\\nout too great risk of life. Here colotomy is indicated,\\nbeing later supplemented by a more radical procedure\\nwhen the patient is stronger and in better condition.\\nAdhesions should be severed and tumors compressing\\nthe bowel treated by radical removal. Surgical treatment\\nof the intestinal stenosis, affording as it does radical re-\\nlief, should be resorted to in every case as soon as the\\ndiagnosis is positive. The only excuse for subjecting the\\npatients to non-operative measures as long as they get along\\nin comparative comfort, is the high mortality which surgi-\\ncal intervention still furnishes. According to Treves, 1 the\\nmortality fluctuates between twelve and twenty per cent.\\nIt is to be hoped, however, that owing to our advanced\\nknowledge of this subject the diagnosis of intestinal ste-\\nnosis will be made quite early, and that the patients by\\nbeing operated upon at an early period will show a smaller\\npercentage of mortality.\\n^oc. cit., p. 560.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0301.jp2"}, "302": {"fulltext": "CHAPTER X.\\nNEKVOUS AFFECTIONS OF THE INTESTINES.\\nGeneral Remarks. The intestinal tract is rich in gangli-\\nonic cells and nerves. The plexus mesentericus Auerbach\\nand the plexus entericus Meissner accompany it through\\nits entire length. The vagus and the splanchnic nerves\\nsurround the intestinal canal with numerous branches and\\nform ramifications with the ganglionic plexus. Although\\na thorough knowledge of the exact action of these different\\nnerve groups has not yet been acquired, still we are certain\\nthat they govern the secretory, absorptive, and motor\\nfunctions of the intestinal canal.\\nSecretion seems to be dependent a great deal upon the\\nganglionic plexus, as can be learned from Moreau s ex-\\nperiment. This iuvestigator ligated an intestinal coil and\\nsevered all the nerves belonging to it. In a few hours the\\ncoil, thus treated, was found filled with a fluid showing\\namylolytic qualities and containing small quantities of\\nalbumin. In order to prove the secretory influence of\\nnerves upon the intestines Fleischer 2 justly refers to\\nthe fact demonstrated by Quincke, Demant, and Mass-\\nloff, 3 that in man as well as in animals after ingestion of\\nfood into the stomach, secretion takes place in the lower\\npart of the intestine, long before the arrival of the chyme.\\n1 Moreau: Centralbl. f. die med. Wissensch., 1868, No. 14.\\n2 K. Fleischer: Krankheiten desDarms, Wiesbaden, 1896.\\n3 Massloff: Untersuchungen aus dem physiologischen Institut zu\\nHeidelberg, Bd. ii.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0302.jp2"}, "303": {"fulltext": "NERVOUS AFFECTIONS OF THE INTESTINES. 283\\nThis also shows that the nerves of the intestinal tract are\\ninfluenced by reflex action from the nerves or the stomach.\\nVasomotor nerve filaments have also been proven to\\nexist in the intestines. Thus stimulation of the splanch-\\nnic nerve causes a contraction, while its section is followed\\nby dilatation of the intestinal blood-vessels. These vaso-\\nmotor nerve filaments are undoubtedly also much con-\\ncerned with absorption.\\nThe motor function of the nerves and their influence upon\\nperistalsis have been studied in an exhaustive manner by\\nNothnagel, Brahm-Houkgeest, and others, and have been\\ndescribed in the chapter on physiology (page 28).\\nAlthough under normal conditions we scarcely perceive\\nany sensations within the intestinal tract, we are neverthe-\\nless certain that sensory filaments exist in the nervous ap-\\nparatus of the intestines. This is revealed by the fact that\\nthe action of some stimuli of greater intensity than normal\\nupon the intestinal wall, gives rise to sensations of pain\\nand pressure. Thus, a person not accustomed to a coarse\\ndiet, after ingestion of a large quantity of cabbage and\\nbeans, for instance, may suffer after six to eight hours\\nfrom pains in the lower part of the abdomen caused by the\\nundue irritation of the small intestine. In pathological\\nconditions the sensory character of the intestinal nerves\\nis evinced very frequently. In fact this is one of the im-\\nportant points which we have to consider in almost any\\naffection of the intestinal canal.\\nThe neuroses of the intestine may be classified into 1,\\nmotor neuroses; 2, sensory neuroses; and 3, secretory\\nneuroses. Very often these different neuroses exist in\\ncombination. Thus, a motor neurosis may exhibit fea-\\ntures belonging to secretory or sensory derangements.\\nThe designation of the neurosis, however, should depend", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0303.jp2"}, "304": {"fulltext": "284 DISEASES OF THE INTESTINES.\\nupon the type most prevalent. All affections of the intes-\\ntines in which no anatomical lesion can be discovered are\\nclassified as neuroses or functional diseases of the intes-\\ntines.\\nIntestinal neuroses may be primary, i.e., the affection\\nemanates from the intestinal tract, or they may be second-\\nary, occurring in connection with nervous manifestations\\nin other organs. Etiologically we know that psychical\\ninfluences, mostly of a depressing nature, as fear, fright,\\nworry and anxiety, are often the causative factors of intes-\\ntinal neuroses. Neurasthenia and hysteria as well as a\\ngeneral neurotic tendency are also liable to produce ner-\\nvous affections of the intestinal tract. In some instances\\nthe latter conditions are due to a reflex action originating\\nfrom some other diseased organ (stomach, the genito-uri-\\nnarjr tract, uterus, etc.).\\nMOTOR NEUROSES OF THE INTESTINES.\\nDiarrhoea.\\nEtiology and Symptomatology. Diarrhoea, meaning too\\nfrequent and usually too watery movements of the bowels,\\nis always due to increased intestinal peristalsis. Diar-\\nrhoea may be the result of various morbid conditions of the\\nintestines, but here we shall describe the form of diarrhoea\\nwhich exists without any apparent anatomical lesions.\\nDiarrhoea may be classed under three groups: 1. Ner-\\nvous diarrhoea (Trousseau). 1 2. Dyspeptic diarrhoea. 3.\\nStercoral diarrhoea.\\n1. Nervous Diarrhoea.. Although all the three groups of\\ndiarrhoea are primarily produced by increased peristaltic\\naction of the bowels which is in turn caused by exagger-\\n1 Trousseau Clinique de l Hotel Dieu, Bd. ii.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0304.jp2"}, "305": {"fulltext": "DIARRHOEA. 285\\natecl action of the nervous apparatus, this group is desig-\\nnated as nervous diarrhoea on account of the predominance\\nof the nervous element. Trousseau was the first to de-\\nscribe nervous diarrhoea. It originates either through\\nundue stimulation of the accelerating peristaltic nerves or\\nthrough some nervous influences which cause a serous\\ntransudation into the intestinal canal. Frequently both\\nfactors are probably implicated.\\nIn many cases the stimulus may emanate from the centre\\nand reach the intestinal ganglia through the vagus, the sym-\\npathetic, or the splanchnic. In some cases, however, the\\nstimulus affects the ganglionic cells of the intestinal wall\\ndirectly. As characteristic, instances of nervous diarrhoea\\nwe would mention those cases in which there are several\\nwatery evacuations after a strong emotion, thus after fright\\nor fear. Here the stimulus arises in the brain centres\\nsupervising intestinal motions. While in these instances\\nwe have to deal with an acute transitory condition, nervous\\ndiarrhoea can also appear in a chronic form (Nothnagel,\\nPeyer 1 There are persons who are attacked with diar-\\nrhoea as soon as they are in a place where a toilet-room is\\ninaccessible. They may then be seized with abdominal\\npains, tenesmus, and diarrhoea. In other persons, again,\\nthe mere sight of a water-closet evokes an intense desire\\nfor an evacuation.\\nOccasionally the diarrhoea is preceded by several other\\nnervous symptoms, as for instance vertigo, giddiness, con-\\ngestion of the head, a sensation of heat all through the\\nbody, fright, shortness of breath, or palpitation of the\\nheart. All these symptoms as a rule rapidly disappear\\nafter a satisfactory movement.\\n1 A. Peyer Die nervosen Affectionen des Darmes bei der Neurasthe-\\nnie des mafmlichen Geschlechts. Wiener Klinik, 1893. Heft 1.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0305.jp2"}, "306": {"fulltext": "2S6 DISEASES OF THE INTESTINES.\\nThis form of diarrhoea is found in persons suffering\\nfrom neurasthenia or hysteria, in debilitated persons, or\\nin perfectly healthy people after a more or less pronounced\\nshock to the nervous system. Moreover it is met with\\naccompanying affections of the spine. Thus Charcot de-\\nscribed attacks of diarrhoea appearing periodically in tabes\\ndorsalis (intestinal crises). Lastly, nervous diarrhoea may\\nexist as a reflex condition in consequence of abnormal proc-\\nesses in the neighboring organs (the genito-urinary tract,\\nuterus, etc.).\\nAs an instance of nervous diarrhoea the following case\\nmay be described:\\nN. S., thirty years old, physician, was always perfectly\\nwell. After a year of hard study and a great deal of care\\nand anxiety he had begun to suffer from frequent loose\\nevacuations during the last six months. As a rule the\\npatient had one or two passages a few minutes after each\\nmeal. Preceding the evacuation rumbling noises were\\nheard in the lower part of the abdomen, while a slight\\nfeeling of discomfort was experienced. The movements\\nwere softer and more watery than usual, but did not con-\\ntain anything abnormal (no mucus, no undigested food).\\nThe patient felt perfectly well in every respect, had a good\\nappetite, slept well, and had not lost weight. Exami-\\nnation of the gastric contents showed the stomach to be\\nperfectly normal. The patient was given no medicines and\\nwas instructed to respond to nature s call in the morning\\nand to try to suppress the evacuations after meals when-\\never possible. For the first few days he succeeded in hav-\\ning no movement after some of the meals, and gradually\\nafter a few weeks was perfectly free from the desire to\\nevacuate the bowels after eating.\\nThe following case is reported by Fischel l\\nA lady, twenty-three years old, complained of a feeling\\n1 F. Fischel Prager med. Wochenscbr. 1891.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0306.jp2"}, "307": {"fulltext": "DIARRHCEA. 287\\nof oppression, cardiac palpitation, and severe attacks of\\ndiarrhoea, which appeared periodically independent of the\\nquality of the food. The passages were watery and of a\\nstrong alkaline reaction, smelled bad, and contained\\ntriple phosphate and considerable amounts of intestinal\\nepithelial cells. The examination revealed a retroflexion\\nof the uterus. After insertion of a pessary the diarrhoea\\nceased.\\nThe diarrhoea appearing after exposure to cold and wet\\nweather is most probably caused by a reflex emanating\\nfrom the nerves of the skin and producing hypersemia of\\nthe intestines. The latter gives rise to transudation into\\nthe lumen of the bowel and also to increased peristalsis.\\nThis form of diarrhoea disappears very quickly (in twelve\\nto twenty-four hours) and does not produce any anatomi-\\ncal changes of the intestinal walls.\\nAnother group of diarrhoeas takes its origin from an irri-\\ntation of the intestinal nerves through some abnormal sub-\\nstances contained in the blood. The cathartic action of\\nsome remedies subcutaneously injected is the best proof\\nof this possibility. The diarrhoea occurring in cases of\\nsepticaemia, of nephritis (with or without uremic symp-\\ntoms), and also diabetes is best explained by the theory\\nof irritating products circulating in the blood. The diar-\\nrhoea accompanying typhoid fever and dysentery in the\\nfirst stage before there has been time for the formation of\\nulcers, is caused by the circulating in the blood of toxic\\nelements produced by the pathogenic micro-organisms.\\n2. Dyspeptic Diarrhoea. Under dyspeptic diarrhoea may\\nbe comprised (a) the diarrhoea which appears after certain\\narticles of food; (b) diarrhoea accompanying abnormal\\nconditions of the gastric contents.\\n(a) Certain foods may cause mushy or watery evacua-\\ntions, as, for instance, fresh fruit, cucumbers, cabbage, and", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0307.jp2"}, "308": {"fulltext": "288 DISEASES OF THE INTESTINES.\\nbeets. The liability to diarrhoea from these foods, how-\\never, greatly varies in different persons. In some people\\nmilk produces diarrhoea, while in others it is rather con-\\nstipating.\\n(b) Pronounced conditions of subacidity of the gastric\\ncontents and still oftener achylia gastrica are associated\\nwith diarrhoea. Here probably the chyme on account of\\nits not having undergone any considerable changes in the\\nstomach exerts mechanically too great a stimulus on the\\nintestinal wall and thus causes the increased peristalsis.\\nHyperchlorhydria, although rarely, is also found associ-\\nated with diarrhoea. Here the chyme containing too much\\nacid most probably produces the increased peristalsis.\\n8. Stercoral Diarrhoea. Stercoral diarrhoea means a diar-\\nrhoea arising in consequence of too great a stimulus from\\nfecal matter.\\nEtiology and Symptomatology. If healthy persons for\\nsome cause or other become constipated for a certain pe-\\nriod of time, the constipation may be followed by diar-\\nrhoea. The latter is generally produced by the formation\\nof certain gases which chemically or mechanically exert a\\nstronger stimulus upon the intestinal peristalsis. Occa-\\nsionally hard scybala, as such, irritate the mucous mem-\\nbrane of the bowel too much and cause increased secretion\\nand peristalsis. In stercoral diarrhoea the evacuations are\\nas a rule at first formed and solid, later mushy and watery.\\nOff and on these watery passages contain several small\\nscybala as hard as a stone. Shortly before the appearance\\nof diarrhoea the abdomen is often quite bloated and borbo-\\nrygmi are heard in the intestines. The patients very fre-\\nquently complain of intense headaches. The passage of\\nbad smelling flatus affords only temporary relief, while a\\ngood movement removes almost all the symptoms. Slight", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0308.jp2"}, "309": {"fulltext": "DIARRHGEA. 289\\ngastric symptoms may accompany this condition. A ra-\\ntional diet effectually arrests the diarrhoea, but after an-\\nother period of constipation it may reappear, and if this\\nhappens very frequently, intestinal catarrh may be the\\nresult.\\nDiagnosis. The diagnosis of nervous diarrhoea can be\\nmade, if anatomical lesions of the intestines can be ex-\\ncluded and if the passages do not contain a considerable\\namount of mucus. The special type of the diarrhoea may\\nbe determined either by the symptoms (nervous diarrhoea\\nproper, stercoral diarrhoea) or by an examination of the\\ngastric contents (dyspeptic diarrhoea)\\nPrognosis. Most cases of nervous diarrhoea give a favor-\\nable prognosis. In some instances the diarrhoea, origi-\\nnally of a nervous origin, assumes a chronic course and\\nultimately produces an enteritis.\\nTreatment. The treatment will vary according to the\\ntype of the diarrhoea. In nervous diarrhoea proper the\\ngeneral condition of the patient must be strengthened and\\nthe remedies will have to be directed toward this end.\\nArsenic and iron will often prove efficient. In some cases\\nthe administration of bromides for a few weeks will be of\\ngreat benefit.\\nIn nervous diarrhoea dependent on a reflex action emanat-\\ning from some other diseased organ, the treatment mast\\nbe directed toward the primary affection.\\nIn all cases of nervous diarrhoea, persistent training of the\\nintestines in the normal direction must be urged by the\\nphysician. The patient should be instructed after having\\nhad his first movement in the morning to refrain from any\\nother evacuations of the bowels during this daj answering\\nnature s call only when absolutely necessary. In quite a\\nnumber of instances the patient at first continues to have\\n19", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0309.jp2"}, "310": {"fulltext": "290 DISEASES OF THE INTESTINES.\\nthe desire for an evacuation quite often, but succeeds in\\ncontrolling it. Later on the desire for defecation appears\\nless often and at last a normal state is reached.\\nIn dyspeptic diarrhoea the treatment should be directed\\ntoward the improvement of the abnormal condition of the\\nstomach. Thus diarrhoea due to hyperchlorhydria can be\\nsuccessfully checked by bicarbonate of sodium taken in half-\\nteaspoonful or teaspoonful doses two hours after meals.\\nThe diarrhoea resulting from achylia gastrica can be rem-\\nedied by a diet rich in vegetable foods, prepared in such\\na manner that they are easily broken up into minute par-\\nticles. Stomachics, intragastric faradization, and gener-\\nally the treatment of achylia gastrica will also control the\\ndiarrhoea.\\nIn stercoral diarrhoea an efficient cathartic is the best\\nmeans of checking the diarrhoea. Diarrhoea having its\\ncause in a faulty composition of the blood should be rem-\\nedied by improving the constitutional condition. If this\\nis impossible the treatment must be symptomatic.\\nIn this connection it may be advisable to describe the\\nmeans we have at our command symptomatically to treat\\ndiarrhoea, no matter of what nature it may be. The first\\nplace must be given to opium, a remedy which has stood\\nthe test of ages and is still the most reliable. It efficiently\\ndecreases the abnormal peristalsis and probably also di-\\nminishes the intestinal secretion. Morphine and the other\\nderivatives of opium act in a similar manner, but opium as\\nsuch seems to be preferable in diarrhceal conditions. Be-\\nsides opium there is hardly another remedy efficiently to\\ncheck increased intestinal peristalsis, although there are\\nseveral others which may arrest the diarrhoea. Among\\nthese may be mentioned nitrate of silver, subnitrate and\\nsalicylate of bismuth, and all the remedies containing tan-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0310.jp2"}, "311": {"fulltext": "CONSTIPATION. 291\\nnic acid. Another important means in treating diarrhceal\\nconditions is heat. A hot-water bag or warm linseed poul-\\ntice applied over the abdomen and warm drinks have a\\nfavorable influence upon the diarrhoea.\\nConstipation.\\nSynonyms. Habitual constipation, atony of the bowel,\\nconstipatio, constipatio alvi, obstipatio.\\nDefinition. By constipation is understood a diminution\\nin the frequency of evacuations of the bowels.\\nGeneral Remarks. Healthy persons have as a rule one\\nevacuation of the bowels daily. Under normal conditions\\na movement occurs almost always at about the same time\\nof the day. The cause of this periodicity lies most prob-\\nably in nervous influences. As mentioned above in the\\nchapter on physiology, the contents of the small intestine\\nare propelled with comparative rapidity. In the large in-\\ntestine, however, the prochoresis is very slow. The upper\\nrectum and the sigmoid flexure form a reservoir for the\\nstorage of the fecal matter. Once in twenty-four hours\\nthrough certain nervous influences the faeces are carried\\nlower down into the ampulla of the rectum and there is\\nthen experienced the desire for defecation. This is accom-\\nplished voluntarily by relaxing the sphincter ani and by\\nexercising a moderate pressure with the abdominal walls\\nafter more or less deep inspirations. No pain is connected\\nwith this act and a rather pleasant sensation is felt after\\nits accomplishment.\\nEven physiologically there is a great variability in the\\nnumber of movements. Some persons have normally two\\nor three movements a day all their lifetime, while others\\nhave only one evacuation every other day or even every\\nthree days. In both instances there may be no abnormal", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0311.jp2"}, "312": {"fulltext": "292 DISEASES OF THE INTESTINES.\\nsensations whatever and we are thus forced to consider\\nthem as physiological. Constipation, therefore, should\\nsignify a condition in which a person has less frequent\\nmovements than he has been accustomed to.\\nIn rare instances, however, the number of evacuations\\nremains the same, but their quantity diminishes. Thus a\\nstagnation of fecal matter in the bowels occurs (copros-\\ntasis). This condition is also usually comprised under\\nthe head of constipation. The quantity of the daily\\nevacuation of the bowel varies greatly, depending princi-\\npally upon the diet. A vegetable diet gives voluminous\\nstools, while one consisting mainly of meats produces only\\na small quantity of fecal matter. The average quantity\\nof fecal matter for twenty-four hours is about 250 c.c.\\nWhile a marked divergence from the above-mentioned fig-\\nure must be recognized as pathological, a small decrease\\nof evacuated fecal matter cannot be easily discovered, the\\nmore so since, according to Woodward, a considerable\\nquantity of the fecal matter is made up of micro-organ^\\nisms whose number is apt to vary greatly, even under\\nnormal conditions.\\nConstipation may be due to organic lesions of the bowel\\n(stenosis of the intestine or catarrhal conditions), or may\\nexist without apparent anatomical changes in the intestinal\\ntract, and thus be functional in nature. The latter class\\nalone is dealt with here Inasmuch as in the great major-\\nity of these cases of constipation a disturbance in the ner-\\nvous apparatus of the intestine may be presumed to exist,\\nwe discuss constipation in this chapter on intestinal neu-\\nroses.\\nEtiology. Habitual constipation may be divided into\\nthree groups: 1. Constipation due to retarded intestinal\\nperistalsis (atony of the bowel). 2. Constipation due to", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0312.jp2"}, "313": {"fulltext": "CONSTIPATION. 293\\na spasmodic contraction of a certain portion of intestine\\n(enterospasmus, spastic constipation). 3. Constipation\\ndepending upon abnormal conditions of other organs.\\nWith regard to the etiology of the first group, namely,\\nconstipation due to atony of the bowels, which comprises\\nby far the greater majority of cases, the following may be\\nsaid In most instances the constipation is brought on by\\na repeated neglect of nature s calls. Thus, young girls\\nwhile in school suppress the desire for defecation out of\\nbashfulness, which gives rise at first to irregularity of the\\nbowels and later on to constipation. The mental state is\\nalso responsible to a great extent for the causation of this\\ntrouble.\\nIt is not among the working class that constipation is\\nmost frequently found, but among the wealthier classes.\\nThis shows that the mode of living has much to do with\\nthis affection. If we would go a little more into detail\\nand try to analyze cases of chronic constipation, we would\\nlearn that the patient had perhaps at first a great deal of\\nworry or of mental strain. At that time his bowels first\\nbecame sluggish and after a while the affection became\\nmore developed. The patient experienced more and more\\ndifficulty, began to take drugs, and after a short time was\\nnot able to have a movement without medicine.\\nOften we find that after an acute gastric catarrh there\\nwas at first a little diarrhoea, which after a few days\\nchanged into constipation. After a short time this would\\nhave disappeared of itself, if the patient in his haste to have\\na movement had not resorted to cathartics, thus upsetting\\nagain the normal state of the intestinal tract, in conse-\\nquence of which chronic constipation developed. Very\\nfrequently the patient has some trouble, perhaps a head-\\nache, and thinks the stomach is disordered, and begins", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0313.jp2"}, "314": {"fulltext": "294 DISEASES OF THE INTESTINES.\\nto live on a one-sided diet, avoids vegetables, butter, fat\\nall substances which excite the peristaltic action of the\\nbowels\u00e2\u0080\u0094 and then constipation arises and assumes a chronic\\nform.\\nIn a limited number of cases the retarded intestinal\\nperistalsis is due to a real muscular weakness of the\\nbowel, the intestinal muscularis being much thinner\\nthan normally. Nothnagel observed some cases in which\\nat the autopsy the muscularis of the large bowel measured\\nin thickness 0.12 to 0.25 mm., while normally it ought\\nto be 0.5 to 1 mm. In these cases the muscular devel-\\nopment of the entire body was poor. It will therefore be\\neasily seen that such rare conditions cannot be recognized\\nduring life.\\nIn former years the opinion prevailed that chronic consti-\\npation gives rise to the developement of numerous nervous\\naffections (neurasthenia, hypochondriasis, hysteria, and\\neven epilepsy and paranoia). Dunin was the first to show\\nthat in reality quite the reverse is true, namely, that con-\\nstipation is the result of many nervous conditions and not\\ntheir origin, for a treatment directed against the existing\\nneurosis in many instances removes the constipation with-\\nout the administration of cathartics. Dunin, however,\\ngoes too far in ascribing all cases of habitual constipation\\nto a neurosis. There are certainly cases of chronic consti-\\npation in which no nervous derangement whatever can be\\ndiscovered.\\nFormerly the cause of constipation was presumed to lie\\nin abnormal conditions of the bowels. Thus, peritonize\\nadhesions of the intestines and congenital malposition of\\nthe bowel have been held responsible for chronic consti-\\n1 Dunin Ueber habituelle Stuhlverstopf ung, deren Ursachen und\\nBehandlung. Berliner Klinik, 1891, Heft 34.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0314.jp2"}, "315": {"fulltext": "CONSTIPATION. 295\\npation. But aside from the fact that these two factors\\nare so rarely found in comparison with the large num-\\nber of cases of constipation, Leichtenstern proved that\\nan abnormal position of the bowels need not cause con-\\nstipation as long as the intestinal lumen is not obstructed.\\nSpasmodic contraction of the bowels or enterospasmus\\nis produced by increased peristaltic action confined to one\\nportion of the bowels. A permanent contraction of a por-\\ntion of the intestine exists which may affect both the circu-\\nlatory and the longitudinal muscles. This spastic state\\nmay be of variable duration and may involve intestinal\\nsegments of different lengths: The contracted portion of\\nthe bowel is almost completely occluded, thus creating\\nan obstacle to the onward passage of the intestinal con-\\ntents.\\nThe enterospasm may involve the entire small intes-\\ntine. The abdomen then appears contracted in the form\\nof a trough. This condition is met with in spinal menin-\\ngitis and in other morbid processes involving the pons\\nand the medulla oblongata. Moreover, the same affection\\noccurs in chronic lead poisoning.\\nMuch more frequent than the diffused enterospasm is\\nthe localized or circumscribed contraction of the bowel\\nwhich usually affects a certain portion of the large intes-\\ntine. Here the abdomen does not show any abnormal\\nappearance on inspection. This condition is frequently\\nmet with in nervous people, neurasthenics, hysterical per-\\nsons, and also in those debilitated by long ailments. Con-\\nstipation of an obstinate nature, lasting for several days,\\nfollowed by a painful evacuation of small balls (like the\\n1 Leichtenstern Verengerungen, Verschliessungen und Lageveran-\\nderungen des Darros. von Ziemssen s Handbuch der speciellen Pa-\\nthologie und Therapie, Bd. vii., 2te Halfte, Leipzig, 1878.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0315.jp2"}, "316": {"fulltext": "296 DISEASES OF THE INTESTINES.\\nfaeces of goats) or leadpencil-shaped fecal matter are the\\npredominant symptoms. Pains in the umbilical region or\\non the left side of the lower abdomen of a constricting\\nnature and relieved after a very small passage, are also\\ncharacteristic of this affection.\\nConstipation Depending upon Diseases of Other Organs.\\nNumerous diseases of the stomach give rise to constipa-\\ntion. Foremost among these are hyperchlorhydria, ulcer\\nand cancer of the stomach, ischochymia, atonic and catar-\\nrhal conditions of the stomach, *and finally achylia gastrica\\nthe last three, however, show a smaller percentage of\\nthis complication. In this group of cases constipation is\\nattributable either to the abnormal qualities of the chyme\\npassing through the digestive canal or to the retarded gas-\\ntric prochoresis or to some retarding reflex act originating\\nin the stomach.\\nTumors of the intestinal canal or of neighboring organs\\ncompressing the bowel, strictures within the intestines, and\\nperitonitic adhesions are also often associated with consti-\\npation. These conditions, moreover, frequently lead to a\\nfar more serious condition, namely, to acute or chronic\\nileus. Catarrhal inflammation of the small intestines alone\\nis also ordinarily accompanied by constipation. Ulcers\\nof the small intestine are sometimes attended by constipa-\\ntion. Ulcers of the large bowel are ordinarily accompa-\\nnied by diarrhoea, excepting dysenteric ulcers, which often\\nproduce constipation. Fissure of the anus and an increased\\ncontraction of the sphincter of the anus are often causes of\\nconstipation.\\nIn many diseases of the brain, spinal cord, and the\\nnerves (cerebro-spinal meningitis, brain tumors, hemor-\\nrhages of the brain, chronic hydrocephalus, myelitis,\\ntabes, neuroses and psychoses) constipation is present.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0316.jp2"}, "317": {"fulltext": "CONSTIPATION. 297\\nIt is due here either to a disturbance of the nervous appa-\\nratus communicating with the centre for defecation, or to\\na diminished sensibility of the intestinal nerves so that\\nstronger stimuli are required than under normal condi-\\ntions.\\nDiseases of the lungs, heart, liver, and kidney increase\\nthe liability to constipation, first, by the hyperemia of\\nthe intestinal mucosa, and, secondly, by the congestion\\nin the portal circulation, which both retard the peristalsis-\\nDiabetes mellitus often gives rise to constipation, first,\\nby the polyuria which drains the organism of water and\\nthus leads to an exsiccated condition of the fecal matter,\\nand, secondly, by the diet, which consists principally of\\nmeat and of a very restricted quantity of starchy food.\\nDiarrhoea, however, is not rarely met with in this disease.\\nAnsemia and chlorosis are also often attended by consti-\\npation. The latter is due to an atonic condition of the\\nbowels, which is one of the symptoms of the general mus-\\ncular atony dependent upon the impoverishment of the\\nblood.\\nMost febrile diseases are also usually accompanied by\\nconstipation. Lack of exercise and an increased elimina-\\ntion of the fluids of the body caused by the greater activity\\nof the lungs and the sudoriparous apparatus are the prin-\\ncipal factors. Constipation encountered in people living\\nin high altitudes must be ascribed, according to Euedi, 1\\nto the same causes. The restricted diet, consisting chiefly\\nof milk, also contributes to a lessened activity of the intes-\\ntinal peristalsis.\\nSymptomatology. In many cases constipation does not\\ninduce any subjective symptoms whatever. Ordinarily,\\n1 Carl Ruedi On Indications and Contraindications of High Alti-\\ntude in Phthisis. The Climatologist, July, 1892.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0317.jp2"}, "318": {"fulltext": "298 DISEASES OF THE INTESTINES,\\nhowever, continued constipation gives rise to sensations\\nof slight pressure, fulness and tension in the abdomen;\\nand borborygmi may at times molest the patient. Occa-\\nsionally intense colicky pains are experienced. These are\\ndue to an increased effort of the intestines to rid them-\\nselves of the accumulated fecal matter by violent contrac-\\ntions. The abdomen is often symmetrically distended,\\nrarely asymmetrically, namely, in partial atony of the\\nbowels.\\nIn patients with thin abdominal walls, a more or less\\nfilled state of some portions of the intestine, especially\\nof the colon, may be perceived by inspection and pal-\\npation. The appetite is often diminished and in some\\ninstances complete anorexia exists. Other gastric symp-\\ntoms belching, nausea, pyrosis, feeling of pressure after\\nmeals, and bad taste in the mouth may be present. That\\nall these symptoms are due to the constipation and not to\\na separate lesion in the stomach, is proven by the fact that\\nthey all disappear as soon as efficient evacuation of the\\nbowels has taken place.\\nBesides these gastric symptoms the following derange-\\nments may be present congestion of the head, dizziness,\\nheadaches, sleeplessness, a despondent feeling, palpitation\\nof the heart, tachycardia, irregularity of the pulse. The\\nlatter symptoms have been considered by many writers to\\nbe due to auto-intoxication from the intestinal tract. Ac-\\ncording to the experiments of Bouchard, 1 however, this\\ndoes not seem to be true, for this investigator has shown\\nthat intoxication within the intestinal tract takes place\\nwhen there is a retention of fluid fecal matter, but not\\nwhen the faeces are solid, for in this condition no absorp-\\ntion of the fecal matter takes place.\\n1 Bouchard Loc. cit", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0318.jp2"}, "319": {"fulltext": "CONSTIPATION. 299\\nConstipation which has lasted for a long time, as a rule,\\nterminates by a spontaneous evacuation of ordinarily very\\nhard masses of fecal matter. The latter often appears in\\nthe form of balls which may be covered with a thin layer\\nof mucus. In some instances the constipation terminates\\nin an attack of diarrhoea. In these cases the diarrhoea has\\nbeen caused by an acute hyperaemia and inflammation of\\nthe intestinal mucosa due to the hardened fecal matter, the\\nlatter becoming liquefied through increased intestinal per-\\nistalsis and secretion. In other instances no spontaneous\\nevacuation takes place and it becomes necessary to make\\nuse of different cathartic remedies in order to produce a\\nmovement of the bowels.\\nEetention of fecal matter may cause not only a slight\\ntransient catarrhal condition of the bowels as just referred\\nto, but may, although rarely, effect more pronounced an-\\natomical lesions, as formation of ulcers (stercoral ulcers),\\nlocal peritonitis, and even perforation of the gut with fatal\\nissue.\\nOne of the serious symptoms which may result from\\ncontinued constipation is fecal colic. The latter begins\\nwith sudden violent pain of a colicky nature in the ab-\\ndomen. In weakened persons fainting spells may occur.\\nThe abdomen is usually greatly bloated and tender on\\npressure. Passing of wind (flatus) gives temporary relief,\\nbut the pains soon reappear and subside only after an\\nefficient evacuation. Fecal colic is mostly observed in\\ncases of obstinate constipation, although it may occur in\\npatients with daily evacuations of the bowels, but in these\\ninsufficient fecal passages must be presupposed. In fact,\\nhardened balls of fecal matter can be discovered in such\\ncases on palpation of the abdomen.\\nThese conditions are not always of a mild character.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0319.jp2"}, "320": {"fulltext": "300 DISEASES OF THE INTESTINES,\\nAs a rule cathartic remedies are efficient. In some cases,\\nhowever, the latter produce energetic intestinal peristalsis\\nand violent pains, but fail to secure a copious movement.\\nUnder these circumstances the patient may after a while\\nsink into a state of collapse and be seized with a paroxysm\\nof vomiting. The clinical picture now resembles very\\nclosely that of ileus. High rectal irrigations or injections\\nof oil into the bowel ordinarily yet produce the desired\\neffect and the patient quickly recuperates. In rare cases,\\nhowever, especially in very old and cachectic persons, these\\nmeans also remain fruitless. Total paralysis of the intes-\\ntine now takes place and the patients are then in a most\\ncritical condition.\\nA frequent complication of constipation is the formation\\nof fecal tumors. They are found most frequently in the\\ncaecum, rectum, and at the colic flexures. These masses\\nmay cause a dislocation of the colon thus, such a tumor\\nmay be felt just above the symphysis and may belong to\\nthe transverse colon which has been dragged down to that\\nregion. Fecal tumors are as a rule easily recognizable.\\nThey are not of a very firm consistency, have a rosary-like\\nconfiguration, are movable, and undergo a change in shape\\nupon pressure. They may be of large size. Thus Levi\\nfound the rectal pouch of a patient suffering for nine years\\nwith constipation filled with a fecal mass weighing four\\npounds. Still larger fecal concretions have been found\\nby Lemazurier. 2 These large masses necessarily dilate\\nthe colon.\\nHabershon described cases in which the dilated colon\\nmeasured twelve to fifteen inches in circumference, and\\nstated that some of the normal sacculations of the colon\\n1 Levi Gazette med., 1839.\\n2 Lemazurier Arch. gen. de med., vol. i.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0320.jp2"}, "321": {"fulltext": "CONSTIPATION. 301\\nmay become distended to sueli a degree that they appear\\nas true diverticula. In the latter fecal accumulations may\\noccur which remain undisturbed by the further passage of\\nthe intestinal contents. These stagnant fecal masses often\\nproduce inflammatory processes which may lead to a de-\\nstruction of the intestinal coats down to the peritoneum\\nThe colon occasionally is distended not only in width\\nbut also in length. The latter circumstance explains the\\nabnormal position of the bowel often present in these\\ncases.\\nAmong the local symptoms which constipation produces\\nhemorrhoids play an important part. They are treated\\nin a special chapter.\\nA host of nervous symptoms may develop in consequence\\nof constipation in people who are apparently not nervously\\ninclined. Thus constipation lasting several days may\\nproduce slight cerebral symptoms, namely, a sensation of\\npressure, weight and dulness in the head, sometimes\\nheadaches and vertigo. The dependence of these symp-\\ntoms upon constipation is proved by the fact that after a\\nfull evacuation of the bowels they all suddenly disappear,\\nbut again return after another period of constipation. We\\nhave as yet no positive explanation of the causation of\\nthese symptoms. Some authors assume them to be of a\\nreflex origin.\\nLeube 1 described several cases of intestinal vertigo in\\nwhich the dizziness was due to pressure existing in the lower\\nend of the bowels, the vertigo appearing only in consequence\\nof irritation of the intestinal walls by fecal matter or a large\\namount of gas, or by the examining finger. Leube concluded\\nthat pressure upon the hemorrhoidal plexuses of the sym-\\n1 Leube Ueber Darmschwindel. Deutsches Arch. f. klin. Medi-\\ncin. Bd. 36, 1885.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0321.jp2"}, "322": {"fulltext": "302 DISEASES OF THE INTESTINES.\\npathetic nerve produces the sensation of vertigo in are-\\nflex way.\\nSenator tried to explain the above symptoms as due\\nto the absorption of poisonous gases within the intestine,\\nsuch as sulphuretted hydrogen, and Nothnagel assumed\\nthat ptomains may be absorbed and thus cause an auto-\\nintoxication. But neither theory seems to hold good; for\\nsulphuretted hydrogen gas exists in too small quantities\\nto produce any marked symptoms, and the fecal ptomains\\ncan scarcely be absorbed from dried-up fecal matter.\\nAs mentioned above, real brain diseases, hypochondria\\nand melancholia, are never due to constipation as such.\\nThere is, however, hardly any doubt that in nervously\\ninclined individuals obstinate constipation may be a con-\\ntributing factor in the further development of some psy-\\nchoses, especially melancholia.\\nFecal fever, which has played a great part in the works\\nof old writers, appears to be due in most instances not to\\nan accumulation of fecal matter but rather to some com-\\nplicating condition, an inflammatory process, a stercoral\\nulcer, a local peritonitis, etc. In infants and children,\\nhowever, who much more readily develop fever, the latter\\nmay be due to accumulation of fecal matter alone. Some\\nof the English writers have referred to chlorosis as due to\\nhabitual constipation, and Clark has treated chlorosis with\\ncathartics. But this view has not been generally accepted\\nand the dependence of chlorosis upon constipation is far\\nfrom being proved.\\nDiagnosis. The recognition of constipation is not diffi-\\ncult, except in those cases in which there is a daily evacu-\\nation of the bowels but not a complete one, so that fecal\\n1 Senator Hydrothionsemie imd Sel bstinfection durch abnorme\\nVerdaimngsvorgange. Berl. klin. Wochecschr., 1868, No. 24.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0322.jp2"}, "323": {"fulltext": "CONSTIPATION. 303\\nmatter is more and more accumulated in the intestine.\\nFrequently hard fecal masses of rosary shape will be dis-\\ncovered on palpation of the abdomen in the region of the\\ncolon. Most often the sigmoid flexure and the caput coli\\nare the favored sites of this phenomenon. The detection\\nof these fecal masses shows the existence of an insufficient\\nevacuation of stools, in other words, constipation.\\nThe diagnosis of pure constipation (habitual constipa-\\ntion) can be made, if organic lesions of the bowels (stric-\\nture, tumor, and also intestinal catarrh) can be excluded.\\nThis diagnosis having been made, it is of importance to\\nfind out to which group the constipation belongs, whether\\nit be due to an abnormal gastric condition, or disease of\\nsome other organ, or to a neurotic affection of the bowel\\nitself (atonic and spastic constipation).\\nConstipation due to anomalies of the function of the\\nstomach can be ascertained only after a thorough analysis\\nof the gastric contents and after resort to treatment directed\\ntoward the improvement of the gastric condition. Con-\\nstipation due to disease of other organs (heart, lungs,\\nkidneys, liver, etc.) may be assumed to exist when an\\nexamination discloses their presence. Constipation due\\nto atony of the bowels is often revealed by a slightly\\nbloated condition of the abdomen with evacuations of hard\\nfecal matter, often balls, sometimes covered with a thin\\nlayer of mucus. While there may be a feeling of despond-\\nency, dizziness, and somnolence, real severe pains are\\nrare. Constipation due to a spasmodic contraction of the\\nbowel is attended with a general feeling of uneasiness and\\npains in the abdomen, occasionally accompanied by fainting\\nfits. The fecal matter is not so hard, although it is evac-\\nuated only after severe straining of the abdominal walls,\\nand is voided in narrow tapelike pieces. The abdomen", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0323.jp2"}, "324": {"fulltext": "304 DISEASES OF THE INTESTINES.\\nis often rather sunken and contracted. Intestinal coils can\\nfrequently be palpated.\\nPrognosis. The prognosis of constipation is favorable in\\nthe large majority of cases, especially with regard to life.\\nIt must, however, be admitted that after having lasted a\\nlong time constipation may give rise to severe, sometimes\\nirreparable anatomical lesions of the intestine, as for in-\\nstance atrophy, peritonitic adhesions, malpositions of the\\nbowel, even perforation with consequent peritonitis and\\ndeath. The latter instances, however, are very rare, if we\\ntake into consideration the large number of persons suffer-\\ning with constipation who reach an advanced age, and they\\nwill most prot5ably become still less frequent if the patients\\ndo not neglect this condition and consult a physician at an\\nearly period.\\nTreatment. Cases of constipation due to dyspeptic con-\\nditions must be treated by first ameliorating the gastric\\ndisorder. Cases of constipation secondary to diseases of\\nother organs must be managed by first applying remedies\\ntoward the improvement of the original trouble. If these\\nalone are insufficient, they must be managed like typical\\ncases of habitual constipation.\\nWith regard to the prophylaxis of constipation, we\\nshould avoid administering cathartics in slight transient\\ndisturbances of digestion and rather let nature take its own\\ncourse. Never put a patient on a one-sided diet for too\\nlong a time the exclusion of vegetables, fruits, and starchy\\nfoods in general, from the diet is frequently the cause of\\nmarked constipation. A hygienic mode of living, regular\\nhabits, less business strain and worry, and more outdoor\\nlife and exercise are of the greatest importance in the pre-\\nvention of constipation.\\nGenerally no purgatives whatever, or as few as possible,", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0324.jp2"}, "325": {"fulltext": "CONSTIPATION. 305\\nshould be used. The chief measures in curing constipa-\\ntion are the following\\n1. The Moral Treatment. It is of utmost importance to\\nallay the patient s anxiety to have a movement. He should\\nbe told to pay as little attention as possible to the condi-\\ntion of his bowels. Absence of a movement for a few days\\nwill cause no harm whatever. Avoidance of purgatives and\\nkeeping the mind of the patient free from worry over the\\ncondition of his bowels is occasionally sufficient to produce\\nspontaneous movements.\\nTraining the patient to have an evacuation at a certain\\ntime every day is also of great importance. The patient\\nshould be taught to go to the watercloset every morning at\\nthe same time and should try to have a passage. In doing\\nthis he should not exert himself too hard and should spend\\nonly three to five minutes for this purpose. In case the\\nattempt be unsuccessful, he should wait until the follow-\\ning morning, unless there is a strong desire to go to stool.\\nTrousseau was the first to advocate this mode of treatment,\\nand the importance of this maxim has since been gen-\\nerally accepted. My own experience coincides with that of\\nothers, and I cannot lay too much stress upon this ap-\\nparently unimportant piece of advice. Even when using\\nother measures in combating constipation we must not\\nlose sight of the influence in traioing the patient.\\n2. Dietetic Measures. The dietetic measures have for\\ntheir object the ingestion of foods which increase the intes-\\ntinal peristalsis and the avoidance of substances which are\\nof a more or less constipating nature. Advocate the drink-\\ning of plain cold water, especially in the fasting condition,\\nthe use of buttermilk, cider, grapes, oranges, and other\\nfruits, raw or cooked (apples, prunes, pears, peaches),\\nlemonade, honey; salmon, sardines, herring, plenty of\\n20", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0325.jp2"}, "326": {"fulltext": "306 DISEASES OF THE INTESTINES.\\nvegetables, spinach, green peas, cauliflower, cabbage, green\\nsalads, rye bread, butter. Avoid strong tea, claret, huckle-\\nberries, cacao and chocolate.\\nSome substances have a constipating effect upon one\\nperson and a purgative effect upon another, as for instance\\nrnilk. In treating the patient we must acquaint ourselves\\nwith his peculiarities in this respect. In prescribing a\\ndiet for patients with constipation we should allow them\\nthe usual foods with a predominance of those just enum-\\nerated. It is needless to say that some of the articles\\nmentioned will not be permissible in every case. Thus a\\npatient with a very delicate stomach should certainly be\\ntold not to take cabbage and cider, etc.\\nIn some instances in which too much vegetable food has\\nbeen taken and a constipation has developed in consequence\\nof the intestine being overburdened with too much ballast,\\nfood articles containing much cellulose will have to be re-\\nstricted. As a rule, however, a mixed diet with a prepon-\\nderance of vegetable food is adapted for most cases.\\n3. Mechanical Measures. The mechanical measures\\nserve to strengthen the bowel and in this way promote a\\nbetter action, or they directly effect a stronger intestinal\\nperistalsis. The mechanical measures comprise massage,\\nexercise, electricity, hydrotherapy, and lastly injections\\ninto the bowel.\\n(a) Massage. The general principles of massage have\\nbeen described above (page 80). Its action consists prin-\\ncipally in producing more efficient peristalsis of the large\\nbowel. It should therefore never be used in conditions in\\nwhich spasmodic contractions of the bowel may be assumed\\nto exist. Its most useful field lies in cases of atony of the\\nbowel.\\nMassage should be applied at first either by the physi-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0326.jp2"}, "327": {"fulltext": "CONSTIPATION. 307\\ncian himself or under his strict supervision. It should\\nnever be applied with much force and it should never\\ncause pain. According to Illoway, the duration of massage\\ntreatment should be from five to fifteen minutes for a\\ngrown person and from three to five minutes for children.\\nThe massage should be employed every other day with\\ngreat regularity for a period of about six weeks at least.\\nIlloway suggests that the massage sittings may be per-\\nformed less frequently as soon as there is a decided\\nimprovement in the condition of the bowels. It is, how-\\never, never advisable to stop the massage treatment sud-\\ndenly, but it should rather be kept up for a long period\\nof time, although later at longer intervals. Massage is\\nbest applied early in the morning in the fasting condition\\nof the patient. During its employment no other remedy for\\nconstipation should be administered unless the latter has\\nlasted several days and gives rise to various symptoms.\\nAuto-massage may also be of benefit. This may be\\ncarried out by the patient himself, kneading his abdo-\\nmen principally over the course of the large bowel with\\nhis right hand or by means of some instrument adapted\\nfor this purpose. Sahli was the first to recommend the\\nuse of a cannon-ball, weighing about three to five pounds.\\nThese balls may be wrapped in flannel and rolled over the\\nabdomen for about five to ten minutes. This procedure is\\nbest performed early in the morning in bed in the fasting\\ncondition of the patient. The ball is best rolled over the\\nabdomen in a spiral direction, principally along the course\\nof the colon. But the other parts of the abdomen should\\nalso be subjected to this procedure. The flannel covering\\nthe ball may be left off if desired. Dr. A. Rose, 2 of New\\n1 Illoway Constipation in Adults and Children, New York, 1897.\\n2 A. Rose New Yorker medizinische Monatsschrift, January, 1893.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0327.jp2"}, "328": {"fulltext": "308 DISEASES OF THE INTESTINES.\\nYork, has practised tliis method quite extensively and\\nwarmly recommends its use. Dr. Arthur Kahn, 1 also of\\nNew York, has invented an apparatus for auto-massage\\nwhich may also be used for this purpose. Rosenheim 2\\nsuggests using auto-massage in the following manner The\\npatient in an upright posture makes short palpating strokes\\nwith the ringers of his right hand inclined somewhat in-\\nwardly over his abdomen for several minutes. In this\\nprocedure also the course of the colon is especially to be\\nconsidered.\\n(b) Gymnastic exercises. Exercises which bring into\\nplay especially the muscles of the abdomen are of great\\nbenefit. Exercises on the horizontal bar, horseback rid-\\ning, mountain climbing, skating, rowing, bicycle riding,\\nare all beneficial, provided these sports are not kept up\\nfor too long a time, and do not cause a superabundant\\nloss of water by extensive perspiration.\\nIndoor gymnastic exercises may also be used. Bend-\\ning of the body, rotations of the trunk, especially in a\\nsiting posture, quickly drawing up the knees toward the\\nthorax in the recumbent position, also alternate squatting\\nand rising are of special benefit. The passive, so-called\\nSwedish movements may also be employed either in a\\nZander Institute or manually by a nurse. Massage and.\\nthese exercises are best applied in conjunction.\\n(c) Electricity. Percutaneous electrization (principally\\nfaradization) of the abdomen has been recommended by\\nsome writers as a cure for constipation. Eecently direct\\nelectrization of the intestine, applying one electrode to the\\nrectum and the other over the abdominal wall, has been\\n1 A. Kahn Centralblatt fur Chirurgie und orthopadische Mechanik,\\nBerlin, 1889, Bd. v., p. 4.\\n2 Th. Rosenheim Krankheiten des Darms, 1893, p. 513.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0328.jp2"}, "329": {"fulltext": "CONSTIPATION. 309\\nused. Boudet s rectal electrode is best adapted for this\\npurpose, especially when galvanization is employed. The\\ninsertion of one electrode in the stomach and the other in\\nthe rectum, as suggested by Kussmaul and Leubuscher, 1\\nhas not come into use to any extent.\\nElectricity seems to act favorably on the intestinal peri-\\nstalsis and it is especially indicated in the treatment of\\nconstipation in conjunction with massage, particularly in\\natony of the bowel. Doumer 2 has very recently recom-\\nmended the use of static electricity. He applies localized\\nfranklinization in the form of sparks or souffles elec-\\ntriques for about five to twelve minutes in the iliac fossae,\\nprincipally the left. By the employment of this method\\nof treatment every other day for a period of two to three\\nweeks Doumer reports having cured the most obstinate\\ncases of chronic constipation.\\n(d) Hydrotlierapeidic means. Hydrotherapeutic meas-\\nures may be applied either alone or in conjunction with\\nthe above-named mechanical means. Hackel 3 gives the\\nfollowing rules In constipation due to atony of the bowels\\nuse a jet of water of about the thickness of the small finger\\nwith the force of two atmospheres, first over the epigas-\\ntrium. The hose of the mobile douche is then placed over\\nthe region of the colon. Charcot s douche is best adapted\\nfor this purpose, as it allows a sudden change of tempera-\\nture. When using the latter apparatus the temperature\\ncan be readily changed to any degree desired during its\\napplication. The alternations in temperature should be\\nconsiderable, often from 102\u00c2\u00b0 F. to 120\u00c2\u00b0 F. Thus both\\nmechanical and thermic effects come into play. After\\n1 Leubuscher Centralbl. f. klin. Medicin, 1887, No. 25.\\n2 E. Doumer et Musin Annates d Electro-Biologie. 1898, p. 722.\\n3 Jeannot Hackel Deutsche med. Wochenschrift, Jan. 5, 1899.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0329.jp2"}, "330": {"fulltext": "310 DISEASES OF THE INTESTINES.\\nusing the douche over the abdomen, it is applied over the\\nchest and back, throwing a fan-shaped jet, the temperature\\nbeing kept constant.\\nIn constipation due to spastic contractions of the bowels\\nHackel applies water under a pressure of two and a half\\nkilograms, letting it flow in the form of a fine spray. It\\nfalls like a fine rain on the abdomen. The temperature of\\nthe water should not be lower than 95\u00c2\u00b0 F. and not higher\\nthan 102\u00c2\u00b0 F. and should not be changed. The duration of\\nthe douche is from two to two and a half minutes. The hose\\nis directed along the course of the colon while the water\\nconstantly runs over the epigastrium. Ninety-six such\\ncircuits over the intestines may be made. Afterward the\\nlower extremities, chest and back, are douched. The skin\\nof the abdomen must not be subjected to vigorous friction\\nafter the douche the extremities, however, should be well\\nrubbed. After the douche the patient should lie in bed\\nfor about five to ten minutes, being warmly covered, and\\nthen may walk for about a quarter of an hour.\\nCold sitz baths (12\u00c2\u00b0 C.) for about five minutes are also of\\nbenefit, as well as a Priessnitz compress or Neptune s gir-\\ndle over the abdomen over night.\\n4. Injections. Injections into the bowels of water alone\\nor of water with the addition of soap, vinegar, common\\ntable salt, or castor-oil are often used with advantage.\\nThe amount of fluid required for a purging effect varies in\\ndifferent persons. As a rule a pint to a quart or one and\\na half quarts are necessary. These water injections should\\nbe made daily at the same hour for a period of three to\\nfour weeks, and then every other day also for the same\\nlength of time.\\nRecently Klemperer 1 has recommended the use of small\\n1 Klemperer Therapie der Gegenwart, 1899, p. 48.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0330.jp2"}, "331": {"fulltext": "CONSTIPATION. 311\\nwater injections into the bowels at bed-time. Half a\\npint of water is injected and the patient is told to re-\\ntain the fluid. The latter is very soon absorbed by the\\nintestine and the patient has an evacuation on the fol-\\nlowing morning. Klemperer cured cases of constipation\\nby giving these small water injections for about three\\nweeks every day, and then every other day for the follow-\\ning two or three weeks.\\nInjections of sweet oil into the rectum, which have been\\nrecommended by Kussmaul and Fleiner, are best adapted\\nfor the treatment of obstinate cases of constipation, espe-\\ncially if due to spasmodic contraction of the bowel. The\\ninjections should be made in the following way Take\\nabout one pint of good olive oil and heat it to the tem-\\nperature of the body. Then take a fountain syringe pro-\\nvided with a soft-rubber rectal tube, and inject the oil into\\nthe rectum. The patient takes the injection while in bed,\\nand it is advisable to have him retain the oil as long as\\nhe can. I usually order it to be taken in the evening, so\\nthat the patient may fall asleep at once and retain it over\\nnight. The following day the oil is passed and an evacua-\\ntion follows. If the patient is treated for two to three\\nweeks with oil, the spasmodic condition will subside. The\\noil injections should then be given every other night for\\na period of two weeks, thereafter twice a week for some\\ntime, then once a week for several months.\\nInjections of glycerin, which were first recommended\\nby Anacker, 1 are also beneficial. Two to four grams of\\nglycerin are dissolved in about three to four ounces of\\nwater and injected into the rectum. An evacuation of\\nthe bowels results in a very short time, ten to twenty\\n1 Anacker: Das Purgativ Oidtmann. Deutsche med. Wochenschr.,\\n1887, p. 823.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0331.jp2"}, "332": {"fulltext": "312 DISEASES OF THE INTESTINES.\\nminutes. The glycerin may also be given in the form\\nof a suppository, acting the same way. While this mode\\nof treatment is very convenient to produce an evacuation\\nof the bowels, it should not be resorted to daily, as the\\nbowel is thereby greatly irritated.\\nSimilar in its action but less harmful is Flatau s method\\nof applying boric acid directly to the rectum. Boric-acid\\npowder, about one to three grams, may be inserted into\\nthe rectum with the finger or blown into it by means of a\\npowder-blower through the anus. A movement of the bow-\\nels occurs half an hour to three hours later.\\n5. Purging Medicaments. In many instances of habitual\\nconstipation the use of drugs must be resorted to. As a\\ngeneral rule we should administer as mild cathartic rem-\\nedies as possible, and instead of increasing the dose we\\nshould rather try to reduce it gradually, and ultimately\\nrelieve the constipation without the help of cathar-\\ntics.\\nThe various preparations of rhubarb are very serviceable.\\nYinum rhei and tinctura rhei aromatica or dulcis may be\\ngiven in doses of from half a teaspoon to one teaspoonful.\\nRhubarb may also be given as a powder in conjunction\\nwith calcined magnesia and bicarbonate of soda, as for in-\\nstance\\n3 Pulv. rad. rhei,\\nMagnes. ustae,\\nSod. bicarb aa 20.0 (3 v.)\\nM. f. pulv. D. ad scatulam. S. One-half teaspoonful two or three\\ntimes a day.\\nPulvis glycyrrhizse compositus is also a very suitable prep-\\naration. It can be given in teaspoonful doses at night or\\nin the morning. It has the following composition\\nJFlatau. Berl. klin. Wochenschr., 1891, p. 231.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0332.jp2"}, "333": {"fulltext": "CONSTIPATION. 313\\nI\u00c2\u00a3 Fol. sennse,\\nHad. glycyrrhizae aa 10.0 (3 iiss,)\\nFruct. fa3niculi,\\nSulph. depur aa 5.0 3 ii)\\nSacch. alb 30.0 i.)\\nAloes is another very efficient and popular remedy. It\\neffects a movement of the bowels in about eight to twelve\\nhours after its ingestion and does not cause any griping.\\nI often give the following prescription\\nIt Aloes 1.0 (gr. xv.)\\nExtr. belladonnse,\\nExtr. stryclm aa 0.3 (gr. v.)\\nExtr. et pul v. glycyrrhizae q. s.\\nUt f. pil. No. xx. S. One pill twice daily.\\nOf the newer remedies podophyllin and cascara sagrada\\nare very valuable. Podophyllin is given in doses of one-\\nsixth to one-third of a grain twice a day. I use the fol-\\nlowing prescription:\\nPodophyllin 0.3 (gr. v.\\nExtr. physostigmatis,\\nExtr. nuc. vomic aa 0.5 (gr. viiss.)\\nM. f. cum extr. et pulv. glycyrrhizce q. s. pil. No. xxx. S. One pill\\ntwice daily.\\nCascara sagrada may be given in the form of fluid extract,\\nfifteen to twenty-five drops twice daily, or cascara sagrada\\nwith maltine, one teaspoonful once or twice daily.\\nSyrup of figs, one teaspoonful at night time, or tama-\\nrind, also one teaspoonful, is often of value.\\nJalap and colocynth belong to the stronger drastic rem-\\nedies, and hardly ever find a place in the treatment of the\\ncases under consideration. Hunyadi Janos water, Fried-\\nrichshaller, Homburger or Eakoczy waters, Apenta, Eu-\\nbinat and the like are also sometimes of benefit. They\\nshould, however, not be used for a long period of time in\\ncases of anaemia and neurasthenia.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0333.jp2"}, "334": {"fulltext": "CHAPTER XL\\nNEKVOUS AFFECTIONS OF ^HE INTESTINES.\\nMOTOR NEUROSES. Continued.\\nParalysis of the Intestines.\\nPartial paralysis of the intestines may occur and give\\nrise to symptoms resembling a complete occlusion of the\\nintestinal lumen. Paralysis arising in consequence of a\\nmechanical obstacle to the passage of the intestinal con-\\ntents has been described above. Here we shall deal with\\nprimary paralysis of the intestine without any organic ob-\\nstacle. In this condition the peristaltic motion of this\\norgan is absent. The passage of fecal matter is thereby\\ninterrupted and symptoms of obstruction result.\\nHenrot distinguishes three forms of intestinal paraly-\\nsis:\\n1. Direct paralysis of a portion of the intestine caused\\nby alterations of its walls. Thus an intestinal coil may\\nbecome paralyzed after repeated forced reposition of a\\nhernia or after it has been incarcerated in the hernial\\npouch for a long time. The paralysis may also occur as a\\nconsequence of a direct trauma or after extensive abdomi-\\nnal operations, and finally after various chronic inflamma-\\ntory and ulcerative processes of the intestine (enteritis,\\ntuberculosis, dysentery).\\n2. The paralysis is caused indirectly in consequence of\\n1 Henrot Des Pseudo-etranglements, Paris, 1865.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0334.jp2"}, "335": {"fulltext": "INTESTINAL PARALYSIS. 315\\na reflex nervous action. Thus contusion of the testicles,\\ninflammation of a hydrocele, abscesses of the abdomen may\\ninhibit the abdominal nerve centre in such a way that the\\nperistalsis ceases, although this is of very rare occurrence.\\n3. The intestinal paralysis may result from general neu-\\nroses (hysteria), from psychoses (melancholia, hypochon-\\ndria), or from affections of the central nervous system\\n(meningitis, brain tumors, tabes dorsalis, myelitis, etc.).\\nBesides these three groups, which are all of a more or\\nless acute character, Eosenheim also mentions paralysis of\\nthe intestines as a consequence of coprostasis due to atony\\nof this organ, which condition is less acute and more pro-\\ntracted. The patient, as a rule, has suffered from consti-\\npation for a long time. Evacuation of the bowels has been\\nartificially produced only after the appearance of many\\nannoying symptoms. At last the usual remedies refuse to\\nwork and the patient now becomes a chronic sufferer.\\nDyspepsia, intense meteorism, and palpitations of the\\nheart are present. The ingestion of food grows smaller\\nevery day and the patient becomes weaker. This condition\\nmay last for weeks and months, and if no radical remedies\\nare resorted to, the patient may ultimately be seized with\\nfecal vomiting and die of the intestinal paralysis.\\nAccording to Eosenheim, a sudden attack of serious in-\\ntestinal obstruction in a patient suffering from chronic\\nconstipation is, as a rule, not caused by paralysis of the\\nintestine, but rather by an occlusion of the intestinal lu-\\nmen through hardened fecal matter.\\nThe diagnosis of intestinal paralysis can be made if all\\nthe other numerous factors causing ileus can be excluded\\nand one of the above-mentioned etiological points can be\\ndiscovered.\\nThe treatment of these cases consists in the applica-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0335.jp2"}, "336": {"fulltext": "316 DISEASES OF THE INTESTINES.\\ntion of electricity (recto-abdominal galvanization), mas-\\nsage, and purgative high rectal injections. Cases in\\nwhich the paralysis is caused by chronic constipation must\\nbe treated by high injections of either ice water two hun-\\ndred to five hundred grams, or water with the addition of\\ntwo hundred to five hundred grams of oil. These injec-\\ntions should be applied twice or three times a day for sev-\\neral days in succession until a satisfactory result has been\\nobtained. Massage and electricity can be used in addition\\nto these injections. Internal purgatives, even croton oil,\\nare not efficacious in this class of cases. The use of mer-\\ncury, however, in doses of three hundred to eight hundred\\ngrams is here of great value. In cases in which the lower\\npart of the colon is the seat of the paralysis, the stagnant\\nfecal matter must be removed with the hand before the\\nrectal injection is resorted to.\\nProctospasmns, or Spasm of the Rectum.\\nThis condition consists in attacks of painful contraction\\nof the sphincters of the rectum and is in most instances\\na secondary affection. It is mostly found in inflammatory\\nand ulcerative processes of the rectum and colon, in fissure\\nof the anus, and also in inflammatory diseases of neighbor-\\ning organs, bladder, prostate, uterus.\\nSpasm of the rectum may, however, occur also indepen-\\ndently as a primary nervous affection. As such it is prin-\\ncipally met with in individuals with a nervous taint, and\\nin diseases of the spinal cord. The attacks of proctospas-\\nmus differ in intensity and also in duration. Sometimes\\nthey last only a short while, a few minutes, sometimes sev-\\neral hours or even days. In the milder form defecation is\\naccompanied by intense pains and takes place only after\\ngreat effort. In the severer forms there is a strong desire", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0336.jp2"}, "337": {"fulltext": "PARALYSIS OF THE SPHINCTERS. 317\\nfor defecation, but notwithstanding the most intense pains\\nand great straining there is no movement of the bowels.\\nIf these attacks last several hours they greatly weaken the\\npatient and render him very despondent. The anus is very\\nsensitive to touch, and a digital examination of the rectum\\nduring the spasm is hardly ever possible. A thorough\\nexamination of the rectum can be made only during anaes-\\nthesia. In instances of very severe proctospasmus a tran-\\nsient paresis or paralysis of the sphincter muscles may\\nresult.\\nThe diagnosis of proctospasmus is easy, as the symp-\\ntoms are very distinct. The diagnosis of the primary ner-\\nvous form will be made if organic diseases of the rectum\\nand of the neighboring organs can be excluded.\\nThe treatment must be directed principally toward the\\nprimary affection. In cases of nervous proctospasmus the\\ntreatment should be symptomatic and consist in the use\\nof narcotic remedies. In severe forms of this malady hy-\\npodermic injections of morphine must be resorted to. In\\nsome instances a forcible divulsion of the sphincter under\\nchloroform narcosis may become necessary.\\nParesis and Paralysis of the Sphincters of the Anus.\\nParalysis of the anal sphincters occurs frequently in con-\\nsequence of long-lasting affections of the rectum. Some-\\ntimes over-exertion of these muscles (tenesmus) ultimately\\nleads to exhaustion. Occasionally ulcerations and infiltra-\\ntions of the rectum iuvolve also the sphincters or entirely\\ndestroy them, thus annulling their functions. The tonicitj\\nof the sphincter muscles may be impaired in persons who\\nhave suffered for a long time from an accumulation of\\nfecal matter in the lower portions of the bowel. The mus-\\ncular apparatus being over-irritated for a long time becomes", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0337.jp2"}, "338": {"fulltext": "318 DISEASES OF THE INTESTINES.\\nweakened and exhausted. Diseases of the brain and spi-\\nnal cord, leading to inhibition of the will power, may like-\\nwise cause paralysis of the sphincters.\\nAtony, paresis, and paralysis form different degrees\\nof this affection. Some patients are not able to keep the\\nrectum tightly closed, and a small amount of secretion con-\\ntinually penetrates through the anus. After defecation\\nthey have the sensation of not having finished the act.\\nSometimes there may be an involuntary movement of the\\nbowels in consequence of the loss of the contractile power.\\nThis, however, occurs only after strong excitement, intense\\nbodily exertion, during urination, and rarely in walking.\\nIn case the paralysis of the sphincters is complete, flatus\\nand fecal matter will escape involuntarily even in a state of\\nrest. In paralysis resulting from proctitis, hemorrhoids,\\nstricture, etc., there is a continuous dripping of a muco-\\nsanguinary secretion which greatly irritates the skin sur-\\nrounding the anus.\\nDiagnosis. Paralysis of the anal sphincter can be recog-\\nnized very easily. The anus appears patulous and the\\nanal folds have disappeared. Two and even three fingers\\nmay be introduced into the rectum without encountering\\nany resistance. In making the diagnosis of a purely ner-\\nvous paralysis anatomical lesions must first be excluded.\\nThis is done by means of a thorough examination of the\\nrectum with a speculum.\\nPrognosis. Paralysis resulting from anatomical lesions\\nof the rectum gives an unfavorable prognosis In the purely\\nneurotic form, however, the prognosis is much better.\\nTreatment. It is of great importance to secure a thor-\\nough evacuation of the bowels, which is best done by rec-\\ntal injections of water twice daily. Paralysis due to fecal\\nimpaction as such, can be entirely remedied by the just", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0338.jp2"}, "339": {"fulltext": "PERISTALTIC RESTLESSNESS. 319\\nmentioned measures alone. Thus Wallace reports a cure\\nin a case of a nine-year-old boy who was troubled for\\nthree years with incontinency of freces, which dropped out\\nwhenever he walked. The patient was treated with water\\nenemas to which castor oil had been added, and later on\\nwith injections of water with the addition of alum. After\\na month s treatment he entirely recovered.\\nIn paralysis due to affections of the central nervous sys-\\ntem electricity and massage may be of benefit. Hypoder-\\nmic injections of strychnine (0.001 to 0.0015 pro dose)\\ninto the anal folds have been recommended by Kosen-\\nheim. Cases in which the paresis of the sphincter is due\\nto a difficulty in urination and a continuous straining in\\norder to void the bladder, the paresis will be improved by\\nartificially emptying the bladder by means of a catheter for\\na considerable length of time.\\nPeristaltic Restlessness of the Intestines.\\nDefinition. Increased peristaltic motions of the intes-\\ntines in such a way that they become visible through the\\nabdominal walls.\\nEtiology and Symptomatology. While in the normal\\nstate intestinal peristalsis is accomplished without being\\nvisible or making itself felt, in pathological conditions\\nincreased peristalsis may exist which can be easily per-\\nceived through the abdominal walls and which is usually\\naccompanied by distinct noises (borborygmi). Increased\\nintestinal peristalsis may accompany any complete or in-\\ncomplete occlusion of the intestinal lumen or it may be\\ncaused by purely neurotic influences. Here only the lat-\\nter form is dealt with, as the former condition is discussed\\nin connection with the organic lesions causing it.\\n1 Wallace St. Barthol. Hosp. Report, 1888.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0339.jp2"}, "340": {"fulltext": "320 DISEASES OF THE INTESTINES.\\nUsually peristaltic restlessness of the intestines occurs in\\nthe form of attacks, lasting several hours in succession and\\nreappearing after more or less long periods of time. In\\nsome instances the patients complain of various movements\\nand noises within the abdomen due to the increased intes-\\ntinal peristalsis, while pain is absent. In other instances\\nthe above sensations are now and then interspersed with\\nsevere colicky pains. The majority of cases of peristaltic\\nrestlessness of the intestines is accompanied rather by con-\\nstipation, seldom there are either normal evacuations or\\ndiarrhoea. In some instances the exaggerated peristaltic\\nmotions continue even after intestinal digestion has been\\ncompleted, and are accompanied by painful sensations.\\nPeristaltic restlessness of the intestines is occasionally as-\\nsociated with peristaltic restlessness of the stomach.\\nPeristaltic restlessness of the intestines is principally\\nmet with in nervous persons, in the hysterical and hypo-\\nchondriacal. Occasionally, however, it occurs in persons\\nwho do not present any other nervous symptoms. In\\nwomen this condition may exist during the monthly periods\\nor pregnancy. In some persons it appears after the inges-\\ntion of highly spiced or indigestible foods, after the exces-\\nsive use of tobacco, after great psychical excitement or too\\nmuch brain work. In other cases, however, none of these\\netiological factors can be discovered.\\nDiagnosis. The diagnosis of peristaltic restlessness of\\nthe intestines is made whenever pronounced intestinal mo-\\ntions are visible through the abdomen. The nervous char-\\nacter of this condition is recognized, first, after exclusion\\nof organic affections of the intestines secondly, by its pe-\\nriodic appearance.\\nThe prognosis is favorable.\\nTreatment. In the first place it is of importance to in-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0340.jp2"}, "341": {"fulltext": "METEORISM. 321\\nvigorate the entire organism and especially improve, the\\ncondition of the nervous system. With regard to diet\\nsufficient quantities of food should be given, but too spicy\\nand indigestible nourishment should be excluded. In\\ncases accompanied by some abnormality of the bowels\\ntheir function should be regulated. The bromides, valer-\\nian, and asafetida are of decided value. Drinking of warm\\nwater or tea and hot applications are useful during the\\nattack. Arsenic alone or in combination with iron is of\\nbenefit in cases combined with anaemia. If the condition\\nassumes a violent character and is accompanied by severe\\npains, a small dose of an opiate, alone or in combination\\nwith belladonna, is appropriate. If the intestinal restless-\\nness appears at night time and prevents the patient from\\nsleeping, chloral hydrate, sulphonal, or trional may be ad-\\nministered. Electricity and massage of the abdomen have\\nbeen variously recommended, but neither of the two ap-\\npears to me to be of great value in this condition. Change\\nof climate and surroundings is often of benefit.\\n31eteorism.\\nMeteorism, tympanites, or flatulency signifies a condi-\\ntion in which there is an excessive accumulation of gas\\nin the intestinal tract.\\nIf not caused by an organic obstruction in the bowel this\\ncondition is due to an abnormal state of the intestinal mo-\\ntion and absorption. Owing to the first factor we describe\\nthis anomaly under motor neuroses.\\nEtiology. The causes of the excessive accumulation of\\ngas are 1, an increased ingestion of gases themselves or\\nof substances which easily form them and 2, a diminu-\\ntion or impairment of their elimination from the intes-\\ntines. The increased introduction of gases mav consist in\\n21", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0341.jp2"}, "342": {"fulltext": "322 DISEASES OF THE INTESTINES.\\nswallowing of air or in drinking beverages highly charged\\nwith carbonic-acid gas. In both instances the gases prin-\\ncipally accumulate in the stomach, although a portion of\\nthem reaches the intestines.\\nIncreased formation of gas within the intestine is the\\nconsequence 1, of various processes of fermentation and\\ndisintegration of carbohydrates and fats, hydrogen and\\ncarbon dioxide being the principal gases 2, of the decom-\\nposition of proteids which produce besides the gases just\\nmentioned sulphuretted hydrogen, carburetted hydrogen,\\nand methyl mercaptan. The increased formation of gas is\\nmostly due to an increased ingestion of easily fermenting\\nfood.\\nA diminished elimination of the gases may be due 1,\\nto an inhibition of the passage of the flatus; and 2, to re-\\ntarded absorption. The passage of flatus is inhibited either\\nby an intestinal obstruction or occlusion, or by a paresis\\nor paralysis of the intestinal muscles. The latter condi-\\ntion is found in peritonitis and in grave infectious diseases,\\nafter shock, in severe anaemia, in spinal affections, and\\nalso in general neuroses. Most cases of meteorism, which\\nquickly appears and just as quickly leaves the patient, are\\ndue to paresis of the intestinal walls and are usually asso-\\nciated with a large number of other nervous symptoms.\\nSymptomatology. A certain degree of tension about the\\nabdomen, more or less pronounced, is almost always expe-\\nrienced by the patient. In some instances the abdomen\\nprotrudes in balloon-shape, the region of the navel being\\nprincipally involved. This picture is mostly met with in\\npatients with relaxed abdominal walls. In cases in which\\nthe latter are tense the accumulation of gases may push\\nthe diaphragm upward. Sometimes the lungs and heart\\nare forced upward and severe dyspnoea develops, which", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0342.jp2"}, "343": {"fulltext": "METEORISM. 323\\nin rare Instances may be followed by asphyxia, collapse,\\nand even death. There is a constant feeling of press-\\nure and a desire to pass wind, while colicky pains are\\nalso occasionally met with. As a rule no flatus can be\\npassed or very inconsiderable amounts at long intervals.\\nDiffering from the form of meteorism just described are\\nthose cases in which there is a slight tension over the abdo-\\nmen and wind is passed from the anus almost constantly\\nfor a long time with much noise. It is highly improbable\\nthat the gases emitted in this variety of cases are really\\nproduced in the intestinal tract for the following reasons\\n1, there is no considerable change in the size of the abdo-\\nmen after a repeated passage of considerable amounts of\\ngas from the anus 2, the absence of relief felt by the pa-\\ntient after the passage of flatus and 3, the almost odorless\\ncharacter of these gases. Eosenheim compares these cases\\nwith those of nervous eructation from the stomach. While\\nin the latter the air is constantly swallowed by the patient\\nand belched up again, in the intestinal variety Eosenheim\\nassumes that the air is constantly pumped into the rectum\\nin order to be again emitted as flatus.\\nThe diagnosis of meteorism is made whenever an exces-\\nsive amount of gas is discovered in the intestines.\\nThe prognosis will depend upon the cause which creates\\nthe tympanites. If it be due to organic lesions of the\\nintestines (occlusion of the lumen) the prognosis is very\\ngrave, while meteorism due to a purely nervous disturb-\\nance gives a favorable outlook.\\nTreatment. In instituting a curative plan for this affec-\\ntion it will be necessary to elucidate the etiological factor\\nof the meteorism. If the latter is caused by an obstruc-\\ntion of the bowel, this primary affection will have to be\\ntreated as such. In most instances of meteorism of neu-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0343.jp2"}, "344": {"fulltext": "324 DISEASES OF THE INTESTINES.\\nrotic origin the following points are of importance Drinks\\nand foods containing or forming a large amount of gas\\nshould be prohibited; thus all carbonated waters, beer,\\nchampagne, and cider should be avoided. Fresh fruits, all\\nkinds of cabbage, leguminous foods, potatoes, coarse rye\\nbread, sweetened cake, rich gravies should be carefully ab-\\nstained from. These rules apply not only when the mete-\\norism is fully developed but in patients with a disposition\\nto flatulency.\\nFormerly numerous intestinal antiseptics were given\\nwith the object of lessening the fermentative processes\\nin the bowels. Eecently, however, the general view pre-\\nvails that they are of no benefit whatever. Benzonaphthol,\\nsalol, and salicylate of sodium are still regarded as the most\\nefficient in this respect and may be tried in suitable cases.\\nThey can perhaps be advantageously administered in\\nSahli s 1 glutoid capsules in order to prevent their ab-\\nsorption in the stomach. Calcined magnesia, lime water,\\ncharcoal, testa prseparata, and subnitrate of bismuth are\\ngiven with the intention of absorbing the gas, although\\ntheir actual effect in this respect can naturally be only\\nvery limited.\\nThe following drugs are believed to have a beneficial\\ninfluence in diminishing the gas, especially in mild forms\\nof flatulency poppy-seed, peppermint, spearmint, thyme,\\ncinnamon, cloves, nutmeg, anise, fennel. These are best\\ngiven in infusions. It has not as yet been scientifically\\nproven whether the reaction following their administra-\\ntion is due to a slight increase of the intestinal peristalsis.\\nBrunton and Cash 2 are of the opinion that the carmin-\\natives, such as asafetida and oil of cloves, have a distinct\\n1 Sahli Deutsche med. Wochenschr. 1897, No. 1.\\n2 Brunton and Cash St. Barthol. Hosp. Report, 1887.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0344.jp2"}, "345": {"fulltext": "METEORISM. 325\\neffect upon the absorption of several gases (carbonic-acid\\ngas and sulphuretted hydrogen).\\nThe removal of the gas per vias naturales through the\\nanus is the most efficient therapeutic measure. This can\\nbe done through cathartic remedies whenever there is no\\ncontraindication against their use. Large cleansing ene-\\nmas of water, with the addition of a teaspoonful of essence\\nof peppermint or oil of turpentine emulsified with an egg\\nto a quart, are of benefit.\\nWhen there are no anatomical lesions, massage of the\\nabdomen and faradization may be of advantage. This\\nalso applies to friction of the abdomen with a. cloth dipped\\nin some alcoholic solutions of aromatics or ethereal oils\\n(linimentum saponis, oleum carvi, cajuputi, terebinthinae,\\netc.). The introduction of a tube into the rectum maybe\\nhelpful in favoring the escape of gas from the lower parts\\nof the colon. In desperate cases in which the meteorism\\nhas reached such dimensions as to endanger life, punc-\\nture of the intestine through the abdomen with the trocar\\nhas to be resorted to. The meteorism of hysterical per-\\nsons often requires no treatment, as it usually disappears\\nof itself. Sometimes, however, it is very obstinate to all\\ntherapeutic measures.\\nSENSORY NEUROSES OF THE INTESTINES.\\nWhile normally no sensations originate in the intestinal\\ncanal which become perceptible even during digestion, in\\npathological conditions this organ may be the seat of the\\nmost painful feelings. The latter originate in the fibres of\\nthe sympathetic nerve. Most of the sensory neuroses of\\nthe intestine consist in an increased excitability of the sen-\\nsory filaments of these nerves. There are tj however, a few", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0345.jp2"}, "346": {"fulltext": "326 DISEASES OF THE INTESTINES.\\nconditions in which a lessened sensibility exists. The\\nlatter relates principally to the sensory nerves of the rec-\\ntum. Normally the entrance of fecal matter into the rec-\\ntum mechanical^ irritates these nerves and creates a desire\\nfor an evacuation, while a lessened irritability of the rectal\\nnerves may fail to produce the above sensation.\\nEnteralgia.\\nSynonyms. Intestinal colic. Neuralgia mesenterica.\\nDefinition. Pains in the intestines.\\nEtiology. Enteralgia is present in most organic lesions\\nof the intestines. Enteralgia of purely neurotic origin,\\nhowever, which is considered in this chapter, occurs inde-\\npently of any anatomical lesions of the intestinal walls.\\nSometimes abnormally strong stimuli may be evolved\\nwithin the intestinal canal, producing painful sensations.\\nThese stimuli may be of a mechanical, chemical, or ther-\\nmal character. Thus, a conglomeration of intestinal\\nworms, foreign bodies, gall stones, or enteroliths may pro-\\nduce intense colic. Sometimes hardened fecal masses\\npress upon the sensory nerves. The intestinal lumen\\nbeing temporarily occluded by these masses, gases collect\\nabove this space and increase the tension within the intes-\\ntinal canal, thus giving rise to intense pain (wind colic,\\ncolica flatulans, which is quite often seen in children).\\nSometimes the ingestion of very coarse foods, indigestible\\nsubstances, tainted foods, too cold beverages, highly fer-\\nmented drinks cause enteralgia. In the gouty diathesis it\\nmay precede a gouty attack or replace it. Similar to these\\nconditions in which the enteralgia takes its origin from\\ntoxic substances contained in the blood and irritating the\\nintestinal nerves, is also the intestinal colic met with in\\nchronic intoxication from lead or copper.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0346.jp2"}, "347": {"fulltext": "ENTERALGIA. 327\\nAside from these forms of enteralgia due to a certain\\ndiscoverable irritating factor, it may also result from a\\nperverted state of the sensory intestinal nerves themselves.\\nThe latter group is principally found in patients affected\\nwith hysteria, or spinal troubles, although it may also be\\nof a reflex nature due to abnormal conditions of neighbor-\\ning organs, kidneys, bladder, uterus, ovaries, and liver.\\nSymptomatology. The symptomatology of enteralgia\\npresents quite a varied picture, in many instances depend-\\ning upon the cause of the enteralgia. If the neuralgia\\nmesenterica is due to an error in diet, it usually begins\\nwith gastric disturbances, belching, nausea, vomiting, and\\nanorexia. In cases in which an accumulation of fecal mat-\\nter produces the enteralgia, obstinate constipation and flat-\\nulence, occasionally alternating with diarrhoea, precede the\\nattack. In chronic lead poisoning there are present a\\nbluish line around the gums near the teeth, retarded pulse,\\nand oliguria.\\nThe principal symptom of neuralgia mesenterica is pain\\nwithin the intestine. It seldom appears suddenly and with\\ngreat violence. As a rule, the pains are at first of light\\ncharacter and gradually increase in intensity. They are\\nof a cutting, throbbing, or pinching nature, and are ex-\\nperienced usually in one and the same abdominal area,\\nmost often in the region of the navel. Starting from this\\nspot they radiate toward the back, the loins, the thighs,\\nand the testicles. In some cases the pain wanders from\\none area to another and may be felt at different times in\\nthe most varied regions of the abdomen. In the latter\\ninstances the pains are accompanied by a visible peristaltic\\nrestlessness of the intestine, often producing gurgling\\nnoises.\\nIn mild cases the pain is quite endurable, and often lasts", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0347.jp2"}, "348": {"fulltext": "328 DISEASES OF THE INTESTINES.\\nbut a short while. In severer forms of enter algia, how-\\never, the pains may be of extreme violence, and in weak\\npatients may produce syncope, while in the more robust\\nthey may give rise to attacks of panting and crying. The\\nface grows pale and assumes an expression of intense suf-\\nfering. The forehead is covered with cold perspiration\\nand the extremities are cold. The entire picture resem-\\nbles very much that of shock.\\nPressure in many instances slightly alleviates the pain,\\nand for this reason the patients often press their hand or\\nsome other hard substance against their abdomen. For\\nthe same reason they are often found lying on their abdo-\\nmen, pressing the latter against the mattress. In cases,\\nhowever, in which the intestinal tract is filled with gas\\nand the abdomen therefore in a tense condition, even very\\nslight pressure increases the pains. Under these circum-\\nstances a suspicion of peritonitis often arises. Ultimately\\nthe pains gradually decrease, and disappear much quicker\\nif the accumulated fecal masses and gases have been evacu-\\nated spontaneously or by means of injections. The attack\\nis then over.\\nSpastic contractions of the intestine are often encoun-\\ntered, especially when the pains are of intense character.\\nIf these contractions involve a large part of the intestine,\\nas is often the case in lead colic, the abdomen appears\\ntrough-shaped. The abdominal walls are quite tense and\\noften very rigid. In case the spasms are limited to iso-\\nlated intestinal coils, the abdomen is not drawn in and at\\nsome places where there are intestinal coils overfilled with\\nfecal matter and gas, may asymmetrically protrude. In\\nstercoral and wind colic the abdomen usually is tympanitic.\\nConstipation is almost always present. Frequently\\nthere is also a retention of the intestinal gases. If the lat-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0348.jp2"}, "349": {"fulltext": "ENTERALGIA. 329\\nter are passed in considerable quantity, the pains often\\nsubside for a short while, or, in some instances, especially\\nin the so-called wind colic, entirely disappear.\\nThe intensity and the duration of the attack are subject to\\ngreat variations. It may last from a few hours to several\\ndays. The pains are sometimes but very slight, and again\\nof such violence that even large doses of opium are hardly\\neffective.\\nAside from the above-mentioned symptoms there exist\\nquite often shortness of breath, palpitations of the heart, a\\nsensation of oppression, tenesmus, strangury, hiccough,\\nvomiting, seldom pollutions and priapism. Occasionally\\ncramps of the calves and even general convulsions are ob-\\nserved. In cases of hysteria hyperesthesia of the abdomi-\\nnal walls is encountered.\\nDiagnosis. Enteralgia is easily recognized when it pre-\\nsents the above-described characteristic picture. Its neu-\\nrotic nature, however, will be inferred from the following\\nfeatures: It appears in attacks, and subsides suddenly.\\nThere are almost always other nervous symptoms present.\\nIn enteralgia due to anatomical lesions of the intestine the\\npain is, as a rule, increased by pressure upon the abdomi-\\nnal walls. Another distinguishing mark for the latter is\\nthat it is more often accompanied by diarrhoea, and that\\nthe dejecta contain pathological admixtures (blood, mucus,\\nrarely pus).\\nWith regard to the differential diagnosis the following\\nconditions which are accompanied by abdominal pains will\\nhave to be excluded Rheumatic affections of the abdomi-\\nnal muscles, lumbar abdominal neuralgia, hyperesthesia\\nof the abdominal walls, peritonitis, biliary and renal colic.\\nRheumatism of the abdominal muscles is characterized\\nby the following features The pain is situated over the", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0349.jp2"}, "350": {"fulltext": "330 DISEASES OF THE INTESTINES.\\nsuperficial area and not within the abdominal cavity. It\\noften changes its seat. It is of longer duration than enter-\\nalgia and does not show any distinct exacerbations nor\\ndiffusion. Pressure increases the pain, while rest in a re-\\ncumbent position eases it. Anti-rheumatic remedies (salol,\\nsodium salicylate, salipyrin) subdue it.\\nIn lumbar abdominal neuralgia the pain is localized on\\nthe surface and limited to one intercostal space which is\\nvery painful to pressure. The pains often radiate to the\\nback, the hypogastrium, and the genital organs. Anti-\\nneuralgic remedies (antipyrin, antifebrin, phenacetin) are\\noften efficient.\\nHyperesthesia of the abdominal wall is, as a rule, met\\nwith in hysteria and neurasthenia. The pains are local-\\nized in the superficial layer. The slightest touch of the\\nskin of the abdomen increases the pain. The faradic cur-\\nrent often quickly removes it.\\nIn peritonitis there is almost always fever, and the pain\\nis increased on pressure. Meteorism is here much more\\nfrequently encountered than in intestinal colic. Frequently\\ndulness in the lower part of the abdomen (exudation) is\\nobserved.\\nBiliary and renal colic are recognized by the situation\\nof the pain which often corresponds to the location of the\\naffected organ. Besides, other symptoms are usually pres-\\nent which are characteristic of the latter (icterus, strangury).\\nPrognosis. The prognosis of intestinal colic is almost\\nalways good with regard to life, for the attack usually ends\\nin recovery. Exceptional cases of death have, however,\\nbeen observed by Oppolzer 1 and Wertheimer. 2\\nTreatment The treatment consists, first, in measures\\n1 Oppolzer: Wiener med. Wochenschr. 1867.\\n2 Wertheimer Deutsches Arch. f. klin. Medicin, 1866, Bd. 1.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0350.jp2"}, "351": {"fulltext": "ENTERALGIA. 331\\ndirected toward the removal of the cause, and secondly,\\ntoward the relief of the pain. In most cases of intestinal\\ncolic a thorough evacuation of the bowels is of benefit.\\nFor this purpose injections of a considerable quantity of\\nwater (one to two quarts) or of olive oil (one-half to one\\npint) are very serviceable. Mild cathartic remedies, cas-\\ntor-oil, calomel, and the like, may also be administered.\\nIn cases in which worms have been found a vermifuge must\\nbe given with the cathartic. If meteorism is quite pro-\\nnounced massage of the abdomen may be tried. If the\\ncolic is due to an error in diet, the latter must be strictly\\nregulated. If due to a general cold, hot beverages (tea,\\ninfusions of camomile and of peppermint), hot poultices\\nover the abdomen are of value.\\nIn nervous enteralgia occurring in patients suffering from\\nhysteria and neurasthenia the treatment should be directed\\ntoward the improvement of the latter conditions. Climate,\\nelectricity, massage, and hydrotherapy play a predominant\\npart here.\\nThe following symptomatic measures which serve to\\nsubdue the pains are of great importance If the colicky\\npains are quite severe, the administration of an efficient\\ndose of an opiate is indicated. Tincture of opium may be\\ngiven in doses of fifteen or twenty drops, or opium ex-\\ntract, 0.03 to 0.05; or morphine, 0.01 to 0.015, may be in-\\njected subcutaneously Even in cases in which the colic\\nis due to a retention of fecal matter, the narcotics just\\nmentioned are indicated, for they relieve the spastic con-\\ntractions of the intestines.\\nDuring a severe attack of intestinal colic the diet should\\nconsist principally of liquids, small quantities of milk and\\nbroth being given at frequent intervals (about every two\\nhours) If the attacks recur quite often, the application", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0351.jp2"}, "352": {"fulltext": "332 DISEASES OF THE INTESTINES.\\nof the galvanic current (one electrode within the rectum,\\nnegative pole, the other over the abdomen) is sometimes\\nof benefit.\\nHypogastric Neuralgia.\\n(Neuralgia hypogastrica, Eomberg. 1\\nEnteralgia limited to the lower portion of the large\\nbowel is termed hypogastric neuralgia. In this condition\\nthere exist disagreeable, sometimes painful sensations in\\nthe lower region of the abdomen and in the lower parts of\\nthe back, accompanied by a violent feeling of pressure in\\nthe rectum and sometimes also in the bladder. In female\\npatients the same sensation may also extend to the uterus\\nand vagina. Sometimes- the patient also complains of\\npainful sensations in the perineum and the thighs. Per-\\nsons suffering from hemorrhoids and women afflicted with\\nnervous and uterine troubles are principally liable to suffer\\nfrom this condition. This form of neuralgia is also fre-\\nquently found in diabetic patients. Sometimes the pa-\\ntients have the sensation as if a foreign body were in the\\nrectum.\\nThe treatment resembles very much that of intestinal\\ncolic. The original trouble predisposing to hypogastric\\nneuralgia should always be first treated. If congested\\npiles are present, application of leeches about the anus\\nand warm sftz baths must be recommended. If the pains\\nare violent, suppositories of opium alone or with bella-\\ndonna should be used. The diet should be a bland one\\nand the bowels should be carefully regulated.\\n1 Romberg Lehrbuch der Nervenkrankheiten, Berlin.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0352.jp2"}, "353": {"fulltext": "HYPERESTHESIA. 333\\nHyper wsthesia, Paresthesia, and Ancesthesia of the\\nIntestine.\\nWhile in the normal state no disagreeable sensations are\\nmanifested during the act of intestinal digestion and defe-\\ncation, in some cases of neurasthenia or hysteria we meet\\nwith exceptions to this rule. Thus, even without apparent\\nanatomical lesions of the intestine, there may be a sensa-\\ntion of pressure, fulness, of pinching, of heat or cold in the\\nlower region of the abdomen a few hours after the inges-\\ntion of food. The same sensations may also occasionally\\nappear without the patient having eaten anything, after\\nbodily exertion and excitements, especially after sexual\\nintercourse.\\nThe rectum and the anus are particularly liable to be\\nthe seat of abnormal sensations. Physiologically a feel-\\ning of fulness is experienced in the rectum when the fecal\\nmass has accumulated in this locality. In case of neuras-\\nthenia a sensation of fulness with an inclination to go to\\nstool may appear, even when the rectum is entirely empty.\\nSometimes a feeling of pressure or weakness in the anal\\nregion may be present; sometimes the patient may be\\ntormented by a constant burning or itching in the same\\nregion. The act of defecation may be accompanied by\\nerections, sometimes by a feeling of uneasiness; quite\\noften a feeling of extreme fatigue after defecation is ex-\\nperienced.\\nAncesthesia of the rectum is observed in the same class of\\npatients. The sensation of fulness in the rectum, which\\ncauses the desire for defecation, is then absent there is,\\ntherefore, never a desire for evacuation. In very pronounced\\ncases of rectal anaesthesia it may occur that even the pas-\\nsage of fecal matter through the anus is not felt. Such a", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0353.jp2"}, "354": {"fulltext": "334 DISEASES OF THE INTESTINES.\\nhigh, degree of anaesthesia, however, is met with only in pa-\\ntients with spinal and brain troubles and in very old and\\ndecrepit individuals. Paralysis of the sphincters, which\\nhas been described above, may occasionally accompany\\nthe anaesthesia of the rectum and thus aggravate the latter.\\nIn suc}i instances involuntary evacuations of the bowels\\ntake place without the patient s knowledge. He becomes\\naware of this fact only after his clothes have been soiled\\nand by the fecal odor.\\nIn the treatment of these abnormal sensations within the\\nintestines attention must be directed toward the improve-\\nFig. 37.\u00e2\u0080\u0094 Rectal Obturator.\\nment of the general condition, thus raising the nervous\\ntone of the organism. Hydro therapeutic measures and\\nclimatic influences are of the greatest importance. While\\ndietetic measures as such are without much influence upon\\nthe nervous disturbances which appear during the intesti-\\nnal digestion, spicy food and alcoholic beverages should,\\nnotwithstanding, be forbidden and an essentially vege-\\ntarian regimen recommended. The abnormal sensations\\nwithin the rectum and anus may be improved by cooling\\nrectal douches, by sitz baths, and also by rectal galvani-\\nzation.\\nIn cases of anaesthesia of the rectum a cleansing enema\\nin the morning will remove the fecal matter and thus be\\nbeneficial during the day. Patients suffering from the", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0354.jp2"}, "355": {"fulltext": "MEMBRANOUS ENTERITIS. 335\\nseverer forms of anaesthesia should wear a rectal obturator\\nheld in place by means of a T-bandage during the day\\n(Fig. 37).\\nSECRETORY NEUROSES OF THE INTESTINES.\\nAlthough there is no doubt that secretory nerves exist in\\nthe intestines for it has been shown that the entrance of\\nfood into the stomach is immediately followed by secre-\\ntion not only in the small intestine but also in distant\\nparts of the large bowel still we are y et very far from the\\nknowledge of their exact location. Nervous diarrhoea,\\nwhich has been described under the motor neuroses, is\\noften accompanied also by an increased flow of intestinal\\njuice. Conditions in which there is a lessened secretion\\nof intestinal juice are not yet positively known. It may\\nbe that they exist in cases of constipation, being perhaps\\nthe cause of the latter in some instances. While, however,\\nin the disturbances just mentioned the increase or decrease\\nof intestinal secretion is a mere hypothesis, one affection\\nof the intestines exists in which increased secretion is posi-\\ntively found. This is the so-called membranous enteritis.\\nMembranous Enteritis.\\nSynonyms. Mucous Colic; Tubular Diarrhoea; Mem-\\nbranous Diarrhoea.\\nDefinition. By membranous enteritis is understood an\\naffection in which more or less large pieces of mucus (usu-\\nally ribbon-like) are passed periodically with the faeces.\\nHistory. This affection seems to have been familiar to\\nthe medical world for several centuries. Paulus iEgineta, 1\\nin speaking of the passage of the inner membrane of the\\n1 Paulus iEgineta Cited from Da Costa, American Journal of the\\nMedical Sciences, 1871, p. 321.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0355.jp2"}, "356": {"fulltext": "336 DISEASES OF THE INTESTINES.\\nintestine, has certainly dealt with cases of membranous\\nenteritis, and erred only in the explanation of these\\nmasses.\\nSennertius and Morgagni recognized these membranes\\nas mucus, which had been inspissated and moulded in the\\nintestine.\\nMason Goocj 2 was the first to describe this affection un-\\nder the name of tubular diarrhoea, which name has also\\nbeen accepted by Woodward. 3 The latter author adds that\\nin case the membranes in a given instance have- no tubu-\\nlar form, the expression membranous diarrhoea is suit-\\nable.\\nF. Siredey 4 contributed a very valuable paper in 1869\\nin reference to the knowledge of this affection. He de-\\nscribed one case of mucous discharge in a man and six\\ncases in women, and arrived at the conclusion that in some\\ninstances these mucous discharges occur in patients whose\\nintestinal tract does not reveal any organic lesion whatever.\\nFor this reason Siredey regards this affection as an in-\\ntestinal neurosis, occurring principally in hypochondriacs\\nand hysterics.\\nWhitehead 5 describes this affection under the name of\\nmucous disease, cites the entire old literature, and gives\\ndetailed rules with regard to treatment and diet. He\\nsays: Exercise, short of fatigue, should be taken daily.\\n1 Sennertius and Morgagni Cited from J. G. Woodward, The\\nMedical and Surgical History of the War of the Rebellion, 1879, part\\nii., vol. i., p. 363.\\n2 Mason Good: The Study of Medicine, cl. 1, ord. 1, species 7,\\nvol. i., Philadelphia, 1825, p. 162.\\n3 Woodward Loc. cit.\\n4 Siredey, F. Note pour servir a 1 etude des concretions muqueuses\\nmembraniformes de l intestin. Union med., Nos. 7-9, 1869.\\n5 Whitehead, W. Mucous Disease. British Medical Journal,\\nFebruary 11, 1871, p. 140.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0356.jp2"}, "357": {"fulltext": "MEMBRANOUS ENTERITIS. 337\\nThe diet is perhaps the point of all others where the great-\\nest mistake is made. An idea, strongly felt by the patient,\\nthat a great amount of strengthening food is required,\\nleads to the further exhaustion of an already enfeebled\\ndigestion. Impress upon the patients the fact that it is\\nthe quantity absorbed which means strength, and not the\\nbulk swallowed, and it is possible to check the error they\\nare so anxious to commit. Certain articles of diet should\\nbe strictly interdicted, the chief of which are the follow-\\ning Liquid food, excepting milk, aggravates in the major-\\nity of cases every symptom; sugar is invariably hurtful;\\ntea, coffee, and alcohol Burgundy being the only wine\\nfrom which I have ever derived benefit vegetables, and\\nfruit also prove injurious.\\nCruveilhier f and Laboulbene a discuss this ailment under\\nthe term pseudo-membranous enteritis.\\nOne of the best papers upon this disease was written by\\nDa Costa, 3 who called it membranous enteritis. This\\nauthor gave a full description of this affection, recognized\\nits nervous character, furnished several detailed cases, and\\nput particular stress upon dietetic treatment. Da Costa\\npermits eggs, milk, bread, and solid food, which is better\\nborne than liquids; tea, coffee, and alcoholic stimulants\\nare to be permitted only in very small quantities. As re-\\ngards vegetables, we must observe whether they pass un-\\nchanged in the stools. Fresh meat juice is serviceable;\\nfrom an exclusive milk diet, even faithfully carried out, he\\nhas seen no good. Furthermore, Da Costa recommends\\nthat great attention be paid to the action of the skin, and\\n1 Cruveilhier: Anat. path, gen., t. ii.\\n2 Laboulbene Recherches sur les affections pseudomembraneuses,\\n1861.\\n3 J. M. Da Costa Membranous Enteritis. American Journal of\\nthe Medical Sciences, 1871, p. 321.\\n22", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0357.jp2"}, "358": {"fulltext": "338 DISEASES OF THE INTESTINES.\\nbelieves baths followed by systematic friction to be very\\nuseful. Daily moderate exercise is advocated, particularly\\nin cool weather, and if possible an occasional trip to the\\nmountains and living out of doors in the bracing mountain\\nair. Everything that can be done to invigorate the diges-\\ntive and nervous systems forms the essential part of the\\ntherapeutics.\\nA few years later there appeared an article by Edwards, 1\\nwho coincided with Da Costa s views in most points,\\nbeing, however, much stricter with regard to diet. He\\nsays: Easily digested or even predigested food should\\nbe supplied, and care should be taken that undigested\\nparticles of food are not irritating the intestinal canal.\\nLey den, 2 in 1882, directed attention to membranous en-\\nteritis in Germany, where also very soon appeared ex-\\nhaustive publications on this subject. Nothnagel 3 sug-\\ngested the name colica mucosa, in order to show that\\na true enteritis need not exist in these cases and that the\\ndisease really is a mucous colic. Eothmann 4 was the first\\nto publish a case of membranous enteritis complicated\\nwith cancer of the skull in which an autopsy was made.\\nBy means of Weigert s stain, or rather by Ehrlich-Hoy-\\ner s thionin (a specific stain for mucus), double-stained\\nspecimens could be obtained, which showed the presence\\nof large quantities of mucus on the surface of the large\\nbowel in the glandular tubules.\\n1 Edwards American Journal of the Medical Sciences, April, 1888,\\np. 329.\\n2 E. Leyden Verhandl. d. Vereins f. innere Medicin in Berlin,\\nDeutsche med. Wochenschr., 1882, Nos. 16 and 17.\\n3 Nothnagel Colica mucosa. Beitrage zur Physiologie und\\nPathologie des Darms, 12tes Capitel, 1884.\\n4 Max Rothmann Ueber Enteritis membranacea. Deutsche med.\\nWochenschr., 1893, p. 999.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0358.jp2"}, "359": {"fulltext": "MEMBRANOUS ENTERITIS. 339\\nEwald, 1 Boas, 2 Kittagawa, 3 Pariser, 4 and others have\\nadded further contributions.\\nEwald laid stress on a ptosis of the colon, Boas on atony\\nof this organ as important factors in this affection.\\nEtiology. Most authors agree that membranous enteritis\\nis quite a rare affection it occurs much more frequently\\nin women than in men (children being only exceptionally\\naffected).\\nThat the nervous element (hysteria, neurasthenia) plays\\na great role in the origin of this trouble, no one can doubt,\\nand W. Mendelson 5 is right when he asserts that neuras-\\nthenia is not absent in any of his cases. Mendelson goes\\ntoo far, however, when he says I believe that the reverse\\nof the proposition may also as confidently be affirmed\\nnamely, that if neurasthenic patients be closely questioned,\\nvery few will be found who have not had at some time re-\\npeated characteristic passages of stringy mucus, associated\\nwith abdominal pains. Membranous enteritis is found\\nin nervous individuals (possibly the affection as such adds\\nmuch to their neurasthenia) but only a small fraction of the\\ngreat mass of neurasthenics is afflicted with this ailment.\\nWith regard to the frequency of membranous enteritis,\\n1 examined my private patients of the year 1897 relative\\nto its presence, and take the following data from my day-\\nbook. The total number of patients was 1,315 772 men,\\n543 women. Twenty of these patients suffered from mem-\\n1 C. A. Ewald: Membranous or Mucous Enteritis. Twentieth\\nCentury Practice of Medicine, vol. ix. p. 265.\\n2 J. Boas Deutsche med. Wochenschr. 1893, No. 41.\\n3 O. Kittagawa: Beitrage zur Kenntniss der Enteritis membrana-\\ncea. Zeitschr. f. klin. Medicin, 1891.\\n4 Pariser Deutsche med. Wochenschr., 1893, No. 41.\\n5 Walter Mendelson: Mucous Colitis a Functional Neurosis.\\nMedical Record, January 30, 1897.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0359.jp2"}, "360": {"fulltext": "340 DISEASES OF THE INTESTINES.\\nbranous enteritis two men and eighteen women. The\\nfrequency of membranous enteritis among sufferers from\\ndigestive disorders expressed in percentages is, in men,\\n0.25 per cent; and in women, 3.31 per cent. Among these\\ntwenty patients, twelve had enteroptosis in a pronounced\\ndegree. Ewald has already pointed out that a prolapse\\nof the colon is frequently found in patients with mem-\\nbranous enteritis. My own observations fully confirm this\\nstatement, for with the prolapse of the stomacli descent of\\nthe colon naturally must be presupposed. It appears that\\nenteroptosis certainly creates a fruitful soil for the devel-\\nopment of membranous enteritis, although it does not di-\\nrectly cause it. Enteroptosis is, as is well known, very\\nfrequent, while membranous enteritis is rare in compari-\\nson with the former. There must, therefore, be still other\\nfactors which are of importance in the causation of mem-\\nbranous enteritis.\\nWith reference to gastric secretion and the motor func-\\ntion of the stomach in this disease, 1 1 have made examina-\\ntions on twelve cases and found the following two points\\nmost conspicuous\\n1. The motor function (prochoresis) of the stomach\\njudged from the amount of contents found one hour after\\nthe test breakfast was increased in eight cases and nor-\\nmal in the four remaining.\\n2. Five cases presented a typical achylia gastrica.\\nConsidering the comparative infrequency of achylia gas-\\ntrica, which hardly amounts to two or three per cent of the\\ndigestive disorders, this large proportion of achylia in pa-\\ntients with membranous enteritis namely, five in twelve\\nis certainly noteworthy.\\n1 Max Einhorn Membranous Enteritis. Medical Record, January\\n28, 1899.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0360.jp2"}, "361": {"fulltext": "MEMBRANOUS ENTERITIS. 341\\nThree cases of membranous enteritis with normal acid-\\nity revealed, besides the increased prochoresis, still another\\nfeature in common with achylia\u00e2\u0080\u0094 namely, the extraordi-\\nnarily small amount of fluid surrounding the scarcely\\nchanged particles of roll, one hour after the test breakfast.\\nAlthough this symptom may occasionally be met with in\\nother cases than achylia, it is nevertheless, as a whole,\\ncharacteristic of this affection. Therefore we are justified\\nin making the following statement In many cases of mem-\\nbranous enteritis typical achylia is present, in some it is\\nlacking, but even then some features characteristic to achj T\\nlia are encountered. In membranous enteritis achylia thus\\nplays a great part. Whether one condition causes the\\nother, or one and the same factor (nervous influences) cre-\\nates both, is difficult to say. The latter, however, is more\\nplausible.\\nSymptomatology. The disease is characterized by at-\\ntacks of rather violent colicky pains in the abdomen, which\\nare followed by the passage of mucous masses with the\\nstools. The mucus may be voided either alone, without\\nany admixture of fecal matter, or it forms a considerable\\npart of the evacuation. Usually the attack is preceded by\\na period of obstinate constipation, and often followed by\\ndiarrhoea lasting a few days, and sometimes accompanied\\nby tenesmus. Gastric symptoms as loss of appetite, fre-\\nquent belching, now and again a burning sensation at the\\npit of the stomach are generally quite pronounced during\\nthe attack. Yomiting may occasionally appear, while fever\\nis, as a rule, absent. The attack lasts three to seven days,\\nand then the pains subside, the diarrhoea ceases, and eu-\\nphoria reappears. More or less constipation, however,\\nand some other dyspeptic as well as nervous symptoms\\npersist. These free intervals last various periods of time", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0361.jp2"}, "362": {"fulltext": "342 DISEASES OF THE INTESTINES,\\n(four weeks to five or six months). In rare instances the\\nmucous discharges may be present continuously.\\nWith reference to the mucous masses, they present a\\ngrayish-white appearance, seldom yellowish, and have\\neither a ribbon-like or membranous form; at times the\\npieces are several feet long ordinarily, however, they are\\nconsiderably smaller. Complete moulds of the intestinal\\nlumen have been observed by several authors, and Leyden\\nnot unjustly has compared this process with that of croup\\nof the larynx. As already stated by Cornil, 1 the false\\nmembranes consist of mucus, mixed with dried-up epithe-\\nlial ovoid cells, which arise from a mucous metamorphosis\\nof the cylindrical cells or the leucocytes. Nothnagel\\nand others have proven the mucous nature of these dis-\\ncharges.\\nAs suggested by Pariser, the mucous nature of these\\nmasses can be demonstrated by treating them, first, with\\nsublimate alcohol, and then staining them with Ehrlich s\\ntriacid solution. A green color appears, which indicates\\nmucus (fibrin treated in the same manner assumes a red\\ncolor). Judging from my experience it is unnecessary to\\ndip these membranes first into sublimate alcohol, as the\\nsame result will follow when they are put directly into the\\nweak triacid solution. Microscopically this substance re-\\nveals a somewhat fibrillary nature, and contains many\\nshrivelled cells, so called by Nothnagel. Micro-organisms\\nare found admixed, although they do not seem to play any\\nimportant part in this affection. In two of my cases mi-\\ncroscopically single-celled corpuscles were found in these\\nmasses, having a distinct nucleus and a tail-like process.\\nThe accompanying drawing shows these corpuscles {Fig.\\n38). These are most probably metamorphosed goblet cells.\\n1 Cornil Cited from Siredey. See above.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0362.jp2"}, "363": {"fulltext": "MEMBRANOUS ENTERITIS.\\n343\\nDiagnosis. The diagnosis of membranous enteritis is,\\nas a whole, simple when the above-mentioned character-\\nistic symptoms, including the mucous discharges, are pres-\\nent. It is, however, necessary to be careful not to mis-\\ntake for mucus other substances admixed in the faeces,\\nFIG. 38.\u00e2\u0080\u0094 Microscopical Picture of Mucous Masses Found in the Evacuation of Mrs. L.,\\nShowing Numerous Cells Having a Nucleus and a Tail-like Process.\\nwhich occasionally resemble shreds of mucous membrane\\nas, for instance, the fibre of an orange, tendons, pieces\\nof tapeworm. A microscopical examination will guard\\nagainst all such errors.\\nThis affection will hardly be confounded with real intes-\\ntinal catarrh, as it presents an entirely different picture\\nand only occasionally may have an abundant secretion of\\nmucus in common with mucous colic. There are, however,", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0363.jp2"}, "364": {"fulltext": "344 DISEASES OF THE INTESTINES.\\ncases of chronic intestinal catarrh which are complicated\\nwith membranous enteritis that is, having typical attacks\\nof mucous colic. The following case presents an instance\\nof this kind\\nMiss L. N twenty-eight years old, had diarrhoea\\neleven years ago for quite a while, which disappeared after\\ntwo or three months. The patient was then well until\\nfour years ago, when she again began to be troubled with\\ndiarrhoea. Soon periods of obstinate constipation ap-\\npeared, which alternated with diarrhoea. The patient re-\\nports having occasionally observed mucus in the passages\\nat times (about every five or six weeks) there appear\\nabdominal pains for about one or two hours, followed by\\nan evacuation of pure mucus, the quantity being one to two\\ntablespoonfuls. The appetite was always good. Now and\\nagain there was belching. The patient lost about twenty-\\nfive pounds in weight. Sleep is undisturbed, only at times\\nrestless for a few days. Her strength greatly failed. Pal-\\npation of the abdomen reveals spots sensitive to pres-\\nsure in the entire course of the colon. The examination\\nof the fgeces in the free interval shows small quantities of\\nmucus well mixed with the fecal matter. The mucous\\nmasses voided after an attack of pains are free from fecal\\nmatter, appearing grayish-white and staining green when\\ntreated with Ehrlich s triacid solution.\\nTreatment. Diet plays the principal part in the treat-\\nment of membranous enteritis. While the older writers\\nlaid stress on scanty light food, it is now generally ac-\\ncepted that abundant nutrition is of the greatest value.\\nThat a fluid diet is unsuitable, the older authors have al-\\nready been cognizant of (Da Costa, Whitehead, Siredey),\\nand this axiom holds good in its entirety even to-day.\\nRecently von Noorden advised a very coarse diet, being\\n1 C. von Noorden Ueber die Behandlung der Colica mucosa.\\nZeitschr. f. practiscbe Aerzte, 1898, No. 1.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0364.jp2"}, "365": {"fulltext": "MEMBRANOUS ENTERITIS/ 345\\nguided by the idea that the intestinal tract should be exer-\\ncised and strengthened by increased work. He recom-\\nmends per day half a pound of bread containing plenty of\\nchaff, leguminous vegetables, garden vegetables rich in\\ncellulose, fruits with small pits and coarse skin, as cur-\\nrants, gooseberries, grapes these being foods rich in un-\\ndigestible material, thus forming much ballast for the\\nbowel. Among fifteen patients subjected to this treatment\\nby von Noorden, seven were permanently cured, seven im-\\nproved, and one was unchanged.\\nThis method has certainly much in its favor it may be\\nbetter, however, not to institute this diet abruptly, as sug-\\ngested by von Noorden, but rather gradually.\\nI, for my part, for some years past have seen to it that\\nmy patients partook of an abundant and nutritious diet,\\nwithout, however, advising substances that were too coarse.\\nAs a whole, I recommend ample food and try to keep the\\npatients on a mixed diet containing plenty of vegetables.\\nIn patients who have lived on a strict diet (as for instance\\nmilk diet or beef and hot water), I arrange the change\\ngradually. The principle here is the same as stated by\\nvon Noorden, only not carried to such an extreme. It ap-\\npears sufficient if the intestines of the patient with mem-\\nbranous enteritis are trained to master the foods customary\\nin healthy persons, and the accomplishment of this object\\nis all that is required. If we subsequently see that the\\norganism amply fulfils its work, a few less digestible foods\\nmay then be added. It is not necessary to recommend\\nthese immediately from the start, nor are they important\\nfor the cure.\\nWith regard to therapeusis, two phases will have to be\\nconsidered the treatment during the attack and the treat-\\nment during the interval. In severe attacks, rest in bed,", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0365.jp2"}, "366": {"fulltext": "346 DISEASES OF THE INTESTINES.\\nwarm poultices over the abdomen, a cleansing enema (of\\nordinary warm water with the addition of some common\\ntable salt or essence of peppermint one teaspoonful to a\\nquart), and afterward the administration of codeine or\\nopium, with or without belladonna, are of value. As long\\nas the pains last it is necessary to give light food (small\\nquantities frequently) In mild attacks a stay abed may\\nnot be requisite, nor the administration of an analgesic\\nremedy, and the diet may be the same as during the in-\\nterval.\\nIn the interval free from pains the treatment consists in\\na methodical application of olive-oil enemas, as suggested\\nby Kussmaul and Fleiner. These enemas are injected into\\nthe bowel at night, at blood temperature, the quantity being\\ntwo hundred and fifty to five hundred cubic centimetres.\\nThe patient is then instructed to try and retain the oil in\\nthe bowel during the night. The patients seldom assert\\nthat they are disturbed in their sleep by these injections\\nand have to answer nature s call. In such an instance the\\nquantity of oil may be reduced to one hundred and fifty or\\none hundred cubic centimetres. The oil should be injected\\nevery night for three weeks; then every other night for\\nthree weeks, and twice weekly for four weeks finally, once\\nweekly for five or six months. Besides, patients must\\naccustom themselves to a regular morning evacuation, by\\npromptly visiting the closet every day at the same hour in\\nthe morning.\\nNext to abundant nourishment the methodical oil cure\\nis of the greatest importance in the treatment of this\\naffection, and the results achieved are, according to my\\nexperience, very satisfactory. The administration of oil\\ninjections in membranous enteritis is mentioned here and\\n1 Fleiner Berliner klin. Wochenschr. 1893, No. 3.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0366.jp2"}, "367": {"fulltext": "INTESTINAL NEURASTHENIA. 347\\nthere in recent literature, especially by Ewald, but its\\nvalue must be placed much higher than heretofore. The\\noil has not only a favorable influence upon the constipa-\\ntion which is always present in this malady, but at the\\nsame time also effects a diminution or a disappearance of\\nthe mucous discharges. How the oil brings this about is\\ndifficult to say. The favorable effect may perhaps be ex-\\nplained by the circumstance that by means of the oil the\\nintestine is not left in an empty condition during the\\nnight, and thereby a spasmodic contraction is avoided,\\nwhich must be regarded as one of the principal factors in\\nthe formation of mucus.\\nIt is evident, according to my statement with regard to\\nthe etiology, that enteroptosis and anomalies of the gas-\\ntric functions (principally achylia) exist in a large number\\nof these cases. It will, therefore, be necessary to bear\\nthese points in mind and to treat the cases accordingly.\\nThe neurotic symptoms present in these cases should not\\nbe neglected in the general plan of treatment. We shall\\nhave to pay attention to a regular hygienic mode of living\\nand ample physical exercise. In suitable cases occasional\\nhydrotherapeutic measures will be of value. The tonic\\nremedies, like iron, arsenic, etc., will also prove beneficial.\\nIntestinal Neurasthenia.\\nThe various intestinal neuroses have been separately\\ndescribed. In practice combinations of different neuroses\\nfrequently occur. Following Rosenheim we designate such\\ncases as intestinal neurasthenia. The appetite as a rule\\nis good and the symptoms usually appear during the pe-\\nriod when intestinal digestion takes place. The symptoms\\ngenerally develop one to three hours after meals and consist\\nin a feeling of pressure, tension, and sometimes of griping", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0367.jp2"}, "368": {"fulltext": "348 DISEASES OF THE INTESTINES.\\nin the abdomen. Occasionally there may be a sensation\\nof nausea, at times an evacuation of the bowels accompa-\\nnied with painful sensations in the abdomen and in the\\nanus. Sometimes palpitation of the heart occurs, some-\\ntimes again a sensation of flashes of heat or of cold extend-\\ning upward. As a rule, the patients feel worse when rest-\\ning, especially in the recumbent position, than when\\nwalking about. After a period of one or two hours the\\nsymptoms usually disappear, to return again later on after\\na meal.\\nConstipation is as a rule associated with this condition.\\nThe quality of the food does not seem to exert much\\ninfluence upon the symptoms, although the latter are\\nmore marked after heavier meals. In a few instances, es-\\npecially when the pains play a predominant part and bor-\\nborygmi occur, diarrhoea is encountered. In these cases\\nthe diarrhoea appears in the middle of the night or toward\\nearly morning, and disturbs the patient s sleep. It is\\nof diagnostic importance that the pains do not in any way\\ndepend upon the quality of the food. Indigestible foods,\\neven taken in considerable quantity, are occasionally well\\nborne, while at other times a small meal, consisting of the\\nlightest food, causes severe symptoms. Intestinal neuras-\\nthenia is sometimes associated with gastric neurasthenia\\nand completes the picture of the other.\\nIn making the diagnosis of intestinal neurasthenia ana-\\ntomical lesions of the intestines must first be excluded.\\nThe treatment consists in hygienic measures which serve\\nto tone up the system, in ample feeding, and in the admin-\\nistration of the bromides, occasionally in conjunction with\\niron and arsenic. With regard to diet all foods are al-\\nlowed excepting indigestible substances, and a preponder-\\nance of vegetable food is to be recommended.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0368.jp2"}, "369": {"fulltext": "CHAPTER XII.\\nINTESTINAL PAEASITES.\\nGeneral Remarks. Most of the animal parasites found\\nin man inhabit the intestinal canal. Leuckart estimates\\nthe number of varieties at about fifty. Not all parasites,\\nhowever, produce morbid conditions. Comparatively few\\nof them evoke a pathological state, either in the intestine\\nby their direct presence, or in the blood by the formation\\nof toxic products which are absorbed and reach the circu-\\nlation. The intestinal parasites are detected by repeat-\\nedly examining the stools. They may be seen or their\\npresence may be assumed from the discovery of their ova\\n(the latter referring to the helminths). There are no char-\\nacteristic symptoms which would be encountered only in\\nmorbid conditions due to animal parasites. The diagno-\\nsis, therefore, must be made by directly discovering them\\nor their eggs in the dejecta. It will always be wise to look\\nfor worms in cases in which gastric and intestinal symp-\\ntoms of a functional character exist, accompanied or not\\nby anaemia and certain neuropathic affections. The intes-\\ntinal parasites are divided into two large groups: (1) Pro-\\ntozoa. (2) Vermes.\\nI. PROTOZOA.\\nAmoeba?.\\nBesides dysenteric amoebae which have been described\\nabove, a similar variety is occasionally encountered giving\\n1 Leuckart Die menscbliclien Parasiten, Leipzig, 1886, Bd. ii.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0369.jp2"}, "370": {"fulltext": "350 DISEASES OF THE INTESTINES.\\nrise to no symptoms whatever or sometimes to slight at-\\ntacks of diarrhoea.\\nSjoorozoa.\\nAmong the sporozoa coccidia are occasionally found in\\nthe stools. This organism is egg-shaped, provided with\\na thin shell, 0.02 mm. long, and contains in its interior a\\nlarge number of nuclei usually arranged in groups. The\\ncoccidia do not seem to have any pathological bearing.\\nInfusoria.\\nTo these belong cercomonas intestinalis, trichomonas\\nintestinalis, and paramsecium coli. All of them are found\\nprincipally in conditions in which diarrhoea is the fore-\\nmost symptom.\\nThe cercomonas intestinalis is pear-shaped, has a distinct\\nnucleus and eight flagellse. The head portion of the body\\ntapers obliquely and presents a depression (Fig. 39). It\\nis not believed to have a direct pathogenic significance.\\nFig. 39.\u00e2\u0080\u0094 Cercomonas Intestinalis (Da- Fig. 40.\u00e2\u0080\u0094 Trichomonas Intestinalis (Zun-\\nvaine). ker).\\nIt is assumed, however, that this micro-organism is liable\\nto prolong pre-existing catarrhal affections of the intestine.\\nTrichomonas intestinalis presents the same features as\\nthe cercomonas and can be distinguished from the latter by\\nits somewhat greater size and the row of fine cilia upon the\\nperiphery of its body (Fig. 40). In fresh dejecta this mi-\\ncro-organism moves around very actively. Zunker found\\nbunker: Deutsche Zeitschr. f praktiscbe Medicin, 1878, No. 1.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0370.jp2"}, "371": {"fulltext": "TAPE WORMS.\\n351\\n^tf\\nit principally in mushy dejecta having a brownish-yellow\\ncolor and a somewhat putrid odor.\\nParamcecium (or balantidium) coli is egg-shaped, 0.1 mm.\\nlong and covered with fine cilia, the latter being densely\\ngrouped about the mouth, while but few of them surround\\nthe anus. In the interior of this or-\\nganism are found a nucleus and two\\ncontractible vesicles, besides fat drop-\\nlets, starchy particles, etc. (Fig. 41).\\nThe balantidium coli was first de-\\nscribed by Malmsten in 1857. In\\nthe fresh stools the balantidium moves\\nabout very rapidly, but it dies as early\\nas one-half an hour to two hours after\\nthe dejecta have been passed. Like\\nthe cercomonas, the paramaecium coli\\nis believed to keep up conditions of\\ndiarrhoea.\\nThe treatment directed against these\\ninfusoria consists in intestinal irriga-\\ntion with* watery solutions of tannic acid, boracic acid,\\nthymol, or quinine.\\nII. VERMES.\\nGestodes (Tape Worms).\\nGeneral Remarks. In describing the disorders caused\\nby tapeworms it is best to include the taenia solium, taenia\\nmediocanellata, and bothriocephalus latus.\\nThe symptoms produced by these three different entozoa\\nare almost identical. In some instances the tapeworm is\\ndomiciled in the intestine for a long period of time with-\\nout manifesting any symptoms. The host may enjoy per-\\n1 Malmsten: Vircliow s Archiv, Bd. xii.\\nd\\nFig. 41. Balantidium\\nColi (Claus). or. Mouth\\nb, nucleus c, a granule\\nof starch which has\\nbeen ingested d, a for-\\neign body in the process\\nof being expelled.\\nHighly magnified.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0371.jp2"}, "372": {"fulltext": "352 DISEASES OF THE INTESTINES.\\nfeet health and only after noticing segments of taenia in the\\ndejecta does he become conscious of his uninvited guest.\\nIn other instances the worm produces intestinal as well as\\ngeneral disturbances. A feeling of pressure at the pit of\\nthe stomach and pains at different points of the abdomen\\nmay be present. Bulimia is frequently encountered.\\nAnorexia and anorexia alternating with bulimia are also\\noccasionally observed. Nausea, even vomiting, may be\\npresent, especially in the morning. The bowels are usu-\\nally constipated. In a few instances, however, there is\\npersistent diarrhoea.\\nBesides these gastro-intestinal symptoms there may be\\npresent various disturbances of the nervous system or of\\nthe blood; dizziness, headache, fainting spells, convul-\\nsions, epilepsy, various forms of paresthesia of the ex-\\ntremities. Some patients, again, look very bad and be-\\ncome emaciated, notwithstanding that they take sufficient\\nquantities of food. The anaemic condition is occasionally\\nvery marked. The patient feels extremely weak, suffers\\nfrom palpitation of the heart, is hardly able to walk, and\\nis subject to fainting spells. In this serious form of anae-\\nmia oedema of the feet and eyelids may exist as well as\\nhemorrhages from the mucous membranes. The micro-\\nscopical examination of the blood in these instances reveals\\npoikilocytosis and also nucleated red blood corpuscles,\\nthus demonstrating the existence of a progressive per-\\nnicious anaemia. The grave condition just described has\\nbeen observed only in the presence of bothriocephalus\\nlatus but not of the other varieties of tapeworms.\\nThe proof that the symptoms described are produced\\nby the tapeworm is found in the circumstance that they\\ndisappear entirely after the removal of the parasite.\\nNone of the above symptoms, however, permits the diag-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0372.jp2"}, "373": {"fulltext": "TAPE WORMS. 353\\nnosis of tapeworm, for they are found also when it is not\\npresent. The diagnosis can be made only by the discov-\\nery of either segments of the parasite or their eggs in the\\nstools.\\nThe tapeworm has a head or scolex, which may remain\\nalive for years, even when separated from the other part\\nof the body, an oblong neck and detachable segments\\n(proglottides). The latter vary in size and in configura-\\ntion the farther away from the head they are situated.\\nThey possess the power of moving. The tapeworm is a\\nflat worm devoid of mouth or intestine. It grows by alter-\\nnate generation through the germination of a pear-shaped\\nprimary host (head) and remains united with the latter for\\na considerable time as a long band-shaped colony. Each\\nmember of the colony forms a sexually active individual.\\nThe proglottides increase in size the more distant they are\\nfrom the head. The tapeworm is an hermaphrodite. It is\\nprovided on its head with four sucking discs, by means of\\nwhich it is enabled to attach itself to the intestinal mu-\\ncosa. It derives its nourishment by means of pores from\\nthe intestinal chyme. The older proglottides contain a\\nlarge number of fructified eggs. The latter are off and on\\nemptied into the intestinal canal and then appear in the\\ndejecta.\\nThe ovum contains an embryo which requires for its de-\\nvelopment an intermediary host. After reaching the stom-\\nach of the intermediary host the envelope of the ovum is\\ndissolved by the gastric juice. The embryo is now set\\nfree and finds its way either by the lymphatics or by the\\nblood-vessels to some place (usually the muscles) where it\\nsettles. Here it surrounds itself with a sac, which later\\non may become surrounded with a calcareous deposit. In\\nthis condition the embryo is called cysticercus or measle.\\n23", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0373.jp2"}, "374": {"fulltext": "S54\\nDISEASES OF THE INTESTINES.\\nWhen the measle again reaches the stomach of a new host\\nit then opens and its scolex advances into the small in-\\ntestine, where it develops into a full-grown taenia.\\nTaenia Solium. Taenia solium, or the armed tapeworm,\\nwhen fully developed, is from two to three metres long.\\nIts head is of pinhead size and spherical in shape. It has\\nfour cuplike suckers, in the middle of which is situated the\\nrostellum, the latter being surrounded with a large number\\nof hooks (Fig. 42). These are arranged in two rows and\\nnumber from twenty-four to twenty-six. Succeeding the\\nhead is a filiform neck, almost an inch long. Commencing\\nat a certain distance from\\nthe head the body is di-\\nvided into segments.\\nThe mature proglottides\\nii\u00c2\u00a7!\\nnil 4\\nFig. 42.\u00e2\u0080\u0094 Head of Taenia Solium with Pro-\\ntruding Rostellum. Magnified 50 diameters.\\n(Ziegler.) v\\nFig. 43.\u00e2\u0080\u0094 Half Developed and Fully\\nMatured Segments. Natural size.\\n(Leuckart.)\\nare 1 to 1.5 cm. long and 6 mm. wide. The genital open-\\ning is situated at the side near the posterior border of the\\nsegment (Fig. 43). The uterus forms a straight median\\ntube, giving off at right angles five to seven branches on", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0374.jp2"}, "375": {"fulltext": "TAENIA SAGINATA. 355\\neach side. These branches are undivided at first, but to-\\nward the periphery ramify in the form of a tuft (Fig. 44).\\nThe eggs are round and provided with a thick shell.\\nTaenia solium inhabits the small intestine of human\\nbeings. The further development of the embryo into\\nA\\nFig. 44.\u00e2\u0080\u0094 Taenia Solium. Showing two proglottides. A, A, pores. (Huber.)\\nmeasles occurs in the intermediary host, the pig, in which\\ncondition they reach the human system and are trans-\\nformed into mature taenias. Rarely the measles (cysto-\\ncercus eellulosae) are found in men, in which instance they\\noccur in various organs, brain, eye, skin, etc. The grav-\\nity of the disease which they produce depends upon the\\nimportance of the organ they involve.\\nTcania Saginata or Mediocanellata. This tapeworm is\\nthe one most frequently observed in America as well as\\nabroad. The taenia saginata is much longer, thicker, and\\nwider than taenia solium. The head is 2.5 mm. large, has\\nfour large sucking-discs but no rostellum, and is often\\npigmented (Fig. 45). The length of the worm is 4 to 5\\nmetres, the proglottides are unusually thick, the widest\\nbeing in the middle. The mature segments occasionally\\nattain a length of 2.5 cm. The uterus lies in the middle\\nof the segment and gives off numerous branches on both\\nsides (about twenty on each side (Fig. 46). The genital\\nopening is situated on the side below the middle. The", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0375.jp2"}, "376": {"fulltext": "356\\nDISEASES OF THE INTESTINES.\\neggs have an elliptical shape, a brownish color, and a con-\\ntour exhibiting radiating streaks.\\nThe taenia saginata inhabits the small intestine of man.\\nIts measles occur in beef, as has been demonstrated by\\nB\\nm\\n1\\na =5\\nHuber l and Leuckart. These measles are usually smaller\\nthan those of taenia solium. Human beings acquire this\\n1 Huber Twentieth Century Practice of Medicine, vol. viii. p.\\n570.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0376.jp2"}, "377": {"fulltext": "BOTHRIOCEPHALUS LATUS. 357\\ntsenia by the consumption of raw beef. The measles have\\nnot as yet been found in man.\\nBothriocephahis Latus, Tcenia Lata or Pig Head. This\\ntapeworm is the longest. It measures from five to eight\\nmetres. The head is elongated, of almond shape, being\\nabout 2.5 mm. in length (Fig. 47). It has two lengthy\\nbig grooves on its flat surface (Fig. 48). The neck is nar-\\nrow, about 2 cm. long. The body is thin and flat like\\na ribbon, excepting the central part of the segments which\\nFig. 46.\u00e2\u0080\u0094 The Uterus and its Branches in a Segment of Taenia Saginata. Enlarged 3\\ndiameters. CHuber.)\\nproject somewhat outward. The genital openings are on\\nthe flat surface in the middle, the female very close to the\\nmale. The uterus has a special opening and four to six\\nvisible uterine convolutions on each side, which look al-\\nmost like a rosette. The eggs are oval, round, with a thin\\nmembrane and a lid (Fig. 49). They measure 0.07 mm.\\nin length and 0.04 in width.\\nThe measle of bothriocephalus latus occurs principally\\nin fish, especially in pike, turbot, perch, and trout.\\nThe taenia lata lives in the small intestine of man, but\\nis also, though rarely, found in dogs. In the northeast-\\nern part of Europe, Holland, Switzerland, and Japan this\\ntapeworm is very prevalent. In America it occurs but in-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0377.jp2"}, "378": {"fulltext": "358\\nDISEASES OF THE INTESTINES.\\nfrequently. As stated above, among the symptoms pro-\\nduced by bothriocephalus anaemia is often observed.\\nAside from the three tape-\\nworms just described there exist\\na few more varieties which are\\nonly rarely met in human\\nbeings. They are\\n(1) Tcenia Nana. \u00e2\u0080\u0094This is the\\nsmallest tapeworm found in\\nman. It measures 10 to 15 mm.\\nin length and may have one hun-\\ndred and ninety segments. The\\nhead has four sucking discs,\\na rostellum, twenty four to\\ntwenty-eight hooklets in a sin-\\ngle row. The proglottides are\\nshort and broad; the genital\\nopenings are on one side.\\nThis tapeworm has been ob-\\nserved principally in Egypt and\\nItaly in children. It usually\\noccurs in large numbers in the\\nsmall intestine, from forty to\\neven five thousand. The symp-\\ntoms produced by this tapeworm\\nare mostly nervous disturbances,\\nfainting spells, occasionally\\neven epilepsy.\\n(2) Tee n i a Cucumerina.\\nThis small cucumber-shaped\\ntapeworm occurs frequently in\\nthe intestine of the dog, but has also been found, although\\nrarely, in small children. The tapeworm is 10 to 40 cm.\\nFig. 47. Bothriocephalus Latus\\nNatural size. (Leuckart.)", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0378.jp2"}, "379": {"fulltext": "TAPE WORMS.\\n359\\nlong and about 3 mm. wide. The measle of this taenia\\ninhabits the flea.\\n(3) Tcenia Flavo-Punctata or Tcenia Diminuta. This\\nparasite is 2 to 6 cm. long and 3.5 mm. wide. Its head\\nis very small, club-shaped, and provided with sucking-\\ndiscs. The measle infests the caterpillar and cocoon of\\nFIG. 48. FIG. 49.\\nFig. 48.\u00e2\u0080\u0094 Head of Botbriocepbalus Latus. Magnified. (Heller.)\\nFig. 49.\u00e2\u0080\u0094 Eggs of Botbriocepbalus. (Krabbe.)\\nasopia famialis and in the coleoptera axispinosa. This\\ntapeworm has been observed in man only a few times.\\n(4) Bothriocephalus Corclaius. This tapeworm resembles\\nin all particulars the bothriocephalus latus except that it\\nis much shorter and that the head merges into the proglot-\\ntides directly without an intermediary neck. It occurs in\\nthe intestine of men and dogs in Greenland.\\nThe list of the tapeworms enumerated above is not com-\\nplete, for there exist the taenia madagascariensis, bothrio-\\ncephalus liguloides, and others, but as these do not occur\\nin Europe or America a description of them does not ap-\\npear to be of practical interest.\\nTreatment. Prophylaxis. In order to escape infection\\nwith tapeworm it is necessary to abstain from raw or me-\\ndium done meats, including fish. The sanitary inspection", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0379.jp2"}, "380": {"fulltext": "360 DISEASES OF THE INTESTINES.\\nof the meat is no absolute guarantee that it is free of\\nmeasles. Thorough boiling or broiling of the meat de-\\nstroys the cysticerci and thus the danger is avoided. In\\norder to diminish the spread of tapeworm it is advisable\\nto free the patient of the worms and thoroughly to destroy\\nthem as soon as possible after they have left the intestine.\\nWhoever examines the proglottides or the ova should care-\\nfully wash and disinfect his hands immediately afterward\\nin order to avoid auto-infection.\\nThe direct treatment of the tapeworm consists in meas-\\nures to expel it from the intestinal canal. This is accom-\\nplished by emptying the bowels previously and giving a\\nvermifuge afterward. The treatment is carried out in the\\nfollowing way For about two days before giving the ver-\\nmifuge the patient is kept on a scanty diet, consisting of\\nsome milk, meat and broth, very little bread or none at\\nall. A laxative (calomel eight to ten grains or castor oil\\none tablespoonful) is given once a day. On the evening\\npreceding the administration of the vermifuge the patient\\nshould have no supper or should take only salt herrings\\nwith onions. On the following morning a cup of coffee or\\ntea is given. Half an hour to one hour later the vermifuge\\nis administered. Among the drugs for the removal of the\\ntapeworms the following are the most efficient\\nMale-fern extract is given in doses of 6 to 10 gm. 3 iss.-\\niiss.), as for instance:\\nExtr. filicis mar. aether 8.0 3 ij.)\\nSyr. simpl 40.0 I i\u00c2\u00a3)\\nS. To be taken iu ten minutes.\\nThe dose of male-fern should never be very high and\\nshould not exceed 10 gm. 3 iiss.), as symptoms of intoxi-\\ncation have frequently been observed.\\nPomegranate root is also an efficient remedy, espe-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0380.jp2"}, "381": {"fulltext": "TAPE WORMS. 361\\ncially if it is fresh. It may be given in an infusion of the\\nbark, three ounces of which are macerated in ten ounces of\\nwater and then reduced to one-half by evaporation. The\\nentire quantity is then taken within half an hour.\\nPelletierine, the active principle of pomegranate root,\\nmay also be used in doses of five to eight grains.\\nFlores koosso, about 20 to 30 gm. 3 v. to si.) of the\\nblossoms are thoroughly mixed in sugar water or lemon-\\nade and should be taken within one-half or one hour, or\\nFlores koosso,\\nMellis despumati aa 3 v. (20 gm.\\nFiat electuarium. S. To be taken in two portions.\\nKamala may also be employed in doses of 10 gm.\\n3 iiss.) mixed in aqua fceniculi or in wine and taken in\\nthe same way.\\nTurpentine 30 to 60 gm. 3 i.-ii.) may be given in cap-\\nsules. After this medicament one or two glassfuls of milk\\nshould be taken.\\nPumpkin seeds (semina cucurbits) may be administered\\nin doses of 120 gm. fiv.), thoroughly mixed with the\\nsame amount of grape sugar.\\nCocoanut has also been recommended for this purpose.\\nThe milk and albumin of an entire nut should be consumed\\nwithin one hour.\\nNaphthalin in doses of 0.6 to 2.0 gm. (gr. x.-xxx.) may\\nbe given in capsules.\\nSalol 3 gm. (gr. xlv.) in capsules may also be advanta-\\ngeously employed.\\nOne or two hours after the administration of the vermi-\\nfuge a cathartic should be given, usually about two table-\\nspoonfuls of castor oil, or citrate of magnesia one to two\\nteaspoonfuls. The resulting evacuation must be thor-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0381.jp2"}, "382": {"fulltext": "362\\nDISEASES OF THE INTESTINES.\\noughly examined and the tapeworm looked for, especially\\nits head.\\nChildren require a correspondingly smaller dose of the\\nabove remedies, according to their age. Patients who are\\ndebilitated, or have intestinal disorders or organic lesions\\nof the digestive tract, should not be subjected to this treat-\\nment, nor should it be employed shortly after typhoid\\nfever or other grave diseases. In these conditions it is\\nnecessary to postpone the treatment until a more oppor-\\ntune time.\\nTrematodes (Fluke Worms).\\nThe trematodes are solid worms of a tongue or leaf\\nshape. They possess a clinging apparatus in the form of\\nFig. 50.\u00e2\u0080\u0094 Distoma Hepaticum, with Male and Female Sexual Apparatus. CLeuckart.)\\nMagnified 2}4 diameters.\\noral and ventral sucking-cups varying in number. Some-\\ntimes they are also provided with hook or clasp like pro-\\njections for this purpose. The intestinal canal is without\\nany anus and is split like a fork nearly throughout its\\nextent. The fluke worms are mostly hermaphroditic. To\\nthese belong\\nDistoma Hepaticum or Liver Fluke. This parasite has\\na leaf shape, is 22 mm. long and 12 mm. wide. The ceph-\\nalic end projects like a beak and bears a small cuplike", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0382.jp2"}, "383": {"fulltext": "DISTOMA LANCEOLATOl. 363\\nsucker, in which the mouth is located. Close behind this\\non the ventral surface is a second suction cup and between\\nthe two lies the sexual orifice. The uterus consists of a\\nFig. 51.\u00e2\u0080\u0094 Eggs of Distoma Hepaticum. (Leuckart.) Magnified 200 diameters.\\nconvoluted bulb-shaped bag situated behind the posterior\\nsucker. On each side of the body lie the ovisacs and be-\\ntween them the much branched testicular canals (see Fig.\\n50). The eggs are oval, 0.13 mm. long and 0.08 mm.\\nwide. They have a brownish color and are provided with\\na lid (Fig. 51).\\nThe liver fluke is rare in man, though frequently found\\nin ruminating animals. It inhabits the biliary ducts and\\nis occasionally found in the intestine and in the inferior\\nvena cava. The symptoms which it produces are varied:\\njaundice, enlargement of the liver, diarrhoea, hemorrhages.\\nFig. 52.\u00e2\u0080\u0094 Distoma Laneeolatum with its Inner Organs. (Leuckart.) Magnified 10\\ndiameters.\\nMost probably the liver fluke reaches the intestinal canal\\nby means of impure water or vegetables.\\nDistoma laneeolatum is 8 to 9 mm. long and 2 to 2.5 mm.\\nwide. It has a lancet shape and the head portion is not\\nspecially marked off -from the body (Fig. 52) The eggs", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0383.jp2"}, "384": {"fulltext": "364\\nDISEASES OP THE INTESTINES.\\nare considerably smaller than those of distoma hepaticum,\\nbeing only 0.04 mm. long (Fig. 53). With regard to its\\noccurrence and symptoms it resembles the liver fluke.\\nDistoma haematobium or Bilharzia kcematobia is fre-\\nquently found in hot climates, especially in Egypt. In\\nFig. 53.\u00e2\u0080\u0094 Egg of Distoma Lanceolatum Shortly After the Formation of a Shell. (Leuck-\\nart.) Magnified 400 diameters.\\nthe United States and in Europe it is very rarely found.\\nThis parasite has separate sexes. The male is from 12\\nto 14 mm. long. Its body is smooth, but in its posterior\\nportion rolled up into a tube, which serves for the recep-\\ntion of the female (canalis gynaecophorus) (Figs. 54 and\\n55). The female is from 16 to 19 mm. long and almost\\nFIG. 54.\\nFIG. 55.\\nFig. 54.\u00e2\u0080\u0094 Distoma Haematobium. (Leuckart.) Male and female, the latter in the ca-\\nnalis gynaecophorus of the former. Magnified 10 diameters.\\nFig. 55.\u00e2\u0080\u0094 Eggs of Distoma Haematobium. (Leuckart.) a, Egg with terminal spine b,\\negg with lateral spine. Magnified 150 diameters.\\ncylindrical. The sexual opening lies in both sexes close\\nbehind the ventral sucker. The distoma haematobium", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0384.jp2"}, "385": {"fulltext": "ROUND WORMS. 365\\nfinds its way into the intestinal canal of man and. then\\nreaches the portal circulation, where it develops. In the\\nintestinal canal it has been encountered very rarely, in\\nwhich case ulcerations of the intestinal mucosa were pres-\\nent. It frequently causes hematuria and great cachexia,\\nterminating fatally in some instances.\\nAs regards treatment, the removal of these fluke worms\\nmust be undertaken in identically the same manner as that\\nof the tapeworms described above.\\nNematodes {Round Worms).\\nThe round worms which occur as parasites have a slen-\\nder, cylindrical, sometimes filiform body, with neither\\nsegments nor appendages. The integument is thick and\\nelastic. The oral opening is at one extremity and provided\\nwith either soft or hornlike lips. The alimentary canal\\nextends throughout the entire body cavity, terminating in\\nan opening upon the ventral side at a short distance from\\nthe posterior extremity. The sexual organs and their ori-\\nfices lie on the ventral surface. The female aperture is\\nlocated at about the middle of the body in the male the\\nsexual orifice is situated close to the anus. The males\\nare usually much smaller than the females.\\nAscaris Lumbricoides {Common Spool or Round Worm).\\nThis worm is one of the most frequently observed para-\\nsites in man. The round worm has a light brown or red-\\ndish color and a cylindrical shape. The male is 20 cm.\\nand the female 30 cm. long. The posterior extremity of\\nthe male is bent in the form of a hook and provided with\\ntwo spicules or chitinous processes. The mouth is sur-\\nrounded by three muscular lips provided with very fine\\nteeth. The sexual opening of the female lies anterior to\\nthe middle of the body (Fig. 56). The eggs when ripe", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0385.jp2"}, "386": {"fulltext": "366\\nDISEASES OF THE INTESTINES.\\nFig. 56.\u00e2\u0080\u0094 Ascaris Lumbricoides. (Perls.)\\nA, Female B, male. (Natural size.)\\nAt a is the female sexual orifice c,\\nthe two spicules of the male b, head\\nextremity (magnified) of the worm,\\nwith the three lips.\\nhave a double shell and\\naround this is an albumi-\\nnous envelope which is ir-\\nregularly shaped, and\\nstudded with excrescences\\n(Fig. 57). The long di-\\nameter of the egg is about\\n0.05 mm.\\nThe round worm pos-\\nsesses a strong odoriferous\\nprinciple which is very\\nperceptible even after the\\nworm has been carefully\\nwashed. According t o\\nHuber, this substance\\nmay occasion urticaria in\\npersons predisposed to this\\neruption. It is not im-\\nprobable that certain of\\nthe symptoms of ascariasis\\nare due to the action of\\nthe same element.\\nThe principal habitat of\\nascaris lumbricoides is the\\nsmall intestine of man. It\\ndevelops here often in large\\nnumbers, fifty to one hun-\\ndred and more occurring\\ntogether. The mode of\\ntransmission, according to\\n1 Huber Twentieth Century\\nPractice of Medicine, vol. viii.,\\np. 583.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0386.jp2"}, "387": {"fulltext": "ASCARIS LUMBRICOIDES.\\n367\\nLeuckart, Grassi, 1 and Lutz, 2 is by ingestioa of the eggs of\\nthe ascaris, there being no intermediate host. The full\\ndevelopment of the round worm from the egg to its period\\nof sexual maturity requires ten to twelve weeks. Infection\\nusually takes place by eggs existing in the soil near dwell-\\ning-places, in the drinking-water, and\\nalso in some foods, principally salads\\nand fruits. Ascaris lumbricoides is\\nmost frequently found in children three\\nto twelve years old, the poorer classes\\nshowing a larger percentage than the\\nwell-to-do. In grown persons the worm\\nis not so frequent. The female sex is\\nmore frequently infected than the\\nmale.\\nThe diagnosis of ascariasis is made\\nby the detection of the worm in the fecal matter, or of its\\neggs, which are easily recognized.\\nSymptoms. Ascariasis may exist without giving rise to\\nany symptoms whatever. Occasionally, however, there are\\nvarious disturbances anorexia, nausea, irregularity of the\\nbowel, meteorism, an irregular pulse; in children black\\nrings around the eyes, much nervousness, even convul-\\nsions. In rare instances progressive ansemia has been ob-\\nserved (Leichtenstern). Anatomically hyperemia of the\\nintestinal wall has been frequently found, erosions are rare.\\nItching of the nose is often present in ascariasis and may\\nbe due to the odoriferous principle.\\nThe round-worm is liable to wander and may then give\\nrise to severe complications. In several instances it has\\nFig. 57.\u00e2\u0080\u0094 Egg of As-\\ncaris Lumbricoides\\n(Leuckart) with Shell\\nand Albuminous En-\\nv e 1 o p e Magnified\\n300 diameters.\\n1 Grassi Centralbl. f Bacteriologie und Parasitenkunde, 1887.\\n2 Adolf Lutz Klinisclies iiber Parasiten des Menschen und der\\nHaustkiere. Centralbl. f. Bacteriologie, 1889.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0387.jp2"}, "388": {"fulltext": "368 DISEASES OF THE INTESTINES.\\nbeen found in the bile duct, in the gall bladder, and even\\nin the liver, producing abscesses and even a fatal issue.\\nThe worm occasionally migrates into the stomach and pro-\\nduces pain and often vomiting. In the latter act it is often\\nexpelled from the mouth. Occasionally it ascends the\\noesophagus and enters the larynx, causing asphyxia, and,\\nin rare instances, even death. It has also been found in\\nhernial sacs and in the peritoneal cavity, but it is gen-\\nerally believed that it cannot penetrate through the\\nhealthy intestinal wall. Obstruction of the bowels by a\\nconglomeration of ascarides has also been thought pos-\\nsible; its real occurrence, however, is denied by Leichten-\\nstern. 1\\nProphylaxis requires total destruction of all the eggs of\\nthe ascaris passed with the fecal matter of the patient.\\nThe grounds near dwellings should be kept perfectly clean\\nand the hands should be frequently washed. All foods\\nshould be protected against a possible infection.\\nTreatment. The treatment consists in freeing the pa-\\ntient from the worms. This is done in a similar manner\\nas in the case of tapeworms. The intestinal tract is kept\\npartially empty for a day or two before the administration of\\nthe anthelmintic. The most efficient remedy for this pur-\\npose is santonin, which is given in a dose of 0.02 to 0.06\\ngm. (gr. ^-i.) twice or four times a day. Then a purgative\\nremedy is given. Some combine the santonin with the\\npurgative and give them together. Thus santonin 0.2 (gr.\\niiiss.), castor oil 60 gm. 3 ii.), twice or three times daily\\none teaspoonful for small children, a dessertspoonful for\\nlarger children, and one tablespoonful for grown people.\\n1 Leichtenstern Verengerungen, Verschliessungen und Lageveran-\\nderungen des Darms. von Ziemssen s Hahdbuch der spec. Path, und\\nTherapie, Bd. vii., Abth. 2.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0388.jp2"}, "389": {"fulltext": "OXYURIS VERMICULARIS. 369\\nThe santonin may also be given in combination with cal-\\nomel; thus\\n3 Calomel 0.05 to 0.1 (gr. i.-ij.)\\nSantonin 0.02 (gr. i)\\nT. d. No. ix. S. One powder three times daily.\\nFlores cinse, the plant from which santonin is obtained,\\nmay also be administered in doses of 0.5 to 2 gm. as\\npowders or as an electuary, with the addition of jalap, 0.1\\nto 0.2 gm.\\nChenopodium or wormseed is also a popular remedy,\\nthe powdered seeds being given in doses of 1 to 2 gm.\\n(gr. xv.-xxx.), or the volatile oil in five to ten drop doses.\\nThymol has also been recommended in doses of 0.5 to\\n2 gm. (gr. vii.-xxx. in twenty -four hours. It maj r be given\\nin gelatin capsules. Irrigation of the bowels with water\\nto which three to five drops of benzene have been added\\nhas likewise been suggested, but does not appear as bene-\\nficial as santonin.\\nAscaris Mystax. A round-worm resembling ascaris lum-\\nbricoides but much smaller and somewhat thinner. This\\nparasite frequently occurs in animals, principally in cats,\\nbut has been discovered very rarely in man. No symp-\\ntoms whatever have been observed.\\nOxyuris Vermicularis, Awltail, Seat or Pin Worm, Mag-\\ngot or Thread Worm. This parasite is white and filiform,\\n4 to 12 mm. long and 0.2 to 0.6 mm. thick (Fig. 58). The\\nmales are much smaller than the females. The oxyuris\\nhas three small knoblike lips. The female possesses two\\nuteri passing backward and forward from the end of the\\nvagina. The opening of the latter is situated above the\\nmiddle of the body. The eggs are 0.05 mm. long and 0.02\\nwide. The contents are granular and the shell appears\\nwhite.\\n24", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0389.jp2"}, "390": {"fulltext": "370\\nDISEASES OF THE INTESTINES.\\nInfection takes place when the eggs of oxyuris reach the\\nstomach. Here the shell opens and the embryo migrates\\ninto the small intestine\\n(Fig. 59). After fructi-\\nfication has taken place\\nthe females usually begin\\nto wander along the in-\\ntestinal canal. In the\\ncaecum they generally\\nmake quite a long sojourn\\nuntil the eggs are almost\\nripe. Then they again\\nbegin to pass down-\\nward. According t o\\nLeichtenstern, Lutz, and\\nHuber, the females do not\\npass their eggs within\\nthe intestinal canal. As\\na rule they first leave the\\nFor this reason the fecal\\nFig. 58.\u00e2\u0080\u0094 Oxyuris Vermicularis a, natural\\nsize b, head c, tail, magnified d, head\\ngreatly magnified.\\nbowel and then deposit the eggs\\nmatter usualty does not contain any eggs.\\nThe symptoms which are most frequently observed con-\\nsist in pronounced pruritus ani due to the irritation pro-\\nduced by the passing of the parasites out from the rectum.\\nFrequently the itching annoys the patient as soon as he\\nretires. Various nervous symptoms are occasionally ob-\\nserved: anorexia, nausea, dizziness, palpitation of the\\nheart, pollutions and spermatorrhoea in the male besides\\ndiarrhoea occasionally occurs. Pronounced anaemia is en-\\ncountered, although rarely. In rare instances the para-\\nsites reach the vagina and cause irritation there. Nymph-\\nomania has then been observed.\\nInfection probably occurs through direct conveyance of", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0390.jp2"}, "391": {"fulltext": "OXYURIS VERMICULARIS.\\n371\\nthe eggs by the unwashed hands of the host. It is also\\npossible that ova dried by the sun exist on fruit, radishes,\\nor salads, in which state they may be carried into the\\nstomach.\\nThe diagnosis of the thread worm is made by inspection\\nof the anal region and by the finding of the oxyuris.\\nWith regard to prophylaxis extreme cleanliness is of the\\ngreatest importance. Fruits should be thoroughly cleaned\\nand then peeled before they are eaten. The eating uten-\\nsils of a person infected with oxyuris should never be used\\nby another, unless they have been thoroughly disinfected.\\nThe same applies to the clothes. Sleeping with an infected\\nperson should be forbidden, and even touching his hands\\nFig. 59.\u00e2\u0080\u0094 Development of Oxyuris Vermicularis. (Heller.) or-e, Segmentation of the\\nyolk f ovum containing tadpole-shaped embryo, seen from the side g, abdominal\\nview of the same h, ovuni with worm-shaped embryo i, embryo escaping from the\\nshell k free embryo capable of motion.\\nrequires immediate washing, as otherwise infection may\\ntake place.\\nTreatment. Santonin is the principal remedy for com-\\nbating oxyuriasis. It is given in the same way as de-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0391.jp2"}, "392": {"fulltext": "372 DISEASES OF THE INTESTINES.\\nscribed in the treatment of ascaris lumbricoides. Here,\\nhowever, irrigations of the bowel with water and the addi-\\ntion of a few drops of benzene or thymol or vinegar (three\\nto four tablespoonsful to a quart), or of sapo medicatus in\\na one-half to one-per-cent solution may be advantageously\\nused. The anal region should be thoroughly cleansed.\\nIf the pruritus ani is quite intense, application to the anal\\nregion and rectum of unguentum hydrarg. cinerei or the\\nuse of a suppository of ung. hydrarg. cinerei 1 gm., in\\ncacao butter 2 gm. will afford relief.\\nAnchylostoma Duodenale. Doclimius Duodenalis or Stron-\\ngylus Duodenalis.- This important parasite was first de-\\nscribed by Dubini l in 1838. Bilharz 2 and Griesinger 3\\nrecognized this parasite as the cause of the Egyptian\\nchlorosis. Some time afterward the anchylostoma was\\nobserved in severe cases of anaemia among workmen in\\ntunnels and brickmakers.\\nThe anchylostoma duodenale is cylindrical in shape, 0.5\\nto 1 mm. thick and 6 to 18 mm. long. It is yellowish or\\ngrayish-white in color, with translucent edges. The male\\nis much shorter than the female. The cephalic end is\\ncurved toward the dorsal surface and is provided with an\\noral capsule at the margin of which there are six hooklike\\nteeth. Further within the capsule there are three sharp\\nchitinous processes (Figs. 60 and 61). The male is more\\nslender and transparent than the female. Its head end is\\nbent backward. The tail end appears somewhat swollen,\\ncontaining the bursa copulatrix, and is much more curved\\nthan the head. In the female the caudal end is pointed\\nand armed with an awl-like prong; the genital opening\\n1 Angelo Dubini: Gaz. med. Lombard., 1843.\\n2 Bilharz Wiener med. Wochenschr. 1856.\\n3 Griesinger: Arch. f. physiolog. Heilkunde, 1854.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0392.jp2"}, "393": {"fulltext": "ANCHYLOSTOMA DUODENALE.\\n373\\nFig. 61.\u00e2\u0080\u0094 Cephalic End of Anchylostoma Duo-\\ndenale. (Schultheiss.) a, Mouth-capsule\\nb, teeth of ventral border c, teeth of dorsal\\nborder; d, buccal cavity: e, skin-sac on\\nventral side of head muscular layer gr,\\ndorsal groove h, oesophagus.\\nFig. 62.\u00e2\u0080\u0094 Eggs of Anchylostoma Duodenale.\\n(Perroncito and Schultheiss.) a, b, c, d,\\nV Different stages of cleavage e, eggs with\\nembryos. Magnified 200 diameters.\\nFig. 60.\u00e2\u0080\u0094 Male of Anchylostoma Duodenale. (Schultheiss.) a, Head with mouth-cap-\\nsule b, oesophagus c, intestine d, anal glands e, cervical glands skin g,\\nmuscular layer h, porus excretorius i, triple bursa fc, ribs of the bursa Z, testicu-\\nlar canal; m, vesicula seminalis n. ductus ejaculatorius o, groove of latter p,\\npenis q, sheath of penis. Magnified 20 diameters.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0393.jp2"}, "394": {"fulltext": "374 DISEASES OF THE INTESTINES.\\nlies behind the centre of the body. The eggs are oval,\\n0.06 mm. in length and 0.03 mm. in width (Fig. 62).\\nThe habitat of the anchylostoma is the duodenum, the\\njejunum, and the upper part of the ileum. Here the worm\\nattaches itself to the intestinal mucosa and feeds by suck-\\ning the blood of his host. According to Leichtenstern, J\\nactive migration of the worm begins at the time of the first\\ncopulation in the fifth week. Young worms change their\\nplace quite frequently and hence give rise to repeated hem-\\norrhages. Colic, and acute anaemia are encountered at an\\nearly period after infection.\\nUnder favorable conditions the eggs develop outside of\\nthe body into rhabditis-like larvae, becoming enclosed in\\na protecting envelope or encysted. In this stage the larvae\\nmay be carried along with the dust and contaminate fruit\\nand water. On reaching the small intestine they develop\\ninto mature worms. This parasite is always encountered\\nin great numbers if present in the intestines. Leichten-\\nstern never found them in a smaller number than one\\nhundred, but sometimes their total reached three thou-\\nsand.\\nThe symptoms produced by anchylostoma consist of gas-\\ntralgia, nausea, occasionally vomiting, constipation, rarely\\ndiarrhoea, and severe anaemia, the latter becoming progres-\\nsively worse. The patient with anchylostoma does not\\ngreatly emaciate, but becomes pale, extremely weak, and\\nsuffers from dizziness and shortness of breath after the\\nslightest exertion. His extremities are cold, slight hemor-\\nrhages occur frequently, and oedema of the ankles devel-\\nops. A systolic murmur may be heard at the apex of the\\nheart, the pulse is accelerated, and fever may be present\\n1 Leichtenstern Centralbl. f klin. Medicin, 1885, and Deutsche med.\\nWochenschr., 1885, 1886, 1887.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0394.jp2"}, "395": {"fulltext": "ANCHYLOSTOMA DUODENALE, 375\\ntoward evening. An inclination to eat earth (geophagia)\\nis not rarely observed.\\nThe dejecta are of a brownish color, although admixture\\nof blood cannot be recognized macroscopically. Micro-\\nscopically Charcot-Ley den s crystals, as well as the eggs\\nof the parasites, are often found in the stools. The urine\\nrarely contains albumin, but frequently indican. The con-\\ndition of the blood resembles that found in pernicious\\nanaemia enormous decrease of the red blood corpuscles,\\npoikilocytosis, nucleated red blood corpuscles, and a slight\\nincrease of the leukocytes, especially of the eosinophile\\ncells.\\nAnatomically the mucosa of the small intestine is found\\ngreatly congested and ecchymoses are visible here and\\nthere. Peyer s patches and the solitary follicles are often\\nswollen. The heart is found hypertrophied and dilated,\\nthe liver and spleen may be diminished in size, normal, or\\nin an amyloid condition. The same can be said of the\\nkidneys. There is no doubt that the principal deleterious\\naction of the anchylostoma consists in the profuse loss of\\nblood caused by the parasites. Whether some toxic sub-\\nstances generated by them participate in producing the\\ngrave symptoms is questionable.\\nThe course of the disease is protracted and its severity\\ndepends greatly upon the number of parasites present. If\\nthe latter is great, the disease may progress quickly and\\nthe patient succumb with the symptoms of general dropsy,\\ndyspnoea, and heart failure or pulmonary oedema. If the\\nnumber of the parasites is small, the patient may live\\nmany years and ultimately recover entirely. Recovery is\\nalso possible by successful expulsion of the parasites from\\nthe intestinal tract.\\nThe diagnosis of ankylostomiasis is made by the pres-", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0395.jp2"}, "396": {"fulltext": "376\\nDISEASES OF THE INTESTINES.\\nence of the symptoms of anaemia in conjunction with the\\ndiscovery of the anchylostoma eggs in the dejecta.\\nWith regard to prophylaxis the\\nabove given rules for the prevention of\\nthe round- and thread-worms are also\\napplicable here. Extreme cleanliness\\nof the body and of the food is of\\ngreatest importance.\\nThe treatment consists in the ad-\\nministration of extract of male-fern,\\nwhich should be employed in the\\nsame manner as described above for\\nthe tapeworm disease.\\nAnguillula Stercoralis. This nema-\\ntode is 0.8 to 1.2 mm. long, the male\\nshorter than the female (Fig. 63).\\nThe male is indigenous in Cochin\\nChina and Italy. In the latter coun-\\ntry it often occurs simultaneously with\\nanchylostoma. If the worms exist in\\nlarge numbers they may produce patho-\\nlogical conditions. According to Golgi\\nand Monti, 1 the anguillula stercoralis\\npenetrates into Lieberkuehn s crypts\\nand there deposits its eggs and young.\\nAnguillula intestinalis, which is 2.25\\nmm. long, belongs to the same variety\\nas anguillula stercoralis and is found\\nunder the same conditions. Only the female of this worm\\nis known. The eggs develop in the intestinal canal and\\nexhibit only the first stages of segmentation at the time\\nof their passage with the faeces.\\n1 Golgi e Monti Arch, per le science med. 1886, No. 3.\\nFig. 63.\u00e2\u0080\u0094 Female of An-\\ng u i 1 1 u 1 a Stercoralis,\\nwith Eggs and Embryos.\\n(Perroncito.) Magni-\\nfied 85 diameters.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0396.jp2"}, "397": {"fulltext": "TRICHOCEPHALUS DISPAR. 377\\nTricliocephalus Dispar. Whip- Worm. This parasite is\\nquite common, but comparatively harmless. Its habitat\\nis the csecum and the neighboring section of the intestine.\\nIt lives upon blood which it abstracts from the intestinal\\nmucosa. This parasite is 4-5 cm. long, the male being\\nsmaller than the female. The head end, which is about\\nthree-fifths of the entire length, is drawn out into a fine\\nthread; the tail end is not so thin, being up to 1 mm. in\\nthickness (Fig. 64). The male has a spiral body from the\\nend of which the spicule projects. The body of the fe-\\nmale is straight and terminates in a blunt extremity. The\\nFig. 64.\u00e2\u0080\u0094 Trichocephalus Dispar. (Heller.) a, Fig. 65.\u00e2\u0080\u0094 Ova of Trlchocephalus\\nFemale b, male. Natural size. Dispar in Process of Develop-\\nment. (Huber.)\\nova are almost lemon-shaped, dark brown in color, 0.05\\nmm. in diameter (Fig. 65). The number of eggs in a sin-\\ngle female was estimated by Leuckart at 58,000. They are\\nhatched out very slowly.\\nLeuckart asserts that the dispersion of the eggs and con-\\nsequent spread of infection may readily occur through\\nwind, rain, or dust, and that the eggs may be ingested with\\nfruit and salads. The number of these worms found in\\none patient is usually small, from six to twenty.\\nThe symptoms are but very slight, occasionally diarrhoea\\nexists, sometimes there are some reflex nervous conditions.\\nThe diagnosis can usually be easily made from the shape\\nof the ova. The passage of the living worms in the stools\\noccurs but rarely.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0397.jp2"}, "398": {"fulltext": "378\\nDISEASES OP THE INTESTINES.\\nPlate I.\u00e2\u0080\u0094 Trichina Spiralis (Huber).", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0398.jp2"}, "399": {"fulltext": "TRICHINA SPIRALIS. 379\\nWith regard to treatment Lutz recommends the admin-\\nistration of thymol Mosler l and Peiper 2 employ rectal\\nirrigation of water, to which a few drops of benzene have\\nbeen added. Extract of male-fern may also be used inter-\\nnally.\\nTrichina Spiralis. The trichina spiralis was discovered\\nby Paget, 3 but its pathological importance was first recog-\\nnized by Zenker. 4 This parasite is observed in two forms,\\nthe trichina of the intestine and the trichina of the muscles\\n(see Plate I.).\\nThe trichina reaches the stomach through the ingestion\\nof pork containing encapsulated trichinae. In the stomach\\nthe capsule opens about three to four hours after the inges-\\n1 Mosler: Darminf usion. Real-Encyclopadie der gesairmiten Heil-\\nkunde, Bd. v.\\n2 Peiper Helminthen. Real-Encyclopadie der gesammten Heil-\\nkimde, Bd. ix.\\n3 Paget, cited after Huber: Twentieth Century Practice of Medi-\\ncine, vol. viii., p. 608.\\n4 Zenker Deutsches Arch, flir klin. Medicin, i. 1866.\\nExplanation of Plate I.\\nFig. 1.\u00e2\u0080\u0094 Muscle Trichina Enclosed in a Fully Developed Cyst. X 240. Cy, cyst; Bg,\\nconnective-tissue envelope Ffr, fat globules.\\nFig. 2\u00e2\u0080\u0094 The Same Removed f roin the Cyst. X 400. Oe, (Esophagus Zk, cell\\nbodies L, side lines Ov, ovary Ch.D, chyle duct.\\nFig. 3.\u00e2\u0080\u0094 Part of the Ovary, x 600. Is readily distinguished from the testicle by the\\nvarying size of the germ cells.\\nFig. 4.\u00e2\u0080\u0094 Male Intestinal Trichina. X 100. T, Testicle d ej, ejaculatory duct Zk,\\ncell bodies.\\nFig. 5.\u00e2\u0080\u0094 Female Intestinal Trichina. X 90. Or, ovary; E, embryos Oe, genital\\nopening from which the embryos escape.\\nFig. 6.\u00e2\u0080\u0094 Free Embryo. X 400. O, mouth A, anus.\\nFig. 7.\u00e2\u0080\u0094 Embryo About Three Days After Having Entered the Muscle Fibre. JJF,\\nnormal muscle fibre.\\nFig. 8.\u00e2\u0080\u0094 Muscle Trichina, About Six Days Old, in the Greatly Swollen Sarcolemma\\nSheath Traversed by Capillary Vessels, Cap.\\nFig. 9.\u00e2\u0080\u0094 Muscle Trichina, Four Weeks Old, Enclosed in a Capsule, Cy A, within the\\nsarcolemma sheath. Sfr; Bh\\\\ connective-tissue capsule in process of active growth; 7c,\\nnuclei 3IF. contents of the sarcolemma sheath at each pole of the capsule.\\nFig. 10.\u00e2\u0080\u0094 Muscle Trichina with Calcified Capsule. FTi, Fat globules.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0399.jp2"}, "400": {"fulltext": "380 DISEASES OF THE INTESTINES.\\ntion of the meat and the embryos rapidly develop. At the\\nend of thirty to forty hours fructification of the young par-\\nasites takes place.\\nThe intestinal trichinae are visible with the naked eye,\\nthe females being 3 to 4 mm. long and the males half this\\nsize. The caudal extremity is thicker than the head end.\\nFive days after fecundation the females give birth to living\\nyoung ones. The young brood wanders directly from the\\nintestine of the host into his muscles. Here they further\\ndevelop. In this condition they give rise to a febrile dis-\\nease accompanied by severe muscular symptoms which\\nmay lead to death. Sometimes the trichinse become en-\\ncapsulated. The symptoms vary according to the number\\nof worms which have been ingested. Gastro-intestinal dis-\\nturbances usually appear on the second or third day after\\nthe ingestion of the contaminated meat. Vomiting, diar-\\nrhoea, colic often appear.\\nThe disease known as trichinosis, which depends upon\\nthe further development of the young embryos in the mus-\\ncles of the host, is not within the scope of this book, and\\nwe refer to this parasite only as far as its occurrence in\\nthe intestines is concerned. With regard to prophylaxis\\npork should never be eaten raw. The treatment after the\\ningestion of trichinous meat consists in the employment of\\nlavage of the stomach, if the physician is called early enough\\nafter the meal. In addition a vermifuge and cathartic rem-\\nedy should be given immediately.", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0400.jp2"}, "401": {"fulltext": "INDEX.\\nAbelmann, 22\\nAbsorption as a function of the\\nbowel, 24\\nAcholic stool, 58\\nAdenoma of the intestines, 167\\niEgineta, Paulus, 335\\nAlbumin in the fseces, 53\\nAlbuminates, putrefaction of, in\\nthe large intestine, 21\\nAlimentation, rectal, 77\\nsubcutaneous, 77\\nAllingham, 37, 172, 185, 188\\nAllingham s rectal speculum, 37\\nAmoeba, 349\\nAmoebic dysentery, 110\\nAmyloid ulcers, 140\\nAnacker, 311\\nAnaesthesia of the intestine, 333\\nof the rectum, 333\\ntreatment, 334\\nAnatomy of the intestine, 1\\nAnchylostoma duodenale, 372\\ncourse, 375\\ndiagnosis, 375\\nprophylaxis, 376\\nsymptoms, 374\\ntreatment, 376\\nAngioma of the intestines, 167\\nAnguillula intestinalis, 376\\nstercoralis, 376\\nAntiperistalsis of the intestine,\\n30\\nAnus, anatomy of the, 16\\nfissure of the, 193\\nAppendicitis, 196\\nAppendicitis, definition, 196\\ndiagnosis, 214\\ndifferential diagnosis, 215\\netiology, 197\\ngeneral remarks, 196\\nmorbid anatomy, 202\\nprognosis, 216\\nsymptomatology, 206\\nsynonyms, 196\\ntreatment, 218\\ncatarrhal, 202\\nindications for operation, 225\\nperforativa, 204\\nsevere form, 204\\nulcerosa et gangraenosa, 204\\nAppendicular inflammation; 196\\nAppendix vermiformis, 13\\nAretaeus, 110\\nAscariasis, diagnosis, 367\\nprophylaxis. 368\\nsymptoms, 367\\ntreatment, 368\\nAscaris lumbricoides, 365\\nmystax, 369\\nAtony of the bowel, 291\\nAuscultation, 45\\nAwl-tail, 369\\nBalantiditjm coli, 351\\nBamberger, 200\\nBarbacci, 200\\nBarthelemy, 114\\nBasch, 55\\nBauhin s valve, 13\\nBayle, 141", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0401.jp2"}, "402": {"fulltext": "382\\nINDEX.\\nBeauchef, 111\\nBeck, Carl, 198, 222\\nBenign tumors of the intestines,\\n167\\nBernard, Claude, 19\\nBienstock, 74\\nBile pigment in the faeces, 57\\nBilharz, 372\\nBilharzia haematobia, 364\\nBiliary acids in the faeces, 57\\nBirch-Hirschfeld, 144\\nBlood in the faeces, 56\\nBoas, J., 42, 48, 90, 212, 214, 219,\\n220, 221, 224, 339\\nBonnecken, 248\\nBorborygmi, 45\\nBothriocephalus cordatus, 359\\nlatus, 357\\nBouchard, 99, 298\\nBoudet, 81, 263, 309\\nBougies, rectal, 43\\nBowel, atony of the, 291\\nBrahm-Houkgeest, 28, 283\\nBrinton, 254\\nBrooks, LeRoy J., 267\\nBrunner s glands, 9\\nBrunton, 324\\nBryant, J. D., 13, 151\\nBull, W. T., 197, 223\\nBunge, 59\\nCaecum, anatomy of the, 12\\nCalm, 261\\nCancer of the duodenum, symp-\\ntoms, 159\\nof the intestine, 150\\ncourse, 163\\ndefinition, 150\\ndiagnosis, 163\\netiology, 150\\nlocation, 151\\nmorbid anatomy, 152\\nprognosis, 164\\nsymptomatology, 154\\ntreatment, 164\\nCancer of the large bowel, symp-\\ntoms, 160\\nof the rectum, symptoms, 161\\nof the small intestines, symp-\\ntoms, 160\\nCarbohydrates in the faeces, 54\\nCarbolic-acid injections in hemor-\\nrhoids, 186\\nCash, 324\\nCatarrh, acute intestinal, 83\\nchronic, of the bowels, 94\\nCauterization in hemorrhoids, 186\\nCelsus, 110\\nCercomonas intestinalis, 350\\nCestodes, 351\\nCharcot, 286\\nChlapowski, 40\\nCholera nostras, 83\\nClapotage, 42\\nClark, Alonzo, 220, 302\\nColic, intestinal, 326\\nmucous, 335\\nColitis, acute, 90\\nColon, anatomy of the, 11\\nascending, 14\\ndescending, 15\\ntransverse, 14\\nCompression of the intestine, 227\\nConcretions in the faeces, 59\\nConstipation, 291\\ndefinition, 291\\ndependent upon other dis-\\neases, 296\\ndiagnosis, 302\\netiology, 292\\nhabitual, 291\\nprognosis, 304\\nprophylaxis, 304\\nsymptomatology 297,\\nsynonyms, 291\\ntreatment, 304\\ndietetic, 305\\nmechanical, 306\\nmoral, 305\\nCooper, 187", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0402.jp2"}, "403": {"fulltext": "INDEX.\\n383\\nCooper-Forster, 155\\nCornil, 342\\nCouncilman, 113, 115, 118\\nCrede, 279\\nCrushing in the treatment of\\nhemorrhoids, 188\\nCruveilhier, 171, 337\\nCurschmann, 258, 264\\nCysts of the intestines, 167\\nDa Costa, 337, 338, 344\\nDamsch, 46\\nDastre, 19\\nDeaver, 222\\nDemant, 282\\nDelafield, F.,101\\nDiarrhoea, 284\\nacute, 83\\ndiagnosis, 289\\ndyspeptic, 287\\netiology, 284, 288\\nmembranous, 335\\nmorning, 101\\nnervous, 284\\nprognosis, 289\\nstercoral, 288\\nsymptomatology, 284, 288\\ntreatment, 289\\ntubular, 335\\nDiet, 74\\nDilatation of the sphincters in the\\ntreatment of hemorrhoids, 185\\nDistoma haematobium, 364\\nhepaticum, 362\\nlanceolatum, 363\\nDochmius duodenalis, 372\\nDouglas fold, 15\\nDoumer, 309\\nDubini, 372\\nDunin, 294\\nDuodenal ulcer, 128\\ncourse, 133\\ndefinition, 128\\ndiagnosis, 133\\netiology, 128\\nDuodenal ulcer, morbid anatomy,\\n129\\nprognosis, 134\\nsymptomatology, 131\\nsynonyms, 128\\ntreatment, 134\\nDuodenitis, acute, 89\\nDuodenum, anatomy of the, 1\\nDutrouleau, 121\\nDynamic ileus, 257\\nDysentery, 110\\namoebic, 110\\ncomplications, 123\\ncourse, 123\\ndefinition, 110\\ndiagnosis, 125\\netiology, 110\\nmorbid anatomy, 115\\nprognosis, 125\\nsymptomatology, 119\\nsynonyms, 110\\ntreatment, 125\\nDyspeptic diarrhoea, 287\\nEdebohls, 198, 207, 208\\nEdwards, 338\\nEhrlich, 338, 342\\nEhrmann, 31\\nEichberg, 113\\nEichhorst, 131\\nEisenlohr, 139\\nElectricity in intestinal obstruc-\\ntion, 263\\nin the treatment of constipa-\\ntion, 308\\nin the treatment of disease, 81\\nElsberg, C. A., 70\\nEmbolic ulcers, 135\\nEmbolus of the arteria mesaraica\\nsuperior, 136\\nof the inferior mesaraic artery,\\n139\\nEndo-appendicitis, 203\\nEnemata in the treatment of con-\\nstipation, 310", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0403.jp2"}, "404": {"fulltext": "384\\nINDEX.\\nEnteralgia, 326\\ndefinition, 326\\ndiagnosis, 329\\netiology, 326\\nprognosis, 330\\nsymptomatology, 327\\nsynonyms, 326\\ntreatment, 330\\nEnteritis, acute, 83\\nchronic, 94\\ncrouposa, 110\\nmembranous, 335\\nnecrotica, 110\\nEnterospasmus, 295\\nErdmann, John F., 267\\nEscherich, 73, 200\\nEsmarch, 189\\nEwald, C. A., 62, 96, 131, 219, 220,\\n224, 339, 340\\nExamination, methods of, 32\\nExtirpation of hemorrhoids, 189\\nFaeces, abnormal admixtures in\\nthe, 51\\nalbumin in the, 53\\nbile pigment in the, 57\\nbiliary acids in the, 57\\nblood in the, 56\\ncarbohydrates in the, 54\\nchemical examination of the,\\n52\\nconcretions in the, 59\\nexamination of the, 49\\nfat in the, 55\\nferments in the, 59\\nfragments of tumor in the, 51\\nmicro-organisms in the, 71\\nmicroscopical examination of\\nthe, 62\\nmucin in the, 53\\nodor, 50\\npeptone in the, 54\\npropeptone in the, 54\\npus in the, 51\\nreaction of the, 52\\nFaeces, remnants of food in the, 51\\nFat in the faeces, 55\\nFecal accumulation as a cause of\\nchronic obstruction, 273\\nfever, 302\\ntumors complicating constipa-\\ntion, 300\\nFerguson, E. D., 233, 267\\nFermentation test, Schmidt s, 55\\nFerments in the faeces, 59\\nof the pancreas, 19\\nFever, fecal, 302\\nFibroma of the intestines, 167\\nFinger cot, 42\\nFischel, 286\\nFischl, 89\\nFissure of the anus, 193\\nFitz, Reginald, 114, 197, 222, 258\\nFlatau, 312\\nFlatulency, 321\\nFleiner, 79, 262, 311, 346\\nFleischer, 59, 214, 282\\nFluke worms, 362\\nForeign bodies, obturation by, 234\\nFowler, 197, 199, 200, 202, 214, 222\\nFrentzel, 265\\nFrerichs, 141\\nFrieclenwald, J., 43\\nFurbringer, 265\\nGall stones, obturation by, 233\\nGalvano-cautery in the treatment\\nof hemorrhoids, 188\\nGerhardt, 137\\nGerry, 114\\nGersuny, 41\\nGibson, C. L., 266\\nGlycerin injections in the treat-\\nment of constipation, 311\\nGolgi, 376\\nGood, Mason, 336\\nGouley, J. W., 267\\nGraser, 189, 259, 264, 265\\nGrasse, 367\\nGraves, 220", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0404.jp2"}, "405": {"fulltext": "INDEX.\\n385\\nGrawitz, 139\\nGriesinger, 372\\nGrisolle, 196, 197, 220\\nGuttmann, P., 204\\nGymnastic exercises in the treat-\\nment of constipation, 308\\nexercises in the treatment of\\ndisease, 80\\nHabershon, 79, 300\\nHabitual constipation, 291\\nHackel, 309\\nHaguenot, 241\\nHall, Marshall, 87\\nHammarsten, 26\\nHarris, 113, 114, 116, 127\\nHaustra coli, 12\\nHawkes, F., 223\\nHegar, 139\\nHemorrhoids, 169\\ncomplications, 189\\ndefinition, 169\\ndiagnosis, 179\\netiology, 169\\nmorbid anatomy, 171\\nprognosis, 180\\nsymptomatology, 174\\nsynonyms, 169\\ntreatment, 180\\nradical, 185\\nHenrot, 314\\nHeryng, 39\\nHeusgen, 155\\nHippocrates, 110\\nHirschler; 22\\nHlava, 113\\nHodenpyl, 200\\nHoffmann, 265\\nHouston, 186\\nHoyer, 338\\nHuber, 356, 366, 370\\nHydrocephaloid, acute, 87\\nHydrotherapy, 80\\nin the treatment of constipa\\ntion, 309\\n25\\nHyperesthesia of the intestine, 333\\nHypogastric neuralgia, 332\\ntreatment, 332\\nIleocecal valve, 13\\nIleum, anatomy of the, 4\\nIleus, 227\\ndynamic, 257\\nIlloway, 307\\nIncarceration, acute, 255\\nInflation of the bowel with air in\\nintestinal obstruction, 262\\nof the intestine, 45\\nInfusoria, 350\\nInjection of water per anura for\\nexamination, 48\\nInjections as a method of treat-\\nment, 78\\nin the treatment of constipa-\\ntion, 310\\nInspection, 34\\nInterrogation, 32\\nIntestinal catarrh, acute, 83\\ndefinition, 83\\ndiagnosis, 91\\nduration, 90\\netiology, 83\\nlocalization, 89\\nmorbid anatomy, 85\\nprognosis, 91\\nsymptomatology, 86\\nsynonyms, 83\\ntreatment, 91\\ncatarrh, chronic, 94\\ncourse, 103\\ndefinition, 94\\ndiagnosis, 103\\netiology, 94\\nmorbid anatomy, 95\\nsymptomatology, 98\\nsynonyms, 94\\ntreatment, 105\\ncolic, 326\\nneurasthenia, 347\\ndiagnosis, 348", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0405.jp2"}, "406": {"fulltext": "386\\nINDEX.\\nIntestinal neurasthenia, treatment,\\n348\\nobstruction, 226\\nobstruction, acute, 226\\ncourse, 247\\ndefinition, 227\\ndiagnosis, 249\\netiology, 227\\nlocation of the obstruc-\\ntion, 251\\nobjective signs, 245\\npathological changes, 236\\nrecognition, 249\\nrecognition of the differ-\\nent forms, 255\\nsymptomatology, 238\\nsynonyms, 227\\ntreatment, 258\\ntreatment, medical, 258\\ntreatment, surgical, 266\\nobstruction, chronic, 268\\ncomplications, 276\\ncourse, 277\\ndiagnosis, 277\\netiology, 268\\nprognosis, 277\\nsymptomatology, 269\\ntreatment, 278\\ntreatment, surgical, 280\\nparasites, 349\\nvertigo, 301\\nIntestine, anatomy of the, 1\\nanaesthesia of the, 333\\ncompression of the, 227\\nhyperesthesia of the, 333\\nobturation of the, 233, 256\\nparesthesia of the, 333\\nstrangulation of the, 228\\nIntestines, motor neuroses of the,\\n284\\nneoplasms of the, 150\\nnervous affections of the, 282\\nclassification, 283\\nparalysis of the, 314\\ndiagnosis, 315\\nIntestines, paralysis of the, treat-\\nment, 315\\nperistaltic restlessness of the,\\n319\\nsecretory neuroses of the,\\n335\\nsensory neuroses of the, 326\\nulcers of the, 128\\nIntussusception, 234, 256\\nagonal, 236\\nIrrigator, Kemp s rectal, 79\\nJaffe, 253\\nv. Jaksch, 54\\nJejunitis, acute, 89\\nJejunum, anatomy of the, 4\\nJi irgens, 97\\nKahn, Arthur, 308\\nKartulis, 112, 113\\nKelly, 37\\nKelly s rectal speculum, 38\\nKelsey, 186\\nKemp s rectal irrigator, 79\\nKerkring s valves, 8\\nKittagawa, 339\\nKlebs, 144\\nKlemperer, 310, 311\\nKlubbe, 262\\nKoch, 112\\nKocher, 264\\nKoenig, 269\\nKorte, 265\\nKossobudskj, 184\\nKraus, 129\\nKuhn, 44\\nKundrat, 166\\nKussmaul, 137, 261, 262, 309, 311,\\n346\\nLaboulbene, 337\\nLafleur, 113, 115, 118\\nLambl, 112\\nLange,F., 186, 192\\nLangenbeck, 188", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0406.jp2"}, "407": {"fulltext": "INDEX.\\n387\\nLarge bowel, physiology of the,\\n18\\nstructure of the, 17\\nintestine, anatomy of the, 11\\nLavage of the bowel, 48\\nin intestinal obstruction,\\n262\\nof the stomach in intestinal\\nobstruction, 261\\nLaveran, 124\\nLegueu, F.. 222\\nLeichtenstern, 67, 226, 228, 295,\\n367, 368, 370, 374\\nLemazurier, 300\\nLenander, 197\\nLeube, 77, 134, 301\\nLeubuscher, 309\\nLeuckart, 356, 367. 377\\nLevi, 300\\nv. Leyden, 214, 338, 342\\nLieberkiilm s glands, 9\\nLigature in hemorrhoids, 187\\nLimbourg, 22\\nLindberger, 22\\nLipoma of the intestines, 167\\nLitten, 136\\nLiver fluke, 362\\nLoesch, 112\\nLudwig, 25\\nLusk, 19, 26\\nLutz, 367, 370. 379\\nLympho-sarcoma of the intestines,\\n*166\\nMacfadyen, 20, 72\\nMadelung, 167\\nMalmsten, 351\\nMarcy, H. O., 267\\nMatterstock, 201\\nMaggot -worm, 369\\nMannaberg, 73\\nMassage in intestinal obstruction,\\n263\\nin the treatment of constipa-\\ntion, 306\\nMassage in the treatment of dis-\\nease, 80\\nMassaiutin, 113\\nMassloff 282\\nMathews, 90\\nMayer, 128\\nMayor, A., 90\\nMcBurney, 41, 197, 223\\nMcCosh, A. J., 223\\nMeckel s diverticulum, strangula-\\ntion by, 230\\nMembranous diarrhoea. 335\\nenteritis, 335\\ndefinition, 335\\ndiagnosis, 343\\netiology, 339\\nhistory, 335\\nsymptomatology, 341\\nsynonyms. 335\\ntreatment, 344\\nMendelson, Walter, 339\\nMercury, metallic, in intestinal\\nobstruction. 265\\nMeteorism, 321\\ndiagnosis. 323\\netiology, 321\\nprognosis. 323\\nsymptomatology, 322\\ntreatment, 323\\nMeydl, 151\\nMeyer, Willy, 223, 224\\nMicro-organisms in the fa?ces, 71\\nMiller, 22\\nMinich. 61\\nMinkowski, 28, 47\\nMiserere, 227\\nMonti, 376\\nMoreau, 282\\nMorgagni, 336\\nMorris? R T., 208, 222\\nMosler, 379\\nMotion of the intestine, 28\\nMucin in the faeces, 53\\nMucous colic, 335\\nMidler. Max. 152", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0407.jp2"}, "408": {"fulltext": "388\\nINDEX.\\nMunk, 25, 27\\nMurphy, 222, 280\\nMurphy s button, obturation by,\\n234\\nMusser, 113\\nMyoma of the intestines, 167\\nNasse, 113\\nNematodes, 365\\nNencki, 19, 20, 72\\nNeoplasms of the intestines, 150\\nNervous aifections of the intes-\\ntines, 282\\ndiarrhoea, 284\\nNeuralgia, hypogastric, 332\\nmesenterica, 326\\nNeurasthenia, intestinal, 347\\nNeuroses of the intestines, motor,\\n284\\nsecretory, 335\\nsensory, 325\\nv. Noorden, C, 56, 344, 345\\nNothnagel, 28, 30, 74, 138, 150,\\n166, 197, 202, 214, 217, 220, 224,\\n235, 269, 283, 285, 294, 302, 338,\\n342\\nNuttal, 72\\nObstipatio, 291\\nObstruction, intestinal, 226\\nObturation of the intestine, 233,\\n256\\nOil injections in the treatment of\\nconstipation, 311\\nOpium in intestinal obstruction,\\n259\\nOppolzer, 330\\nOsier, 113\\nOxyuris vermicularis, 369\\ndiagnosis, 371\\nprophylaxis, 371\\nsymptomatology, 370\\ntreatment, 371\\nPaget, 379\\nPalpation, 40\\nPancreatic juice, digestive power\\nof, 19\\nParesthesia of the intestine, 333\\nParalysis of the intestines, 314\\nof the sphincters of the anus,\\n317\\ndiagnosis, 318\\nprognosis, 318\\ntreatment, 318\\nParamecium coli, 351\\nParasites, intestinal, 349\\nParatyphlitis, 196\\nParenski, 135\\nParesis of the sphincters of the\\nanus, 317\\nPariser, 53, 339, 342\\nPassio iliaca, 227\\nPean, 280\\nPeiper, 379\\nPenzoldt, 214, 219, 220, 224\\nPeptone in the faeces, 54\\nPercussion, 44\\nPeristalsis of the intestine, 28\\nPeristaltic restlessness of the in-\\ntestines, 319\\ndefinition, 319\\ndiagnosis, 320\\netiology, 319\\nsymptomatology, 319\\ntreatment, 320\\nPerityphlitis, 196\\nPetriquin, 220\\nPettenkofer, 57\\nPeyer, 285\\nPeyer s patches, 11\\nPfluger, 30\\nPhlebectasia hemorrhoidalis, 169\\nPighead, 357\\nPiles, 169\\narterial, 172\\ncapillary, 172\\nvenous, 173\\nPilliet, 139\\nPin-worm, 369", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0408.jp2"}, "409": {"fulltext": "INDEX.\\n389\\nPlica Douglasii, 15\\nPoelchen, 145\\nPolypi of the intestines, 167\\nPooley, 186\\nProctitis, 90\\nProctoscopy, 37\\nProctospasmus, 316\\ndiagnosis, 317\\ntreatment, 317\\nProlapse of the rectum, 189\\nPropeptone in the faeces, 54\\nProtozoa, 349\\nPuncture of the bowel in intestinal\\nobstruction, 264\\nPurgatives in the treatment of\\nconstipation, 312\\nPutrefaction of albuminates in the\\nlarge intestine, 21\\nQuincke, 50, 113, 282\\nRachford, 19\\nRectal alimentation, 77\\nbougies, 43\\nelectrode, 81\\nspecula, 37\\nRectum, anaesthesia of the, 333\\nanatomy of the, 15\\nprolapse of the, 189\\nReichmann, 39\\nRibbert, 198\\nRiedel, 202, 224\\nRieder, 66\\nRoentgen rays in examination of\\nthe bowel, 39\\nRomberg, 332\\nRose, A., 263, 307\\nRosenbach, 46, 247\\nRosenheim, 102, 167, 308, 315, 319,\\n323, 347\\nRosenslein, 25, 27\\nRoss, 113\\nRothmann, 338\\nRotter, 197\\nRound-worms, 365\\nRoux, 186, 197\\nRubner, 27\\nRuedi, 297\\nRuneberg, 46\\nRushmore, J. D., 267\\nSahli, 197, 217, 220, 307, 324\\nSalmon, 187\\nSalvioli, 25\\nSands, 197\\nSarcoma of the intestines, 166\\nSasaki, 97\\nSchiff, 28\\nSchmidt, 54, 58\\nSchmidt s fermentation test, 55\\nSchmidt-Muhlheim, 25\\nSchmitz, 22\\nSchnetter, 46\\nSchoening, 150\\nSchuberg, 113\\nScolecoiditis, 196\\nSeat-worm, 369\\nSecretory function of the intes-\\ntines, 18\\nneuroses of the intestines, 335\\nSenator, 302\\nSenn, 263\\nSennertius, 336\\nSieber, 20, 72\\nSigmoid flexure of the colon, 15\\nSimon, 43\\nSims, 37\\nSims rectal speculum, 37\\nSiredey, F., 336, 344\\nSmall intestine, anatomy of the, 4\\nstructure of the, 6\\nSodre, 111, 116, 126\\nSolitary follicles of the intestines,\\n10\\nSonnenburg, 197, 214, 224\\nSpasm of the rectum, 316\\nSpasmodic contraction of the\\nbowel, 295\\nSpecula, rectal, 37\\nSpool-worm, 365", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0409.jp2"}, "410": {"fulltext": "390\\nINDEX.\\nSporozoa, 350\\nS romanum, 15\\nStarke, 129\\nStein, R, 224\\nStengel, 113\\nStercoral diarrhoea, 288\\nStewart, 267\\nStockton, 113\\nStokes, 220\\nStool, acholic, 58\\nStrangulation of the intestine, 228\\nStricture of the rectum as a cause\\nof chronic obstruction, 275\\nStrongylus duodenalis, 372\\nSubcutaneous alimentation, 77\\nSutton, E. M., 47\\nSyms, Parker, 267\\nSyphilitic ulcers, 144\\nTaenia cucumerina, 358\\ndiminuta, 359\\nflavopunctata, 359\\nlata, 357\\nmediocanellata, 355\\nnana, 358\\nsaginata, 355\\nsolium, 354\\nTaenia? of the large intestine, 12\\nTalamon, 197\\nTapeworms, 351\\nprophylaxis, 359\\ntreatment, 359\\nTavel, 200\\nThermocautery in the treatment\\nof hemorrhoids, 188\\nThierfelder, 72\\nThread-worm, 369\\nThrombotic ulcers, 135\\nThrombus of the mesenteric veins,\\n139\\nToxic ulcers, 145\\nTransillumination of the bowel, 39\\nTrastour, 262\\nTreatment, methods of, 74\\nTrematodes, 362\\nTrematodes, treatment, 365\\nTreves, 192, 214, 236, 240, 259, 262,\\n264, 266, 268, 270, 271, 281\\nTrichina spiralis, 379\\nsymptoms, 380\\nTrichinosis, 380\\nprophylaxis, 380\\ntreatment, 380\\nTrichocephalus dispar, 377\\ndiagnosis, 377\\nsymptoms, 377\\ntreatment, 379\\nTrichomonas intestinalis, 350\\nTrousseau, 284\\nTuberculous ulcers, 141\\nTubular diarrhoea, 335\\nTympanites, 321\\nUlcer, duodenal, 128\\nUlcers, amyloid, 140\\nembolic, 135\\nof the intestines, 128\\nS3 r philitic, 144\\nthrombotic, 135\\ntoxic, 145\\ntuberculous, 141\\nUrobilin in the fseces, 57\\nValve, ileo-csecal, 13\\nof Bauhin, 13\\nValvulge conniventes Kerkringi, 6\\nVan Cott, 199, 201\\nVermes, 351\\nVermiform appendix, 13\\nVerneuil, 185\\nVertigo, intestinal, 301\\nVirchow, 140\\nVoit, 19, 24, 26\\nVolkmann, 162\\nVolvulus, 232, 255\\nVolz, 201, 220\\nWallace, 319\\nWeber, L., 108\\nWeigert, 338", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0410.jp2"}, "411": {"fulltext": "INDEX.\\n391\\nWeir, 197\\nWertheimer, 330\\nWhip-worm, 377\\nWhitehead, 189, 336, 344\\nWiggin, Fred. H., 267\\nWilligk, 129\\nWilson, 200\\nWolf, H. J., 224\\nWoodward, 83, 96, 269, 292,\\n336\\nWorms, intestinal, 351\\nZenker, 379\\nZiemssen, 45, 263, 264\\nZuckerkandl, 198\\nZunker, 350", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0411.jp2"}, "412": {"fulltext": "", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0412.jp2"}, "413": {"fulltext": "", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0413.jp2"}, "414": {"fulltext": "MAY 16 1900", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0414.jp2"}, "415": {"fulltext": "", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0415.jp2"}, "416": {"fulltext": "LIBRARY OF CONGRESS\\n021 062 225 1", "height": "3853", "width": "2485", "jp2-path": "diseasesofintes00einh_0416.jp2"}}