MODERN MEDICINE 
ITS THEORY AND PRACTICE 
IN ORIGINAL CONTRIBUTIONS BY AMERICAN AND 
FOREIGN AUTHORS 
EDITED BY 
SIR WILLIAM OSLER, Bart., M.D., E.R.S. 
REGIUS PROFESSOR OF MEDICINE IN OXFORD UNIVERSITY, ENGLAND; HONORARY PROFESSOR OF MEDICINE IN 
THE JOHNS HOPKINS UNIVERSITY, BALTIMORE; FORMERLY PROFESSOR OF CLINICAL MEDICINE IN 
THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA, AND OF THE INSTITUTES OF MEDICINE 
IN MC GILL UNIVERSITY, MONTREAL, CANADA 
AND 
THOMAS McCRAE, M.D. 
PROFESSOR OF MEDICINE IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA J FELLOW OF THE ROYAL COLLEGE OF 
PHYSICIANS, LONDON; FORMERLY ASSOCIATE PROFESSOR OF MEDICINE, THE JOHNS HOPKINS UNIVERSITY 
VOLUME III 
DISEASES OF THE DIGESTIVE SYSTEM-DISEASES OF 
THE UBINABY SYSTEM 
SECOND EDITION, THOROUGHLY REVISED 
ILLUSTRATED 
LEA & FEBIGER 
PHILADELPHIA AND NEW YORK 
1914 Entered according to the Act of Congress, in the year 1914, by 
LEA & FEBIGER, 
in the Office of the Librarian of Congress. All rights reserved. CONTRIBUTORS 
THOMAS R. BROWN, M.D., 
Associate in Medicine in the Johns Hopkins Medical School, Baltimore, Md. 
JULIUS FRIEDENWALD, M.D., 
Professor of Gastro-enterology in the College of Physicians and Surgeons, 
Baltimore, Md. 
A. E. GARROD, M.D., F.R.C.P. (Lond.), F.R.S., 
Physician to and Lecturer on Chemical Pathology at St. Bartholomew's Hospital, 
London; Physician to the Hospital for Sick Children, Great Ormond Street, 
London, England. 
JAMES B. HERRICK, M.D., 
Professor of Medicine in the Rush Medical College, Chicago, Ill. 
A. O. J. KELLY, M.D., 
Assistant Professor of Medicine in the University of Pennsylvania; Professor of 
the Theory and Practice of Medicine in the University of Vermont; Professor 
of Pathology in the Woman's Medical College of Pennsylvania, Philadelphia. 
JOHN McCRAE, M.D. (Tor.), M.R.C.P. (Lond.), 
Lecturer on Pathology in McGill University, Montreal; Assistant Physician to 
the Royal Victoria Hospital, Montreal, Canada. 
CHARLES F. MARTIN, M.D., 
Professor of Medicine and Clinical Medicine in McGill University, Montreal; 
Physician to the Royal Victoria Hospital, Montreal, Canada. 
EUGENE L. OPIE, M.D., 
Professor of Pathology in Washington University Medical School, St. Louis, Mo. 
WILLIAM PEPPER, M.D., 
Assistant Professor of Clinical Pathology and Dean of the School of Medicine 
in the University of Pennsylvania; Visiting Physician to the Philadelphia 
General Hospital, Philadelphia. 
DAVID RIESMAN, M.D., 
Professor of Clinical Medicine in the University of Pennsylvania and the Phila- 
delphia Polyclinic and College for Graduates in Medicine, Philadelphia. 
HUMPHRY DAVY ROLLESTON, M.A., M.D. (Cantab.), F.R.C.P., 
Senior Physician to St. George's Hospital; Physician to the Victoria Hospital 
for Children, London; and sometime fellow of St. John's College, Cambridge, 
England. 
ALFRED STENGEL, M.D., 
Professor of Medicine in the University of Pennsylvania, Philadelphia. 
CHARLES G. STOCKTON, M.D., 
Professor of the Principles and Practice of Medicine and Clinical Medicine in 
the Medical Department of the University of Buffalo, Buffalo, N. Y. 
HUGH HAMPTON YOUNG, M.D., 
Associate Professor of Genito-urinary Surgery in the Johns Hopkins University, 
Baltimore, Md. 
V CONTENTS 
PART I 
DISEASES OF THE DIGESTIVE SYSTEM 
CHAPTER I 
INTRODUCTORY DISCUSSION ON THE DISEASES OF THE DIGES- 
TIVE APPARATUS 17 
By Charles G. Stockton, M.D. 
CHAPTER II 
DISEASES OF THE MOUTH AND SALIVARY GLANDS .... 39 
By David Riesman, M.D. 
CHAPTER HI 
DISEASES OF THE (ESOPHAGUS 76 
By John McCrae, M.D. (Tor.), M.R.C.P. (Lond.) 
CHAPTER IV 
FUNCTIONAL DISEASES OF THE STOMACH 106 
By Julius Friedenwald, M.D. 
CHAPTER V 
ORGANIC DISEASES OF THE STOMACH 168 
By Charles F. Martin, M.D. 
CHAPTER VI 
DISEASES OF THE INTESTINES 286 
By Alfred Stengel, M.D. 
CHAPTER VII 
DISEASES OF THE LIVER, GALL-BLADDER AND BILIARY DUCTS 442 
By the Late A. O. J. Kelly, M.D. 
Revised by William Pepper, M.D. 
CHAPTER VIII 
DISEASES OF THE PANCREAS 599 
By Eugene L. Opie, M.D. 
CHAPTER IX 
DISEASES OF THE PERITONEUM 655 
By Humphry Davy Rolleston, M.A., M.D. (Cantab.), F.R.C.P. 
CHAPTER X 
SPLANCHNOPTOSIS. VISCEROPTOSIS. ENTEROPTOSIS. GLE- 
NARD'S DISEASE 747 
By Thomas R. Brown, M.D. 
VII VIII 
CONTENTS 
PART II 
DISEASES OE THE URINARY SYSTEM 
CHAPTER XI 
INTRODUCTION TO THE DISEASES OF THE KIDNEY .... 765 
By John McCrae, M.D. (Tor.), M.R.C.P. (Lond.) 
CHAPTER XII 
MALFORMATIONS OF THE KIDNEY. CIRCULATORY DISTURB- 
ANCES OF THE KIDNEY 785 
By John McCrae, M.D. (Tor.), M.R.C.P. (Lond.) 
CHAPTER XIII 
ANOMALIES OF URINARY EXCRETION . . 791 
By A. E. Garrod, M.D., F.R.C.P. (Lond.), F.R.S. 
CHAPTER XIV 
UREMIA 830 
By A. E. Garrod, M.D., F.R.C.P. (Lond.), F.R.S. 
CHAPTER XV 
NEPHRITIS: INTRODUCTION AND ETIOLOGY - ACUTE NEPH- 
RITIS 845 
By James B. Herrick, M.D. 
CHAPTER XVI 
CHRONIC NEPHRITIS AND AMYLOID DISEASE OF KIDNEY . . 880 
By James B. Herrick, M.D. 
CHAPTER XVII 
PYOGENIC INFECTIONS OF KIDNEY, URETER, AND PERIRENAL 
TISSUES 937 
By Thomas R. Brown, M.D. 
CHAPTER XVIII 
TUBERCULOSIS OF THE KIDNEY 976 
By Thomas R. Brown, M.D. 
CHAPTER XIX 
TUMORS OF THE KIDNEY 994 
By Hugh Hampton Young, M.D. 
CHAPTER XX 
URINARY LITHIASIS: RENAL AND URETERAL CALCULI . . . 1007 
By Hugh Hampton Young, M.D. 
CHAPTER XXI 
GENITO-URINARY DIAGNOSIS. DISEASE OF THE PROSTATE . 1026 
By Hugh Hampton Young, M.D. 
INDEX 1041 PART I 
DISEASES OF THE DIGESTIVE SYSTEM 
CHAPTER I 
INTRODUCTORY DISCUSSION ON THE DISEASES OE THE 
DIGESTIVE APPARATUS 
By CHARLES G. STOCKTON, M.D. 
In this introduction it is intended to discuss certain critical relations 
that may exist between disturbed physiological activity and structural 
changes as expressed in morbid processes. The subject is to be con- 
sidered from several different aspects as divided in the succeeding 
headings. 
1. The Whole and the Part.-We are accustomed to look upon diges- 
tion as the function of an extensive and complicated apparatus, but it is 
so intimately related with the functions of other parts of the body that 
it is difficult to draw lines of precise limitation beyond which it can be 
said digestion has no part and receives no reciprocal activity. We 
commonly speak of the digestive apparatus as including the alimentary 
tract and those important glands which contribute specific secretions to 
the advancement of digestion; but as absorption and assimilation, on 
the one hand, and the formation and withdrawal of katabolic and waste 
products, on the other, are immediately related to the preliminary diges- 
tion, it is impossible to form a clear conception of the diseases of the 
digestive organs without taking into consideration the state of other and 
contributing parts of the organism. While it makes for simplicity in 
description to exclude from implication those organs not commonly 
grouped with the digestive apparatus, this does not result in a correct 
understanding, and, therefore, if one is to find an explanation not only 
for a disturbed physiological state, but also, in instances, for structural 
changes in the digestive organs, he must widen the field and direct his 
study to the nervous system including its psychical manifestations, to 
the fluids of the body, to the blood pressure, the metabolism of the 
tissues, and to the state of the emunctories. The importance of these 
matters is perhaps unconsciously recognized when we declare that good 
digestion depends upon restful sleep, fresh air, sunlight, physical exercise, 
and the proper activity of the bowels, kidneys, and skin. When we 
disregard these essential matters, it is difficult to form a just conception 
17 18 
DISEASES OF THE DIGESTIVE SYSTEM 
of the nature of digestive disturbances, or to prescribe successfully thera- 
peutic measures for their relief. For this reason one may truly say 
of a given dyspeptic, the trouble arises in the brain, or in the lungs, the 
heart, the kidneys, etc. The pathology of stomach diseases is not limited 
to that organ, but is the expression there of disturbances that may be 
widely distributed through the whole body. This fact applies to other 
parts as well as to the stomach. Answering Virchow's question, " Where 
is the disease?" we have sought to give each disease a local habitation, 
but this is only a relatively justifiable conception as regards any disease, 
although more true of some than others. There are probably no diseases 
referable solely to the kidneys, the heart, or the blood; the man is sick, 
and it appears here or there. 
Although a large proportion of the affections of the digestive apparatus 
are functional, many cases with which we are confronted present an asso- 
ciation of functional and structural abnormalities. Congenital malforma- 
tions, displacements of abdominal viscera, and hernia, both internal and 
external, are structural defects; the infiltrations like amyloid disease, 
the more specific infections like cholera, typhoid fever, amoebic dysentery, 
and tuberculosis must be regarded as beginning their effects upon the 
body through their action upon its structure. But almost immediately 
these lead to functional disturbance, both local and general, and there- 
fore the state of general vitality of the patient conditions the functional 
activity of each organ, and is a potent factor in the outcome of any local 
disease. 
Many facts relating to digestion have come into our possession during 
the past twenty years, but the mere accumulation of facts and their 
presentation in isolation is not the most satisfactory method of studying 
a subject. By what laws are these facts related ? In what is the favorable 
activity of one organ dependent upon that of another? Of the various 
links in the digestive chain, which are the more indispensable? If we 
shunt the action of certain parts through surgical intervention, what will 
be the final result in the organism? These are questions of vital impor- 
tance, and by arranging our data with a view to answering such inquiries 
we throw most light upon the subject as a whole. 
2. Individuality in Disease.-It is necessary to value carefully the 
individual equation. On the one hand misconception may arise when 
generalizations are based on the manifestations of a single case. On the 
other hand the question of individual peculiarity and idiosyncrasy must 
be carefully weighed, so that we may avoid the feudality of classification 
and the tryanny of established rule. For instance, von Noorden has 
shown that certain starches are comparatively successful foods in par- 
ticular diabetics, although quite the reverse is true in other patients with 
this disease. Through idiosyncrasy the eating of potatoes or the flour of 
certain grains, although usually acceptable, in an occasional individual 
invariably excites intense gastro-intestinal distress. This action of cer- 
tain foods is explained probably by the theory of anaphylaxis. Idiosyn- 
crasy applies to other matters than food. The sensitiveness of some per- 
sons to the ill effects of mental excitement, physical fatigue, or exposure 
to cold must not be overlooked, nor must it be cast into a rule. DISCUSSION ON DISEASES OF THE DIGESTIVE APPARATUS 
19 
3. The Interrelation of Digestive Functions.-Common experience has 
taught us that the mental state and the sense of taste in some unknown 
way affect the primary digestion. Thus worry induces leanness, and 
happiness favors the opposite condition, in a measure independently 
of the amount of food taken. Some of the steps by means of which 
these effects are obtained are explained by the work of Pawlow. The 
digestive secretions and the motor activity of the stomach and intes- 
tine are excited by proper psychical stimulation. Distress may either 
inhibit or overexcite. Hirsch and von Mering have established the fact 
of an intimate relationship between gastric secretion and motion, and the 
secretions of the duodenum, pancreas, and liver. The presence of acid 
gastric juice in the duodenum leads, through reflexes arising in the latter, 
to the closure of the pylorus, preventing temporarily a further escape 
of gastric contents. This gastric juice within the duodenum, until 
neutralized by those secretions, stimulates the secretion of pancreatic 
juice, bile, and succus entericus; thereupon the pylorus again opens 
and the rhythmic movements of the stomach expel a further portion of 
the gastric juice into the duodenum, which, in turn, leads again to the 
closure of the pylorus. This reciprocal action demonstrates the important 
relation of one part of the digestive apparatus with another. Bayliss 
and Starling have shown that the presence of acid gastric juice in the 
duodenum stimulates the secretion of secretin, a substance which, passing 
into the blood and reaching the pancreas, excites in that organ its specific 
secretion; so it would seem that the intermittent and regular discharge 
of acid gastric juice into the duodenum is indirectly the normal stimulus 
of the pancreatic secretion. Trypsin, which was formerly supposed to be 
a secretion of the pancreas, has been shown by Pawlow and his students 
to be the result of the action of a substance found in the succus entericus, 
known as enterokinase, acting upon trypsinogen, which is secreted by 
the pancreas. 
Attention has been called to the fact that psychical conditions may 
influence salivation and gastric secretion; then there follows stimulation 
or depression of the motor activity of the stomach and intestine, of the 
secretions of the duodenum, the pancreas, and the liver, and finally, 
the formation of at least one substance that activates the secretion of 
the pancreas and other organs which otherwise would remain relatively 
passive. 
The impulse starting in a psychic state does not end in its effects 
upon the liver and pancreas. The functional activity of the small intes- 
tine is greatly influenced by the presence therein of the right proportion 
of secretion from the liver, pancreas, and other glands, and intestinal 
digestion would suffer in case of decrease or derangement in this supply. 
Under such conditions irritation of the intestinal mucosa, disturbance of 
its motor function, and lowering of the resistance of the part would result. 
With such a state of affairs it would be expected that bacterial life, 
especially within the gut, would be multiplied, fermentation occur, and 
infection be facilitated. 
With physiological economy, there goes on in health the absorption of 
biliary salts and probably other substances by the intestine in order to 20 
DISEASES OF THE DIGESTIVE SYSTEM 
maintain a proper balance of the organism. When there exists a marked 
disturbance of intestinal digestion we have reason to suppose that it 
interferes with this absorption. While the liver may be embarrassed 
through not receiving by way of the portal circulation the usual supply 
of recovered substances, it suffers at the same time because of the absorp- 
tion of the products of putrefaction. It has been shown by Adami that 
living bacteria reach the liver from the intestine. When the liver is thus 
overtaxed, a general toxemia supervenes, the whole body is injured, and 
hemolysis is often exaggerated. There exists a remarkable, although 
somewhat obscure, relationship between the liver and the kidneys, and 
under conditions described renal elimination may be decreased or other- 
wise deranged. To these evils others may be added when the colon, 
suffering in turn, contributes to the general toxemia. Delafield has 
emphasized the frequency of chronic colitis as the result of interstitial 
nephritis, and others have recognized the injurious effects of colitis upon 
the kidneys. 
Relatively great importance attaches to the pylorus, duodenum, 
pancreas and gall-bladder. A fuller acquaintance with the functions of 
these organs not only throws light on the clinical course of the digestive 
diseases, but serves to warn us that surgical intervention must take into 
account the possible harm from any great disturbance of the relations of 
these parts. 
4. Adaptability and Vicarious Action of the Digestive Functions.- 
At the same time we are impressed by the facility with which one por- 
tion of the alimentary tract is able to dispense with the assistance which 
it ordinarily receives from another, and by the success with which nature 
adapts herself to the absence of the function of the stomach and of large 
portions of either the small intestine or colon. With complete atrophy of 
the gastric mucosa, or with the bile diverted through a fistula from its 
intestinal course, or with the pancreas made practically functionless 
through chronic inflammation, the patient may survive and maintain a 
moderate degree of general nutrition. The loss of the function of a single 
digestive organ may not be accompanied by as serious results as ensue 
from lowering of vitality in the apparatus generally, such as follows 
grave diseases of the nervous system, or the chronic intoxications and 
infections. The organism seems capable of sustaining almost in entirety 
the loss of function of certain of the digestive organs. Nutrition some- 
times fails as the result of depression, affecting all parts of the appar- 
atus at one time. But to reiterate, it would be a misapprehension to 
suppose that health can be perfect after the loss of function of any one of 
the important digestive organs, or after the removal of parts, as, for 
instance, the stomach. 
5. The Relatively Great Importance of Motor Functions.-Our under- 
standing of digestive diseases has been much advanced by a clear 
conception of the role of motion in health and in disease as compared 
with that of secretion. It appears to the writer that the importance of 
motor disturbances of the digestive tract is not yet fully recognized. We 
find that although Nature adapts herself more or less successfully to the 
absence or derangement of what would seem to necessary secretion, DISCUSSION ON DISEASES OF THE DIGESTIVE APPARATUS 
21 
she immediately resents marked disturbances of motility, whether there 
is overexcitation or overdepression. Especially, we find that evil results 
are brought about by such interruption of motion as gives rise to stagna- 
tion of gastro-intestinal contents or the interruption of the flow' of secre- 
tion from the great digestive glands. In the latter case the mischief is 
not alone from the retention of secretion but from the results of stagnation 
and from the infections and intoxications which are thereby entailed. 
In a sense it may be said that an exception exists in the instance of the 
large intestine, where, in event of chronic constipation, we observe a 
considerable stagnation without necessarily serious consequences. This 
may be explained from the fact that it is the function of the lower part 
of the colon to retain its contents, and therefore in constipation we have 
to deal merely with the exaggerated function, going on ultimately to 
disease. But even here we recognize the evil consequences that result in 
some instances from even moderate stagnation, for constipation in certain 
individuals is immediately succeeded by general digestive derangement 
as w ell as by important constitutional symptoms. This is especially true 
of those unaccustomed to constipation or those in w hom there is inade- 
quate activity of the lungs, liver, and kidneys. In relation to the kidneys 
and liver, this statement is likely to pass unchallenged by some W'ho would 
doubt its applicability to the lungs, but we probably fail to recognize 
the full importance of elimination by way of the lungs. Sufferers from 
emphysema, chronic fibroid pneumonia, or continued pulmonary conges- 
tion, are strikingly relieved by timely stimulation of the skin, bowels, 
and kidneys. Doubtless this arises in part through forwarding the 
circulation and assisting oxygenation, but the practitioner may convince 
himself that the element of elimination must also be counted. 
The studies of Cannon indicate that our conception of the nature of 
gastro-intestinal motion has to be revised, and it is probable that new light 
will be throwm upon certain digestive derangements as a result. 
6. The Nature of Functional Disturbances of Digestion.-The nature 
of the so-called functional diseases is best apprehended by studying them 
along general lines such as those suggested. The tangled symptomatology 
is easily misunderstood, and, for a long time, the pathology and the 
pathogenesis for the most part evaded the clinician. So far as relates to 
the stomach, a better conception of the facts followed soon after Leube's 
adaptation of Kussmaul's stomach tube as an instrument of diagnosis. 
It was then seen that the state giving rise to a complex of symptoms form- 
erly described as "indigestion" was not a single pathological entity, 
that it was in fact not one thing, but a varied derangement of gastric 
activity, the more or less direct result of irritation or depression of the 
autonomic and sympathetic nerves. Therefore, these functional affec- 
tions were early divided into two classes: first, functional disease from 
excitation, and second, from depression. This division, though useful 
and at times helpful, is not so simple as it appears; for in not a few' patients 
we may discover evidences of an irritative character at one time and of a 
depressive at another. Symptoms from excitement may not materially 
differ from those following depression, and both may be manifestations 
of physiological fatigue, whether arising from particular or general sources 22 
DISEASES OF THE DIGESTIVE SYSTEM 
of exhaustion. These different manifestations were soon divided into 
three classes and termed disorders of secretion, motion, and sensation. 
Now, while this is a natural and probably permanent step in classification, 
it must be materially modified and supplemented in order to make it of 
value in the understanding of the actual disease. True, we do occa- 
sionally meet with a disturbance that seems to be wholly motor, secretory, 
or sensory, as, for instance, cardiospasm or gastralgia; but, with few 
exceptions, we find a complex in which two or all of these divisions of 
symptoms occur. 
The trend of events that make up a definite and more or less constant 
group is to be recognized, and the complex identified and named only after 
a careful study of the situation. This study must not be limited to the 
mere investigation of the functional behavior of the stomach. Com- 
monly, the etiology of the trouble will be found in some remote and per- 
haps unexpected region, in some leak of general energy, if the expression 
is permissible, or in some undiscovered irritation of the nervous system. 
Thus a retroverted uterus, proctitis, or a displaced kidney may indirectly 
lead to important digestive disturbances, even more frequently causes of 
gastric asthenia are to be found with eye strain. This subject has been 
so widely discussed in America, and from so many points of view, that it 
is somewhat threadbare; yet its signal importance remains largely dis- 
regarded. Irregular or asymmetrical astigmatism is the visual defect 
most often responsible for the functional disturbance, but it is not always 
in astigmatism of high degree that the trouble arises. It is more com- 
monly found in instances of moderate degree of astigmatism with axes 
differing in the two eyes, and especially in anisometropia. Although 
not limited to that period of life, the nervous disturbances following these 
visual defects are apt to appear after the age of maturity, and are espe- 
cially active when the crystalline body begins from age to lose in pliability. 
We are indebted to Gould for insisting upon the reality of the matter. 
Formerly our text-books referred to but few gastric disorders save the 
well-established structural processes. With the advent of newer methods 
of study there arose a tendency to multiply the number of gastric neuroses 
until the array of titles in a modern book on stomach diseases becomes 
bewildering. Undoubtedly much good has come from this minute investi- 
gation of functional disorders of the stomach. Among other advantages, 
it has added to our knowledge of the physiology, but now that so many 
years of conscientious work have been paid out and so many valuable 
facts have been gathered in, we are in an admirable position to review 
the material along the lines that experience and a sense of proportion 
would direct. 
When this has been well done we shall doubtless agree that our concep- 
tion of stomach troubles has undergone an absolute reconstruction since 
the days when text-books treated of "indigestion" and "flatulent dys- 
pepsia;" but we shall admit also that there has been something of over- 
refinement in the classification, description, and management of the gas- 
tric neuroses. It is rather remarkable that this outgrowth of recognized 
gastric neuroses should have occurred during an epoch in which a basis 
in definite morbid anatomy was required of practically all diseases; and DISCUSSION ON DISEASES OF THE DIGESTIVE APPARATUS 
23 
at a time when if no structural abnormality was shown to bear a constant 
relation to a symptom-complex, the pathogenesis of that disease was 
held in doubt. Notwithstanding this, our assembly of nervous affections 
of the stomach, for which no morbid structural setting was found, was 
adopted into our nomenclature and was not disputed by most of our 
clinicians. 
Hereafter, as now, we shall doubtless admit that this was a decided 
advance; but already we are discovering that we had in several instances 
misconceived the real meaning of the situation. In accepting the doctrine 
that we might have an array of motor, secretory, or sensory disturbances 
merely as the expression of a neurosis, we became too oblivious of the 
fact that this supposed neurasthenia might in fact rest upon some definite 
local disease that escaped detection. 
7. Functional Disturbances in Relation to Structural Disease.- 
This oscillation of opinion that makes for a resting in the truth has come 
in part as a result of the surgical treatment of abdominal diseases. It 
was seen that after the removal of gallstones and the drainage or excision 
of the gall-bladder, not a few of the supposed neuroses promptly disap- 
peared, and the physician who had rested satisfied with the diagnosis of 
hyperchlorhydria was disconcerted. Gastric derangement is now recog- 
nized as a common manifestation in appendicitis and other structural 
diseases of the lower digestive tract. We are aware that from such 
causes arise gastric hyperesthesia, hyperchlorhydria, and hypersecretion, 
besides the syndrome of transient pyloric obstruction with characteristic 
delay in emptying the stomach even amounting to food stagnation. 
This latter event may be encountered in cases in which there is no struc- 
tural narrowing of the pylorus or duodenum, but merely a reflex or spas- 
modic affection of the pylorus, with or without coincident derangement 
of gastric secretion, but, necessarily, with serious digestive disturbance 
both in the stomach and duodenum. 
We have long known that this train of events was a natural accompani- 
ment of pyloric or duodenal ulcer. Now that cholecystitis, appendicitis, 
etc., are admitted as causes, there is difficulty in persuading some men to 
believe that pyloric spasm ever occurs as the result of a neurosis; on 
the contrary, they hold that there is always local irritation in the region 
of the pylorus. They affirm the local cause and leave the burden of proof 
with those who yet hold the position that there remains a proportion of 
cases in which the functional element is the only and sufficient cause. 
As the evidence in support of this opinion has a fitting application to 
other supposedly functional disorders, it may be profitably mentioned. 
To begin with, only a neurotic origin has been able to explain a few 
of the reported cases of congenital pyloric stenosis. Then there is the 
analogy of spasm in the sphincter portion of other organs. The idiopathic 
dilatation of the oesophagus following cardiospasm which Meltzer has 
elucidated, is an example, to which may be added vesical and anal spasm, 
besides the involuntary contraction in laryngismus, vaginismus, etc. 
Still further evidence is found in the cure of these morbid contractions 
by measures directed solely toward calming excitability. Finally, the 
surgeons have learned the futility of attacking neurotic affections by 24 
DISEASES OF THE DIGESTIVE SYSTEM 
operative measures, for the symptoms not only continue, but often 
increase thereafter. That there may remain some hidden structural 
defect is possible, but, in the light of ascertained facts, improbable. 
Indeed, when we come to analyze the cases of pylorospasm secondary to 
a diseased gall-bladder, it will be found that some of them present no 
signs of former perigastritis nor extension of inflammation to the pylorus 
or duodenum. In these very cases, then, we must admit some indirect 
functional excitation, differing, it is true, from our conception of a neurosis 
but leaving something that morbid anatomy fails to explain. This 
functional nerve excitation may be comprised in the principle of increased 
reaction in certain individuals, or in any individual at some particular 
time, to stimulation in some instances of the nerve fibres of the vagus 
and in others to stimulation of the fibres of the sympathetic; that is, 
the possibility of a vago-tonic or sympathetico-tonic state requires con- 
sideration in the absence of structural explanation for the cause of spasm. 
An unprejudiced view would seem to grant that a disordered nervous 
system may at times give rise to cardiospasm or pylorospasm, but the 
warning should be kept in mind that we should seek the cause in some 
marked irritation at or near the abnormal contraction. 
8. Structural Changes Resulting from Functional Disorders.-Ac- 
cepting the doctrine that many gastric disturbances arise from nervous 
causes with and without assignable irritation at some point remote from 
the stomach, the question occurs as to how far it is possible for structural 
diseases of the stomach to result from severe or prolonged insult to the 
nervous system. The belief has long been held that gastric atony and 
even dilatation may ensue from long-continued nervous depression. 
It is not difficult to explain gastrectasis as the result of pyloric or upper 
intestinal obstruction, but there is a large residuum of cases of dilatation 
in which no obstruction is found, and their origin is usually attributed 
to prolonged nervous depression and overtaxation of the stomach with 
resulting myasthenia. In this connection it is interesting to note the 
accumulation of cases of acute dilatation of the stomach following surgical 
procedures. These are not limited to abdominal operations or injuries, 
for there are wTell-authenticated cases which have developed after exten- 
sive injury to one of the extremities or joints, or subsequent to grave 
pneumonia, or accompanying acute tuberculosis or carcinoma. In a 
proportion of these cases a real obstruction is found, usually in the duo- 
denum, occasioned by compression of the gut between the root of the 
mesentery and the spinal column, the result of dragging of the intestines 
downward which sometimes occurs in great relaxation of the abdominal 
wall. In a majority of cases no cause save nervous shock has been 
discovered. 
An important lesson is to be learned from these cases. That gastric 
and duodenal dilatation can occur within a few hours, with manifestations 
so serious that death usually results unless proper intervention is resorted 
to, and that this can occur without any preceding injury to the stomach 
or other abdominal viscera, seems a striking illustration of the relation- 
ship that exists between innervation and the well-being of the digestive 
apparatus. Until autopsy becomes more general, we are not likely to DISCUSSION ON DISEASES OF THE DIGESTIVE APPARATUS 
25 
know what percentage of unexpected fatal terminations after surgical 
operations may depend upon this accident. 
If acute gastrectasis can arise from great depression of visceral inner- 
vation, it is conceivable that depression of lesser degree and long con- 
tinuance may result in atony; and if to this we add the element of over- 
taxation of the stomach from indiscreet eating, we may easily explain 
those cases of gastric atony which do not result from obstruction. 
One who has had wide experience in the examination of gastric contents 
is aware of the striking influence which the state of the nervous system 
has upon gastric secretion. It is not uncommon to find instances of hyper- 
chlorhydria which disappear as soon as the patient follows a quiet, 
orderly life. On the other hand, systematic rest, with consequent im- 
provement in the general health, often leads to the return of normal 
secretion in hypochlorhydria. In many instances it will be found that the 
neurasthenic state that gives rise to the gastric symptoms may not depend 
upon inherited weakness nor upon general nervous exhaustion, but as 
before mentioned, rather upon the overfatigue of some particular part 
of the nervous system. Mere local treatment of the stomach unaccom- 
panied by improvement in other directions is usually unsuccessful in 
inducing a cure. 
One naturally inquires whether these long-continued disturbances of 
secretion may not lead to inflammatory and other lesions of the gastric 
mucosa. Gastritis has rightly been given extensive consideration in 
most treatises on stomach diseases, though according to the experience 
of some, its frequency is exaggerated. The disease is to be regarded as 
an infection of the stomach. One is impressed, however, with the truth 
long ago pointed out by Beaumont, that the recuperative and regenera- 
tive power of the gastric mucosa is remarkable, and we find that not only 
inflammation, but moderate trauma of the stomach, goes on to rapid 
repair, provided the general conditions are favorable. What is often 
regarded as gastritis is in fact a functional irritability of the stomach 
lining, a hyperesthesia gastrica, and not a true inflammation. In the 
extremes of age or when resisting power has been greatly reduced by 
long-continued fatigue, general infection, or great nervous depression, 
experience shows that gastritis is readily excited and that, when once 
present, it is likely to continue until the general health is improved. 
This is also true of the gastric neuroses, and just as hyperesthesia and 
motor irregularity may be caused and continued by systemic depression, 
so also may this be true of gastritis. Apparently a good deal of confusion 
exists in the mind of the average practitioner as to when a case is 
inflammatory and when it is merely one of functional irritability. It 
is important to make the differentiation, but it is occasionally difficult, 
as also is the recognition of the etiological factors upon which either 
affection is based. While it is understood that a functional disturb- 
ance may arise as a result of nervous depression or excitement, that 
gastritis may depend upon such depression is not sufficiently recognized. 
One must not dwell too much upon systemic depression as a cause in 
the development of gastritis; it is only a factor which predisposes to infec- 
tion. It is commonly and justly believed that the toxemias also invite 26 
DISEASES OF THE DIGESTIVE SYSTEM 
gastritis. This probably results from a lowering of vitality in the gastric 
mucosa such as the intoxications may induce in other tissues. Local 
disturbances like acute constipation, hepatic congestion, and overloading 
the stomach are factors which generally aid in setting up this inflam- 
matory reaction. The point should be made that while one person 
easily withstands indiscretion in diet, another immediately suffers from 
gastritis, and this is true because of the lowered resistance to infec- 
tions which exists in certain individuals, a truth paralleled in infections 
of other organs; thus some individuals are predisposed to such infections 
as appendicitis, colitis, and cholecystitis. 
9. Structure and Function in Relation to Peptic Ulcer.-In the search 
for the etiology of peptic ulcer we have discovered a number of other 
things, but not precisely that, and the ground has been so much tramped 
over that the boundaries of the question are considerably obscured. It 
is highly probable that though we include in one group cases found post- 
mortem, those produced experimentally, and those recognized clinically, 
they are not necessarily exactly the same thing. Gastric ulcer has been 
produced in animals experimentally by prolonged feeding on infected food. 
Inferentially, the same result would obtain in man; nevertheless, except 
when stagnation exists, the stomach with peptic ulcer is remarkably 
free of the usual evidences of infection. Virchow apparently solved the 
problem by the hypothesis of thrombus, and this cause has been shown 
to explain rare cases, though it apparently has no place as a cause in the 
great majority. A like conclusion attaches to the theories that gastric 
hyperacidity, lowered alkalinity of the blood, local trauma or the acci- 
dental manifestations of other diseases, like tuberculosis, syphilis, scurvy, 
or diabetes, are the direct and single cause. That the gastric mucosa 
may suffer ulceration like other surfaces of the body and from identical 
causes will probably not be disputed, but it is scarcely justifiable to 
regard all these instances as peptic ulcer. 
If we consider the method of development of peptic ulcer we perceive 
two things, namely, gastric hyperacidity and lowering of vitality of 
tissue at a circumscribed point; we fail to account for the special 
cause that may explain the devitilization of tissue at these points. We 
should consider the following facts: (1) Classical acute peptic ulcer is 
prone to occur in chlorotic young women, and, although the exceptions 
are many, the rule must not be obscured. (2) Classical chronic or indu- 
rated peptic ulcer is prone to occur in men past middle age. (3) Peptic 
ulcer is prone to localize itself either at the lesser curve on the posterior 
surface near the pylorus, or in the duodenum. (4) Its tendency is to 
continue, to become chronic. (5) Some ulcers show immediately a design 
to perforate, others seem forever limited to the mucosa. In acute ulcer 
there is usually present an overactivity in the secretion of very acid 
gastric juice. 
In reviewing these special features we recall unquestioned instances 
tending to nullify the rule; but too much weight should not be given to 
the exceptions in a subject holding so many possibilities of confusion; 
we should rather attempt to trace the usual lines more deeply, while at 
the same time noting and interrogating the unusual. After doing this 27 
DISCUSSION ON DISEASES OF THE DIGESTIVE APPARATUS 
it would seem clear th^t in the gastric ulcer of the dead house we are 
dealing with several entities-differing in cause, tendency, history, and 
termination-although there are certain manifestations in which they 
are alike. 
It would seem that there is some as yet unknown factor at work in the 
cause of true peptic ulcer, some factor which lowers the vitality of tissue, 
especially in certain regions of the stomach and duodenum. Apparently 
this factor is relatively common in early adult life in women, and after 
middle life in men, and in the latter is more disposed to chronicity. 
What is this factor? Will it be found in the local deficiency of antibodies, 
as suggested by Weinland? In local ischemia? In preceding lesions of 
neurotrophic nature, analogous to herpes or to the perforating ulcer of 
the integument? These questions remain unanswered, and the operative 
treatment of gastric and duodenal ulcer, while proving that the disease 
is more frequent than we were prepared to admit, and showing that, in 
men, duodenal peptic ulcer is seen about as often as gastric ulcer, has 
not materially aided in explaining the nature of the process. The 
hypothetical disappearance of antibodies may well account for the loss 
of tissue, but how shall we explain the local deficiency in antibodies? 
May this not rest in the neurotrophic realm? 
Whatever may be the exciting cause, we are reasonably certain that 
the increased activity of the gastric secretion and its overacidity con- 
tribute much toward the rapid evolution of the ulcer and toward its 
chronicity. The pain and gastric irritability are to be explained in part 
by the pyloric and gastric spasm and by the delay in the onward passage 
of chyme. Thus, the rationale of the usual medical treatment by rest, 
diet, alkalis, local sedatives, and external applications is made evident. 
When failure follows this treatment, the result would seem to be attribut- 
able largely to the fact that it requires the utmost attention and pains 
to prevent interruptions in the course of treatment, and that a short 
interruption may prove sufficient to overcome what has been gained by 
days of patient effort. Whether food is denied or in proper form is given 
frequently and persistently, the idea of keeping the gastric acidity low 
and overcoming the element of spasm must never be forgotten; even after 
gastro-enterostomy done to procure drainage, the benefit resulting from a 
modified diet and a lowered gastric acidity is of considerable importance. 
By a control of the functional activity of the organ we are able to 
modify the course of the structural disease. Of course, this principle is 
not limited to gastric ulcer, but illustrates the important and persistent 
interrelation that exists between organs and functions. Perhaps we 
should be more earnest in tracking structural diseases to a starting place 
in functional derangement, to the finding of lowered resistance in some 
areas of tissue as the result of biochemical deficiency, possibly neuro- 
trophic in its inception. All this may strike some men as lacking the 
evidence of acknowledged experience, but such a decision would be 
premature. There are many facts to be marshalled in its support. The 
bizarre and rather unaccountable manifestations grouped by Osler under 
the head of Angioneurotic (Edema should be recalled as an illustration 
of visceral lesions apparently secondary to neurotrophic disturbance. 28 
DISEASES OF THE DIGESTIVE SYSTEM 
We observe herpes facialis, sometimes persisting for weeks, appearing 
in some individuals whenever the health is depreciated by fatigue or other 
general causes. Such eruptions are prone to attack a certain area, 
reappearing in the same place and occasionally accompanied by severe 
pain. We occasionally observe perforating ulcer of the arm or leg persist- 
ing indefinitely, resisting topical treatment and recurring after excision. 
We should recall Raynaud's disease and also the curious non-traumatic 
hematoma auris, particularly observed in the insane. Marked sub- 
cutaneous extravasations of blood appear in certain neurotics in various 
parts of the body, disappearing, then recurring after a period of health. 
In one patient the writer observed this at intervals during several years; 
the attack sometimes alternated with, sometimes were accompanied by, 
the classical symptoms of gastric ulcer, and occasionally by hematemesis 
of grave character. In erythema multiforme one may observe the wide 
involvement of the mucous membrane, and one severe case was observed 
in which this disease was accompanied by the symptoms of gastric ulcer. 
This collection of presumably neurotic affections associated with struct- 
ural lesions shows an indubitable relation between the nervous system 
and the integrity of tissue. 
We have insufficient experimental evidence to prove that either a 
nerve lesion or a neurotrophic disturbance is a frequent cause of peptic 
ulcer, but the behavior of the affection strongly suggests the possibility. 
These statements are intended to emphasize a principle that seems to 
be too little recognized, that of the very close relationship existing in all 
parts of the organism between the structure and the functions which 
utilize that structure. It is true that we often find a structural change 
to explain the supposed functional disturbance, but it seems equally true 
that the functional disturbance may be the forerunning etiological factor 
in, sometimes the cause of, the structural disease. 
The hyperchlorhydria so commonly present in peptic ulcer is often 
intensified by food retention, secondary to pyloric spasm, and the same 
cause is responsible for some cases of that condition usually called gastro- 
succorrhcea. However, there are cases of excessive secretion in which 
hyperchlorhydria is not dependent on spasm. It was long believed 
that this might be produced by local stimulation occasioned by the open 
ulcer. Pawlow's observations tended to discredit this view. He failed to 
excite gastric secretion in animals by irritation locally applied, although 
juice flowed freely at the sight of food and upon its introduction into the 
stomach. A highly acid secretion is made to flow in dogs as a result of 
faradization of the mucosa. Recently, A. Schiff has been able to excite 
the flow of gastric juice by local stimulation when the factor of psychic 
effects and the presence of food in the mouth or the stomach were elimi- 
nated. Clinically, we find that the acidity is increased by feeding and 
even by the suggestion of eating, as demonstrated by Pawlow. But we 
also know that hyperchlorhydria is present in gastric ulcer even when 
the patient is fasting and when the psychic influence is wanting. It is 
probable, therefore, that gastric secretion is excited by the irritation of 
an ulcer as well as by the suggestion or presence of food. 
One may conclude that there is usually an excessive secretion and at DISCUSSION ON DISEASES OF THE DIGESTIVE APPARATUS 
29 
times retention of gastric juice in this disease, and there can be no doubt 
of the unfavorable effect of the hyperacidity in the course of the ulcer. 
Further, we know that chlorosis, so often associated with ulcer, is gen- 
erally accompanied by hyperchlorhydria, and that an impressionable 
nervous system at least predisposes to the oversecretion. 
10. The Question of Secretion.-The behavior of the stomach in 
the matter of secretion presents a problem not yet elucidated. By the 
action of certain proteins upon the mucosa of the pyloric end of the 
stomach there is excited in the glandular structure of the part a sub- 
stance which passes into the general circulation, returns to the gastric 
mucosa, and excites therein an active secretion of gastric juice. Pawlow 
and Popielski have shown that this secretion occurs after the destruction 
of all nerves connecting the stomach with the ganglionic centres. Edkins 
has shown that it is not the result of a local reflex in the gastric walls, 
but is owing to a chemical influence, in mode of action similar to that of 
secretin and other so-called hormones or internal secretions. It is inter- 
esting to discover that the secretions of the stomach are governed by 
influences other than psychic or reflex nervous mechanisms. The facts 
lead us to conclude that gastric secretion may be stimulated by psychic 
influence, by direct stimulus occasioned by food in the stomach, and, 
finally, by the specific action of some chemical substance formed in the 
pylorus and acting through the blood upon the remaining portions of 
the mucous membrane of the stomach. 
We still await the application of these physiological findings to explain 
certain conditions observed clinically. Although many cases of so-called 
gastrosuccorrhoea are in reality but instances of retention, there remains 
a group exempt from stagnation, but in which, although the stomach is 
washed out at bedtime, there is found a considerable amount of gastric 
juice present in the fasting stomach in the morning. Sometimes the 
secretion is so excessive as to lead to morning vomiting; in contrast is 
achylia gastrica, in which no secretion whatever can be discovered. Some 
patients who suffer from hypersecretion suddenly, and so far unaccount- 
ably, experience a diminution or suppression of secretion; in other words, 
a patient who one day is an example of hyperchlorhydria, on the succeed- 
ing day or week will show a continued absence of hydrochloric acid free 
or combined. When gastric secretion is for a long time absent, we 
describe the condition by the term "achylia gastrica." This affection, 
frequently seems to be unrelated to any morbid change in the structure 
of the gastric mucosa. In prolonged cases the glandular structure 
undergoes atrophy, and restoration of secretion becomes impossible. 
It would be easy to explain these cases by inflammatory or degenera- 
tive processes in the mucous membrane of the stomach, but such condi- 
tions are apparently absent in the early stages of a large proportion of 
cases. At times the disease is susceptible of satisfactory improvement 
following local stimulation and general treatment; but often the trend of 
the disease is toward permanent loss of function. Lacking the stimulus 
of the free hydrochloric acid, the pylorus does not contract firmly, and 
the unchanged gastric contents pass into the duodenum, sometimes very 
soon after the meal is eaten. In such cases the stomach will be found empty 30 
DISEASES OF THE DIGESTIVE SYSTEM 
an hour after the ingestion of food, or if the stomach tube is employed soon 
enough to regain the stomach content, it will be found to have undergone 
no digestive change except such as depends upon the action of the salivary 
ferments. Since we have come to look upon the proper quantity and 
quality of gastric juice as the normal stimulus of duodenal digestion 
and as the signal for secretion in the pancreas, liver, and intestine, it is 
difficult to understand how patients suffering from achylia gastrica are 
enabled to continue in fair health and with moderately good general 
nutrition. Such, however, is sometimes the case. Patients with achylia 
gastrica followed for fifteen years, while never well, are yet not materially 
worse than at the beginning of the observations. In some instances 
there was apparent improvement which coincided with pregnancy and 
disappeared as soon as the period of lactation had passed. 
In health the amount of pancreatic secretion seems to be controlled by 
the stimulus received in the duodenum from the gastric juice, therefore a 
very acid secretion should excite a proportionately active duodenal and 
pancreatic secretion. On the other hand, a lowered gastric acidity should 
be followed by lowered secretion from the other digestive glands. While 
this correlation and interaction between the digestive secretions seem 
normally to proceed in an orderly way, there must occur some deviation 
from the principle in case of achylia; otherwise we should find the disease 
to be a much more serious one than it actually is. Starling shows that 
the secretion from the pancreas is induced through the action upon it of 
secretin and apparently without the intervention of nerve mechanism. 
While this seems probable from physiological experiment, it does not 
perfectly accord with clinical experience. 
On examination of the stools of patients with achylia gastrica, although 
it is common to find that too great a proportion of the food is passed 
undigested, and although probably a certain amount of it has undergone 
disintegration through the action of bacteria, still it is evident that the 
patients digest and assimilate a reasonable proportion of food, as they 
are able to maintain their weight at a somewhat lower standard, and to 
develop a fair, although diminished, energy. We have in the recent 
accdunts of the physiology of digestion an explanation of certain of the 
phenomena observed in achylia gastrica, but we are embarrassed in that 
they explain too much. In other words, we find that the victims of 
achylia gastrica suffer far less than should be expected. 
It would appear that some of the secretions are activated through 
certain stimuli with which we are as yet unacquainted, otherw ise it would 
be difficult to explain the comparatively good state of health w hich many 
patients enjoy subsequent to closure of the pylorus associated with gastro- 
jejunostomy. 
It is interesting in this connection to consider the question of natural 
and artificial inhibition of peptic digestion. There are cases in which 
despite high acidity of the gastric content, depending upon free hydro- 
chloric acid, proteolytic digestion does not proceed; something has blocked 
the digestive process. The explanation of this inhibition has been sought 
for in various directions. Apparently there are some natural causes of 
inhibition, perhaps depending upon the stomach itself through the DISCUSSION ON DISEASES OF THE DIGESTIVE APPARATUS 
31 
formation there of antibodies. But certain foods and drugs also exercise 
an inhibitory action on digestion. The albumoses, gelatin and maltose, 
for instance, have a definite inhibitory effect, while lactose and most 
carbohydrates have none. In certain instances the concentration of the 
gastric juice is found to interfere with the digestion of proteins as well 
as other foods, and when the secretion of the stomach is diluted the 
digestive process is apparently favored. These facts may account for 
the curious behavior of the gastric digestion often observed clinically; 
the total acidity of the stomach content may be high, the amount of free 
hydrochloric acid may be above the recognized standard, and yet diges- 
tion does not proceed. In reviewing the question Sailer concludes that, 
after attributing to certain foods and drugs the power of inhibiting gastric 
digestion, and admitting that the element of concentration under special 
conditions operates to produce a like effect, there remains a group of 
facts that may be best explained on the hypothesis of the presence of an 
antipepsin such as has been announced by Danielewsky and Weinland. 
This substance may have a role, not only in protecting the walls of the 
stomach, but also, in certain conditions, of inhibiting proteolysis in 
the gastric contents. 
With long-continued absence of gastric secretion, a certain proportion 
of patients show very defective intestinal digestion. In other cases the 
intestinal digestion seems very satisfactory, and we are forced to conclude 
that besides the acid secretion of the stomach there must be some other 
agent that acts to stimulate the production of secretin. Whatever 
this agent may be, its presence is more manifest in some cases than in 
others, if we are to explain thereby the variations seen in the intestinal 
digestion occurring in cases of achylia gastrica. 
Oil passing into the duodenum acts to stimulate the production of 
secretin with an efficacy second only to that of the acid chyme. Probably 
the fatty foods in a measure replace the gastric juice in setting the secre- 
tion into circulation in cases of achylia gastrica. There would seem to a 
clinical confirmation of this statement in the successful therapeutic use 
of oils in relieving the diarrhoea that is sometimes such a troublesome 
symptom in achylia gastrica. 
Another important matter relates to disturbances in metabolism espe- 
cially when this involves functional disturbances of the liver. Careful 
examination of the stools shows that there is a wide variation in the 
amount of biliary coloring matter discharged in the intestine. The 
study of the quotidian secretion of the bile, so far as can be judged by 
that which escapes through a biliary fistula, confirms the belief that at 
least one function of the liver shows considerable change in activity from 
time to time. From the evidence we may conclude that these temporary 
modifications of hepatic function are directly influenced through the 
nervous system, through psychic impulses, excitement, fatigue, or depres- 
sion. Drugs have comparatively little effect on the secretion of bile, 
apparently more upon metabolic processes, but the state of the nervous 
system seems to be potent in this regard. The secretion of bile is stimu- 
lated by the administration of biliary salts and in a somewhat less degree 
by the taking of oils. In health the entrance of acid chyme into the duo- 32 
DISEASES OF THE DIGESTIVE SYSTEM 
denum excites the outflow of bile, a result apparently dependent upon the 
action of hydrochloric acid upon the mucous membrane of the duodenum, 
thereby leading to the production and absorption of secretin in the blood. 
It will thus be seen that the mechanism of the secretion of bile seems 
identical with that of the pancreatic juice. In each case it seems to 
require the presence of secretin carried through the blood to the organ 
in question. 
11. Infection in Relation to Digestion.-The importance of recognized 
infection in the etiology of structural diseases of the liver and biliary 
apparatus leads to the suspicion that unknown infections of moderate 
activity have much to do with the variations of functional power of the 
liver that are commonly ascribed to other causes. It must be owing to 
an acquired or inherent resistance that the liver is not more markedly 
and frequently deranged than it is by the occurrence of an unwholesome 
condition of the gastro-intestinal tract. Clinical experience leads to the 
conclusion that the constant presence in the intestine of pathogenic 
microorganisms and other sources of intoxication, which may not materi- 
ally disorder the economy, must be tolerated by means of some form of 
immunity. It is further observed that with unusual nervous depression 
this protective barrier of immunity becomes insufficient; the symptoms 
of toxemia result, and not infrequently those of infection as well. 
Undoubtedly these manifestations are not confined to the liver, for we 
perceive similar occurrences in the parenchyma of the stomach and 
intestine in gastro-enteritis. It can scarcely be an error to infer that 
organs that are thus intimately correlated and thus largely influenced 
by the sympathetic and autonomic systems of nerves must react to 
untoward nerve influences; and under such circumstances, when, so to 
speak, "the guard is down," the infection most readily breaks through 
and intoxicants still further perturb the function. We may find illustra- 
tive examples most often in young children, as in the effect of fright, 
injury, or heat exposure. 
12. Visceral Blood Supply in Relation to Digestion.-This resistance 
to disease on the part of the liver seems to be proportioned in a measure 
to the liberality of the blood supply, and fails when, from narrowing of the 
hepatic artery, the supply of oxygen is decreased. While it is impossible 
to measure the precise reponsibility of each fact that operates in the 
development of the morbid process, it is evident that weight must be 
given not only to that which circulates in the blood, but to the volume 
of blood as well; and it is for this reason that of late more thought has 
been given to the question of sclerosis in the abdominal aorta and its 
branches. 
Years ago it was suggested that in case of unusually large and numerous 
inosculations of the branches of the portal vein with the systemic veins, 
a sufficient auto-intoxication to produce definite symptoms might result. 
The explanation of coma in hepatic cirrhosis was adduced as an illustra- 
tion. The introduction of epipoplexy enabled us to observe effects of such 
inosculations artificially produced, and it must be admitted that some 
justification is found for the claim that toxic effects may be induced in 
this way. Especially is this true before the organism has accommodated DISCUSSION ON DISEASES OF THE DIGESTIVE APPARATUS 
33 
itself to the change in the circulation, and presumably, also, when the 
portal blood is for any reason in a specially toxic condition. 
Not alone the liver may be the victim of these vascular defects, but also 
the other abdominal viscera. Thus some forms of pancreatitis are to 
be explained, and not a few instances of that disease of multiple etiology, 
colica mucosa. Arteriosclerosis, aortitis, and peri-aortitis abdominis may 
be held to account for many degenerations, functional disturbances, and 
special symptoms of the digestive apparatus. Among the latter are 
included neuralgias, motor disturbances, and lowered secretion. In 
those free from structural disease of the vessels, troublesome visceral 
disturbances resulting from vasomotor excitation or depression may occur. 
Perhaps certain affections whose origin is attributed to perturbation of the 
nervous system, and which are called functional, are so in a different sense 
than that conceived. They may properly be charged to morbid condi- 
tions of the vasomotor centres. 
This would seem to be true especially of mucous colitis, an affection 
that has been accounted for by many morbid processes, some of them 
opposite in nature, but all perhaps possessing in common the quality of 
excitement or depression of the blood supply through disturbance of 
vasomotor centres or through more direct influence, and hence leading 
to prolonged congestion or ischemia of the colon. What is true in this 
part of the intestine may well be so in other parts and other organs. 
Vasomotor disturbance is an old conception, long used to explain visceral 
diseases, and although this view has been carried to extremes, it has 
never been quite dislodged, and undoubtedly, in a proportion of cases, 
is a source of trouble. 
Passive congestion of the abdominal viscera at once induces a lowered 
functional activity and later degenerative structural changes. At first 
there is depression of the specific secretions with an increased activity of 
the muciparous glands. The motor function of the stomach and intestine 
becomes hesitating, irregular, and feeble, discomfort or distress is experi- 
enced, digestion is delayed and imperfect, while an exuberant growth of 
bacteria leads to fermentation and increased toxicity of the gastro- 
intestinal contents. A lowered resistance of the tissues favors the 
entrance of pathogenic microorganisms and the setting up of inflam- 
matory changes of a low order which, with the assistance of an increased 
toxicity, account for the degeneration of the parenchyma and the suc- 
cessive ingrowth of connective tissue in the digestive organs in prolonged 
portal stasis. 
13. False Combinations of Secretion.-Disharmony.-The inter- 
relation of the secretions, the enzymes, and activating substances is 
complex but interesting. By conjoint action they apparently lead to 
amazing results, and some of these still remain incomprehensible. There 
are both clinical and experimental reasons for believing that disharmony 
in physiological reactions may result in profound disorder of the digestive 
organs and even in the most serious organic diseases. Perhaps no better 
instance of the latter can be pointed out than pancreatitis induced by 
experimental injection of the duct of Wirsung with bile or with artificial 
gastric juice. Undoubtedly certain cases of pancreatitis follow obstruc- 
VOL. in-3 34 
DISEASES OF THE DIGESTIVE SYSTEM 
tion in the ductus choledochus at the ampulla and the escape of bile into 
the pancreatic duct. Possibly the more acute cases may ensue from the 
entrance of gastric juice into the pancreatic channels passing from the 
duodenum. This seems more probable in light of the work of II. U. 
Williams. lie shows that gallstones may so far dilate the outlet of the 
ductus choledochus as to make easy the entrance of duodenal contents, 
including bacteria and chemical agents, which might thus find their way 
into the pancreas. These dramatic and antagonistic results of misplaced 
physiological secretions seem in part to be demonstrated by the relief 
observed to follow the drainage of the biliary tract in chronic pancreatitis. 
There are doubtless other instances of injury inflicted inside the redoubts 
and not by the enemy. Some of these we rather dimly perceive, others 
are undiscovered, yet we see their results. 
14. The Place of the Biliary Tract in Digestive Pathology.-The 
gall-bladder is a prolific source of disease in the abdominal organs. A 
great proportion of diseases of the gall-bladder develop as the result of 
infection, a statement which applies with equal force to the various forms 
of cholangitis. Without entering into the discussion of the means by 
which microorganisms find entrance into the bile passages, we find them 
present there, and as a result, an inflammation of greater or less severity 
is often established. The more acute infections give rise to suppuration 
or necrosis of the gall-bladder, while the milder ones set up an inflam- 
matory oedema of the lining mucosa, and thus embarrass the natural 
ebb and flow of bile. The lining of the gall-bladder is not destroyed, but 
is irritated, and, as a result, an excess of cholesterin is secreted and the 
changed condition of the bile contained in the gall-bladder leads to the 
formation of calculi, in the centre of which, if the stones are recently 
formed, colonies of bacteria are usually found. The conditions which 
seem most favorable to the enlargement of a biliary calculus appear to be 
a slight inflammation of the lining of the gall-bladder with temporary 
and recurring obstruction to the cystic duct. Under these conditions 
the stone is likely to increase by laminated formation, and its presence in 
an irritated gall-bladder may excite spasm of its walls, which induces the 
symptoms known as hepatic colic. 
The inflammation of the biliary apparatus and the increased tension 
put upon it lead to more or less permanent changes in the parts, such as 
dilatation of the biliary canals, widening of the outlet of the choledochus, 
and inflammatory adhesions uniting the gall-bladder to the surrounding 
parts. Concurrent with these events there is usually much sympathetic 
disturbance of other viscera sometimes so marked as to distract attention 
from the original seat of trouble. With the biliary apparatus crippled 
future infection is facilitated, and recurrence of cholecystitis and cholan- 
gitis is frequent unless the patient acquires an immunity through improve- 
ment in the general health. Diathesis is an important factor in dis- 
turbing immunity and diathesis is closely related to metabolic peculiarity. 
When protein or carbohydrate metabolism is faulty, infection occurs more 
readily and in order to successfully oppose it special attention may be 
required as to diet and elimination. DISCUSSION ON DISEASES OF THE DIGESTIVE APPARATUS 
35 
15. Some Peculiarities of Pancreatitis.-As before stated there seems 
to be a definite relation between diseases of the biliary apparatus and 
pancreatitis. There is accordingly a belief that this disease, whether 
acute or chronic, follows upon the entrance of infectious microorganisms 
through the duct of Wirsung. While this is doubtless true in some cases, 
there are yet instances of acute hemorrhagic pancreatitis in which no 
infection is demonstrable, despite careful search. It is recognized that 
the destruction of the gland and the production of the fat necrosis of 
Balser, so often an accompaniment of the acute forms of pancreatitis, 
are definite results of autolysis of the gland structure through the action 
of its own ferments and the digestive effects of these ferments on the fatty 
tissues in various parts of the abdomen, and even (through the lymphatics) 
in other parts of the body. Hemorrhage into the substance of the pan- 
creas occurs at times without trauma, inflammation, or other assignable 
cause. It remains one of the unsolved questions. 
16. Correlation of the Abdominal Viscera through the Vagus and 
Sympathetic.-There apparently exists a relation between the suprarenal 
glands and the functional activity of the pancreas and liver. The appear- 
ance of glycosuria in instances of intoxication with adrenal extract seems 
to bear on this relation. The abdominal sympathetic and vagal nerves 
are associated closely with the function of the suprarenals as well as with 
that of the pancreas and liver. Meltzer found that when the cervical 
sympathetic ganglion was removed from animals their pupils dilated 
widely upon the instillation of adrenalin solution. Loewi, suspecting 
that inhibition of nerve influence might lead, through action upon the 
function of the liver, to hyperglycemia and glycosuria, and supposing 
this inhibition to be connected with the pancreas, practised the ablation 
of this organ. In the animals thus operated on there appeared the usual 
glycosuria, and, in verification of his hypothesis, when adrenalin solution 
was instilled in the animals' eyes marked mydriasis immediately appeared. 
Following this he applied adrenal solution to the eyes of 18 diabetic 
patients, and of these, 10 at once showed mydriasis. In 28 non-diabetic 
patients the reaction failed in all but 2. One of these proved to have 
obstruction of the duct of Wirsung, and the other had Graves' disease. 
These results indicate that the functions of the pancreas, liver, adrenal 
bodies and kidney are closely related through the autonomic and sympa- 
thetic divisions of nerves. 
Sialorrhoea, as a definite symptom of pancreatic disease, is largely 
discredited, yet its concurrence must be admitted, sometimes in pan- 
creatic calculus, again in cancer of the head, and occasionally associated 
with transient glycosuria. The reality of so-called pancreatic diarrhoea 
should not be too quickly abandoned. By the study of the unusual 
phenomena we may dispel the mist that obscures the field wherein play 
some of the most incomprehensible vital processes. 
17. Splanchnoptosis and Overtension of the Peritoneum.-The 
displacements of viscera contribute in several ways to derangements of 
digestion. Gastroptosis may interfere with the motor function of the 
stomach through increased traction upon its membranous supports, thus 
giving rise to discomfort as well as interference with the blood supply. 36 
DISEASES OF THE DIGESTIVE SYSTEM 
The results of displacement of the small intestine are less understood, 
but ptosis of the colon, including displacement of the cecum and the 
sigmoid, is not infrequently the source of symptoms and of disease. 
The shortening of the ascending colon, thus raising the cecum to the 
upper part of the abdomen, the displacement of the colon downward, 
the exaggeration of the flexures, and the displacement of the transverse 
colon downward so that it appears as a long loop, occasionally as a double 
loop reaching the pelvis, are among the dislocations. Jacobi pointed 
out that the sigmoid flexure in the fetus is relatively very long, and this 
disproportion occasionally continues beyond infancy, even to adult life. 
Another common defect is the extension of the so-called omega loop of the 
sigmoid to the right until it may reach the region of the cecum. This 
is occasionally associated with extremely sharp bending of the sigmoid. 
The displacements of the stomach and the colon are apparently more 
important than those of the small intestine; at any rate, they are better 
understood. From excessive angulation of the sigmoid, stasis and dilata- 
tion of the colon are frequently developed. This angulation is also a 
contributing factor in exciting sigmoiditis, and is a source of embarrass- 
ment in the treatment of that affection. It is not appreciated that 
incomplete hernia is often the cause of more or less continuous 
abdominal distress and sometimes severe pain which is experienced 
in regions somewhat remote from the point of irritation. This is 
seen in the very minute epigastric hernise which frequently are found 
in the linea alba, and also in incomplete and unsuspected herniae 
of the inguinal and femoral canals. As these symptoms have been 
repeatedly shown to result from external hernia, it is fair to presume that 
like results obtain from internal hernia. It is probable that some of the 
patients who have undergone repeated abdominal explorations, hoping 
for a discovery of the source of pain and other symptoms, are in fact 
suffering from unsuspected traction of some part of the peritoneum or 
intestine which is caused by hernia. 
As vestiges of past inflammation, adhesions of one part of the peri- 
toneum with another sometimes remain, and the unnatural traction thus 
induced may so far irritate the peritoneum as to occasion pain and, 
reflexly, considerable derangement of the digestive processes; or there 
may be sufficient adhesion of the intestine or stomach to embarrass peris- 
taltic movement and delay the onward passage of the contents. The 
symptoms thus induced, while of little moment in the more phlegmatic, 
become important in those hypersentitive beings who are prone to have 
abnormal abdominal sensation, and in whom a harmonious physiological 
digestion is more often the exception than the rule. In such individuals 
relief is sometimes obtained by judicious medical gymnastics and psycho- 
therapy, while surgical measures rather augment the complaint, either 
because of the new adhesions formed or because the attention of the 
introspective patient becomes more firmly fixed on himself. 
According to Wilms, the pain occasioned by disease or irritation in the 
abdominal viscera is really produced by means of traction communicated 
to the.mesentery. The cerebrospinal system of nerves, distributed to the 
parietal peritoneum, is the seat of most abdominal pain. Some think DISCUSSION ON DISEASES OF THE DIGESTIVE APPARATUS 
37 
that the splanchnic and pneumogastric nerves are not implicated, but 
that abdominal pain is excited only in the endings of the cerebrospinal 
nerves, distributed to the parietal peritoneum (Lennander). Traction 
upon the mesentery or upon the adhesions irritates these sensory nerves. 
Overdistension of a loop of intestine leads to stretching of the mesentery 
and indirectly to tension of the parietal peritoneum. 
From this point of view it is easy to understand how pain may be 
excited in regions somewhat remote from the seat of mechanical pressure 
or tugging, as occurs in hernia, adhesions, and visceral displacements. 
18. Psychoneuroses in Relation to Digestion.-Frequently an asso- 
ciation exists between digestive disturbances and the more definite 
neuroses and psychoses. Long continuance of infection of the digestive 
tract inducing a lowering of the general nutrition, leads to depression 
or irritation of nerve tissue, and sometimes appears to be the exciting 
cause of brain disease and also adds to its continuance. This is shown 
by the marked improvement that follows an enlightened course of dietetic 
and other treatment especially directed to the betterment of primary 
digestion. On the other hand, the lowered vitality, induced by definite 
nerve disease, is almost invariably accompanied by digestive disturbance. 
Illustrations of this fact are observed when the nervous disease rests 
upon inheritance rather than upon long-continued nerve strain. It is 
probable that infection and toxemia are much concerned in these morbid 
processes, both nervous and mental. With a lowered resisting power, 
infection of the digestive tract is easily excited 
Under these conditions the intoxications increase because of accom- 
panying faulty elimination. It is commonly observed that victims of 
nervous or mental disease suffer from urinary inadequacy, and from 
depression of the other emunctories. To this may be added the element 
of faulty metabolism which succeeds upon disturbance of organs of 
internal secretions, as, for instance, the adrenals and thyroid. Enterop- 
tosis with atony and dilatation of the hollow abdominal viscera is fre- 
quently encountered in the neurotic and the insane. Besides, conges- 
tion and degeneration of the glandular structures often occur, including 
the liver and pancreas, as well as the secreting tissues of the stomach 
and intestine. 
19. Variations in the Intestinal Flora in Their Relation to Diseases of 
the Digestive Tract.-The character of the intestinal flora, particularly 
that of the colon, is a matter requiring careful consideration. When 
patients are deprived of foods containing animal proteins, remarkable 
improvement is reported to follow the deliberate attempts to plant 
new orders of bacteria, the presence of which is antagonistic to those 
microorganisms more especially concerned in the putrefaction of animal 
proteins and the incidental production of toxic substances. 
To recur to the question of motor insufficiency and imperfect drainage, 
the importance of which in the clinical course of digestive disease has 
been pointed out, the matter appears more conspicuous in the light of 
the bacteriology of the intestine. Indication for attention to this source 
of trouble may be found in the urine. While we know that certain 
urinary toxins are the products of metabolism more or less normal, and 38 
DISEASES OF THE DIGESTIVE SYSTEM 
hence depend upon the state of the cellular tissues, clinical observation 
and laboratory study reveal that, to a considerable extent, other urinary 
toxins develop in the intestine. The infections of the gastro-intestinal 
tract occur both with and without inflammation, but in either event 
they are accompanied by derangements of secretion. Subacute gastro- 
enteritis may be followed by degeneration of the glandular parenchyma 
and even by exudation into the muscular layers, followed by round-cell 
infiltration and subsequent motor weakness of the stomach and intestine. 
According to Sir Arbuthnot Lane, the evil effect of imperfect colonic 
drainage, induced by the presence of kinks in, adhesions to, or deformity 
of the colon, extend to all parts of the economy. He would remove the 
cause of intestinal intoxication by resection of the colon. The results 
which he has obtained are very instructive to the clinician. 
It is because of the similarity in the symptoms between functional 
derangements on the one hand and of infection and inflammation on the 
other that there has arisen the confusion in differentiating these condi- 
tions. The difficulty is not lessened by the fact that infection is prone 
to follow certain of the neuroses; in fact, they often co-exist. Lowered 
vitality of a part favors infection, and then there exists a causal relation 
between neurasthenia and appendicitis, cojitis, or other inflammatory 
involvement of the digestive apparatus. CHAPTER II 
DISEASES OF THE MOUTH AND SALIVARY GLANDS 
DAVID RIESMAN, M.D. 
A thorough examination of the mouth by all available methods is 
of great value, not only in the study of diseases localized in or confined 
to the oral cavity, but also in the investigation of general morbid states. 
Examination of the mouth is, however, often neglected, probably because 
so frequently good general health is found associated with a wretched 
condition of the gums and teeth. But this fact should not make us 
indifferent to the importance of morbid conditions in the mouth as sources 
of general disturbance and as features of diagnostic value. A good deal 
can be learned by a simple routine inspection. The "blue line of lead 
may clear up the diagnosis in an obscure case. The presence of pyorrhoea, 
ulcerative processes and abscesses may afford a clue to the etiology of 
chronic arthritis or a general septicemia. Pigmentation of the mucous 
membrane may suggest the existence of Addison's disease. 
A proper study of the mouth comprises inspection of the lips, gums, 
teeth, tongue, floor of the mouth, salivary glands, and general buccal 
mucous membrane. In cases of disturbed taste, false teeth and plates 
should be removed to ascertain their condition and that of the parts 
with which they are in contact. The sensation of taste should be tested 
in the accustomed ways; the saliva should be examined as to its consist- 
ency, quantity, odor, reaction, and chemical composition. A bacterio- 
logical study of the mouth may prove useful, and should be undertaken 
when diphtheria or other specific process is suspected. Palpation may 
often aid inspection. 
Bacteriology.-The mouth is the constant habitat of many bacteria, 
by far the largest number of which are harmless saprophytes; but there 
are some that possess pathogenic properties, which they display, either 
in the mouth or elsewhere, when suitable conditions obtain. If the 
care of the mouth is neglected, the number and variety of pathogenic 
and non-pathogenic bacteria increase. The bacterial flora of the mouth 
is of course derived chiefly from without, from the air, food, and drink; 
but when infective processes are active in the organs or parts communi- 
cating directly or indirectly with the mouth, the bacteria concerned in 
them may find their way to the oral cavity. Thus in pulmonary tuber- 
culosis, tubercle bacilli may be deposited by the sputum in the mouth; 
and it has been shown by Biedl and Kraus that the salivary glands are 
capable of eliminating bacteria circulating in the blood. 
Despite the fact that the oral cavity teems with bacteria, wounds about 
the mouth usually heal by first intention. This is to be explained by the 
39 40 
DISEASES OF THE DIGESTIVE SYSTEM 
fact that the saliva is after all, as Clairmont1 has shown, not a good culture 
medium for bacteria, although its bactericidal power is extremely weak. 
Aside from individual differences, there is a natural difference between 
the saliva of the submaxillary and that of the parotid gland. In most 
animals the first furnishes a secretion that has only a slightly deleterious 
action upon bacteria; while parotid saliva is capable of inhibiting the 
growth of several species of organisms. Those of the pyogenic group 
seem to suffer most in that respect, especially if the secretion is artifi- 
cially stimulated. When abundantly secreted, the saliva may become 
sterile. 
The researches of W. D. Miller2 have shown that there is a group of 
bacteria more or less peculiar to the mouth. Their identification, how- 
ever, is not yet complete, as the majority have been found in stained 
preparations only, and have not been cultivated on artificial media. 
The following are the most constant mouth bacteria: 
Leptothrix innominata (Miller) occurs in all mouths in which a white 
deposit is found along the gum margin. 
Bacillus maximus (Miller) is the largest of the buccal organisms and 
is found especially in dirty mouths. It is similar to the Leptothrix 
buccalis maxima (Miller), the difference being that the latter does not 
give the iodine reaction, and has segments of greater length; but it 
may be that the two are identical. 
lodiococcus vaginatus (Miller), according to Migula,3 is really a mixture 
of bacteria. Micrococcus gingivae (Miller) is found in pyorrhoea alveo- 
laris and also in healthy mouths. Cladothrix buccalis is found attached 
to the teeth and in carious dentine. 
Streptococcus brevis is the most common species of mouth bacteria. 
By using it as a test, Gordon was able to detect contamination with 
minimal quantities of saliva, and to prove that during speaking, particles 
of saliva were dispersed a distance of forty feet in front and twelve feet 
behind him. 
Bacillus gangrenes pulpae is found almost constantly (95.3 per cent.) 
in diseased pulps and in dental caries. It possesses the power of pro- 
ducing gangrene of the pulp and softening of the teeth. Bacillus necro- 
dentalis occurs in deep layers of carious dentine. Bacterium gingivitidis 
(Kruse) was found in the mouth during an epidemic of scurvy. 
The other bacteria that have been found in the mouth, and which are 
more important from a clinical point of view, are Staphylococcus pyogenes, 
Streptococcus pyogenes, Bacillus pyocyaneus, and the pneumococcus. 
These are sometimes found in the mouths of healthy persons. Longcope 
and Fox4 have shown that virulent forms of the streptococcus and 
pneumococcus are more common in the mouths of healthy persons during 
the winter months than at other times. 
Friedlander's pneumobacillus, Bacillus pseudodiphthericus, and Bacillus 
diphtheria have also been found. The last is of course ■ present when 
1 Wien. klin. Woch., 1896, No. 47. 
2 Die Mikroorganismen der Mundhohle, Leipzig, 1892. 
3 System d. Bakterien, ii, p. 218. 
4 Bulletin of the Ayer Clinical Laboratory, Pennsylvania Hospital, iii, 1906. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
41 
diphtheria exists; but it may also be found in a number of healthy 
children. Erich Muller1 found it in 24 out of 100 children examined. 
The Bacillus tuberculosis is present in the fluids of the mouth in persons 
suffering from laryngeal and pulmonary tuberculosis, when the sputum 
contains the organism. 
The typhoid bacillus was found in the mouth in 50 per cent, of the 
cases examined by Purjesz and Pert.2 Not only was it present in the 
early stages, but it was obtained as late as the fourth and eighth week of 
convalescence. The bacillus of glanders, the bacillus of rhinoscleroma, 
and Bacillus leproe may be found in the mouth. 
The Bacillus fusiformis of Vincent, according to its discoverer, is 
normally present in the mouth.3 Its relation to ulcerative stomatitis 
is discussed farther on. It is usually associated with a spirillum or 
spirochete. A number of anaerobic bacteria have been isolated by Ozaki.4 
The virus of rabies is present in the saliva of animals suffering from 
rabies. 
Spirochetes are common in the mouth, but have not been sufficiently 
studied. They'are often associated with fusiform bacilli; at times also 
with a curved, sausage-shaped organism that was originally described 
by Miller as Spirillum sputigenum. The Spirochaeta dentium of Miller 
which was found by Koch in the covering of both carious and sound 
teeth, and by Migula in association with other dental bacteria, requires 
further identification. 
SEPTIC INFECTION OF ORAL ORIGIN 
Oral Sepsis.-Caries of the teeth, alveolar abscess, and various forms 
of stomatitis, being bacterial processes, may lead to disease at a distance 
from the mouth in one of two ways: (a) By the absorption of toxins 
and bacteria into the blood stream; (6) by the swallowing of pus 
containing toxins and bacteria. 
(a) It is not improbable that some cases of cryptogenetic sepsis, 
ulcerative endocarditis, etc., have their primary source in the mouth. 
The writer has seen a case of fatal septicemia due to dental abscess. 
Oral sepsis plays an important role in the etiology of many forms of 
arthritis. Bull states that in 172 cases of arthritis deformans in which 
special search was made for an infective focus, 141 (76 per cent.) had 
badly decayed teeth or had lost teeth. 
(b) William Hunter5 considers oral sepsis a factor of great importance 
in the pathogenesis of pernicious anemia. The swallowing of pus in 
dental cario-necrosis, in alveolar abscess, and in stomatitis leads to 
septic gastritis. The writer has looked in vain in a number of cases of 
pernicious anemia for evidences of oral sepsis, although he has noticed 
the glossitis to which Hunter calls attention. Yet whatever the results 
1 Jahrbuch f. Kinderheilk., Band xliii, p. 54. 2 Wien. klin. Woch., 1912, p. 1494. 
3 Ann. de I'Inst. Pasteur, 1899, xiii, p. 609. 
4 Centralbl. f. Bacterial, u. Parasitenk., 1912, Orig. 62, p. 76. 
5 Pernicious Anemia, London, 1901, p. 200 et seq. 42 
DISEASES OF THE DIGESTIVE SYSTEM 
of suppurative and necrotic processes in the mouth may be, Hunter's 
insistence on the importance of combating them is entirely warranted. 
The general practitioner, as a rule, pays too little heed to the condition 
of the teeth. Wherever there are cavities, they should be cleansed 
and filled, if that is possible. Rotten stumps should be pulled out and 
replaced by artificial teeth. Not only will mastication and, indirectly, 
digestion be improved thereby, but possible sources of infection that 
may eventually impair the health are removed.1 
Offensive Breath.-The unfortunate possessor of an offensive breath 
is seldom directly aware of it. Among the causes of the condition are 
lack of care of the mouth; mouth breathing due to the existence of 
adenoids, enlarged tonsils, or badly placed teeth; poorly fitting artificial 
devices; ozena, empyema of the antrum, tonsillitis, diphtheria (in the last 
the odor is characteristic); local diseases of the mouth, as the various 
forms of stomatitis, especially the mercurial form; scurvy and caries of 
the teeth. In most acute febrile diseases the breath is somewhat offensive; 
in typhoid fever it is quite peculiar. A rather characteristic offensive 
breath, according to Rolleston, is found in cirrhosis of the liver. It 
resembles the smell of dried and decomposing blood. It is probably 
due to a failure of the antitoxic function of the liver and the consequent 
passage into the blood of poisons generated in the alimentary canal. 
Hence, it is a bad omen. 
A sweetish breath is common in chlorosis and in diabetes; the odor is 
fruity in diabetes with acid intoxication, also in the non-diabetic forms 
of the acidoses; a urinous odor is found in uremia; and a peculiar odor 
difficult to describe characterizes septicemia. A permanent offensive 
breath is found in diverticulum of the oesophagus and in certain cases of 
atony and dilatation of the stomach. The odor in the latter cases is 
probably disseminated by the expiratory air, the gases producing it 
being taken up by the blood and eliminated through the lungs. This 
is also true of some cases of cystitis with ammoniacal decomposition of 
the urine. An offensive breath is common in carcinoma of the larynx, 
in some form of bronchitis, in pulmonary tuberculosis when there are 
cavities, and in abscess and gangrene of the lung. A particularly repulsive 
fetor is sometimes due to putrid plugs in the crypts of the tonsils. In 
hemoptysis the breath has a somewhat sour odor. There is sometimes 
an offensive breath in menstrual disorders and after the use of certain 
drugs, as arsenic, phosphorus, the bromides and iodides. The offensive 
odor following the abuse of alcohol is more often due to fusel oil and 
other ingredients than to the alcohol itself. 
Treatment.-Most important is the determination of the cause and 
its removal, if possible. In addition, the use of antiseptic mouth washes 
is indicated. Miller recommends the following: 
q-Acidi benzoici gr. xc ( 6.0) 
01. menthae pip Hlxv ( 1.0) 
Tr. eucalypti 3j ( 30.0) 
Alcohol, absol giij (100.0) 
1 Rosenberger, Infections of the Mouth, including Oral Sepsis and Dental Decay. 
Philadelphia, 1911. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
43 
Avery satisfactory wash is the liquor antisepticus of the Pharma- 
copoeia; also the following: 
R-Potass, chloratis 5.0 
Tr. myrrhae 5.0 
Aquae rosae q.s. ad. 90.0 
DISTURBANCES OF SENSATION 
A. Disturbance of General Sensation.-(a) Anesthesia.-This is 
usually of hysterical origin, and more often unilateral than bilateral. 
As a rule, it extends to all qualities of sensation. In the rare cases not 
due to hysteria, the lesion involves the superior or inferior maxillary 
nerve or the tympanic plexus, or is located in the cerebrum, in which 
case there is complete anesthesia of one-half of the body. 
(6) Hyperesthesia and paresthesia (formication, pricking, tingling) are 
usually the accompaniment of local processes, as the various forms of 
stomatitis; but they may be due to hysteria or to lesions of the central 
nervous system. They may, especially paresthesia, be the precursors 
of anesthesia and paralysis. 
B. Disturbances of Taste.-Abolition of taste, agusia, may be general 
or partial, persistent or transitory. Transitory agusia depends on local 
conditions, being common in dryness of the mouth, particularly when 
that is due to oral breathing. If partial, it may affect one-half of the 
tongue or the anterior or posterior portion. In agusia of the anterior 
third the lingual nerve or the chorda tympani is involved. In glosso- 
pharyngeal lesions the agusia affects the posterior portion of the tongue. 
Centric agusia, that is, agusia due to disturbances in the gustatory 
centre in the uncinate gyrus, is theoretically conceivable, but has not 
yet been demonstrated. Agusia may coincide with general anesthesia 
of the mucous membrane, such as is found in hysteria. Hyperagusia 
is practically seen only in hysteria. 
Paragusia, or gustatory paresthesia, is common in hysterical persons 
and in the insane. It is also observed in some cases of facial palsy and 
in old cases of otorrhoea; in both of these it affects the half of the 
tongue on the diseased side. Sometimes the epileptic aura takes the 
form of an abnormal gustatory sensation. In persons with fever and 
in those suffering from gastric disturbances there is at times a total 
perversion of taste, on account of which tastes agreeable to them in a 
state of health become insupportable. The writer had under observa- 
tion a man suffering from neurasthenia and moderate arteriosclerosis, 
who had constantly a sweet taste, for which no cause could be found. 
There was no diabetes and no abnormality in the mouth to explain it. 
In the absence of febrile affections and peripheral nerve lesions, the 
prognosis in paragusia should be extremely guarded, as it may be a 
forerunner of mental trouble. 
THE LIPS 
In a state of health the border of the lips is of a bright red color, 
which disappears on pressure, but returns instantly. There are marked 44 
DISEASES OF THE DIGESTIVE SYSTEM 
differences in thickness and in the amount of mucous membrane exposed. 
A moustache on the upper lip causes it to become thick and also a little 
elongated. A thick lower lip is characteristic of certain races, and is 
seen pathologically in myxoedematous idiots. The upper lip is thickened 
in the scrofulous. 
The so-called double lip is a hypertrophy or enlargement not of the 
whole lip, but of the labial glands, which causes a projection between 
the teeth and the red portion of the lip. The appearance produced is as 
if the affected lip were doubled, hence the names "levre double" and 
"Doppellippe." According to Eddington,1 it occurs in young men, and 
affects especially the upper lip. The writer has also seen it in a woman. 
A lip thus deformed is liable to become dry, cracked and ulcerated. 
The treatment consists in the removal of a strip of mucous membrane, 
including all the enlarged glands. 
A change in the shape of the lips may occur as the result of long- 
continued mouth breathing. The lips are pale and flabby, the upper 
lip is shortened, the lower often thick and rolled outward. 
Fissure of the lips is common, and occurs usually in the centre, but 
also at the angles. Fissures at the angles of the mouth, rhagades, are 
most frequently seen in congenital syphilis and in scrofula. 
Changes in the color of the lips and of the mucous membrane of the 
mouth are common. The lips are blue or cyanotic on exposure to cold, 
in asphyxia, in pneumonia, in emphysema, in congenital and in some 
types of acquired heart disease, in mediastinal tumor, in rupture of an 
aneurism into the superior vena cava, in polycythemia rubra and in 
poisoning with coal-tar products. In one of the writer's patients an 
attack of enterocolitis was always preceded and accompanied by intense 
blueness of the lips. Pallor of the lips and oral mucous membrane is 
found in anemia, hemorrhage, chronic parenchymatous nephritis, and 
in aortic stenosis. It is not always a positive sign of anemia, as the blood 
may be fairly normal and yet the lips be pale. In conditions leading to 
inspissation of the blood, as in carcinoma of the alimentary tract, the 
lips may be of a deep red, almost maroon color. In diabetes there is 
at times a striking redness of the lips, which the writer has usually found 
associated with a similar condition of the ears. In jaundice the mucosa 
on the inner surface of the lips has a yellow'ish tinge, which becomes 
more noticeable if the blood is pressed out with a glass slide. Semmola 
and Geoffreddi2 state that if a jaundiced patient forces his mouth wide 
open, tw7o yellow streaks can be seen on the soft and a portion of the 
hard palate. In lead poisoning, in addition to the characteristic blue 
line along the gums, there may be flame-shaped, bluish patches on the 
inside of the lips. In the so-called blue-gummed negro, bluish or brownish 
pigment stains are seen on the gums, rarely on the inside of the lips. 
The presence of brownish patches on the inside of the cheeks, on the 
palate, or lips is an important diagnostic sign in Addison's disease. 
Unnatural dryness of the lips occurs in fevers and in ordinary colds. 
In the former the lips and teeth are often covered with brownish crusts 
1 Glasgow Medical Journal, 1906, Ixv, p. 81. 
2 Twentieth Century Practice, ix, p. 477. PLATE I 
The Blue Line of Lead Poisoning, with a Deposit of Lead in the 
Lower Lip. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
45 
called sordes, which when picked leave a bleeding surface. Tremor of 
the lip is seen in general paralysis of the insane, in alcoholism, in 
hysteria, and in typhoid and other long-continued fevers. 
Eruptions.-The most frequent is the fever blister-herpes labialis, 
cold sore-usually found on the skin surface and red border. There 
may be but a single vesicle, more often there are several, which become 
confluent with the formation of reddish-brown crusts. According to 
Schamberg,1 herpes simplex is most common in childhood and early life; 
55 per cent, of the cases occurring between the ages of ten and thirty 
years. Herpes is an accompaniment of pneumonia, malaria, and cere- 
brospinal meningitis. It is comparatively rare in influenza, and exceed- 
ingly uncommon in typhoid fever. There is a belief among clinicians 
that the occurrence of herpes in pneumonia is a favorable omen. 
Herpes is of infectious origin; but the cause is probably not a single 
specific microorganism. 
Treatment.-Spirits of camphor freely applied in the earliest stages may 
abort an outbreak of herpes; the lesions when present may be painted 
over with tincture of benzoin-several applications are made and 
allowed to dry; they are repeated two or three times daily. When 
crusts have formed, ointments, such as cold cream, camphor ice, zinc 
ointment, etc., favor their early separation. 
Eczema is common in the upper lip in children having acrid nasal 
discharges. Parasitic skin diseases may attack the lips. 
Inflammation of the Labial Glands.-Baelz's Disease.2-This is a chronic 
disease affecting the mucous glands of the lips. It begins as an indolent 
swelling and gradually leads to ulceration, without causing either enlarge- 
of the lymph glands or constitutional symptoms. It probably depends 
on a special infection, but is not syphilitic, although its appearance 
may lead to the suspicion that the patient has a labial chancre. There 
is usually an accompanying superficial catarrhal stomatitis. The disease 
yields readily to applications of dilute tincture of iodine. 
Tumors of the Lips.-The principal tumors of the lips are angioma 
(hemangioma), lymphangioma, and carcinoma. 
Harelip.-This is a congenital deformity, consisting of one or more 
fissures in the upper lip, resulting from an arrest of development. The 
fissure is not in the median line, but corresponds to the line of junction 
between the intermaxillary and superior maxillary bones. Harelip may 
be single or double. The treatment is surgical. 
THE MOUTH 
INFLAMMATION OF THE MOUTH 
Catarrhal Stomatitis.-Catarrhal, simple, or acute stomatitis is a mild 
disease, characterized by redness and swelling of the mucous membrane 
1 Jour. Amer. Med. Assoc., March 2, 1907. 
2 Unna, Monats. f. prakt. Dermal., 1890, xi, p. 317. 46 
DISEASES OF THE DIGESTIVE SYSTEM 
and by increased secretion of saliva. It is produced by irritants 
acting not too violently, these being mechanical, thermic, or chemical; 
as food too hot, too cold, too highly seasoned, or too sour; alcohol, 
tobacco; sharp edges of decayed teeth, caries of the teeth, tartar, denti- 
tion, difficult or fruitless sucking, hare-lip, the use of pacifiers, etc., 
improper care of the mouth, badly fitting teeth, and mouth breathing. 
Catarrhal stomatitis is present in many infectious diseases, partly as 
a result of the same cause, partly because of decomposition of food in 
the mouth, etc. Thus it is found in scarlet fever, measles, typhoid fever, 
influenza, smallpox, and gastric and intestinal disorders. It is also 
present, either alone or as an accompaniment of other forms of stomatitis, 
after the use of certain drugs, such as mercury, iodides, lead, bromides, 
bismuth, and arsenic. In diabetes, nephritis, and cachectic states a 
more or less pronounced catarrhal stomatitis is often found. When the 
process is confined to the gums it is designated gingivitis. 
Pathology.-Hyperemia, increased secretion, and proliferation of cells 
are the changes usually found. The ordinary mouth bacteria are 
present in augmented numbers. 
Symptoms.-There is moderate pain, which is increased on the ingestion 
and mastication of food; infants and young children are apt to cry and 
to protrude the tongue; sucking is difficult. The saliva is increased in 
quantity and becomes sticky and pasty. The sense of taste is im- 
paired; the appetite diminishes; and in children there may be fever and 
at times even emaciation. Examination reveals swelling and redness 
of the mucosa; the tongue is tooth-marked; the interdental processes of 
the gums are enlarged, red, and thickened. The mucosa is covered with 
a tough, whitish saliva, usually in patches. In severe cases the papillae 
of the tongue are prominent and bloody at their tips (papillitis). The 
breath is offensive. 
Treatment.-Aside from the removal of the cause, cleanliness is usually 
all that is required. Simple antiseptic mouth washes, such as a 2 to 3 
per cent, solution of boric acid, sodium borate (2 to 3 per cent.), or 
potassium chlorate (1 to 3 per cent.) will suffice. If the gums are spongy 
they may be touched with glycerite of tannin (1 to 10), and a little 
tincture of myrrh may be added to the mouth wash. In infants, the 
mouth, after nursing, should be washed with sterile water and the anti- 
septic then applied on a pledget of cotton or linen. 
Aphthous Stomatitis.-This is characterized by the formation of 
cream-white patches or plaques firmly adherent to and embedded in the 
mucosa. It is most common in children, but may occur in adults, espe- 
cially in women at the menstrual periods, after parturition, and during 
lactation. It is rare before dentition, and increases in frequency with 
its beginning and up to the end of the second year. There is in some 
cases a marked tendency to recurrence. 
Etiology.-The bacteriology has not been thoroughly studied; but 
Levy, in eight cases, found staphylococci, associated in one with Oidium 
albicans. Streptococci were not found. Faulty hygiene of the mouth, 
decomposition of food remnants, and the irritative influences of dentition 
are predisposing factors. Whether the disease is contagious has not been DISEASES OF THE MOUTH AND SALIVARY GLANDS 
47 
definitely established; not infrequently it occurs in several members 
of the same household. Hirsch1 believes trauma to be important. 
Symptoms.-Aphthae are small, round, or oval plaques or ulcers varying 
in size from that of a pinhead to 0.5 cm. in diameter. They form with 
great rapidity, are sharply circumscribed, and surrounded by a reddish, 
slightly elevated border. The favorite sites are the tip and edges and 
under surface of the tongue, the inside of the lips, and the labiogingival 
pouch. Their number is usually small, although at times new ones 
appear as the old ones undergo healing. Often two ulcers are located 
opposite each other on the gums and on the lip. The pain is usually 
intense, quite out of proportion to the importance of the affection, and 
interferes with mastication. Salivation is present, the tongue is coated, 
the breath offensive, the temper irritable; there may be a little fever. 
Reference has been made to recurrent aphthae; in persons predisposed 
to them any trivial disorder of the general health may bring on an attack 
of aphthous stomatitis. Aphthae do not lead to scar formation. 
Treatment.-The digestive tract and general health must receive atten- 
tion, only in this way can the tendency to recurrence be removed. 
The local treatment consists in the use of antiseptic washes and, if 
necessary, mechanical cleansing of the teeth by a dentist. The ulcers 
may be touched with caustic, preferably the solid stick of silver nitrate. 
Baginsky recommends the application of a solution of potassium per- 
manganate (1 to 150). Hirsch advises tincture of iodine or a 10 per cent, 
solution of chromic acid. Alum is also useful. 
A confluent form of aphthae in children is described by du Pasquier.2 
It is a serious affection, and is either primary or secondary to broncho- 
pneumonia, gastro-intestinal disorders, or one of the exanthems. The 
lesions may appear benign at first, but are rebellious to treatment. 
There is fever and emaciation; at times an infectious erythema appears 
and constitutes a grave symptom. The disease lasts from one to two 
weeks, and may terminate in bronchopneumonia or meningitis. There 
is also a fulminant form ending fatally in twenty-four or forty-eight 
hours after the appearance of the aphthae. The most striking post- 
mortem finding is a fatty degeneration of the liver. 
Bacteriological examination of the oral lesions shows a polymicrobism, 
various round and rod-shaped organisms and Vincent's spirilla being 
found. It is quite probable that this form of stomatitis and the ordinary 
aphthous form are two etiologically different diseases. An affection 
resembling aphthae, but at times forming more diffuse whitish patches 
has been described by Mann3 and by Schomerus.4 In the lesions the 
pneumococcus was isolated in pure culture. 
Ulcerative Stomatitis.-The term ulcerative stomatitis is loosely used 
to designate ulcerative conditions in general as well as a specific disease 
of indeterminate etiology. It occurs in children and adults, and is 
largely due to lack of care of the mouth, decayed and sharp-edged teeth, 
and in children to improper feeding. Crowding of the teeth is also an 
1 Ueber die aphthose Mundentzundung, Inaug. Diss., Leipzig, 1904. 
2 Rev. mens. d. mat. de I'enf., 1903, xxi, p. 353. 
3 Munch, med. Woch. 1909, p. 72. 4 Ibid., 1909, No. 4. 48 
DISEASES OF THE DIGESTIVE SYSTEM 
important factor, ulcers not rarely forming on the cheeks and gums from 
pressure by wisdom teeth. Poisoning with mercury, lead, phosphorus, 
and iodine is a predisposing cause, as are also infectious diseases, scurvy, 
etc. Older writers have described epidemic outbreaks of ulcerative 
stomatitis, especially in barracks; but the condition was probably a 
different one, in some cases perhaps foot and mouth disease. 
Bacteriology.-In addition to the common pyogenic organisms, the 
fusiform bacillus of Vincent (Plant-Vincent) is probably an important 
factor in the production of the disease. This bacillus is a polymorphic 
anaerobe, growing at 37° C., on serum-containing media. It is practically 
always associated with spirochetes, and is found in a great variety of 
affections, e. g., ulceromembranous angina, hospital gangrene, tropical 
ulcer, mercurial stomatitis, scurvy, pulmonary gangrene, peribuccal 
abscesses, and noma. Both the bacillus and the spirochete stain easily 
with dilute carbol fuchsin. The latter has been cultivated by Miihlens. 
Symptoms.-The process, which is almost invariably limited to the 
region of the teeth, begins at the margin of the gums. The gums swell, 
become dull red in color, and are covered with a veil-like haziness; sub- 
sequently they become yellowish and necrotic, bleed easily, and stand 
away from the teeth. In the early stages the swollen gums may in part 
envelope the teeth, while the interdental processes protrude as thick, red 
ridges. As the edges ulcerate the teeth become more and more exposed. 
By lifting away the gums from the teeth, ulcers may sometimes be dis- 
covered quite early on the dental surface below the free edge. The 
ulcerative process may spread to contiguous parts of the lips, cheeks, 
or tongue, and the teeth may drop out. Salivation is profuse, and the 
odor of the breath horribly fetid. Chewing and swallowing are difficult, 
and in children there is fever; even in adults there may be slight rises 
of temperature. The duration varies from a few days to several weeks, 
but as a rule is not more than ten days. 
Treatment.-Removal of the cause is of prime importance. The teeth 
should have careful attention and the mouth should be cleansed with 
antiseptic washes, such as the liquor antisepticus or hydrogen peroxide. 
Internally potassium chlorate in small doses seems to be of much value, 
but it should be administered with caution, especially in children; its 
use should not be prolonged. In severe cases the employment of silver 
nitrate locally is helpful. Gerber1 has found salvarsan useful in Vincent's 
angina. This would justify its employment in severe cases of ulcerative 
stomatitis due to the Vincent bacillus and spirochetes. 
A few words may be devoted to mercurial stomatitis (salivation), a 
subvariety of the ulcerative form. Its mode of origin is not quite clear, 
but it is generally held that the mercury, by its reducing action, injures 
the tissues and in that way prepares the way for pathogenic bacteria. 
Some persons have an idiosyncrasy to mercury, and in them a single 
small dose, or perhaps two or three small doses, will produce salivation. 
Preexisting diseases, such as chronic nephritis, cirrhosis of the liver, 
etc., favor its development. Infants without teeth and the edentate aged 
1 Deutsch, med. Woch., 1911, Nos. 30 and 46. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
49 
are not liable to mercurial stomatitis. In grave cases death may ensue 
from extensive ulceration or gangrene and septic absorption. 
The treatment consists in the discontinuance of the mercury and the 
use of antiseptic washes, as hydrogen dioxide (2 to 3 per cent.), and, 
internally, potassium chlorate, gr. ij to iv (gm. 0.12 to 0.24). Mikulicz 
and Kuemmel recommend iodoform paste or strips of iodoform gauze 
laid in the mouth and Bockhart1 potassium chlorate in powder or in 
the form of a 50 per cent, tooth paste. 
Gangrenous Stomatitis.-Synonyms: Noma; cancrum oris; Wasser- 
krebs (German). This is a comparatively rare form of infection of the 
mouth. Like hospital gangrene, which in some respects it resembles, 
it was more frequent in pre-antiseptic days. Its chief feature is a rapidly 
spreading gangrene involving the cheeks, gums, and alveolar processes. 
It is more common in childhood and in hospital than in private practice. 
Although occasionally an independent affection, it is, in the majority 
of instances, an accompaniment of or sequel to infectious diseases, such 
as measles, scarlet fever, diphtheria, typhoid fever, whooping-cough, 
pneumonia, malaria, and dysentery. In rare cases it follows mercurial 
stomatitis. The old view that it is caused by the administration of 
mercury has been disproved. It usually affects children between the 
ages of two and five years, and seems to be more common in the spring 
and autumn; in adults it is exceedingly rare. Some authors have 
reported cases of so-called idiopathic gangrene of the mouth, in which 
the disease set in spontaneously without any preceding illness on the 
part of the individual attacked. 
Bacteriology.-Various bacteria have been either isolated in culture 
or found in stained preparations, but for none of them has the crucial 
test of reproducing the disease by inoculation been done. The most 
common organisms are the fusiform bacillus and the spirillum of Vincent. 
Streptococci, staphylococci, pseudodiphtheria bacilli, and perhaps true 
diphtheria bacilli and pneumococci are also found. Hellesen2 isolated 
a Gram-positive, non-encapsulated diplococcus, which in animals 
produced a typical and specific necrosis of tissue. 
Symptoms.-The cheek and lip become swollen and the overlying skin 
glazed, colorless, and hypesthetic; a small ulcer forms on the mucous 
surface, rapidly becomes gangrenous, and advances in depth and width 
until the integument is reached. If the latter also melts down in the 
gangrenous process, a perforation results. The hole may be small, or 
the gangrene may speedily involve nearly the entire cheek, the gums, 
and even the alveolar processes, so that the teeth are exposed and 
loosened. In the gravest cases, the tongue and palate may become 
affected. In rare instances, the gangrene involves the outer parts of the 
cheek and spares the mucosa. Noma is nearly always unilateral. 
The consitutional symptoms are often strangely mild when contrasted 
with the local process. Fever may be present; when present it is usually 
of a hectic character, at least in the terminal stages. The odor is very 
foul; the submaxillary lymph glands are enlarged. The disease has a 
1 Monals. f. prakt. Dermal., xxxiv, 1902, p. 113. 
2 Jahrb. f. Kinderh., 1908, Ixvii, p. 294. 
vol. in-4 50 
DISEASES OF THE DIGESTIVE SYSTEM 
very high mortality-from 75 to 80 per cent. The duration is from one 
to two weeks; recurrences have been noted. Death when it occurs is due 
to bronchopneumonia or to exhaustion, which in some cases is hastened 
by a septic diarrhoea. 
Treatment.-Removal of the diseased tissue by the knife or Paquelin 
cautery under anesthesia, the wound being afterward dressed anti- 
septically, is the most efficient treatment. Destruction of the odor is 
best accomplished with formaldehyde, potassium permanganate, or 
iodoform. Diphtheria antitoxin has been employed in some cases, on 
the ground that the diphtheria bacillus was present; but it is quite 
probable that the bacillus was not the Klebs-Loeffler, but the pseudo- 
diphtheria bacillus. An abundance of food and alcoholic stimulation 
are indispensable. 
Swoboda1 described a gangrenous inflammation of the tooth germ 
in the newborn, causing a destruction of the gums, with subsequent 
sequestration of the crowns of the teeth in infants that are still far 
from the normal period of dentition. The cause is probably a septic 
infection, and the prognosis is always fatal. 
Thrush.-Synonyms: Mycotic or hyphomycetic stomatitis; Soor 
(German); muguet (French). Thrush is a form of stomatitis char- 
acterized by the formation of whitish patches largely composed of 
the causative fungus, the Oidium albicans. It occurs chiefly in infants, 
rarely in adults. 
The Oidium albicans of Robin is generally accepted as the etiological 
agent; although some authorities hold the Saccharomyces albicans buccalis 
to be the cause of the disease. The oidium is a pleomorphic organism 
presenting under two forms, (a) small, yeast-like bodies and (b) filaments, 
both of which are usually found together in the mouth. The virulence of 
the organism may be augmented by passage through animals. Although 
in the body the oidium probably elaborates a poison, none has been found 
in artificial cultures. 
Rajat and Peju2 have isolated two types of fungus, one in which the 
cells are of the average size of yeast cells and the other in which they are 
from six to eight times as large. The small-celled variety was present 
in all (70) the benign cases, that is, in those yielding promptly to treat- 
ment; the large-celled forms were present in 5 tenacious cases. 
Thrush seldom, if ever, appears in healthy individuals; but chiefly in 
those whose vitality is impaired. In infancy trivial disorders may prepare 
the way-simple colds, slight intestinal disturbances; while in older chil- 
dren and adults, usually the aged, pneumonia, typhoid fever, and the 
exanthemata are the predisposing causes. In early life the epithelium is 
more easily penetrated; moreover, there is in the newborn, according to 
Grosz,3 a tendency to a desquamative process producing a thin, grayish 
deposit, which favors the development of thrush. An acid condition of 
the saliva, normal in infants and in older children easily produced by 
fermentation of milk remnants, facilitates the growth of the fungus. 
1 Die Therapie der Gegenwart, 1904, xlv, p. 515. 
2 Comp. Rend. Soc. de Biologic, 1906, Ixi, p. 523. 
3 Jahrb. f. Kinderh, 1896, xlii, p. 177. PLATE II 
FIG. 1 
FIG. 2 
Herpetic Inflammation of the Mouth and Tongue. PLATE Ill 
Herpetic Inflammation of the Mouth and Tongue. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
51 
The too vigorous washing of the mouth practised by some nurses after 
the birth of the child may act in the same way. The disease is contagious 
and is transmitted by dirty nipples and dirty feeding bottles. 
Symptoms.-The first sign is the formation of small, whitish points 
on the tip and edge of the tongue and on the inner surface of the lips, 
places on which desquamation of the mucous membrane is favored by 
the act of sucking. The points grow into patches of varying size, and 
may cover the entire inner surface of the mouth like a coat of plaster. 
In some cases the disease extends to the oesophagus and stomach; the 
nose and larynx may also be affected, rarely even the vulva. The patches 
consist of mycelial threads and epithelial cells, with leukocytes in small 
numbers. The mucosa is red and bleeds easily if the patches are forcibly 
detached. Nursing in infants and in older children deglutition and 
mastication are difficult. There may be slight fever and restlessness; 
an eczema of the buttocks is sometimes noted. Several writers have 
recorded cases of thrush metastasis. 
Diagnosis.-All that is necessary is to examine a bit of the deposit 
under the microscope. Sometimes the patches are mistaken for curds 
of milk, which in appearance they closely .resemble. 
Treatment.-For prevention, pasteurization of the milk and cleansing 
of the bottles and of the mouth after feeding are important. Ordinarily, 
the disease yields readily to simple measures, such as wiping away the 
patches with a piece of soft linen or gauze soaked in boric acid or sodium 
bicarbonate solution, the mucous membrane being afterward brushed 
with the same solution, or with a weak solution of mercuric chloride 
(1 to 4000), sodium hyposulphite (1 to 25), or. a weak solution of borax 
or potassium permanganate. Such constitutional treatment as is 
suggested by the underlying conditions must be instituted. 
Herpetic Stomatitis; Herpes Buccalis; Stomatopharyngitis Herpetica 
or Herpetiformis.-Various herpetiform eruptions affect the mouth 
aside from the simple herpes of the lips. Some are associated with herpes 
of the pharynx; others are limited to the oral cavity, usually its posterior 
portion. In a case of the writer's, the vesicular eruption involved the 
tongue, lips, gums, and tonsils, and it was associated with a violent 
conjunctivitis. (See Plate III.) The vesicles were small, yellowish 
white, and on the gums became confluent. There was some fever, 
inability to swallow, salivation, and pain. The condition presented the 
picture of an acute infection. Only one culture was made, and that was 
negative. As pneumonia is an occasional, though rare, complication of 
herpes of the mouth and pharynx, the latter may, like the former, be 
of pneumococcic origin. In women a herpetic stomatitis sometimes 
occurs at the menstrual period. 
Treatment.-This consists in the use of the milder antiseptic washes, 
as, for example, liquor antisepticus (1 part to 2 or 3 parts of water). 
Gonorrhoeal Stomatitis.-This occurs in the newborn from five to 
twelve days after birth, in the form of whitish patches on the anterior 
two-thirds of the tongue, leaving a free border from 2 to 5 mm. wide; 
also on the anterior half arches, and the posterior border of the alveolar 
process of the upper jaw, along the free edge of the gums anteriorly, 52 
DISEASES OF THE DIGESTIVE SYSTEM 
and occasionally on the frenum of the tongue and lips. A reddish reaction 
zone surrounds the exudate. The functional disturbances are slight, 
and the process heals without scars in from four days to four weeks. 
In adults it is rare. The cause in children is infection of the mouth with 
the gonococcus during birth. 
Treatment.-Silver salts in dilute solution (1 to 2 per cent.), as a rule, 
bring about rapid cure; mercuric chloride (1 to 7000) may also be used. 
Bednar's Aphthae.-These are small, whitish plaques occurring in the 
newborn in the region of the hard palate. They are probably due to 
pressure of the tongue or the nipple during sucking, their development 
being favored by the general tendency to epithelial desquamation in the 
first few days of life. Baumm1 considers the forcible cleansing of the 
mouth, practised after birth by some nurses, to be the real factor. The 
ulcers heal spontaneously as a rule; in rare cases they constitute the 
atrium of a general infection. 
TUMORS OF THE MOUTH 
Carcinoma.-This may start in the mucous membrane of the cheeks, 
the gums, about the angles of the mouth, the lips, or in the floor of the 
mouth. It is usually of the squamous type, more frequent in men than 
in women, and very malignant. Early operation is the only treatment 
that promises good results. 
Cysts.-The most common cystic tumor of the mouth is the so-called 
ranula (French grenouillette), which may arise from the sublingual 
gland or its ducts, from Wharton's duct, or from a small group of glands 
-the glandula incisiva-in close proximity to the neck of the middle or 
lateral incisor. In rare instances a ranular growth may take its origin 
from the remains of the thyroglossal duct, or from the branchial clefts, or 
finally, from Blaudin-Nuhn's glands on the under surface of the tongue. 
It is at times difficult in a given case to determine the origin of a cyst, 
but it may be remembered that those from the thyroglossal duct have 
a lining of columnar ciliated epithelium, while those arising from the 
acini or excretory ducts of the salivary glands have a lining that more 
or less faithfully reproduces the epithelium of the parent structure. 
Suprahyoid and submental cysts are sometimes found associated with 
cysts of the sublingual region, with which they may communicate, but 
they may also exist independently. The ordinary ranula results from 
obstruction of the gland duct, and is in its nature a chronic tumor. 
An acute ranula has also been described; it is due to an acute inflamma- 
tion of the duct of the submaxillary or sublingual gland, or of both. 
Cysts of the parotid gland are extremely rare. One with a lining like 
that of the mouth is reported by Morestin. 
Symptoms.-The characteristic symptom of ranula is the presence of 
a cystic tumor on the floor of the mouth, usually just to one side of the 
median line, pushing up the mucosa, which is tightly stretched over it, 
and displacing other structures. Fluctation is easily obtained. 
1 Berl. klin. Woch., 1891, p, 8a >. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
53 
Treatment.-Evacuation of the contents is an uncertain method, 
unless combined with strong cauterization of the lining wall. The old- 
fashioned seton is still in vogue, and may give good results. In some 
cases excision is necessary. 
A dermoid cyst on the floor of the mouth has been described by 
Brentano.1 Mixed tumors, to be more fully described in the section 
on Salivary Glands, are also to be found in various parts of the mouth. 
DERMATOSES OF THE MOUTH 
Various affections of the skin may simultaneously or independently 
affect the mucous membrane of the mouth.2 
Urticaria.-In severe cases of urticaria, especially in giant urticaria, 
similar lesions may appear in the mouth. The tongue and uvula may 
be enormously enlarged; there is intense burning and thirst and at times 
alarming shortness of breath. 
Angioneurotic oedema is characterized by a sudden painless swelling 
of the parts involved. The lips when affected, and they are a very 
common seat of the disease, are swollen to an enormous size and stand 
out as huge, stiff, fleshy masses. It is most common in women, and has 
a tendency to recur. Gastro-intestinal symptoms, especially nausea and 
vomiting, may be present, but are not constant. 
Treatment.-The oedema tends to disappear spontaneously, and 
remedies seem to have but little influence over it. Benefit may be 
gained from calcium lactate, given in 10 grain doses (gm. 0.6) three 
times a day. If there is any disorder of the gastro-intestinal tract, this 
must be corrected, and the diet should be simple. 
Psoriasis. - It is doubted by many whether psoriasis occurs on the 
mucous membrane. In the cases in which no lesions of the skin existed, 
the buccal disease was either leukoplakia or some other non-psoriatic 
condition. A probable genuine case is, however, reported by Oppenheim.3 
Lupus Erythematosus.4-This invades the mouth from the face and 
usually presents itself as superficially inflamed areas, having an elevated, 
deep-red border marked radially by dilated veins; in the centre of the 
patches the mucous membrane is atrophic, violaceous, and dotted with 
countless fine white or bluish-white points or lines. Some of the plaques 
show erosion of the surface and are covered with a yellowish-white deposit 
that cannot be detached. In older foci the appearances may be some- 
what different-the edges are less elevated, and usually have extending 
from them fine arborescent prolongations. The most frequent seat of 
lupus erythematosus is the cheek corresponding to the space between 
the upper and lower teeth. In the differential diagnosis, eczema, 
lichen planus, pemphigus, leukoplakia, and perhaps psoriasis have 
to be considered. 
1 Deutsch, med. Woch., 1906, p. 164. 
2 Only the most important can be mentioned here; for a fuller account the reader 
is referred to text-books on diseases of the skin, particularly to Stelwagon, Schamberg, 
and especially the exhaustive work of Trautmann. 
3 Monat.f. prakt. Dermal., 1903, xxxvii, p. 489. 
4 See the article of Kren, Arch. f. Derm. u. Syphilis, 1907, 83, p. 13. 54 
DISEASES OF THE DIGESTIVE SYSTEM 
Treatment.-This consists in counterirritant and absorptive applica- 
tions and cauterization, but is usually of little avail. Unlike lupus 
vulgaris, lupus erythematosus is not greatly influenced by the .r-rays. 
Lichen Planus.-The lesions of the mouth are nearly always found in 
association with lichen planus of the skin; in rare instances they antedate 
the latter. They appear in the form of whitish dots, plaques, or streaks, 
giving to the mucous membrane an appearance as if it had been cauterized 
with silver nitrate. The lesions are unattended by any inflammatory 
reaction and may persist for years without change. The disease is most 
common in those whose nervous systems are depressed. 
Treatment.-This in the main is general, the common tonics-iron, 
strychnine, quinine, and cod-liver oil-being the remedies indicated. 
Arsenic in ascending doses (up to 10 minims of Fowler's solution) is a 
valuable agent; mercury is also useful, especially in cases in which arsenic 
fails. Itadium is worthy of a trial. 
Pemphigus.-Pemphigus may appear on the mucous membrane of 
the mouth, the lesions being widely scattered over the gums, the roof 
of the mouth, and the soft palate. Farlow1 reported two obstinate 
cases, in which successive crops of vesicles appeared. At various times 
lesions were also present on the cornea, in the nose, in the vagina, and 
on the leg. The treatment consists in the use of alkaline antiseptic 
wrashes to prevent secondary infection, and the administration of arsenic. 
Local anesthesia (cocaine, orthoform) may be necessary to render eating 
possible. 
Acne.-This is rarely found on the mucous membranes. Unna2 
described a case affecting the upper lip, in a woman who had acne of the 
mouth and chin. The lesions yielded to treatment with resorcin ointment 
and ichthyol soap. 
Eczema.-Eczema sometimes affects the vermilion of the lips. 
Tinea Circinata.-This may spread from the face to the lips and mouth. 
Scleroderma.-This sometimes attacks the mouth, leading to atrophy 
of the mucous membrane and to its adhesion to the submucous tissue. 
It may also cause falling out of the teeth. 
Erysipelas.-In rare cases erysipelas of the face extends to the mouth, 
producing a deep redness and swelling of the mucosa, and profuse saliva- 
tion. The soft palate and uvula are especially involved, and their swell- 
ing causes pain and difficulty in deglutition. In severe cases the tongue 
may be involved, as well as the pharynx and larynx. The diagnosis 
is only assured if erysipelas co-exists, or has immediately preceded or 
immediately followed. In persons having repeated attacks of erysipelas, 
groups of small vesicles are sometimes found in the mouth. They may 
be of the nature of lymphatic varices. 
CHANGES IN THE MOUTH DUE TO GENERAL DISEASE 
Typhoid Fever.-In addition to the familiar changes in the tongue, 
typhoid fever produces alterations in the mouth of a less well-known 
1 Boston Med. and Surg. Jour., 1904, cli, p. 671. 
2 Monats. f. prakt. Dermal., 1890, xi, p. 321. PLATE IV 
The Mouth Lesions in Scurvy, DISEASES OF THE MOUTH AND SALIVARY GLANDS 
55 
character. These consist in ulceration, usually on the upper part of 
the anterior faucial pillar, on the tongue, uvula, cheeks, lips, and labio- 
gingival folds. Devic1 observed these ulcerations 81 times in 220 cases 
of typhoid fever (36.8 per cent.). They appear between the seventh 
and fourteenth days of the disease, are shallow, and are preceded by a 
slight discoloration of the mucosa. As a rule they heal in from one to 
two weeks without leaving any permanent defect. Bacteriologically 
only the common mouth organisms were found in Devic's cases; but 
Blume2 discovered the Eberth bacillus in three out of five cases of ulcera- 
tion of the palate. The regions at which the ulcers occur are more or 
less points of compression. As the ulcers are superficial and heal readily, 
the maintenance of oral cleanliness is sufficient. The frequent presence 
of the typhoid bacillus apart from ulcers has been shown by Purjesz 
and Perl. 
Uremia.-The mouth is frequently affected. There may be an insup- 
portable dryness, or an actual stomatitis which is due to bacterial infec- 
tion. Instead of dryness of the mouth, there may be salivation without 
any stomatitis to account for it. Reneon believes that the salivary 
glands may act vicariously for the kidneys. Uremia may also lead to 
parotitis. The tongue may be dry and of a maroon-red color. In one 
case of uremia under the writer's care a tough grayish-white mem- 
brane covered lips, gums, cheeks, and pharynx-no other organism but 
the staphylococcus was demonstrable. Salivation was extraordinarily 
copious, in part because of inability to swallow. 
Diabetes.-The tongue in diabetes is large, red, "beefy," and fissured 
at the margin; the mouth is dry; the teeth are often carious. Pyorrhoea 
alveolaris is frequent. Diabetes insipidus presents nothing but dryness 
of the mouth. 
Pernicious Anemia.-In some cases dental necrosis and ulcerative 
processes are found in the mouth, which Hunter considers an important 
factor in the etiology. 
Leukemia.-The mucous membrane of the mouth may become the 
seat of lymphoid hyperplasia similar to that found in the lymphatic 
glands, spleen, and intestines. The infiltrations show a tendency to undergo 
necrotic change leading to extensive ulceration and pseudomembranous 
and gangrenous processes. In acute leukemia, gingivitis and ulcerative 
stomatitis may be among the first signs. As the gums bleed easily, and 
as there is marked fetor of the breath, the condition may be mistaken 
for scurvy. 
Scurvy.-The gums in scurvy are of a purplish color, soft, and bleed 
easily; the teeth are loosened; there is salivation and intense fetor of 
the breath. (See Plate IV.) Babes has isolated an organism, Bacillus 
gingivitidis, which is found in association with the streptococcus. Oral 
changes are not always present in scurvy. In the differential diagnosis 
the possibility of acute leukemia must be kept in mind. 
Locomotor Ataxia.-Oral conditions found in locomotor ataxia are 
perforating ulcer (mal perforant buccal) and falling out of the teeth. 
1 Troullieur, Gaz. des hop., February 13, 1908, 18, p. 207. 
2 La Semaine med., January 22, 1908. 56 
DISEASES OF THE DIGESTIVE SYSTEM 
The latter is usually entirely painless and may be followed by resorption 
of the alveolar processes. At times there is anesthesia of the mucous 
membrane. The buccal changes are probably dependent upon a periph- 
eral neuritis. 
Pregnancy.-Hyperesthesia, paresthesia, and salivation are common. 
Sometimes there is inability to chew certain articles of food, which in a 
case of the writer's extended only to the eating of celery. Pain in the 
teeth, for the relief of which the teeth are often foolishly sacrificed, is a 
common symptom of pregnancy. At times there is a true gingivitis. 
Varicella.-Lesions may occur in the mouth in chicken-pox, but the 
vesicular stage is rarely observed. 
Variola.-Lesions of the mouth may appear simultaneously with 
those upon the skin or later; they are in the form of pustules that soon 
become macerated and transformed into superficial ulcers. The tongue 
may be spared. 
Treatment.-Weak solutions of borax or boric acid, potassium chlorate, 
or potassium permanganate should be employed. The lesions may be 
touched with dilute tincture of iodine or the tincture of chloride of 
iron. 
Koplik's spots in measles, the strawberry tongue of scarlet fever, 
and analogous conditions are described under the respective diseases. 
Pyorrhoea Alveolaris.-Synonyms: Bigg's disease; periostitis alveolaris 
dentalis; general periodontitis, etc. This is a widespread affection of 
obscure etiology, occurring usually in persons over thirty years of age. 
Involving, as it does, a loss of teeth in the best years of life, it ought to 
interest physicians much more than it has hitherto done. If physicians 
and dentists would combine in a study of the disease, perhaps the mystery 
that surrounds it might be lifted. 
Symptoms. - The gingival mucous membrane is congested and of a 
deep-red or purplish color. As the gums become detached coincidentally 
with the destruction of the pericemental membrane and the alveolar 
osseous tissue, pockets are formed between the root and the alveolus, 
which are almost constantly filled with inflammatory products and 
food debris. On pressure against the gums, these pockets may be 
emptied of their purulent or semipurulent material. The affected teeth, 
which are tender to the touch, but usually free from caries, gradually 
become loosened and eventually exfoliated. A general catarrhal condition 
of the mouth and a characteristic fetor are usually present. The disease 
may persist for months or years, and while it lasts there is constant 
swallowing of the purulent exudate and tissue debris, which in time 
may cause local disturbances in the stomach and general disease. The 
possible part played by these factors in the production of digestive 
disorders is often overlooked. 
Diagnosis.-But little difficulty attends the diagnosis. As a rule, 
several teeth are affected, chiefly the upper incisors. The swollen, reced- 
ing gums, and the oozing of pus from pockets beneath the margin are 
easily discovered signs. Pyorrhoea alveolaris may be an early symptom 
of diabetes mellitus and of tabes dorsalis, and it may exist for 
years without being perceived by the patient. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
57 
Treatment.-Patients should be referred to the dentist for oral treat- 
ment. This consists in the removal of all salivary deposits and the scaling 
and polishing of the surfaces of the teeth. As a stimulating applica- 
tion to the gums after mechanical cleansing, either tincture of iodine 
or glycerite of tannin may be used. The mouth should be frequently 
cleansed with a mouth wash, such as the liquor antisepticus diluted or 
carbolic acid solution (1 per cent.). 
Of late, radio-active waters in the form of mouth washes and local 
radiation with radio-active salts have been recommended. The use of 
vaccines with proper local treatment has given excellent results in some 
cases. 
TUBERCULOSIS OF THE MOUTH 
This is rarely primary, at least not in the pathological sense; clinically, 
it may be; at any rate, cases occur in which, aside from the oral or salivary 
tuberculosis, no other tuberculous lesion is demonstrable. At times, 
however, repeated careful examination may reveal another focus that 
constitutes the primary source. In the tonsils an apparent primary 
localization of tuberculosis has been described. 
Tuberculosis in the form of lupus may spread from the face to the 
mouth. The ordinary form of tuberculosis is usually the result of a 
direct infection of the mouth with bacteria from the sputum. If there 
is a hematogenic infection, it has not been demonstrated. It is not 
likely that this occurs in the tongue, as muscle tissue in general is seldom 
affected by tuberculosis. Tuberculosis of the lips is occasionally seen 
in tuberculous subjects. It assumes the form of an ulcer, which is not 
easily distinguished from chancre. 
Miliary nodules may appear on the flesh of the gums; ulceration may 
occur along the free edge and extend to the hard palate, The condition 
has followed tooth extraction in tuberculous subjects. Tuberculosis of 
the soft palate sometimes occurs in persons with pulmonary tuberculosis. 
The tongue is the commonest seat of oral tuberculosis, the lesion 
being due to infection from the sputum. Cases are recorded in 
which the sputum did not seem to be the cause of infection; but 
in which the latter came from without. The only instance seen by 
the writer occurred in a street-car conductor, who had the habit of 
wetting the transfer tickets with his tongue, so as to be better able to 
separate them with his fingers. S. von Ruck reported 19 cases observed 
among 5000 patients (0.38 per cent.). 
The disease appears in one of several forms, as circumscribed sub- 
mucous nodules (tuberculomas), which in time ulcerate, as a disseminated 
process, and rarely in the form of tuberculous fissures or rhagades. The 
nodules are either single or multiple, and may remain stationary for a 
long time. Eventually, ulcers form which are shallow, irregular in out- 
line, have undermined edges, and are covered with a grayish-white 
slough; toward the margin miliary nodules may be seen. Ulcers occurring 
in association with advanced tuberculosis of the lungs have a greater 
tendency to spread in extent and depth than those that are apparently 58 
DISEASES OF THE DIGESTIVE SYSTEM 
primary. The lymph glands are rarely affected. There is not much 
pain in the usual chronic non-spreading or slowly spreading ulcers. 
Diagnosis.-A careful history and discovery of tuberculosis elsewhere 
aid materially. In differentiating tuberculous and carcinomatous 
ulcers, the following points are important: tuberculous ulcers may be 
multiple; the edges are softer and less infiltrated; there is less pain, and 
less frequent involvement of the lymph glands than in carcinoma; the 
age of the patient is also of importance. 
Treatment.-If the pulmonary disease is far advanced, treatment is 
hardly worth while. In other cases, total excision of the tuberculous 
area is the best procedure. If not possible, the ulcers may be removed 
with the thermocautery or sharp spoon. For the dressing of the ulcers, 
iodoform is best. 
SYPHILIS OF THE MOUTH 
In the clinical course of syphilis, lesions of the mouth occupy a prominent 
place. The primary sore is found there in the largest number of cases of 
so-called extragenital syphilis. The lesion may be only a fissure or a 
superficial flat erosion, with a pseudomembranous covering. It is usually 
single, and, even if small, leads to marked glandular enlargement. Its 
commonest sites are the lips, especially the lower, the tongue, the hard 
and soft palate, and the tonsils. The danger of infection to others 
renders it important to make a correct diagnosis early. This is well 
illustrated by the epidemic of chancre of the lip from kissing reported 
by Schamberg,1 in which a man gave chancre of the lip to eight persons. 
If it is a case of syphilis insontium, the patient is generally unaware 
of the nature of his ailment. In the diagnosis tuberculous and cancer- 
ous ulcers have to be considered. The demonstration of the Treponema 
pallidum in smears from the ulcer facilitates the diagnosis. 
Secondary Lesions.-The secondary lesions in the mouth are an 
erythema and the so-called mucous patch. The latter, which is among 
the most infectious of the syphilitic lesions, is a pearly or milk-white 
area upon a red inflamed surface. The patches are irregular in outline, 
and variable in size and number. They are found in all parts of the 
mouth, most frequently upon the lips, the palatal arches, and the tonsils. 
At the angles of the mouth they lead to rhagades. They appear about 
the same time as, or before, the roseola on the skin and may be painful 
or painless. The diagnosis is not always easy; leukoplakia is to be 
excluded by its chronicity and by its not occurring on the tonsils and 
soft palate, as well as by the Wassermann and therapeutic tests. 
Treatment.-The local treatment consists in the use of antiseptic 
washes in the mouth and direct application of 1 per cent, mercuric chloride 
solution, of a solution of nitrate of silver (10 to 20 per cent.), or chromic 
acid solution (5 to 10 per cent.). It is best to use wooden applicators 
and tongue depressors, and burn them afterwards. 
Tertiary Lesions.-Tertiary lesions in the mouth are of the nature 
of gummata and require no special description. Their most frequent 
1 Jour. Amer. Med. Assoc., September 2, 1911. PLATE V 
Syphilitic Lobulation of the Tongue. "Cobble-stone Tongue." DISEASES OF THE MOUTH AND SALIVARY GLANDS 
59 
sites are the hard and soft palates; but they may be found in the tongue, 
lips, and rarely in the cheek. In the palate they usually lead to perfora- 
tion. The tertiary lesions of the tongue may, according to Fournier, be 
divided into two types-sclerosing and gummatous glossitis. In the 
former the infiltration does not break down, but cicatrizes and gives 
to the tongue a nodular or puckered appearance (langue lobee, langue 
rhagadiforme). The gummatous lesions break down and ulcerate. A 
teritary lesion may be mistaken for a primary sore, but, besides being 
usually deeper, it is not accompanied by marked adenopathy. The 
history, moreover, is helpful. 
Treatment.-The treatment consists in the vigorous use of salvarsan 
and of mercury and potassium iodide. 
Hutchinson's Teeth.-A crescentic notching of the upper central 
incisors with a peg shape was described by Jonathan Hutchinson as a 
sign of inherited syphilis. It is found in the permanent set, and dis- 
appears with advancing years through the wearing down of the edges of 
the teeth. Seldom is the regular crescent found in conditions other than 
syphilis, and the presence of such teeth always suggests a careful search 
for additional evidence of congenital lues. 
ACTINOMYCOSIS OF THE MOUTH 
Actinomycosis of the mouth is not very common.1 When it affects 
the lips it produces a tumor-like formation resembling carcinoma. The 
cheek is not often the seat of the disease. In a case of Kaposi's, the trouble 
began on the inner side of the cheek corresponding to the position of a 
carious tooth removed a short time before. In the jaw, the fungus 
commonly attacks the periosteum, producing a periostitis alveolaris, 
especially in the lower jaw. In the tongue the disease assumes a tumor- 
like appearance, the nodules ranging in size from that of a pea to that 
of a chicken's egg; they are found especially near the tip of the organ. 
The cause of actinomycosis is the actinomyces fungus, which is prob- 
ably conveyed to the mouth clinging to grain-. There is no proof of 
contagion in man from animals. Carious teeth are a predisposing cause 
by favoring stomatitis, which in turn renders infection with the fungus 
easier. The cavities in decayed teeth have been suspected to be the 
breeding places of the actinomyces, but this is not proved. 
Treatment.-Excision of the diseased area should be done when 
possible, combined with the use of potassium iodide. 
LEPROSY OF THE MOUTH 
This affects the mouth and tongue only secondarily. It appears in 
the form of nodules, which, in the tongue, may be symmetrically situated 
on both sides of the raphe; by their coalescence, extensive infiltrating 
plaques may be formed. Ulceration is rare. The histological lesions are 
like those of leprosy elsewhere. 
1 Centralbl. f. die Grenz, der Med. u. Chir., 1900, Band 3, iii, p. 561. Also Deut. 
Ztihnheilk. in Vortragen, Heft 30, 1913; Zeil. f. inn. med., June 30, 1913. 60 
DISEASES OF THE DIGESTIVE SYSTEM 
SCLEROMA OF THE MOUTH 
This reaches the mouth through the posterior nares, and produces 
infiltrated areas covered with a somewhat bluish-red mucosa. After 
a time very hard nodules appear that are not usually spontaneously 
painful, but somewhat tender on pressure. They scarcely ever suppurate, 
but may become superficially ulcerated. The infiltration consists of 
two layers-an upper vascular layer and a lower rich, in cells and 
traversed by fibrous bands, to which the extreme hardness is due. 
The similarity to a round-celled sarcoma is quite marked. 
THE TONGUE 
The coating of the tongue hardly has the diagnostic value attached 
to it by the older clinicians. Nevertheless, it gives much information 
and a study of it should not be neglected. It may depend upon local 
conditions in the mouth or nasopharynx; upon causes arising from the 
gastro-intestinal canal; or upon general conditions. A heavy coating 
is compatible with good health, and the clean tongue is not always a 
sign that the alimentary canal is performing its functions properly. 
Some persons have a furred tongue on slight provocation, while others, 
in severe affections, do not. The tongue is usually heavily coated in 
persons with restricted movements of the jaw. 
An exclusive milk diet nearly always produces a coating of the tongue, 
probably chiefly because of the suspension of the masticatory movements. 
In some persons even a single glass of milk will give rise to this condition. 
A coated tongue is found in mouth breathers, in fevers, and in some forms 
of dyspepsia. In hyperchlorhydria the tongue is usually dark red, moist, 
and clean; it is also at times remarkably clean and red in diabetes 
mellitus. It is pale and heavily coated in anacidity and clean in gallstone 
disease often when gastric symptoms are marked. 
Anomalies.-Aglossia, a total absence of the tongue, is extremely rare. 
There is indeed only one indubitable case, that of Jussieu (Rosenthal).1 
Microglossia, smallness of the tongue, is likewise rare. 
Macroglossia, large tongue, is usually applied to enlargements of the 
tongue not due to acute inflammation, and is of four varieties: (a) 
Lymphatic (lymphangioma); (b) cavernous (hemiangioma); (c) muscular 
or parenchymatous, the rarest, of which Helbing2 reports a case; (d) 
neuromatous macroglossia, of which cases have been described by 
Abbott and Shattuck3 and Wagner.4 A chronic enlargement, due to 
syphilis, might be added to the foregoing. Macroglossia is generally 
bilateral, but may be unilateral, as in the case of Little,5 in which it was 
1 Die Zunge, 1903, p. 17. 
2 Jahrb. f. Kinderh., 1895 to 1896, xli, p. 442. 
3 Annals of Surgery, 37, 1903. 
4 Cited in Ztschr. f. d. gesam. Med. u. i. Grenzgeb., May 26, 1913. 
8 British Journal of Dermatology, 1906, xviii, p. 181. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
61 
probably due to congenital syphilis; and in that of Maas, in which it 
was associated with congenital hypertrophy of one-half of the body. 
The chief causes of macroglossia are cretinism and syphilis; the former 
producing especially the lymphangiomatous form, which may be asso- 
ciated with macrocheilia, large lip. In the cases due to cretinism, thyroid 
extract might be useful. In a case reported by Comroe1 a cure was 
brought about the excision of a V-shaped piece. 
Doubling of the tongue, excessively long tongue, and bifid tongue have 
been described, but are unimportant. 
Congenital deformities of the frenum are supposed to be common, 
and to the so-called tongue-tie the laity ascribe delayed talking and 
difficulty in sucking. Cutting of the frenum is, however, very rarely 
necessary, although Makuen2 has reported a case of rapid speech develop- 
ment in an adult following the operation for tongue-tie. In a case of 
the writer's, a trained nurse, the tongue-tie prevented protrusion of the 
organ but did not materially interfere with speech. 
Tongue swallowing may occur if the frenum is too long. The tongue 
may roll back and so press against the posterior wall of the pharynx that 
the entrance to the larynx is occluded and suffocation results. 
Tongue sucking is especially common in Mongolian idiots. It leads 
to marked fissuring of the tongue and to enlargement of the papillae. 
Scrotal tongue (langue scrotale) is a term much used by the French to 
describe a fissured tongue resembling the scrotum in its roughness. It 
is difficult to find an explanation for it, although sometimes there is a 
history of gastro-intestinal disorders. Some of the patients in early life 
were arthritic subjects. The condition may run in families. 
Black Tongue.-Synonyms: Lingua nigra; nigrities linguae; hyper- 
keratosis of the tongue; melanotrichia of the tongue; melanoglossia; 
German-Haarzunge. This is a condition in which a brownish or black 
patch appears on the posterior portion of the tongue, in the neighborhood 
of the circumvallate papillae. It is either smooth or covered with densely 
intertwined hair-like processes varying in length up to 1 cm. The 
hairs are elongated filiform papillae that have become pigmented and 
cornified. Some hold that the black discoloration is due to a mould; 
but Blau found no mould in four cases. The causes of black tongue 
seem to be various. Ileidingsfeld3 thinks that the true or permanent 
cases have a congenital origin and are due to some anomaly of develop- 
ment. The spurious cases of black tongue are caused by local or 
general irritating or infectious agencies, such as tobacco, syphilis, 
antiseptics, etc. A parasitic origin has not been established. It has 
been found in syphilis, diabetes, neuralgia, etc. It may come and go 
without treatment, and this suggests that it depends upon changes in 
the salivary secretion. There are usually no subjective symptoms. 
Varicose Veins of the Tongue.-Dilatation of the ranine veins on 
the under surface of the tongue is not uncommon; but the veins on 
the dorsum may also become varicose, especially those running from the 
base forward to the circumvallate papillse. The causes are local. 
1 Cleveland Med. Jour., September, 1911. 2 New York Med. Jour., 1895, p. 20. 
3 Jour. Amer. Aled. Assoc., December 17, 1910. 62 
DISEASES OF THE DIGESTIVE SYSTEM 
Hemorrhage from the Tongue.-Bleeding tongue, glossorrhagia. 
This is most often traumatic, but may occur in purpura and other 
hemorrhagic conditions, and in hysteria, of which the writer has 
seen a striking example. (See Plate VI.) 
Paralysis of the Tongue.-Glossoplegia. This may be due to central 
or peripheral lesions of the nervous system, and is either unilateral or 
bilateral. Unilateral glossoplegia may be caused by disturbance of one 
of the hypoglossal nerves; it is also present in the majority of cases of 
cerebral hemiplegia. The tongue is deflected toward the paralyzed 
side. The chief cause of bilateral glossoplegia is progressive muscular 
atrophy. 
Spasm of the Tongue.-The tongue participates in the general muscular 
commotion in epilepsy, chorea, etc. Spasm limited to the tongue, a 
sort of tic, has been described; spasm of the facial and masticatory 
muscles may be associated with it. Some cases of spasm are hysterical; 
in some no definite cause is discoverable. 
Paralysis of the Soft Palate.-This, like glossoplegia, may be unilateral 
or bilateral. In the unilateral form the palate on the affected side hangs 
lower than on the normal side. In bilateral palsy the entire palate droops 
and is motionless during speaking and breathing; speech and swallowing 
are disturbed, and food regurgitates through the nose. The most impor- 
tant causes are neuritis following infectious diseases, especially diphtheria; 
bulbar palsy, tumors at the base of the brain in the posterior fossa; 
aneurism of the vertebral artery; and tabes dorsalis. 
Glossitis.-Acute inflammation may be due to biting of the organ 
during an epileptic convulsion, biting by insects, burns, or to the irritation 
of a rough, carious tooth. An acute glossitis occurs in smallpox, erysipelas, 
scarlet fever, and typhoid fever, and usually accompanies severe forms. 
Tobacco may also cause glossitis and is responsible for the so-called 
smoker's patch. 
Symptoms.-The affected side of the tongue swells and at the point 
of injury becomes covered with a grayish-white membranous deposit. 
The swelling may be so great that the tongue hangs out of the mouth. 
Pain and discomfort are severe and mastication may be impossible. 
The saliva is increased in amount and is sticky. The condition usually 
terminates in resolution; but in about one-third of the cases, according 
to A. B. Bennett,1 suppuration ensues. When unilateral in the beginning 
(hemiglossitis), it rarely spreads to the other side. 
Treatment.-Antiseptic mouth washes are indicated. In severe cases, 
and when abscesses form, a long, deep incision must be made into the 
substance of the organ. 
Papillitis Lingualis; Linguopapillitis.-This is a painful condition of 
the tongue, which reveals nothing to the naked eye, but the magnifying 
lens shows small, ulcerating points hidden in the folds of the mucosa 
about the fungiform papillae of the tip and margin of the tongue. 
Treatment.-The painful points should be touched with the galvano- 
cautery, aided by a lens. 
1 Albany Med. Ann., 1906, v, p. 667. PLATE VI 
Bleeding Tongue in Hysteria. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
63 
Ulcer of the Frenum.-Ulcer is most common in children suffering 
from whooping-cough, and is due to the forcible protrusion of the tongue 
and impact of the frenum against the teeth during the paroxysms. 
Glossitis Papillosa Acuta; Glossitis Papillaris.-This is an inflam- 
mation limited to the circumvallate papillie, and is characterized by 
slight difficulty in swallowing, burning, and sticking sensations in the 
throat, and an irritative cough. An acute form has been described by 
Michelson.1 Stetter,2 under the name of glossitis papillaris, reports 
four cases with histological studies. Tuberculosis may produce conditions 
very similar to the ones described. 
Wandering Rash of the Tongue.-Synonyms: Geographical tongue; 
exfoliatio areata linguae; etat lichenoide; annulus migrans; Zungenfratt; 
etat tigre; glossitis exfoliatricans marginata; desquamation en aires. 
This interesting condition of the tongue is characterized by circinate, 
crescentic, or circular patches in which the epithelium is desquamated. 
The patches may be multiple or single, they may affect the dorsum or 
the margin of the tongue and are bordered by a slightly elevated, whitish 
ring which is sometimes double-contoured. When the patches are 
multiple and affect a large part of the tongue the fantastic shapes give 
a remarkable appearance well described in the name geographical tongue. 
The patches may come and go suddenly; their shape and size may alter 
rapidly. Contiguous patches may fuse. In some cases a single patch 
may remain for a long time unchanged. 
Etiology.-The cause is not definitely known. Gastro-intestinal 
disorders and heredity are possible factors. A single patch may be due 
to a sharp tooth. Syphilis is not responsible for the condition. 
Histological examination shows a superficial desquamation of the 
epithelium, the latter being replaced by a coagulated exudate containing 
leukocytes and degenerated epithelial cells. The cells of the deeper 
layers of the mucosa are in a state of cloudy swelling. Some authors 
have found the changes most marked in the lower strata of the mucosa. 
Symptoms.-There are usually no subjective symptoms except a little 
burning or sensitiveness. The affected area looks paler and smoother 
than the surrounding parts. The lymphatic glands may be enlarged; 
in women the condition is apt to be worse at the menstrual periods. 
Some patients, fearing cancer, become hypochondriacal. 
Treatment.-It usually subsides without treatment. Attention should 
be given to the gastro-intestinal canal. The patient's mind should be 
put at rest as regards cancer. A mouth-wash of sodium hyposulphite 
and glycerin, of each 10 parts, and water 180 parts, may be used. 
Moeller's Glossitis; Glossodynia Exfoliativa; Chronic Superficial 
Glossitis.-This is a very painful affection of the tongue, characterized 
by bright-red lines or patches at the margin and tip. The pain, which 
is the principal symptom, is out of proportion to the local lesion, and is 
much increased by chewing and speaking. The disease chiefly affects 
women, especially those who are weak and decrepit. The cause is 
unknown. The only instance seen by the writer was in a woman with 
1 Berl. klin. Woch., 1890, p. 1094. 
2 Arch.f. klin. Chir., 1898, Ivi, p. 324. 64 
DISEASES OF THE DIGESTIVE SYSTEM 
pernicious anemia. Local treatment was of no avail; the x-ray and 
applications of nitrate of silver were tried without effect. With an 
improvement in the blood the condition subsided, but recurred; the 
patient eventually died of anemia. 
Glossodynia.-Pain of the tongue, without gross lesion to account for 
it, is not uncommon; usually the pain is referred to the anterior third 
of the organ or along the margin of the tip. It is often difficult to 
ascertain the cause; but in a search for it the classification of Chaveau1 
may prove helpful. He names the following varieties: 
1. Glossodynia secondary to trigeminal neuralgia, especially of the 
inferior dental branch of the trigeminal. 
2. Glossodynia of the insane, usually starting as a local paresthesia. 
3. Glossodynia of tabes, corresponding to the crises in other organs. 
4. Glossodynia of hysteria. 
5. "Rheumatism" of the lingual muscle or rheumatic glossodynia. 
6. Glossodynia attributable to local causes. These may be extrinsic 
or intrinsic. Among the extrinsic causes are (a) dental affections and 
artificial teeth (causing papillary hypertrophies and other lesser lesions); 
(6) granular pharyngitis and hypertrophy of the posterior pillars, and 
of the lingual tonsil, etc. Among intrinsic causes are mentioned (a) 
lingual varices; (6) chronic glossitis from tobacco, alcohol, spices, iodine, 
lead, gout, etc., and (c) papillary hypertrophy. 
Leukoplakia.-Synonyms: Leukoplasia; psoriasis linguae; tylosis 
linguae; ichthyosis buccalis; keratosis buccalis; smoker's patch. This 
is a chronic disease of the mucous membrane of the tongue, rarely of 
the lips, cheek, palate, and gums, characterized by thick, elevated, 
indurated, whitish patches having either a fissured or more rarely a 
smooth appearance. 
Etiology.-There is a connection between syphilis and leukoplakia, 
but that the former is the cause cannot be maintained, in view of the 
investigations of Erb2 and Neisser.3 Nevertheless, the frequency of a 
history of syphilis, in 65 per cent, of the cases of leukoplakia, according 
to Schoengarth,4 and in Pulvermacher's5 54 cases, seem to justify the 
contention that leukoplakia is a parasyphilitic lesion. Ivy6 obtained a 
negative Wassermann in 2 out of 3 typical cases. This was also true of 
one of the writer's cases that eventuated in carcinoma. Smoking is also 
an important factor, and explains in a measure the predominance of 
the disease in the male sex. Of Pulvermacher's 54 patients, only 1 was 
a woman. The use of spices, condiments, and alcoholic beverages must 
be mentioned among the possible causes, likewise irritation by carious 
teeth and badly-fitting dental devices. As leukoplakia has been found 
associated with diseases of the skin characterized by scaling and keratosis, 
it may be looked upon as an expression of a general tendency to hyper- 
keratosis, to which the mouth is excited by frequently repeated or 
1 Arch. gen. de Med., 1900, ann. 77, n. s., iii, p. 66. 
2 Munch, med. Woch., 1892, Nr. 42. 
3 Quoted by Mikulicz and Kummel, Die Krankheiten des Mundes. 
4 Ueber Leukoplakia lingualis el buccalis; Diss. Breslau, 1896 
5 Wien. klin. Woch., 1906, xiii, p. 963. 
6 New York Med. Jour., April 13, 1912. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
65 
long-continued irritation of various kinds. The most common dermal 
association is psoriasis. 
The disease is most common in the male sex and in adult life, although 
Hartzell reports a case of extensive leukoplakia associated with keratosis 
of the skin in a young girl aged eleven years. The disease progressed 
steadily until at the age of twenty-six there was carcinoma of the tongue. 
Pathology.-The principal feature is a hyperkeratosis of the mucous 
membrane. The epithelium, especially the corneous layer, is greatly 
thickened. The subcorneous stratum contains many cells filled with 
eleidin droplets and granules. Mitotic figures are abundant in the 
deeper layers of the rete mucosum; while the elongated papillary pro- 
cesses are extensively infiltrated with leukocytes. 
Relation to Epithelioma.-The transformation of leukoplakia into 
cancer is indubitable. This is not a complication or an accident, but 
a distinct evolutionary development, the causes of which reside in the 
histogenesis of leukoplakia. It occurs in about 20 per cent, of the cases. 
Symptoms.-In the early stages leukoplakia appears in the form of 
deep-red erythematous patches, which after a short time assume a 
bluish-white color, looking as if the mucous membrane had been painted 
over with a strong solution of silver nitrate. Gradually the patches 
become thicker and larger, and, in the case of the tongue, may cover the 
mucosa so completely that the papillae are no longer visible. The parts 
affected are in the order of frequency: tongue, lips, cheek, gums, and 
palate. The pharynx and the base of the tongue posterior to the circum- 
vallate papillae are rarely involved. The patches may be smooth, more 
often they are fissured. To the touch they have a tough, leathery feel. 
The superficial layer can at times be picked off easily without much 
bleeding being produced; regeneration quickly takes place. 
The subjective symptoms are slight, unless the fissures are deep and 
raw, in which case there may be pain on chewing. The patient who is 
aware of his leukoplakia is apt to become hypochondriacal, fearing 
either cancer or that syphilis is returning under a new form. 
Treatment.-This avails but little, and it is doubtful whether it is 
possible to prevent by any form of application the development of carci- 
noma. Cleanliness of the mouth, cessation of smoking, abstention from 
irritant spices, and the removal of sharp-edged teeth are important. 
Antiseptic treatment and strong caustics more often do harm than good. 
A 10 per cent, solution of tincture of iodine has been recommended, and 
Hartzell advises applications of salicylic acid (1 to 100 or 150). The x-ray 
cautiously employed has been of some value in the hands of Hartzell 
and Schamberg (personal communication). Bockhart insists that 
leukoplakia cannot be cured unless the patient stops smoking. In five 
cases he had success with the following local treatment: the diseased 
areas were rubbed once a day or once in two days with balsam of Peru; 
in addition the mouth was rinsed from six to twelve times a day with 
from | to 3 per cent, salt solution. He considers the saline washing 
more important than the application of the balsam. Antisyphilitic 
treatment is not only useless but often harmful. Local astringents, 
such as myrrh, are injurious. 
vol. in-5 66 
DISEASES OF THE DIGESTIVE SYSTEM 
Smooth Atrophy of the Tongue.-This is an atrophy of the epithelial 
covering and of the large sebaceous glands at the base of the tongue, 
which is found more often in acquired syphilis than in any other con- 
dition, and has been considered a pathognomonic sign of this disease. 
Goldschmidt1 found it in 17 per cent, of 140 cases of secondary, and in 
47 among 60 cases of tertiary syphilis. But as it is also found in non- 
syphilitic subjects, it cannot have the diagnostic value ascribed to it. 
L. S. Milne2 found it 39 times in 505 autopsies (25 male, 14 female). 
Among 36 syphilitic cases, it occurred 14 times, a sufficiently large 
proportion to make the relation significant. It was also found a few 
times in tuberculosis. In examining for it, the finger or the mirror may 
be used. With the former, the unnatural smoothness of the base of the 
tongue is perhaps more readily detected. 
Riga's Disease.-Synonym: Produzione sottolinguale. This is a 
benign tumor-like excrescence on the lingual frenum of infants. It is 
most common in Italy, whence nearly all the observations and studies 
have come. Good accounts, with bibliographies, are found in the articles 
of Ernst Deutsch3 and E. Audard.4 The cause is in dispute, but in 
some cases it is of mechanical origin (decubital), due to irritation by the 
lower incisor teeth. Histologically, it is a papillomatous growth. 
Symptoms.-The disease appears between the ages of three and 
eighteen months and is equally common in both sexes. It is probably 
not contagious; some Italian writers, however, consider it so. It lasts 
from two weeks to two months; although some cases are on record that 
persisted for from eighteen to twenty months. It must be distinguished 
from the ulcer of whooping-cough, chicken-pox, syphilitic ulceration, 
herpes, and impetigo. 
Treatment.-If a cause is discoverable, it should be removed. If there 
is irritation by teeth, they should be extracted. In persistent cases, 
caustics, silver nitrate or tincture of iodine, may be applied, or the 
growth may be excised. 
Tumors.-Fibroma, usually of the hard variety, is found on the surface 
or in the substance of the organ. Sarcoma is a comparatively rare tumor, 
generally spindle-celled, and occurs in the substance of the tongue. 
Thyroid Tumors.-A small tumor is sometimes found at the base of 
the tongue in the region of the foramen caecum, which histologically is 
made up of tissue closely resembling that of the thyroid gland and the 
origin of which is to be traced to the remains of the thyroglossal duct. 
Glas5 reported a case of adenomyoma occurring in the same region as 
the thyroid tumor, traced to the remains of the ductus lingualis. 
Carcinoma is the most frequent tumor found in the tongue. It is 
commoner in the male sex (66 to 3 in the statistics of Meller), and 
extremely malignant. Patients not operated on usually die in less than 
a year after the appearance of the first symptoms. 
Amyloid tumor is rare; an example is recorded by Gross.6 
1 Berl. klin. Woch., 1899, Nr. 43. 2 Jour. Amer. Med. Assoc., September 23, 1911. 
3 Arch. f. Kinderh., 1905, xl, p. 168. 
4 Rev. mensuelle des mal. de I'enfance, 1902, xx, p. 49. 
6 Berl. klin. Woch., 1905, 18, p. 746. 6 Deut. Zeit.f. Chir., 1906, 84, p. 462. 67 
DISEASES OE THE MOUTH AND SALIVARY GLANDS 
THE SALIVARY GLANDS 
The normal saliva is composed of the secretions of the salivary glands- 
the parotid, submaxillary, and sublingual-and of the mucous glands 
of the mouth. It is a watery, opalescent, slightly stringy fluid, of a 
feebly alkaline reaction, and has a specific gravity of from 1002 to 1008. 
Its principal organic constituents are mucin-a diastatic ferment- 
ptyalin, oxydases, and slight traces of protein. Urea, according to 
some authorities, is also present. Among the inorganic constituents are 
potassium and sodium chloride, potassium sulphate, sodium carbonate, 
calcium carbonate and phosphate, potassium sulphocyanide, and carbon 
dioxide. The total solids amount to from 5 to 10 parts per 1000. The 
freezing point is 0.20° C. Apart from the fact that the protein is a 
glycoprotein, nothing definite is known of its nature. The potassium 
sulphocyanide content varies considerably. In smokers it is said to be 
greater (0.2 per 1000) than in non-smokers (0.03 or 0.04 per 1000). 
The secretion of the saliva is under the control of two sets of nerves: 
one from the brain, the other from the sympathetic system. In the 
case of the submaxillary gland, the cerebral impulses are conveyed by 
fibres of the facial nerve running in the chorda tympani. Studies on 
animals have shown decided differences in the saliva following separate 
stimulation of these two types of nerve fibres. The sympathetic saliva 
is scantier, thicker, and richer in solids, particularly in mucin, than the 
chorda saliva. A third variety of saliva is the so-called paralytic saliva, 
which follows poisoning with curare or section of the gland nerves. 
The normal daily quantity of saliva varies from 1400 to 1500 cc. 
The reaction, usually alkaline, is subject to variations. It may be 
acid or neutral even in health; in diabetes, fevers, and dyspepsia it is 
often acid. In making tests, the possiblity of acid mouth washes being 
used should not be overlooked. The relative proportion of organic as 
well as inorganic constituent changes in response to variations in the 
stimulus. Von Zebrowski has shown that the quality of the excitant 
and intensity of its action, as well as the locality and manner of its 
application, are of importance. The secretion of saliva is stimulated 
more by those substances that require longer chewing. In unilateral 
mastication, the gland on the active side is especially stimulated; the 
opposite gland also secretes, but more slowly, and the saliva contains 
a somewhat larger amount of organic substances. 
Stern and Lederer,1 in a study of the saliva in 158 cases of diabetes 
mellitus, found the quantity increased in 8, diminished in 89, normal 
in 63. The reaction was acid in 47, alkaline in 92, neutral in 8. Glucose 
was found in 85. The diastasic quality was unchanged in 90 per cent. 
When the sugar disappeared from the urine it also disappeared from the 
saliva. In acute gastritis an acid secretion was found in 8 out of 20 cases, 
being caused in 2 by lactic acid and in 2 by acetic acid. In hyperchlor- 
hydria an increase of secretion was found in 27 out of 182 cases; the 
1 Jour. Amer. Med. Assoc., 1904, xliii, p. 1765. 68 
DISEASES OF THE DIGESTIVE SYSTEM 
reaction was acid in 71, alkaline in 41, neutral in 5, amphoteric in 65. 
The acid reaction was due to lactic acid in 12, to acetic acid in 12, to 
lactic and acetic acids in 9, to hydrochloric acid in 6. In pyloric stenosis 
the reaction was acid in 5, alkaline in 8; in hypochlorhydria the reaction 
was acid in 2, alkaline in 15, and amphoteric in 6. Urea is increased in 
severe nephritis and in uremia. 
1. Increase of salivary secretion (hyperptyalism, ptyalism, salivation, 
sialorrhoea, sialosis) is often apparent rather than real, the saliva, normal 
in amount, not being swallowed. This is the case in paralysis of the 
muscles of deglutition, or of those of the lips and tongue; in quinsy and 
other forms of tonsillitis, and in severe types of pharyngitis, when 
swallowing is painful. True hyperptyalism is a condition in which more 
than the normal amount of saliva is secreted. Its causes are various: 
(a) Local.-The different forms of stomatitis; dentition; and chorea, 
by reason of the active masticatory movements. 
(6) Reflex.-Hyperchlorhydria; gastric ulcer; nausea; pregnancy; tri- 
geminal neuralgia; helminthiasis; pancreatic calculus; pain from various 
sources. The most profuse salivation ever seen by the writer occurred 
in a man who had been operated upon for hernia. No tangible cause 
aside from the operation could be found. In a woman, suspected of 
being a morphine habitue, there was a constant flow of a sticky saliva 
while she was under surveillance and could not obtain the drug. The 
salivation subsided immediately after a small morphine injection. 
(c) Direct nerve stimulation, either central or peripheral; migraine; 
bulbar palsy; uremia; certain poisons, as, for example, mercury. The 
salivation in the last-named is only in part due to stomatitis, for it often 
precedes inflammatory changes in the mouth. Certain drugs, such as 
pilocarpine, act through direct stimulation of the nervous system. Hys- 
terical and neurotic salivation, which in some cases depend on direct 
nervous influences may also be reflex. 
Salivation in Children.-Salivation is normal in infants; it is increased 
by dentition, but is not dependent upon it. Salivation is present in all 
forms of stomatitis, and, without any local changes in the mouth, in 
cretinism and idiocy. Jordan reported two cases of "idiopathic saliva- 
tion" in children. The dribbling began during dentition and continued, 
without any apparent cause, after the process had stopped. 
2. Diminution of secretion (hypoptyalism, aptyalism, absence of 
secretion) occurs in fevers, especially in pneumonia, typhoid fever, 
and septic fevers; after the use of atropine; in fright and excitement 
(the rice ordeal); in loss of fluid through diarrhoea or the elimination 
of dropsical effusion; in cirrhosis of the liver when ascites is forming, 
and in atrophy of the salivary glands. The writer has also noticed an 
annoying dryness in arteriosclerosis with great hypertension and polyuria, 
with and without thirst. 
Xerostomia.-Under the name of xerostomia, or dry mouth, Jonathan 
Hutchinson1 described a condition of distressing dryness due to sup- 
pression of the salivary secretion. It is most common in women (32 
1 Clin. Soc. Trans., 1888, xxi, p. 180. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
69 
women to 4 men, in Hall's table),' and usually resists treatment. In a 
case of the writer's, a woman aged thirty-eight years, the dryness had 
lasted two years, and was so great that the patient had to rise two or 
three times a night to wet her mouth. The urine amounted to two liters 
a day, had a low specific gravity, 1008, and was free from albumin and 
sugar. There were also darting pains in the tongue (glossodynia), and 
her speech was somewhat disturbed. In other cases reported, mastication 
and swallowing were affected. 
The tongue and mouth are dry, red, and glazed, and there seems to 
be suppression not only of the salivary secretion, but also of that of the 
buccal glands. In 8 cases of 39 (Hall) the parotids were enlarged. The 
disease began suddenly in 6; in 6 it followed mental shock, and in 4 
influenza or other slight febrile affections. 
Etiology.-The condition is in the majority of cases best explained on 
the basis of a disturbance of the nerve centres controlling the secretion 
of the salivary and buccal glandsi In some instances it may be due to 
a primary affection of the salivary glands, since it is present in the 
so-called Mikulicz's disease. Zagari2 found atrophy of the parotid and 
submaxillary glands (histologically determined) in a case of xerostomia 
in a woman aged fifty years, who had died of a gradually increasing 
emaciation and marasmus. 
Treatment.-The condition has generally proved rebellious to treat- 
ment. The galvanic current is worth a trial, and pilocarpine in small 
doses may also be employed. 
Acute Inflammation.-Acute inflammation of the parotid gland- 
parotitis-appears in two forms: the epidemic parotitis or mumps, and 
the so-called secondary parotitis, which is found associated with typhoid 
and septic fevers, pneumonia, dysentery, pyelitis, smallpox, measles, 
scarlet fever, and is also seen at times after abdominal operations, 
especially oophorectomy. As far as the writer's observation goes, it 
is most common with diseases situated below the diaphragm. In obscure 
febrile cases the appearance of a parotitis should lead the physician to 
consider carefully the possibility of typhoid fever, abscess in the pelvis 
of the kidney, or a perinephritic abscess. The condition has also been 
called splanchnic parotitis. A parotitis occurring in the course of 
hemiplegia was described by Gilbert and Villaret.3 In both cases 
observed by them the parotid on the paralyzed side was affected. 
Parotitis Due to Drugs.-The writer has seen an acute enlargement 
of the parotid gland following the administration of potassium iodide; 
it may also occur as a complication of lead poisoning. 
Chronic Inflammation.-Chronic inflammation usually depends on 
retention of salivary secretion, and is most common in the parotid. The 
gland is enlarged and hard, and may resemble a malignant tumor. The 
disease is attributable to an infection propagated from the buccal cavity, 
and is often associated with the presence of stones in the ducts or the 
1 Quarterly Medical Journal, 1898-99, vii, p. 26. 
2 11 Policlinico, 1907, xiv, Medical Section. 
3 Sem. med., 1906, p. 104. 70 
DISEASES OF THE DIGESTIVE SYSTEM 
glands themselves. The size of the gland varies according to the degree 
of obstruction and retention. 
Sialodochitis Fibrinosa.-Under this name Emden' reports the follow- 
ing case: A woman, aged fifty-four years, suffered at first in long inter- 
vals, later, regularly every eight days, from bilateral swelling of the 
submaxillary and sublingual glands. The attack began with burning 
pain in the tip of the tongue, was unaccompanied by fever, and produced 
a firm, dense infiltration of the glands. The whole process subsided 
after three days, with expulsion from the salivary caruncles of fibrinous 
plugs, and with profuse salivation. The plugs measured several centi- 
meters in length and branched dichotomously. Emden compares the 
condition to fibrinous bronchitis, and, while not denying the possibility 
of a secretory neurosis, attributes it to inflammatory changes in the 
salivary ducts. Analogous cases have been reported by Xaegeli-Aker- 
blom,2 and by Viaud,3 who coined the term " whartonitis." 
Periodic Swelling of the Salivary Glands.-Certain persons are subject 
to recurrent attacks of swelling of one or both parotid glands which 
subsides quickly in a day or two. It is probably due to temporary 
obstruction of Stenson's duct and seems to follow exposure to cold, 
but may have other causes. Cases of this type have been reported 
by Lange4 and by Luders.5 
Tuberculosis.-The salivary glands are not often attacked by tuber- 
culosis, a comparative immunity they share with the pancreas. Even 
experimentally, infection of the glands is not easily accomplished unless 
their nutrition is first disturbed by trauma. In man tubercle bacilli 
may reach the glands through the blood, the lymphatics, the excretory 
duct, or by direct extension from neighboring parts. It is still a question, 
however, whether in the so-called primary form of tuberculosis the 
disease is not located in a lymph gland occasionally found embedded 
in the parotid, from which the disease extends to the parenchyma proper. 
Mintz6 collected 8 cases of so-called primary tuberculosis affecting the 
parotid; and O'Zoux7 found 4 of the submaxillary. Legueu and Marien, 
finding in their cases chiefly parenchymatous lesions, concluded that 
the infection had been propagated along the duct. Bockhorn,8 Mintz,9 
and Lecene10 believe in lymphatic transmission, the principal lesions in 
their cases having been found in the intra-acinous connective tissue. 
The infection, whether it travels by the one route or by the other, usually 
occurs through carious teeth or ulcerated gums about such teeth. Tuber- 
culosis of the salivary glands is of slow development, and is generally 
mistaken for the so-called mixed tumor. 
1 Sitzungsbericht des aerztl. Vereins in Hamburg, 1897. 
2 Monats. f. Ohrenheilk., 1895, Band xxix, S. 80. 
3 These de Paris, 1894. 
4 Deut. med. Woch., 1912, No. 6. 
5 Ibid., No. 12. 
6 Deut. Ziet.f. Chir., 1901, Ixi, p. 290. 
7 Arch. din. de Bordeaux, 1897, vi, p. 28. 
8 Arch. f. klin. Chir., 1898, Ivi, p. 189. 
9 Deut. Zeit. f. Chir., 1901, Ixi, p. 290. 
10 Rev. de Chir., 1901, xxiii, p. 524. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
71 
Syphilis.-This is rare, and has hitherto been found principally in the 
sublingual gland, occasionally in the parotid gland (Crile). It is usually 
of the tertiary form, and in the differential diagnosis, which may be 
difficult, the history, the Wassermann test, and the therapeutic test 
give the most assistance. 
Tartar or Salivary Calculus.-Tartar is a laminated deposit upon the 
teeth, varying in color and density. The common sites are the lingual 
surfaces of the lower incisors and canines, and the buccal surfaces of 
the upper molars. Two varieties are described, the soft and the hard; 
the former being rapidly deposited, buff colored and abundant; while the 
latter is slowly deposited, dark, and firmly adherent to the tooth surface. 
Calcium carbonate and calcium phosphate make up the bulk of salivary 
calculi. Traces of iron phosphate and silica are sometimes present. 
The deposit of tartar leads to more or less absorption of the alveolar 
process and to chronic gingivitis. 
Treatment.-This consists in the removal of the tartar by a dentist. 
Careful brushing of the teeth is the only means of retarding the accu- 
mulation of salivary calculus. 
Stones Proper; Salivary Calculi.-Stones may form in the ducts, 
rarely in the glands themselves, the most frequent site being Wharton's 
duct, at a point from 10 to 20 mm. from the salivary caruncle. They 
seldom exceed the size of a pea, and are composed chiefly of calcium 
phosphate or calcium carbonate, which constitutes from 62 to 95 per 
cent, of the stone. They are usually single, but in the case of Brin there 
were four in one duct. Duct stones are cylindrical and smooth; gland 
stones usually round or irregular. The writer has seen three cases of 
salivary calculus, all in women. 
Etiology.-Stones formed in the ducts may have a foreign body, such 
as grains, seeds, bits of food or tartar as a nucleus, but it is probable 
that the impetus to stone formation is given by bacterial infection. 
Inflammatory changes in the glands, by bringing about a change in the 
consistency of the saliva, may lead to stone formation. In several 
cases there was long-continued irritation of the mouth by a pipe. 
Symptoms.-Stones located in the glands do not, as a rule, give rise 
to marked symptoms, although the gland may be enlarged, firm, and 
tender. The characteristic feature is an intermittent pain along the 
floor of the mouth, the so-called salivary colic, which usually comes 
on during eating and persists for from one to several hours. It is asso- 
ciated with a similarly intermittent tumefaction of the gland and a 
distension of the proximal part of the obstructed duct. At times there 
is a purulent discharge (pyorrhoea salivaris) which may be exceedingly 
offensive. The stone can generally be detected by sounding, by digital 
palpation, or by means of the or-ray. 
Salivary calculi situated on the floor of the mouth may simulate 
ranula, from which they may be distinguished by noting that in calculus 
the flow of the saliva is stopped and that a probe cannot be passed along 
the duct, while careful digital exploration or the z-ray may reveal the 
concretion. Malignant disease, actinomycosis, and tuberculosis must 
also be borne in mind. 72 
DISEASES OF THE DIGESTIVE SYSTEM 
Treatment.-The treatment consists in the removal of the stone. 
Sometimes this can be accomplished by pressure and a probe. The 
writer succeeded by these means in a case in which the concrement was 
located near the outlet of Stenson's duct. When the stone is deep-seated, 
operation is necessary. In rare instances the stone becomes quiescent 
and demands no special treatment. 
Fra. 1 
x-ray picture of a salivary calculus. 
Tumors.-The most interesting as well as the most important new- 
growth is the so-called mixed tumor, which has puzzled pathologists 
for many years. Clinically, it is a slowly growing, movable, smooth 
or nodular tumor, usually painless, disfiguring, and often reaching an 
enormous size. It is more common in the parotid than in any other 
of the salivary glands, the distribution, according to Boehme, being as 
follows: 74.1 per cent, of all cases affect the parotid, 7.7 per cent, the 
submaxillary, and 1.1 per cent, the sublingual. The skin is rarely 
adherent. The tumors have a capsule composed of fibrous connective 
tissue; sometimes nodules of unchanged or inflamed salivary gland tissue 
are included within the capsule. From the capsule septa extend inward 
and subdivide the tumor into lobules. The color varies from reddish 
to yellowish gray. According to the amount of mucoid or hyaline 
degeneration, the surface is opaque, glistening, or gelatinous; at times 
cystic spaces are present. If the tumor is malignant, it bursts through 
its capsule and infiltrates the neighboring tissues; it may cause metastasis 
in the regional lymph glands, but transference to distant organs is rare. 
The soft tumors are more malignant than the hard ones, though local 
recurrence is more common in the cartilaginous forms. 
Microscopic studies reveal a very complicated structure, suggesting 
in some cases carcinoma, and in others sarcoma. Mucoid and fatty 
tissue and cartilage may still further obscure the picture. In a goodly 
proportion of cases, in 14 of 26 studied by Ehrich, squamous epithelium 
is present and may show characteristic horny changes. The cells which 
constitute the tumor parenchyma proper are arranged in larger or 
smaller masses resembling gland acini, or in tubules, the lumen of which DISEASES OF THE MOUTH AND SALIVARY GLANDS 
73 
is lined with cubical or cylindrical cells. It is the origin of these cells 
that has given rise to most dispute. Some authorities hold that the 
cells spring from the endothelium of the lymph spaces or perivascular 
lymph sheaths, and that the tumors must be classed with the endothe- 
liomas and peritheliomas. Kiittner,1 in a study of 97 tumors of the 
submaxillary gland collected from the literature, found 64 to be endo- 
theliomas, 6 sarcomas, 3 adenomas (?), 5 carcinomas, and 19 of doubtful 
nature. The endotheliomas may be benign or may resemble sarcoma 
and carcinoma in the malignancy of their course. Those not having 
cartilage show a greater tendency to malignancy than the enchondromas. 
There are many writers, however, who contend that not only mor- 
phologically, but also histogenetically, the tumor cells are epithelial. 
Given certain conditions of growth, endothelium can easily assume the 
shapes of epithelial cells. Those tumors in which masses of squamous 
epithelial tissue are found may, as many have shown, take their origin 
from remains of the branchial arches. Guleke2 believes that some of 
the parotid tumors are teratomas and arise from germinal displacements 
of the original salivary gland "Anlage;" this latter contributing the 
cellular elements of the tumor, while the myxomatous, cartilaginous, 
and osteoid tissue is derived from the remains of the first branchial arch. 
Wood3 is also inclined to the view that they arise from embryonic dis- 
placements of epiblastic tissue during the process of formation of the 
parotid and submaxillary glands and the branchial arches. So far as it 
is possible to decide, those who contend for the epithelial origin have 
the best of the argument. 
Treatment.-This is surgical. 
Other tumors of the salivary glands are sarcoma, cases of which are 
described by Kelly, Lotheissen, and Schridde,4 lipoma and chondroma. 
Von Mangoldt describes a cavernoma-a congenital telangiectatic 
growth, which was found associated with angioma of the overlying skin. 
Bidone5 also reports a case and reviewed the literature fully. An echino- 
coccus cyst has been described. 
SYMMETRICAL ENLARGEMENT OF THE LACRIMAL AND SALIVARY 
GLANDS-ACHROOCYTOSIS, MIKULICZ'S DISEASE 
The first complete description of this was given by von Mikulicz.6 
It is a chronic inflammation affecting the salivary and lacrimal glands; 
but there are cases, evidently of the same nature, in which the salivary 
glands alone are affected. Blood changes are rare; in some cases, how- 
ever, the blood presents the picture of leukemia or pseudoleukemia. The 
lymphatic glands may be enlarged and at times there are analogous 
1 Beitr. z. klin. Chir., 1896, xvi, pp. 181 to 256. 
2 Arch. f. klin. Chir., 1906, Ixxxi, p. 275. 
3 Annals of Surgery, 1904, xxxix, pp. 57, 207. 
4 Beitr. z. path. Anat. u. z. Allge. Path., 1903, xxxiv, pp. 136 to 142. 
5 Arch, di Ortopedia, 1897, xiv, p. 398; 1898, xv, p. 16. 
6 Munch, med. Woch., 1888, p. 759; Beitr. z. Festschrift f. Billroth, Stuttgart, 1892, 
p. 610. 74 
DISEASES OF THE DIGESTIVE SYSTEM 
infiltrations of the skin. The enlargement of the salivary glands is due 
chiefly to a diffuse lymphoid hyperplasia, and not to hypertrophy of 
the parenchyma proper. Von Brunn is of the opinion that the disease 
is due to some infectious agent carried to the glands in the blood stream, 
von Brunn1 classifies the forms of Mikulicz's disease as follows: 
I. Cases without blood changes. A. Without involvement of lymph- 
atic glands or spleen, (a) Symmetrical enlargement of the lacrimal and 
salivary glands. (6) Symmetrical enlargement of the lacrimal glands 
alone. (c) Symmetrical enlargement of the salivary glands alone. 
B. With enlargement of lymphatic glands and spleen, (a) Symmetrical 
enlargement of the lacrimal and salivary glands. (6) Symmetrical 
enlargement of the lacrimal and salivary glands with infiltration of the 
skin. 
II. Cases with blood changes. A. Grave anemia with lymphatic 
pseudoleukemia and aplasia of the bone marrow. B. Leukemia. 
Histologically the cases are classified by Hase2 into three groups: 
1. Cases with hyperplasia of the normally present lymphatic tissue. 
2. Cases of a chronic inflammatory character presenting tuberculous 
granulation tissue without caseation. 
3. Cases of tuberculous granulation tissue with the presence of tuber- 
cle bacilli or positive tuberculin reaction. 
A case in a negro has been reported by Ziegler.3 In children the 
Mikulicz syndrome is not rare but is usually associated with pseudo- 
leukemia or leukemia. According to Tileston4 the term Mikulicz disease 
should be reserved for those cases of chronic painless bilateral enlarge- 
ment of the salivary and lacrimal glands in which pseudoleukemia and 
leukemia can be excluded. The cases occurring in the last named disease 
should be classified as pseudoleukemia or leukemia with the Mikulicz 
syndrome. Howard's5 article also contains a good bibliography. 
Napp6 describes a case of Mikulicz's disease in a woman aged twenty- 
seven years, in whom in addition to the enlargement of the lacrimal, 
submaxillary, and parotid glands there were submucous nodules on the 
lips and cheeks and in the conjunctiva. In the conjunctival nodules, 
which were the only ones examined, tubercle bacilli were found. On 
the strength of this case, Napp accepts the view of Meller that Mikulicz's 
disease is not a disease but a symptom complex produced by a variety 
of causes, such as leukemia, pseudoleukemia, a typical lymphomatosis 
(sarcoma), and tuberculosis. For the treatment of the condition, Pfeiffer 
recommends the z-ray. 
Atrophy.-In addition to the shrinkage of the glands accompanying 
advancing age (senile atrophy), there is an atrophy of obscure nature 
that may or may not affect all of the glands simultaneously. In a case 
of such atrophy reported by Dubreuil-Chambardel,7 the condition 
1 Beitr. z. klin. Chir., 1905, xlv, p. 225. 
2 Inaug. Diss., Leipzig, 1912. 
3 New York Med. Jour., December 11, 1911. (Bibliography.) 
4 Amer. Jour. Dis. of Children, November, 1911. 
6 Internal. Clinics, 1909, 19 ser. T., 30. 
6 Zeitschf. Augenheilk., 1907, 17, p. 513. 
7 Province med., xxi, p. 6. DISEASES OF THE MOUTH AND SALIVARY GLANDS 
75 
revealed itself by an almost absolute smoothness of the floor of the 
mouth, and by hollows in the region of the parotid glands. The patient, 
an otherwise healthy man, aged sixty-one years, complained of dryness 
of the mouth. The urine was increased in amount to 2000 cc. in a day, 
but was free from albumin and sugar. Such an atrophy may be the 
underlying cause in some cases of xerostomia. 
LUDWIG'S ANGINA 
This is an inflammation-a cellulitis-of the tissues of the floor of 
the mouth in the submaxillary region. The primary focus is usually 
some insignificant lesion in the mouth, as a carious tooth, tonsillitis, 
an ulcer, etc., the infection travelling by way of the lymphatic vessels 
to the submaxillary lymph glands. In 18 cases studied bacteriologically 
the streptococcus was found alone in 6 cases, the streptococcus associated 
with other organisms in 8, the staphylococcus alone in 2, the pneumo- 
coccus alone in 1, and an undetermined bacillus in 1. Males are far 
more often affected than females. 
Symptoms.-The disease usually begins acutely, with slight fever, 
and at times difficulty in swallowing. Coincidentally an indurated 
swelling appears in the region of the submaxillary gland, on one or both 
sides which soon extends along the cellular tissue toward the chin, toward 
the parotid, and down toward the larynx or the sternum. The sublingual 
tissues form a hard congested swelling arranged like a cushion just 
inside the inferior maxillary bone, and force the tongue upward and 
toward the opposite side. The skin over the swelling, during the first 
four or six days, is movable, then it becomes reddened, oedematous, 
and adherent; at times there is crepitation. Soon an opening forms in 
the floor of the mouth through which a thin grayish or reddish-brown 
fluid is discharged; at the same time the constitutional symptoms become 
more severe, the fever higher, sleep is disturbed, profuse sweats, delirium, 
and dyspnoea appear, and the characteristic typhoidal state, due to 
septic infection, is developed. 
Death, in the majority of cases, occurs from invasion of the larynx, 
the lower respiratory tract, and in some cases of the lungs. The mortality 
is high; of 106 cases collected by Thomas, 43 died. 
Treatment.-This is surgical; the best incision being that of Delorme, 
over the submaxillary gland and parallel with the lower jaw. CHAPTER III 
DISEASES OF THE (ESOPHAGUS 
JOHN McCRAE, M.D. (Tor.), M.R.C.P. (Lond.) 
Descriptive.-The oesophagus begins at the upper border of the 
cricoid cartilage and ends at the cardiac orifice; it measures, on an 
average, 24.4 cm. (about nine and three-quarter inches); at birth it 
measures 8 cm.; at the level of the sixth cervical cartilage it lies in 
front of the vertebrae, then it comes slightly forward, and at the seventh 
dorsal vertebra it bends slightly to the right, then to the left to reach 
the opening through which it passes the diaphragm. It enters the 
stomach at a point corresponding to the origin of the twelfth left rib 
from the twelfth dorsal vertebra, and the cardia lies about 40 cm. from 
the upper incisor teeth. The oesophagus is divided, for descriptive and 
other such purposes, into a cervical part 5 cm. long, a thoracic 18 cm. 
long, and an abdominal 2 cm. long. If it is desired to know the distance 
from the incisor teeth to the cardia, Rosenheim gives the following rule: 
Take a point 2 cm. below the most prominent part of the occipital 
protuberance, measure from it to the origin of the twelfth rib, and add 
7 cm. (from uvula to upper teeth) for the total figure. It is probable 
that for the most part the walls of the tube lie in contact with one another, 
but it is yet undetermined whether or not the cardia lies open when 
the organ is at rest; Killian considers that the cricopharyngeal muscle 
forms a sphincter or mouth of the oesophagus, just as the cardia is that 
of the stomach. 
The oesophagus is lined by stratified pavement epithelium. In the 
upper part the muscularis is composed mostly of striated, and in the 
lower half of unstriated muscle fibres, although the demarcation is not 
distinct. Mucous glands in rather scanty numbers lie in the submucosa 
and open by ducts which pierce the muscularis mucosae; glands of a 
different kind are found between the level of the cricoid cartilage and 
the fifth ring of the trachea, lying superficial to the muscularis; these 
glands contain not only mucous cells, but also cells similar to the parietal 
cells of the glands of the stomach; and at times typical stomach epithe- 
lium is found aggregated in areas of considerable size, which on superficial 
examination resemble shallow ulcerations, of which the true nature 
becomes apparent only on microscopic inspection. These are found 
in 3 to 6 per cent, of all cases. In the lower part of the oesophagus are 
the cardiac glands, which are similar to the cardiac glands of the stomach. 
The arterial supply consists of an anastomotic network, which is 
supplied from above downward by the inferior thyroid, the posterior 
bronchial arteries, and the oesophageal branches of the aorta. The 
lower end is supplied by the left coronary artery of the stomach, and 
76 DISEASES OF THE (ESOPHAGUS 
77 
anastomoses occur from the inferior phrenic vessels. The venous out- 
flow travels by three main channels, of which the first leads to the inferior 
vena cava by the diaphragmatic veins; the second leads to the superior 
vena cava by way of numerous branches, the inferior thyroid, the peri- 
cardial, the posterior mediastinal, the intercostal, and the diaphragmatic 
veins. These last lead to the azygos or to the vena cava itself. The 
third channel, most important in its relation to varices of the oesophageal 
veins, leads by way of the left coronary vein of the stomach to the portal 
system. The venules leading to all three channels are closely interlaced 
throughout the oesophageal walls. 
The lymphatics of the oesophagus lead from the upper part to the deep 
cervical nodes lying in the vicinity of the bifurcation of the carotid artery, 
and from the inferior part to the nodes of the posterior mediastinum, as 
far as the diaphragm. 
The nerves supplying the oesophagus are, above, the recurrent branches 
of the vagi, and below, a plexus formed of branches direct from the 
trunks of the vagi, into which enter branches of the sympathetic. 
The question whether or not absorption occurs from the oesophagus 
is not yet authoritatively settled; probably the oesophagus can absorb, 
but rarely obtains opportunity therefor. 
Methods of Examination.-Palpation.-This may give information of 
a tumor high up in the oesophagus, and the glands connected therewith 
may sometimes be felt, or a diverticulum full of food material may be 
palpated, and sometimes emptied by pressure; but the application of 
these methods is necessarily very limited. 
Percussion.-Percussion will prove useful very rarely; it may assist 
in the determination of a large diverticulum or tumor. 
Auscultation.-This gives little satisfactory information; over the 
whole extent of the oesophagus, when fluid is swallowed, a gurgling sound 
may be heard, which may cease at the level where an obstruction exists; 
the sounds may be heard over the neck, down the left side of the spine, 
and finally at the angle made by the left costal margin with the xiphoid 
cartilage. Very commonly at this point, six or seven seconds after 
swallowing, a sound is heard which is interpreted by some as fluid passing 
through an almost closed or half-closed cardiac orifice, by others as a 
sound produced in the stomach. In some people, immediately after 
swallowing, a sound is heard which is taken to indicate the passage of 
fluid through the open cardia. Succussion sounds are sometimes heard 
in large diverticula. 
Stomach Tube, Sounds, Bougies, etc.-These are very useful as instru- 
ments of examination, as well as in the treatment of oesophageal disease. 
The best for a preliminary examination is the soft-rubber tube, and if, 
subsequently, sounds are necessary, the graduated, gum-elastic English 
sounds, which when heated become flexible and can be bent to the desired 
shape, may be used. Briefly stated, the rules for all such examinations 
are these: Ostentatious cleanliness beforehand is necessary, so that 
nausea or disgust through mental channels is not excited; let the patient 
sit with the head thrown slightly forward and the chin raised; if necessary, 
paint the pharynx with 10 per cent, cocaine solution. Do not put the 78 
DISEASES OF THE DIGESTIVE SYSTEM 
fingers in the patient's mouth unless it is necessary; glycerin as a 
lubricant may generally be dispensed with, the tube being best taken 
last from cold, clean water; if sounds are used, from warm water; direct 
the patient to take full, deep breaths, and enforce this upon him at 
any time be becomes excited. Contra-indications to the use of the tube 
are as follows: Absolute: Aneurism, recent hemorrhage, recent corrosion, 
or ulceration. Relative: Advanced arteriosclerosis or cardiac disease, 
acute oesophagitis, or cirrhosis of the liver when varices may be suspected. 
(Esophagoscope.-The findings from this, to the practised eye, are of 
the utmost value; the discomfort it causes the patient and the difficulty 
of its use by the physician have not yet allowed its widespread employ- 
ment. Even with the development of fluoroscopy, there yet remains 
a great field of usefulness for this instrument. 
The Fluoroscope.-In the examination of the oesophagus, the use of 
the fluoroscope is constantly becoming more widespread, and while 
the great majority of cases examined indicate a freely moving and prop- 
erly timed passage of the swallowed material, the method is extremely 
useful in the detection of stenoses of different kinds, and, occasionally, 
of diverticula. It is usual to employ a barium sulphate or bismuth 
mixture which is swallowed by the patient at the instant ordered. In 
health the narrow mass of the fluid is seen quickly to descend and pass 
into the stomach, whereas if there be hindrance to such passage it is 
seen to stop and change its form at the level concerned. Semisolid food 
mixed with barium sulphate or bismuth may be observed even better, 
and under ordinary circumstances it does not happen that sufficient 
material adheres to the walls of the gullet to cast a shadow. Gelatin 
capsules of the ordinary type (8 to 10 mm. in diameter) filled with 
barium sulphate or bismuth, are also used, and it is to be remembered 
that these almost invariably momentarily stick opposite the top of the 
arch of the aorta, and, indeed, may not pass this point until the patient 
has made repeated swallowing efforts; this must not be taken to indicate 
a stricture. In the case of organic stricture, the barium sulphate or 
bismuth remains in the oesophagus sufficiently long for a radiogram to 
be made. It has been observed when stenosis is organic that liquid food 
may be seen to leak away slowly through it; whereas if the stenosis be 
a spasmodic one, when it relaxes, the entire mass of food is seen to drop 
away at once. In malignant growth there is sometimes a zig-zag lumen 
outlined by the barium or bismuth adhering to it. The oesophagus 
is best examined with the fluoroscope when the patient is in the oblique 
position, that is, with the view-point from the patient's right front 
toward his left back. 
CONGENITAL MALFORMATIONS 
These are not common, and are clinically of so little importance as 
to deserve the merest mention; they consist, for the most part, of a 
series of variations dependent on the fact that embryologically the 
oesophagus and pharynx have a common origin, separation being com- 79 
DISEASES OF THE (ESOPHAGUS 
plete at the fifth week. With failure of this separation, oesophago-tracheal 
fistulse of varying size arise; the two tubes may actually form but one 
in part of their course. Fistulae1 or more properly, sinuses, may be found 
on the anterior wall, each having its own muscle coats. (Esophageal 
cysts2 may arise from separation of such sinuses, or, again, may be 
true retention cysts from mucous glands. 
The continuity of the oesophagus may be interrupted by a stenosis 
or obliteration. Thus the tube may be open above and below, and its 
central part may be represented by a mere cord. Either the upper or 
the lower segment may open into the air passages. It sometimes happens 
that the oesophagus, although patent, opens into the trachea, and 
aspiration pneumonia is thus produced before any suspicion can arise 
of abnormality. Two gullets have been known to exist side by side. 
The anomalies that are congenital and consistent with life are referred 
to in different parts of this article. 
INFLAMMATION OF THE (ESOPHAGUS 
Acute (Esophagitis.-Etiology.-This is infrequently found at autopsy, 
but is probably much more frequent in life. It occurs by extension of 
disease from the pharynx or stomach, or from other nearby organs, is 
excited by mechanical irritation, such as a foreign body or a rough 
sound, by hot liquids, corrosives, or other chemical irritants, and occurs 
as an accompaniment of inflammation of mediastinal tissue or other 
parts near but external to the oesophagus, and in various acute diseases, 
as diphtheria, scarlatina, variola, measles, pyemia, and typhoid fever. 
It is remarkable that the oesophagus has so great an immunity to the 
spread of infections from the pharynx; it must have impressed anyone 
who has had the opportunity of seeing autopsies upon patients who 
have died of scarlet fever or diphtheria, that when the oesophagus is 
laid open its pale, healthy surface contrasts vividly with the reddened 
hyperemic pharyngeal structures, and that the infection stops short 
at a well-defined line which marks the level at which the walls of the 
gullet appose. Cases in which the inflammation spreads to the oesophagus 
and even ulceration of the same3 are observed at times, but are the 
exception. The food and saliva must constantly wash down infective 
material from the mouth, but this remains only momentarily; there 
must be another explanation, which is perhaps that the oesophagus is a 
strongly resistant part. Even when corrosives are swallowed it often 
escapes with less injury than the pharynx or the stomach, and it is certain 
that the constant passing of rough particles of food seems rarely to tear 
the oesophageal membrane. 
Special Pathology.-Many different forms and degrees of inflammation 
are recognized, as catarrhal, follicular, ulcerative, phlegmonous, exfolia- 
tive, or necrotic, the relation of which to one another is close. In the 
1 Ciechanowski and Glinski, Virchow's Archiv, Band cxcix, 420. 
2 Kern, Virchow's Archiv, Band cci, 135. 
3 Rolleston, reported in Schmidt's Jahrbuch, 1912, Band cccxv, Heft 1. 80 
DISEASES OF THE DIGESTIVE SYSTEM 
ordinary catarrhal form the wall is reddened, and there is excess of 
secretion with desquamation as a sequence. This is the usual result of 
fluid too hot or mildly irritative, not to say corrosive, or as adjunct in 
the vicinity of foreign body or new-growth, although here it is of little 
clinical significance. Such an oesophagitis may be the result of a passive 
hyperemia from cardiac disease, although the long continuance of such 
a cause generally operates to place it in the class of chronic disturbance. 
This simple form may be associated with the exanthemata, or the mem- 
branous type may be observed where an actual fibrinous membrane, not 
to be confounded with the desquamating dead layers, is present. Very 
rarely, the membrane is truly diphtheritic, which obviously may lead to 
ulceration. The pocks of variola have been frequently found in the 
oesophagus, Wagner finding them in about 13 per cent, of a large series. 
Various other forms of disease are occasionally noted; in the condition 
termed follicular oesophagitis the mucous glands of the upper part of 
the tube can be distinguished as lumps, sometimes of the size of 6 or 7 
mm. in diameter, which exude abundant mucus through the dilated duct 
on pressure; microscopically, such glands are found to have undergone 
a mucoid degeneration, to be surrounded by a zone of inflammatory 
infiltration, and each area may finally form an ulcer. 
Allied to this condition is the formation of retention cysts, when the 
thickened epithelium occludes the duct; these cysts, which may attain 
a diameter of 1.5 cm., have been known to become infected, and the 
result is the formation of an abscess, circumscribed but tending to extend 
its boundaries. Should this occur, we have an example of purulent 
or phlegmonous oesophagitis, although the etiology of the latter is 
generally other than this. It most frequently happens in the upper 
part of the tube subsequent to the lodgement of a foreign body, the 
action of a corrosive, or by extension of an extraneous inflammation. 
Several cases are recorded in which, some days after drinking lye, mucosa 
and submucosa have been shed as a membrane. Dorr, indeed, found 
one such piece 30 cm. long, this doubtless including parts of the pharyn- 
geal mucosa and Neisser1 has lately reported another case in which the 
cast was 30 cm. in length. When abscesses form they are apt to under- 
mine the mucosa and lead to the establishment of sinuses, or even of 
fistuhe into the respiratory tract. The possibility of the causation of 
peri-oesophageal abscesses in this way is also to be remembered. The 
course of the infection may, however, be in the other direction, and 
peri-oesophageal abscess may undermine from the outside, or the disease 
in the oesophagus may be the result of extension from a perichondritis, 
a vertebral abscess, suppurative lymph nodes, or even from empyema. 
In such cases the mucosa may be finally perforated. Such an accident 
is not necessarily fatal; here belong those wonderful cases in which large 
pieces of the lining, sometimes the entire lining of the tube, have been 
cast off in one mass, although the cases were not instances of corrosive 
poisoning. Where a long-continued inflammation has existed, strong 
retching or vomiting has separated the layers, and cure is reported after 
1 Berl. klin. Woch., Jan. 3, 1910. DISEASES OF THE (ESOPHAGUS 
81 
a cast 13 cm. long had been so expelled (Stern). Birch-Hirschfeld 
reported long ago a case in which a 20 cm. cast was expelled three days 
after the onset of the first oesophageal symptoms; the patient promptly 
recovered. In the necrotic form ulceration occurs alternating with 
fibrin-covered areas; on these latter an actual membrane often forms, 
and the ulcerations may give rise to hemorrhages; this combination has 
been reported as following many of the acute infectious diseases and in 
cases of sepsis. In the Royal Victoria Hospital autopsy series a girl, 
aged nineteen years, dead of septicemia, showed in the oesophagus 
multiple irregular ulcerations, the result of thromboses of small vessels. 
One of these perforated into the left pleura, and caused a hemorrhagic 
pleurisy. 
Corrosive (Esophagitis.-(Esophagitis from corrosives may be referred 
to, although it is obvious that the pathological condition will fall under 
one or other heading already dealt with; a single case of corrosion may 
combine several different forms at the same time in different parts of 
the tube. Where the corrosion is comparatively mild, the epithelium 
is whitened and converted into a rough membrane peeling off in patches, 
but leaving an apparently intact membrane below it. The epithelium 
may be colored according to the corrosive used. Thus, sulphuric acid 
generally blackens, carbolic whitens, and nitric acid gives a yellow color 
to the surface. When the corrosive is a very severe one, the mucosa is 
converted into a dirty gray slough, peeling off irregularly from a reddened, 
hemorrhagic surface, which is greatly inflamed; the muscular coat is 
in these cases extremely flabby and the tube sags. A little later these 
tissues become black and gangrenous-looking. Should death not occur 
soon, suppuration and ulceration in any direction may happen, and at 
the best, healing will be attended with the highest degree of stricture. 
Infective (Esophagitis -In the specific infections, besides diphtheria 
and variola mentioned above, the ulcers of typhoid fever are occasionally 
found in the oesophagus, the latter happening once in 83 autopsies 
upon cases of typhoid fever in our series. Thrush is found as a result 
of extension from the mouth, but in most instances is of little impor- 
tance. 
Symptoms.-When corrosives have been swallowed, the history and 
inspection of the pharynx generally make the case clear. There is 
usually severe pain along the course of the gullet, dysphagia, and 
expectoration of mucus, often bloody. Thirst is extreme. In the severest 
cases there may be no pain. With regard to other forms of oesophagitis, 
with lesions of so variable intensity, it is not easy to set down a train 
of symptoms that will be accurate for all; it is of the utmost importance 
to know if damage has been done to the gullet by food material or 
other foreign body. Apart from the history, the most dependable 
symptom is inability to swallow or pain in swallowing; pain may exist 
when the head is moved violently, especially backward, and when the 
oesophagus can be reached from the neck, pressure may elicit tenderness. 
There is often thirst, and sometimes regurgitation of swallowed material 
which may be coated with mucus. Hard, dry food, or very hot or very 
cold fluids, will give more pain than less irritating material. If a sound 
vol. in-6 82 
DISEASES OF THE DIGESTIVE SYSTEM 
be used (it is usually contra-indicated), great pain is caused, which is 
apt to remain for a considerable time after its withdrawal. 
Sequelae.-Slight degrees of inflammation are almost certain to dis- 
appear completely, and severe degrees, with ulceration, are equally 
certain to be followed by stenosis. Any inflammation may progress 
and lead to the ulcerative or phlegmonous form, which in turn may give 
rise, with or without perforation, to peri-oesophageal abscess. If the 
inflammation leads to perforation, especially low down in the oesophagus, 
the respiratory tract, trachea, bronchus, or pleura, is likely to be invaded 
by the escaping material. 
Diagnosis.-(Esophagitis, especially if it occurs in the course of some 
severe disease, will generally be overlooked. Excessive pain from the 
use of tube, sound, or oesophagoscope, should suggest the possible 
existence of oesophagitis and the immediate discontinuance of its use. 
Treatment.-In the severe forms, such as occur in the swallowing of 
corrosives, oil may be given, but after this the gullet is to be left absolutely 
alone, and fluids should be given by the rectum; should this not be 
possible, gastrostomy may be required. If the secretion is very great, 
and pain and nervousness cause the patient to make constant swallow- 
ing efforts, morphine had better be employed; ice-bags may be applied 
to the stomach, neck, or back; hot applications also are serviceable. 
Thrush requires mild antiseptic drinks. For the slighter forms of 
oesophagitis little treatment is necessary if it be remembered that the 
blandest and most mucilaginous forms of food are the best, and that 
all the oesophagus needs is a little time, and complete freedom from 
irritation; demulcent drinks are of great use; ice may be sucked and 
cold drinks in small quantities are grateful, and presumably do no 
harm; occasional draughts of bismuth emulsions are useful. The use 
of tube, sounds, or bougies is contra-indicated in the acute stage. The 
greatest degree possible of physiological rest is the solution of the problem. 
Chronic (Esophagitis.-It is largely an arbitrary matter as to what we 
designate acute or chronic oesophagitis. Reference will be made here 
to certain chronic inflammations, and to several diseased conditions, 
such as rupture, dilatation, and diverticulum, which have some relation- 
ship to the degenerations of the oesophageal wall, whether these are 
actually caused by inflammation or not. Chronic oesophagitis is found 
chiefly in drunkards, occasionally in heavy smokers, and as a result of 
extension of pharyngitis or gastritis. Occasionally it may follow a 
repeated or long-continued congestion brought about by disease of the 
heart or lungs. The condition is often found at autopsy, and is gener- 
ally overshadowed during life by the symptoms of more apparent lesions. 
Special Pathology.-The most frequent form of chronic inflammation 
is that which shows a series of grayish streaks corresponding to the 
crests of the longitudinal folds into which the tube falls when at rest. 
Where the sides of the rugae lie in apposition this membrane is not 
apparent, and the mucosa is generally dusky red or bluish, the attrition 
serving to rub off the membrane as soon as formed. The membrane 
appears to consist of degenerated superficial layers with little or no fibrin. 
This picture differs little from that of acute catarrhal oesophagitis, DISEASES OF THE (ESOPHAGUS 
83 
except that the lividity of the wall is more extreme. This low grade of 
disease may exist for a long time without giving rise to any symptoms, 
but long persistence leads to mucosal thickening and sometimes to a 
granular appearance of the membrane. Next to this, and closely allied 
to it, is the so-called leukoplakia, in which there are white, yellow, or 
gray plaques of irregular size and distribution, overlying and alternating 
with thickened and reddened mucosa and submucosa; these areas are 
slightly harder and more raised than the rest of the mucosa, and are 
underlaid by inflammatory infiltration. This is precisely the same con- 
dition that is well known in the mouth, and it is thought to have some 
etiological force in the causation of carcinoma, although the figures 
cannot be said to be conclusive. The strongest causative factor in the 
production of leukoplakia of the oesophagus is alcoholism. There is 
found also the form of oesophagitis in which the mucosa is dark red and 
granular, without any evidence of fibrin or membrane. All these varieties 
are of the same significance, and seem to occur under similar conditions. 
Chronic oesophagitis may be characterized by a gray, oedematous 
mucosa as well as by a hyperemic one; there may be an increased quan- 
tity of mucus secreted; the thickening of the mucous layers occurs at 
times so irregularly as to give rise to papillate or polypoid outgrowths. 
As an accompaniment of this, the openings of the mucous glands are at 
times evident. Ulceration does not appear to be frequent, save in 
the most severe cases; pigmentation of the mucosa is uncommon, and 
atrophy of the mucosa probably does not occur, save in old age. 
Symptoms.-The most common complaint is uneasiness, scarcely 
amounting to pain, in swallowing; it is rarely severe, although this 
depends entirely on the degree of the lesion, and is generally referred by 
the patient to the upper part of the oesophagus, and by the observer 
to the pharynx, which is usually inflamed. 
Sequelae.-Because the infective agent is less virulent or the tissues 
more habituated, chronic inflammation is less likely to lead to severe 
destruction and subsequent stenosis than in the case of acute inflamma- 
tion. It is likely that chronic oesophagitis precedes unexplained cases 
of rupture and dilatation; it is, therefore, far more important in the 
light of those lesions to which it predisposes than for its own sake. 
Treatment.-Various forms of treatment have been advocated, but 
the condition will continue to be, in most cases, untreated. The removal 
of an exciting cause, such as alcohol or tobacco, is necessary; extremely 
hot or pungent foods are to be avoided; it is possible by demulcent 
fluids to smear the oesophagus with material which will adhere to its 
walls for a time; the passage of a tube to apply such fluids or pastes is 
admissible. A useful method of applying astringent drugs to the oesopha- 
geal wall is the daily use of a soft tube smeared with a paste which is 
solid at ordinary temperature but melts at body heat. Such a paste 
can be made of cacao butter mixed with tannic acid (10 per cent.) or 
silver nitrate (5 per cent.). The tube is allowed to remain ten or more 
minutes until the paste is melted and transferred to the wall of the 
oesophagus. Solutions of cocaine (1 to 2 per cent.) and eucaine (3 to 4 
per cent.) are used to allay pain, and solutions of tannin and silver nitrate 84 
DISEASES OF THE DIGESTIVE SYSTEM 
(1 per cent.) are advised. If such solutions are used, swallowing in the 
recumbent posture seems advisable. 
Ulcers of the (Esophagus.-It is not exactly rational to separate these 
from the foregoing inflammations. Ulceration may occur as a step in 
the process of oesophagitis, but several forms of this lesion yet remain 
to be described. These are the so-called decubitus ulcers, pressure 
ulcers, peptic ulcers, and uremic ulcers. At the same time that these 
are separated from acute and chronic oesophagitis, it is done with no 
intention of suggesting that we are dealing with other than inflammatory 
processes, or at least those modifications of inflammatory processes 
which we are accustomed to call degenerations. 
Decubitus Ulcers.-These are found in emaciated persons who have 
suffered from exhausting disease. They are usually shallow, round 
erosions, with little or no surrounding reaction, and are situated on the 
anterior and posterior walls of the oesophagus, at the level of the cricoid. 
Each is the counterpart of the other, and they are caused presumably 
by the attrition of the apposed walls while the patient lies recumbent, 
the oesophagus being pressed between the cartilages of the larynx and 
the vertebral column. They give rise to no symptoms. 
Pressure Ulcers.-These may appear on the inner surface of the oesoph- 
agus as a result of compression from without by an aneurism or other 
mass. The lessened blood supply from the pressure doubtless lowers 
the resistance of the part, so that these are closely related to the 
foregoing. 
Peptic Ulcers.1-So long as the etiology of gastric ulcer remains obscure, 
it is rational to consider peptic ulcer of the oesophagus as a sequence, 
although perhaps a distant one, of inflammatory conditions of the wall. 
It occurs generally in the lower part of the gullet under conditions 
similar to those in which gastric and duodenal ulcers occur, which, in 
fact, it often accompanies. Yet it must be said that it has generally 
been reported in elderly, alcoholic men, which fact alone casts doubt 
upon the exact parallelism. It may be said that the prevailing opinion 
is in favor of peptic ulcers being the result of a combination of thrombosis 
of the area affected, with subsequent digestion. 
Symptoms.-The condition causes difficulty in swallowing, sometimes 
vomiting of blood, occasionally a fatal hemorrhage, and the course, 
apart from the last-named accident, is likely to be a chronic one. Diag- 
nosis is difficult and the malady must be distinguished from varices of 
the oesophagus and ulcer of the stomach. 
Treatment-This is exactly that of acute oesophagitis, gastrostomy 
being the most satisfactory method. 
Uremic Ulcers.-Ulcers of the oesophagus occur in uremia, and are 
doubtless comparable to the better-known but equally ill-understood 
ulcerations found in the colon in uremia; in thirteen cases of uremia in 
the Royal Victoria Hospital, oesophageal ulcerations were found twice. 
1 For literature, see Kappis, Mitth. a. d. Grenzgeb. d. Med. u. Chir., 1910, xxi, p. 746. DISEASES OF THE (ESOPHAGUS 
85 
RUPTURE OF THE (ESOPHAGUS 
Rupture of the oesophagus is rare, but has happened in a well-authen- 
ticated series of cases. Cohn1 has collected all the cases available. 
Etiology.-Much discussion has occurred as to whether a healthy oesoph- 
agus ever ruptures; the writer's belief is that it does not. At the same 
time, in some cases that have been carefully examined, no trace of 
disease has been found; with regard to this, it must be borne in mind 
that many degenerations are not evident to the examining eye, even in 
heart muscle, where we are accustomed to look for them. 
"Spontaneous" rupture of the oesophagus has always occurred with 
a high internal pressure, such as is caused by the passage of a very large 
bulk of solid or fluid, coincident with a strong diaphragmatic contraction; 
thus, it is oftenest during severe retching or vomiting that the viscus 
gives way. Zenker considers that a rapid degeneration of the wall of 
the oesophagus is produced by the presence of a pepsin-containing fluid 
regurgitated from the stomach, which remains at body heat, at the same 
time that a condition of weakened oesophageal circulation is present; this 
degeneration is the predisposing, as the high intra-oesophageal pressure 
is the effective, cause of "spontaneous" rupture. Such degeneration 
could be effected only upon the internal layers, and it is extremely 
likely that an equally effective or more effective cause would be a degene- 
ration, inflammatory, or other, of the muscular wall. Adhesions which 
tie the oesophagus to surrounding structures are important, as they 
lessen the elasticity of the tube. 
Symptoms.-Rupture of the oesophagus is characterized by severe, 
sudden pain in the chest, a choking sensation, retching or bloody vomit, 
and collapse. All of the cases have proved rapidly fatal, although in 
some death has been sufficiently delayed to allow the signs of interstitial 
emphysema of the mediastinal tissue to develop. 
IDIOPATHIC DILATATION OF THE (ESOPHAGUS 
Idiopathic dilatation of the oesophagus will be dealt with when the 
subject of ectasia is taken up; suffice it to mention here that there are 
certain diffuse dilatations for which a cause cannot be assigned; in the 
absence of cardiospasm and other stenoses these are thought to be due 
to atonic degeneration of the wall. 
INFECTIVE GRANULOMATA OF THE (ESOPHAGUS 
Tuberculosis.-Tuberculous disease of the oesophagus is rare, but may 
occur by inoculation with tuberculous material which is swallowed; 
more commonly than this, the disease appears as areas of ulceration, 
1 Mitth. a. (I. Grenzgeb. d. Med. u. Chir., 1907, xviii, p. 295. 86 
DISEASES OF THE DIGESTIVE SYSTEM 
which have extended from the bronchial lymph nodes, the trachea, 
occasionally the dorsal vertebra1, or even the lungs; or, finally, the 
oesophagus may share in a general miliary tuberculosis. Thus it will 
be seen that the oesophagus suffers late in the disease, when any symp- 
toms to which it might give rise are overshadowed by others, so that 
the diagnosis can be made but rarely. There is no certain symptom 
or group of symptoms, although with advanced disease elsewhere severe 
pain on swallowing suggests its presence. Guisez and Abrand1 have 
collected a sufficient number of cases to permit of a classification into 
three types; first, those arising by continuity from outside the oesophagus, 
second, ulcerative, by hematogenous or lymphogenous infection, and 
third, those attended by sclerosis and stenosis. 
Syphilis.2-Syphilitic disease of the oesophagus is rare, and takes the 
form of stenosis, gumma and ulceration. Therapeutic evidence in favor 
of its existence, namely, that the disability disappears after the use of 
antisyphilitic measures, is apt to be inaccurate. In the treatment of 
ulcer or stenosis, constitutional treatment is even more important than 
local measures. 
Actinomycosis.-Actinomycosis and blastomycosis of the oesophagus 
have been described, and trichiniasis also occurs. 
NEUROSES OF THE (ESOPHAGUS 
There is a tendency to think that neuroses exist without organic 
lesions but in the oesophagus, as elsewhere, it is well to remember that 
some lesion may exist which is a point of origin for the stimuli that call 
forth the symptoms. The lesion may be, often is, quite inconsiderable 
and out of proportion to the symptoms it excites, but the results of 
treatment will at times be much better if it be borne in mind that such 
may exist. In many cases not the slightest deviation from the normal 
state is to be detected. 
Sensory Neuroses.-Disturbance of the sensory functions of the 
oesophagus usually takes the form of hyperesthesia and paresthesia; 
anesthesia is said to occur after such infections as diphtheria, but is 
very difficult to determine. The two former conditions are more definite, 
and hyperesthesia is frequently present, although it is often not a neurosis 
but an accompaniment of actual disease, such as inflammation or new- 
growth. Paresthesia takes very different forms, such as pain in swallow- 
ing, a feeling as if the tube were closed, a sensation of weight, a feeling 
as if there were a foreign body in the oesophagus, and finally the sensation 
of a lump which is usually called the globus hystericus, which last is 
described at times as ascending, and at others as descending. The surface 
of the oesophagus sometimes is described as feeling "rough;" in any of 
these conditions the distress may be less during the taking of food, 
although this is by no means to be depended upon, for the neuroses may 
1 Rev. de Chir., July, 1909, p. 23; see also Gard&re, Gaz. des Hdp., 1910, Ixxxiii, 15; and 
Staehelin-Burckhardt, Arch. f. Verd.-Krankh., 1910, xvi, p. 484, who cites references. 
2 Progres Med., 1910, No. 10, p. 131. DISEASES OF THE (ESOPHAGUS 
87 
be severe enough to lead to marked inanition by starvation. These 
paresthetic states are often the accompaniments and sometimes the 
results of hyperacidity and allied conditions of the stomach that are 
called neuroses, and a familiar form is that described as "burning," 
which may extend as high as the pharynx; it must be kept in mind that 
this symptom is often the result of insufficiency of the cardiac orifice 
and the consequent regurgitation of (hyper) acid fluid. The use of the 
tube, sound, or oesophagoscope may demonstrate that there is no gross 
organic disease, and the recognition of a neurosis of the stomach, or an 
unbalanced state of the nervous system in general, may be a useful 
guide to the recognition of the true state of affairs. 
Diagnosis.-It is not easy to make useful suggestions as to the diagnosis 
of the neuroses, as the symptoms and the organic diseases that may be 
simulated are so numerous. In general, it may be said that the greatest 
care is necessary that organic disease be not overlooked, and the more 
unusual neuroses can be determined only after careful exclusion. 
Treatment.-This requires that the general cause be recognized and 
the state of the nervous system in general be improved; because of the 
reality of the distress to the patient, symptomatic treatment is frequently 
necessary, and may take the form of regularly administered drinks, such 
as weak tea, soda-water, weak solutions of tragacanth or acacia; in bad 
cases these may be followed by opium in small doses, tr. opii, TTlx (cc. 
0.6), with aqua laurocerasi, TTlxx (cc. 1.2) or 0.25 to 0.5 per cent, solution 
of silver nitrate, of which half a dram in water three times a day will 
usually suffice. Weak solutions of cocaine (1 to 2 per cent.) may be 
used by the help of the stomach-tube and removed after ten minutes' 
application. 
Motor Neuroses.-The motor neuroses are more important than the 
sensory, and are practically confined to spasm in various situations. A 
few cases of merycism, or rumination, do occur, which are evidently 
connected with a relaxation of the cardiac orifice; some cases have been 
quoted to show that a real "fore-stomach" may occur as in ruminants, 
this hypothesis depending on the presence of a sac at the lower part of 
the oesophagus just above the cardia. In a case recently reported,1 the 
sac when distended, attained a width of 23 cm. 
Before going on to speak of spasm proper of the oesophagus, it may be 
mentioned that some consider the globus hystericus to be spasm in its 
lowest degree; that is, that an actual point of contraction may pass up 
and down in a kind of peristaltic action of the tube. Whether this be 
the case or not, mild temporary spasms, which last but for a moment 
do exist, and almost as soon as the patient recognizes that the food 
does not pass freely they yield, just as their better developed brethren 
yield to the application of the tube or sound. The patient has a mo- 
mentary sensation that the food is obstructed, and that is all. It is only 
when the spasm is severe and consistent that there is damage wrought. 
Etiology.-Spasm which is purely neurotic, called idiopathic, exists 
chiefly in young adults, rarely in children, and oftenest in females. 
1 May, Munch, med. Woch., October 12, 1910. 88 
DISEASES OF TIIE DIGESTIVE SYSTEM 
Excitable, nervous people and hysterical persons are the ones most 
frequently afflicted, and a shock, fright, or anger is often the signal for 
an attack; the older writers seldom fail to mention the dread of hydro- 
phobia as an excitant. Pregnancy appears at times to have this disturbing 
effect. There are also cases which are not idiopathic but reflex, occurring 
generally in the same kind of people as the idiopathic. As a result of 
errant stimuli, excited by a diseased condition of structures which have 
a related nerve supply, or stimuli arising in a functionally disordered 
central nervous system, or even stimuli originated by some slight lesion 
of the oesophagus itself, the motor nerves of the oesophagus carry impulses 
which result in a spasmodic contraction of the muscles, occurring most 
often at the upper part of the tube or at the cardiac orifice of the stomach. 
Notwithstanding the reality of the muscular contraction, the cases 
which have died with a spasmodic stenosis have failed to show any sign 
at autopsy, although one or two reported cases have indicated a possible 
persistence of the condition after death. The most usual site of a spas- 
modic closure of the oesophagus is at the cardia, and whether this be 
considered oesophageal or gastric matters not for practical purposes. 
These stenoses are found in various parts of the tube, and the spasm 
is not necessarily always at the same place. When an organic stenosis 
exists, a spasmodic stenosis at the same or a different part of the tube 
may be superadded. 
An extreme degree of spasm of the oesophagus is described under the 
name of (Esophagismus. A striking case, recently reported,1 details that 
extremely prostrating attacks with retching, profuse salivation, and 
intense pain under the lower part of the sternum, were relieved by the 
administration of atropin. 
While oesophageal spasm is under consideration, it is well to remember 
that it tends to be followed by dilatation of the tube above the site of 
spasm, and that although the spasm may be relieved, there is a great 
tendency to permanence of the sacculation. Myer2 considers that such 
dilation occurs in patients who have a congenital asthenia, such as is 
often exhibited by the occurrence of enteroptosis. 
Symptoms.-The slighter degrees of the disease show a sudden, variable 
inability to swallow; one cannot predict what kind of food is likely to 
excite it; in some it is hot, in some cold, in some solid, and in some liquid; 
at times the larger the mass the more easily it is swallowed. The attempts 
at swallowing are often audible, and the attention of others is apt to 
increase the difficulty experienced by the patient. Variability of symp- 
toms is very noticeable. Emaciation is absent in the slight or moderate 
cases. In severe cases dysphagia may be complete, so that regurgitation 
of material eaten some time before may happen, the material indicating 
by the absence of hydrochloric acid or pepsin that it has not reached the 
stomach. The act of attempting to swallow' is accompanied by dragging 
pain in the retrosternal region, and fluids are sometimes more difficult 
to sw'allow than solids. Dyspnoea, oppression, palpitation of the heart, 
1 Tibbetts, Practitioner, London, August, 1911. 
2 Jour. Amer. Aled. Assoc., October 29, 1910, lv; see, also, Myer and Carman, ibid., 
1912, lix, p. 1278. DISEASES OF THE (ESOPHAGUS 
89 
syncope, and even convulsions may accompany the attack. The con- 
dition may be momentary or continue for hours, and the liability to 
recurrence has been known to last through half a long lifetime. 
Diagnosis.-This is important, and must be made from inflammatory 
narrowing, stenosis by malignant growth, general or partial dilatations, 
impacted foreign bodies, or even from the pressure of a mass outside 
the oesophagus. A goitre has been known to exert such pressure. To 
distinguish spasm from diverticulum, it must be remembered that in 
the former there can be no real ructus or vomiting of stomach contents 
during the spasm, but the tube alone can be emptied; with a diverticulum 
the stomach may regurgitate food, although the diverticulum be full. 
The fluoroscope is essential for such observations. The age, sex, and 
character of the patient are of importance, and the most useful single 
characteristic of spasm of the oesophagus is the variability of the symp- 
toms. Very complete information may be obtained from the use of the 
stomach tube, which is sometimes found to be grasped by the stricture, 
most often at the cardia; after a few moments or minutes the spasm 
passes off, and the tube passes easily; if a sound be used it ought to be 
of fairly large calibre, such as 1 cm. diameter, but information is at times 
subsequently obtained by the different diameters of the sounds that will 
pass on different occasions in the same patient. The sound is generally 
the quicker, and from the physician's stand-point more satisfactory 
than the tube. Atropin, gr. (gm. 0.0006) administered a few 
minutes before passing the sound will sometimes tend to relaxation of a 
spasmodic stricture. It must not be forgotten that organic lesion may 
coexist with spasmodic stenosis. If large sounds do not pass, it is 
rational to give an anesthetic, and if it pass during anesthesia, the 
condition is spasmodic. Stenosis which disappears after the use of 
antispasmodics, the sound, or galvanism can be almost certainly, deter- 
mined as spasmodic. The sound must be used with great care, for false 
passages are occasionally made, and Kummel1 reports two fatal cases, 
in which by reason of the absence of external hemorrhage and lack of 
subjective disturbance, the accident was not observed at the time. 
Treatment.-In this it is obvious that, as in other neuroses, the main 
object is to render the general health and tone of the nervous system so 
good that the spasm will cease to occur; if a local cause exist, to which 
the spasm may be attributed, it should be removed; such causes have 
been found in chronic disease of the tonsils, the presence of a foreign 
body in the ear, intestinal parasites, and many diverse slight derange- 
ments to which attention would scarcely be directed in time of health. 
The food which the patient thinks the best is desirable, although the 
character of this is subject to change. Generally, warm or sweet fluids 
are less apt to excite spasm than cold or acid ones. 
In cases that are at all severe the use of the tube or sound is necessary, 
and it is often notable that although the use of the sound will usually 
overcome the spasm, it will not necessarily prevent its recurrence; when 
the spasm has yielded to the sound or the tube, it does not always follow 
1 Deutsch, med. Woch., 1911, xxxvii, No. 46. 90 
DISEASES OF THE DIGESTIVE SYSTEM 
that food taken immediately will be allowed to pass, but sueh is generally 
the case. The tube, or preferably the sound, should be inserted gently 
until it meets the obstruction, where it is sometimes grasped; if grasped, 
it should be allowed to remain until released, which generally happens 
in a few moments or minutes; if not grasped, a gentle equal pressure 
should be kept up until the obstruction is felt to yield. If the spasm 
be frequent, it is of the very greatest importance that the patient's 
nutrition be kept up; in severe cases, the performance of a gastrostomy 
for temporary use is at times justified. 
Many ingenious appliances have been devised for the dilatation of 
spasmodic stenoses, most of which are based upon the use of a rubber 
bag, placed in the area to be stretched and subsequently distended by 
fluid with observation of the pressure obtained. 
OTHER (ESOPHAGEAL AFFECTIONS ARISING FROM THE NERVES 
Paralysis.-This is known as a sequence of diphtheria, and is charac- 
terized by partial or complete inability to swallow, the first indication 
of its existence frequently being the regurgitation of liquids through the 
nose, due to an associated paralysis of the palate. In an uncomplicated 
paralysis of the oesophagus the food bolus sticks, and the gullet is as 
little able to regurgitate it as to pass it downward. As soon as it is 
recognized, the greatest care must be exercised lest food be aspirated 
into the air passages. If the physician is in doubt as to the efficiency 
of the muscles of deglutition, tube-feeding must be instituted. The 
condition is curable only by time, although the constant hypodermic 
injection of strychnine, gr. (gm. 0.003) thrice daily, appears to be 
of advantage. 
Herpes.-At least one well-authenticated case of herpetic eruption1 
in the oesophagus has been reported, but it is worthy of mention rather 
as a curiosity than as a condition likely to be met, as is also pemphigus,2 
which may be mentioned as an actual happening. 
DILATATION OF THE (ESOPHAGUS 
Diffuse dilatation or ectasia of the oesophagus is that form of widening 
which occurs generally above a stenosis of the lumen, although it may 
occur when no stenosis is evident. It is generally fusiform, although 
the weight of the ingesta tends to make a considerable bulging toward 
the lower part of the sac; in the case of a stricture, spasmodic or organic, 
the greatest dilatation usually occurs immediately above the site. The 
majority of all ectasias are in the lower third of the tube. 
Etiology.-Although sometimes found as a congenital lesion, an organic 
stricture of the cardia or other part of the tube is the most common 
cause; spasm of the cardia can undoubtedly give rise also to dilatation, 
1 Holub, Ther. der Gegenwart, September, 1906 
2 Tamerl, Wien. klin. Woch., 1904, No. 29. DISEASES OF THE (ESOPHAGUS 
91 
which is brought about by the pressure of the food, which is unable to 
make its way through the orifice. Many so-called idiopathic cases1 have 
been described, upon the etiology of which it is idle to speculate; it is 
supposed in these cases, as well as in those which are secondary to 
stricture, that atony or degeneration of the muscle has occurred. In 
some of the cases of this class a marked hypertrophy of the muscle is 
found, but this is more likely to be a resultant and compensatory change 
than a primary condition. Fleiner, Strauss, and others consider that 
these dilatations are explained by a congenital defect in the enteromeres, 
and that this is combined with a cardiospasm of neurogenic origin. 
Those spindle-shaped ectasias which are widest at the middle are prob- 
ably due to the muscular weakness being greatest at that part, but 
the shape as observed at autopsy is probably quite different from the 
shape that is assumed when food is passing down; at such a time it is 
likely that the most extreme dilatation exists in the lowest part of the 
ectasia. Beneke's2 view is a sensible one, which is that the traction and 
bulging of the lowest part of the sac, when it contains food, pulls together 
the walls of the upper part of the undilated tube below, thus causing 
a kind of valve action at that point, which still further prevents the 
egress of the sac contents. The wall of the oesophagus in a dilatation 
is generally inflamed, and often ulcerated, which assists greatly in keeping 
up the causative spasm. With the use of the fluoroscope a constantly 
increasing frequency of dilatation as a result of spasm is observed, 
and "cardiospasm with secondary dilatation" is now a well-recognized 
occurrence. 
Symptoms.-These are generally masked by those of the stricture 
which gives rise to the dilatation; there is difficulty in swallowing, fluids 
and soft foods being most easily taken; the saliva is increased; regurgita- 
tion of undigested food with mucus is common; when the dilatation 
contains food there is often pain in the sternal region, a sense of oppres- 
sion, dyspnoea, and regurgitation of the contents of the sac; with decom- 
position of the ingesta, foul breath and a bad taste in the mouth are 
present. The sound may pass without difficulty, although sometimes 
it will be obstructed in so decided a way as to give rise to the supposition 
that an organic stricture exists, even in a spasmodic case; when it is in 
the dilatation, the excursion of its distal end is freer than usual. In 
ectasia, as in diverticulum, the sac may be emptied and the contents 
found to lack hydrochloric acid, pepsin, and rennin, or the tube cannot 
be inserted as far as the stomach. The frequency with which the wall 
of the sac becomes inflamed by the decomposition of food brings it about 
that there may be continual discomfort in the sternal region, even when 
there is no food present in the oesophagus. There may be actual pain, 
radiating from the region of the cardia along the rib margins, and regur- 
gitation of the sac contents may occur even before the conclusion of 
the meal; or again, this may be deferred until the patient is asleep and 
lying upon the side. 
1 Pietrkowski, Arch. f. Verdauungskrank., Band x, Heft 2. See also Lerche, Amer. 
Jour. Med. Sci., 1907, cxxxiv. 
2 Deuts. Aerzte-Zeitung, June 15, 1901. 92 
DISEASES OF THE DIGESTIVE SYSTEM 
Diagnosis.-This depends upon careful observation of the symptoms 
and examination of the contents of the sac for the absence of stomach 
secretions; the use of the tube or sound may demonstrate the wide sac 
and the causative stenosis, and sometimes the spasm. When the con- 
dition is suspected, it can best be verified by the use of a bismuth mixture 
put into the oesophagus and viewed by the fluoroscope, although Kraus 
points out that in early cases even this, as a rule, fails. The conditions 
with which it is most likely to be confused are organic stenoses without 
dilatation and deep diverticula. 
Prognosis.-Ectasia, if not extreme, is consistent with long life, 
although occasionally death is brought about by inanition, which should 
be considered rather as a result of the stricture than the dilatation. 
If the spasm be cured, a moderate degree of care in the selection of food, 
avoidance of coarse and cold foods, as a rule, and slowness in eating, 
will usually enable the patient to live comfortably. The prognosis in 
an uncomplicated case rests upon the completeness with which nutrition 
can be carried on. The presence of severe inflammation of the wall is 
a menace, in that the muscle may be affected and weakened and the 
dilatation thereby increase, but especially because ulceration may occur, 
which carries with it the danger of perforation. 
Treatment.-In cases due to spasmodic or organic stricture the treat- 
ment of the primary condition dominates the case. Treatment of the 
dilatation is unsatisfactory. When it is recognized as arising from 
cardiospasm, combined with treatment of the spasm, electrization of the 
walls by a stomach-tube electrode has proved beneficial. Apart from 
the treatment of the organic stenosis or the spasm, it is often useful to 
wash out the sac every night, and so avoid the decomposition of its 
contents, and combat the inflammation by the use of silver nitrate 
solution (1 to 3 per cent.) or solution of boracic acid (2 to 3 per cent.). 
Atropin may be administered in the usual doses with good effect. 
DIVERTICULA OF THE (ESOPHAGUS 
Etiology and Pathology.-Diverticula of the oesophagus are pouches 
of the wall whose cavities connect with the lumen of the viscus; the 
sac may be connected with the organ by a narrow neck, or it may be 
funnel-shaped, in which case no neck, properly so-called, exists. Diver- 
ticula are classed as "pressure diverticula" when they are caused by 
pressure from within, and "traction diverticula" when the force is 
exerted from without. These two forms have nothing in common, save 
that both are dilatations of the oesophageal wall, yet custom has led 
to their being treated together. Their pathology is widely different, 
and pressure diverticula, which will be treated of first, are most frequently 
not oesophageal but pharyngeal diverticula. Of pressure diverticula, 
then, it may be said that they are at times congenital, but the majority 
are the result of disease in the oesophagus or in the surrounding structures. 
The congenital diverticula are usually due to defective fusion of the 
muscle coats of the two sides at the median line posteriorly, and when DISEASES OF THE (ESOPHAGUS 
93 
lateral appear to result from a lack of complete obliteration of the 
branchial clefts. Most diverticula, however, are not of this nature, but 
result from disease in the oesophageal wall. 
Pressure diverticula1 are oftenest found high up on the posterior wall 
of the oesophagus at the point where pharynx and oesophagus meet, 
opposite the unyielding cricoid cartilage, but they may be found else- 
where, when they show a predilection for the natural narrowings of 
the tube. Their causation is doubtless due to the fact that the effect 
of pressure of the wall between a firm bolus of food and a hard organ 
externally (such as tracheal calcification, a calcified thyroid, or even, it 
is said, a calcareous artery) is to injure the tissues; they are deprived 
of physiological rest by the constant movements entailed in eating and 
drinking. When the oesophageal wall is thus weakened, the muscular 
and supportive tissues become insufficient and stretch easily; after each 
considerable distension the wall fails to contract to its proper degree, and 
the lumen of the tube remains a little wider at this point than normal, 
and each successive dilatation increases the size of the pouch. When 
the wall is weakened, a diverticulum is caused by a stretching of the 
muscle fibres and a separation of one from another; when an individual 
group of fibres breaks, or when this separation occurs, a hernial protrusion 
of the mucosa and submucosa through the gap follows; rarely these 
protrusions are still covered by an incomplete muscle layer, but even 
when this is not the case the thickened submucosa forms a wall that is 
at times as thick as the normal oesophagus. When they result from such 
a hernial protrusion, they often have a narrow, slit-like opening; not- 
withstanding this, they may attain a large size, when their liability to 
rupture constitutes a menace. The increase of intra-oesophageal pressure 
by the passage of food distends yet more the beginning sac, and because 
of their production thus by pressure from within, these are called " pres- 
sure or pulsion diverticula." They occur most frequently in the male 
sex, and in middle or advanced life; it is supposed by some that pressure 
diverticula in the continuity of the tube are really the final result of 
traction diverticula; if this be true, these would be properly called 
"pressure traction diverticula," a class described by some authors. 
The "traction diverticula" are produced in quite a different way from 
that already described; some nearby structure, such as a lymph node, 
gains adhesion by inflammation to the outside of the tube, and the 
contraction of the inflammatory tissue during the process of fibrosis or 
scar formation makes a constant traction on the wall, which is pulled 
out at this point. A high intra-oesophageal pressure during the passage 
of food assists this process, and a small, frequently funnel-shaped diver- 
ticulum results. Since the lymph nodes at the tracheal bifurcation are 
oftenest the cause of this form of diverticulum, it is most frequently 
found at this level on the anterior wall. Tuberculosis, extremely common 
in these nodes, is a frequent excitant; Zenker and Heller have pointed 
out their liability to inflammation secondary to pericarditis; caries of 
the spine has also caused it. 
1 See Riebold, Deuts. Archiv f. klin. Med., 1904, Ixxx. 94 
DISEASES OF THE DIGESTIVE SYSTEM 
Schmorl found traction diverticula in 3.5 per cent, of all autopsies' 
(a figure which appears excessive), and one-third of these had led to per- 
foration into surrounding tissues, under which circumstances they may 
lead to infiltration and subsequent gangrene of the lungs, rupture of a 
bloodvessel, or some such accident. These diverticula appear so insig- 
nificant on the oesophageal wall that one cannot at first understand that 
they are liable to perforation; yet one in our own series appeared to be 
only 2 or 3 mm. deep, but a fine probe inserted passed up what looked 
like a fibrous cord, fully a centimeter to the peritracheal node situated 
on the outside. In this narrow passage a small piece of solid material, 
such as a seed, might readily become caught, and the funnel shape of 
the diverticulum tends to allow any such foreign body to pass up into 
the narrow channel beyond. Once lodged here, it could ulcerate its 
way out. It may be said that the question of the origin of diverticula 
of the oesophagus has occupied attention far beyond its merits and the 
volume of controversial literature on the subject is very large. 
Symptoms.-Traction diverticula, from their small size, give no 
symptoms and are rarely discovered during life, and then only by 
oesophagoscopic or fluoroscopic examination. Pressure diverticula of 
the oesophagus, if small, give no symptoms and are frequently not 
recognized. If, however, a diverticulum be large, and be filled by liquid 
or food material, the decomposition of this and the irritation produced 
thereby will give rise to vomiting; the patient may feel a sensation of 
"something in the throat;" there often is difficulty in swallowing, which 
is greater when the diverticulum is full, so that it compresses the oesopha- 
gus proper. Under such circumstances respiration may be interfered 
with and the neck may be larger than usual, or an actual tumor appear. 
Pain is rarely present, unless ulceration of the diverticulum exists; it 
must be remembered that even a small diverticulum may become the 
seat of ulceration by lodgment of a seed or small, hard food particle. 
From the decomposition of its contents foul breath arises, and the 
inflammation so set up may spread to the oesophagus itself, or may even 
proceed to ulceration and rupture, with the formation of peri-oesophageal 
abscess; or the break may occur into the thoracic cavity, setting up 
gangrene of the lung or empyema; a diverticulum has been known to 
burst into a tuberculous cavity of the lung. When the diverticulum is 
small the tube will readily pass it, but as it becomes larger the tube is 
often directed into the sac itself, where the mobility of its lower end and 
the impossibility of passing it farther may assist the diagnosis. The 
tube is especially liable to pass into the sac if the latter is full, thereby 
pushing the oesophagus forward out of the direct line and taking its 
place. 
Diagnosis.-This may be made occasionally by palpation if the 
diverticulum be sufficiently high to appear in the neck; if filled with 
air it will be tympanitic, if with fluid, dull on percussion, and external 
pressure will sometimes succeed in emptying it. Cooper2 states that a 
succussion splash may be heard in certain patients, and advises that in 
1 Riebold, Deut. Archiv f. klin. Med., 1904, Ixxx, Heft 5 und 6. 
2 Jour. Amer. Med. Assoc., 1910, Iv, p. 856. DISEASES OF THE (ESOPHAGUS 
95 
the morning, when the diverticulum may be empty, as much water as 
possible be drunk: the neck is then seized and shaken. A diverticulum 
situated high up will rarely become completely full, for the act of swal- 
lowing tends to empty it. If lower down, the failure to find hydrochloric 
acid in the regurgitated material may indicate that it does not come 
from the stomach, and the stomach tube may succeed in reaching fluid 
at so high a level that it could not be in the stomach; if the tube can be 
passed with certainty into the diverticulum, which is often a matter 
of much difficulty, a mixture of carbonate of bismuth and syrup of acacia 
can be introduced, which will render the diverticulum opaque to the 
or-rays. It must always be borne in mind that the sac is easy to perforate. 
The diagnosis has been made by recognizing food which has been eaten 
several meals previously, when the stomach has previously regurgitated 
food more lately taken. However, unless one or other of these accidental 
circumstances gives a clue, the recognition of diverticulum is very difficult 
in the absence of fluoroscopic examination. In a recent case under my 
own observation, the patient had a spasmodic stricture, sometimes only 
momentary. Under examination by ar-rays, a diverticulum appeared 
which filled during the brief period of spasm, and instantly emptied as 
the spasm relaxed. 
Treatment.-Diverticula large enough to be recognized demand 
treatment, although this is not very easy. Feeding by the tube, when 
it is possible to pass it by the orifice of the diverticulum, is advisable, 
and if the shape of the sac be determined, and the neck of it found to 
admit the procedure, surgical removal should be advised. This as yet 
applies only to those situated in the neck, but the surgical methods of 
differential pressure for intrathoracic work, now so extensively used, 
extend the possibilities of operation. In the event of a diverticulum 
being recognized, and the advent of ulceration observed, e. g., by the 
presence of blood in the contents, rectal feeding or gastrostomy will be 
necessary for a time because of the danger of rupture. While erosions 
are healing, potassium bromide, 3 i j (gm. viij), or morphine, gr. | (gm. 
0.03), daily, may be used to lessen irritability, although physiological 
rest by withholding food is the most rational procedure. Regular 
washing with water greatly assists the patient by the prevention of 
decomposition, thus lessening inflammation, and by increasing the tone 
of the muscle. At intervals of a few days, a solution of silver nitrate 
(1 per cent.) may be used, and the washing of the sac can be taught to 
an intelligent patient. When cardiospasm is present, the occasional 
passage of a large bougie will assist in overcoming it, but this procedure 
should always be done by the physician, and never by the patient. 
Electrolysis is widely used by employing a gastric electrode inside the 
sac. The most important requirement is a well-regulated, rich diet; fats, 
butter, and oils are desirable, and when ordinary feeding is practised, 
one or two teaspoonfuls of melted butter or olive oil are recommended 
to be taken a little before food time, to act as a lubricant. Many patients 
are able to empty the sac by certain gymnastics, such as the motions 
of rowing; it is obvious that, apart from washing, a sac can scarcely be 
kept clean by such measures alone. 96 
DISEASES OF THE DIGESTIVE SYSTEM 
STENOSIS AND STRICTURE OF THE (ESOPHAGUS OF 
NON MALIGNANT ORIGIN 
Obstruction of this nature, apart from benign tumors, to be spoken 
of later, may be congenital or acquired; the latter may be spasmodic 
or organic (fibrous). The spasmodic variety has been already dealt 
with as a neurosis. 
Etiology.-A congenital stenosis has been undoubtedly found in a 
number of cases with no trace of fibrosis; it is generally in the upper part 
of the oesophagus, annular or fusiform in shape, and concerns the mucosa 
and submucosa only. A case is described by Mayer which underwent 
cure. The condition is an extremely rare one, and before deciding that 
a stenosis is congenital the history should be carefully searched for even 
a slight trauma. 
The fibrous stenoses take origin in any inflammation, wound, corrosion, 
burn, or ulceration in which the loss of substance is so great that a con- 
siderable amount of fibrosis replaces it. In a general sense it follows 
that the greater the loss of substance, the more certainly will a serious 
degree of stenosis occur, and the greater the length of surface implicated 
in the original lesion, the greater will be the longitudinal extent of the 
stenosis. In the case of corrosives, the more concentrated they are, 
the greater likelihood there will be of a rapidly ensuing stricture, while 
much diluted corrosives are apt to form more slowly developing and less 
complete stenoses. Thus it follows that with a very severe corrosion 
the patient will probably never be free from dysphagia until the stricture 
is formed, whereas the lesser grades of corrosion may seem to heal, and 
after a period of normal patency one finds with disappointment that 
the sequela of the corrosion has to be reckoned with, months later, in 
the guise of a slow stenosis. The sites where stricture is most likely to 
occur are the natural narrowings, i. e., at the cricoid, the tracheal bifurca- 
tion, and the diaphragm, yet definitely annular stenoses are at times 
found elsewhere. The peculiar liability of these parts is due to the 
momentary delay of the corrosive or burning material at those points. 
The entire oesophagus has been stenosed in certain cases. When the 
stenosis is once established a moderate degree of dilatation is often to 
be observed above it. (See Plate VII, Fig. 1.) 
Sequelae.-In cases of stenosis, inflammation, either due to the injury 
which caused the stenosis or as a secondary result of it, may spread to 
the surrounding structures, or may lead to perforation. A possible sequel 
is injury or even perforation by the sound, especially when dilatation 
or pouching of the oesophagus above allows the sound to stray from the 
lumen. 
Symptoms.-The invariable sign of stenosis is difficulty in swallowing, 
which is constant, generally progressive, and fluids are more easily taken 
than solids. Pain is generally absent. The food that does not pass 
through is regurgitated after a variable time; the presence of a dilatation 
above the stricture is likely to be accompanied by delay in the regur- 
gitation. The patient generally knows his capacity for swallowing liquids PLATE VII 
FIG. 1 
FIG. 2 
FIG. 8 
Ive^n^L ®tenos's oflowe>' half of oesophagus of a child, resulting from drinkina 
lye. Dilatation of gullet above the stenosis. drinkin g 
Fig. 2. Epithelioma of oesophagus. A flat shallow 
spreading over a relatively large surface. Shallow' derated growth is seen 
Fig. 3.-Epithelioma ofcesophagus. The upper part of the growth is flat the 
"1- " 
(From specimens in McGill Medical Museum.) DISEASES OF THE (ESOPHAGUS 
97 
at any time, and will, in partial stenoses, not exceed the amount that 
can pass down; the food or drink is felt to "stick" at a certain point, 
referable generally to the top of the sternum. The point of stenosis 
can be determined accurately by the tube or sound, although a second 
lower stenosis may exist; when the site of the stenosis is determined, 
graduated sounds should be used, beginning with the large and proceeding 
to the smaller ones, until one is found which can enter the stricture. It 
is to be remembered that the existence of the stenosis tends to excite 
spasm, and this at first may make the stenosis appear more extreme 
than it really is. If the stenosis is at all considerable, the auscultatory 
sounds can be recognized as ceasing at the affected level. In the absence 
of treatment, any degree of stenosis will be attended with loss of weight 
from malnutrition, because the mental anxiety attendant on the dys- 
phagia tends to keep the patient from using his oesophagus even up to 
its limited capacity. 
Diagnosis.-This must be made between this condition and stenosis 
from carcinoma or from spasm; foreign bodies (which have been known 
to remain in the oesophagus for astonishingly long periods); polyps and 
external tumors pressing on the oesophagus must also be considered. 
The history of injury is of the highest value. In any case, before proceed- 
ing to the examination, one must be reasonably sure that aneurism 
does not exist; then one must consider carcinoma, because it is the most 
frequent and likely cause; its rapid progress and the greater degree of 
emaciation, with absence of a definite trauma, are all useful indications. 
The x-rays will frequently determine if a foreign body be present; the 
benign tumors, such as polyp, are rare, but they may be impossible to 
differentiate, save by the non-progressive nature of the lesion. 
Prognosis.-This cannot be given in so many words, but depends 
upon the degree to wThich nutrition can be kept up and the certainty 
with which aspiration of food into the respiratory tract can be avoided. 
The earlier the stage at which treatment is begun, and the more youthful 
the patient, the better is the prognosis for cure. 
Treatment.-This is palliative and curative, and the latter should 
always be tried. Many surgical procedures have been advised which 
depend for their reasonableness upon the site of the obstruction; excision 
of the stricture, internal and external oesophagostomy, even the cutting 
of the stenosis by fishing-line, have all been, at times, successful. Rapid 
dilatation is dangerous, but in cases of cardiac stenosis gastrostomy 
followed by dilatation from the stomach is rational. Considered broadly, 
the best treatment is gradual dilatation; as was stated during the con- 
sideration of spasm of the oesophagus, there are various means of accom- 
plishing this: a thread may be swallow'ed, upon which a wire is run, and 
on this, in turn, bulbs or olives of varying size are projected: or rubber 
bags distended by fluid may be used; or, as is probably most likely in 
the case of the physician, the old-fashioned sound may be the means 
available. This last consists in the passage of the largest sound that 
will pass, every other day for several times, then using the next largest 
similarly for a time; the sound should be left in for ten or more minutes 
at each treatment. In this way the stricture will sometimes yield com- 98 
DISEASES OF THE DIGESTIVE SYSTEM 
pletely, after which it is well to pass a large sound at rare intervals to 
be warned of a recurrence and to prevent it. If nutrition is failing, 
gastrostomy should be done, even while the treatment is in progress, 
or before it is begun. A most important fact is that careless use of the 
sound may irritate the surface and add to the stimulus already producing 
the fibrosis, while the danger of perforation, especially when there is 
dilatation of the gullet above the stenosis, must always be remembered. 
Fortunately, the stenosis is generally funnel-shaped, and, therefore, 
the sound is insensibly guided in the right direction. The bloodless 
nature of the operation does not render it unworthy of the best surgical 
skill that can be obtained. Ingenious operations devised for the con- 
struction of a new gullet from portions of the stomach or even from the 
skin have not proved their feasibility. 
A number of case reports, chiefly from German sources, speak favorably 
of the employment in organic stricture of thiosinamine (allyl sulphocar- 
bamide); repeated injections are made hypodermically of gr. j to ij (gm. 
0.06 to 0.12) every two or three days, and the result is said to be softening 
of the stricture to such an extent that where bougies could not be passed 
they were readily admitted after a few administrations. Zuberbiihler1 
advises electrolysis, the kathode being placed upon the stricture, and a 
current of 5 to 20 ma. used for five minutes at a time. 
Palliative treatment includes such measures as gastrostomy and the 
wearing of a permanent tube to allow of passage of fluids through the 
structure; the latter device is especially useful, as it eliminates the 
spasmodic increase of the stenosis. As a palliative measure, oesophagos- 
tomy is not as simple as gastrostomy, and is probably not preferable. 
CARCINOMA OF THE (ESOPHAGUS 
The most important disease of the oesophagus is cancer, which com- 
mands attention by reason of the readiness with which the narrow lumen 
of the organ is obstructed, as well as by the importance of the neighboring 
structures which are likely to be infiltrated. So frequent is the occurrence 
of carcinoma that we may say that in every patient between the ages 
of forty and seventy years, with a stenosis of the oesophagus without 
other evident cause, the odds are overwhelmingly great that it is due 
to carcinoma. 
Cancer of the oesophagus is surpassed in frequency of occurrence only 
by cancer of the uterus, female breast, and the stomach. Figures, as 
usual, are'conflicting; our Montreal series of 5480 autopsies shows 29 
cases of oesophageal carcinoma, a percentage of 0.53. Kraus2 gives 
figures which aggregate 216 cases out of 45,405 autopsies, a percentage 
of less than 0.5; but as some of these series date back as far as 1830, it 
is possible that certain cases may have been overlooked. The Russian 
statistics show an astonishing frequency of the disease, one series indicat- 
ing that the oesophagus was the seat in more than 32 per cent, of all 
1 Berl. klin. Woch., 1908, xlv, p. 16. 
2 Kraus, Die Erkrankungen der Speiserdhre, Wien, 1903 (Nothnagel's System). DISEASES OF THE (ESOPHAGUS 
99 
carcinoma cases; a series of 981 cases of carcinoma, compiled from Kraus, 
gives a percentage of 20 for the oesophagus, but this contains three series 
of Russian cases. Our series at the Montreal General and Royal Victoria 
Hospitals, in 3882 cases, gave 265 carcinomas, 24 of which were of the 
oesophagus, i. e., 9 per cent. Tn this series it is surpassed in frequency 
by carcinoma of the stomach, female breast, and of the colon; into this 
list, ordinarily, would come the uterus, although, as usually happens 
in General Hospitals, autopsy figures in regard to carcinoma of the uterus 
are very low. In using autopsy figures it must be remembered that the 
breast and uterus, which are comparatively accessible and admit of 
surgical treatment, show a frequency of occurrence far below their real 
position. In 38,000 hospital entries at the Royal Victoria Hospital, 
Montreal, there were 53 cases of carcinoma of the oesophagus. 
Etiology.-Carcinoma of the oesophagus is a disease of middle or 
advanced life, being found most frequently between the ages of fifty 
and sixty years; the earliest case of which a record was found was at 
nineteen years; one case in our own series occurred in a woman aged 
thirty-two years. The male is much more liable than the female sex, 
the largest series showing a ratio of 3 to 1. Smaller series show as great 
a preponderance as 7 to 1. 
Our knowledge of the causative factors of this disease, as in carcinoma 
elsewhere, is very small; irritation has been considered as of more moment 
than any other contributing cause, and alcoholics are considered as 
especially liable. Stress is laid upon the occurrence at the physiological 
narrowings, and upon the histories frequently given by patients in whom 
the first symptoms followed the swallowing of a mouthful of hard food 
or of hot material. The arguments in favor of trauma as yet appear 
insufficient. It is also to be pointed out that carcinoma not infrequently 
seems to spring from scars of the oesophagus, from traction diverticula, 
and from the walls of dilatations; but this, as well as its occurrence in 
drinkers, is probably but another way of saying that chronic inflammatory 
conditions predispose to its occurrence. Paul Wolf1 cites three cases, 
to which Schmorl adds two, in which carcinoma of the oesophagus 
developed at the site of a spondylitic deformity of the vertebra?. He 
points out that it may be that the vertebral deformity caused a bend in 
the oesophagus at this point, so that irritation caused by the passage 
of food was added. 
Special Pathology.-Carcinoma of the oesophagus is nearly always 
primary, and its most common mode of occurrence as a secondary growth 
is when it spreads by extension from a growth of the cardiac end of the 
stomach, or less frequently from the thyroid gland, in which cases the 
growth is of the same nature as the original neoplasm. 
The tumors vary much in appearance and extent, perhaps because 
one sees them at autopsy in so widely different stages. By reason of 
the organ involved, death frequently occurs from intercurrent disease 
or accident; thus it happens that often one is enabled to see a growth 
not long after its commencement. At times the carcinoma appears as 
1 Munch, med. Woch., 1903, No. 18. 100 
DISEASES OF THE DIGESTIVE SYSTEM 
an isolated mass on one wall, oftenest the anterior; at other times a 
flat growth spreads over a relatively great area (Plate VI, Fig. 2). Gray 
or white or yellowish white in color, it often shows little scattered islets 
extending from the periphery of the main growth; very frequently the 
growth is annular, encircling the tube (Plate VI, Fig. 3). Again, a section 
through the stenosis will show a yellowish-white thickening of the wall 
of the gullet with comparatively slight evidence of nodular growth on 
the mucosal surface; or again, one finds a large, soft, irregular, cauli- 
flower-like, fungating mass that seems to more than fill the lumen of 
the oesophagus, whose ulcerated surfaces bear witness to the difficulty 
with which patency of the tube has been maintained. As a rule, not 
more than one or two inches of the tube are implicated, but cases have 
been known to affect the entire length of the organ. All degrees of hard- 
ness are found, but generally the mass is soft; a real scirrhus carcinoma 
has not come under personal observation. Degenerations are the rule, 
and necrosis of large parts of the tumor is very commonly seen. One is 
frequently struck by the fact that the tumor mass seems inconsiderable 
in comparison with the symptoms to which it gives rise. 
The degree of stenosis depends on the size and the consistence of the 
growth plus the possible spasmodic stenosis set up by its presence. By 
the lodgement of food and the weakening of the walls a dilatation is 
often formed above the stenosis. Variations in the degree of stenosis 
occur, so that the occurrence of ulceration and the detachment of pieces 
may be the signal for the subsequent easier passage of food. Ulceration 
in the main growth is almost sure to occur from the attrition of the 
apposing walls of the gullet, and from the passage of food; the irregularity 
of the growth makes many small hollows and bays, in which decom- 
position is likely to be set up and the ulceration thereby hastened. 
Strangely enough serious hemorrhage from such ulcerations is rare, and 
the amount of blood is small; pieces of the growth which are detached 
either are regurgitated or pass into the stomach and are digested. 
Histologically, most oesophageal carcinomas are squamous-celled 
(epitheliomata), although adenocarcinomas are found in a certain number 
of cases, taking origin from the glands scattered throughout the organ. 
Of the former class, many are properly basal-celled carcinomas: perhaps 
one might say that all of the squamous-celled carcinomas exhibit some- 
where in their structure the basal-celled quality. The growth is fre- 
quently seen arranged in the familiar circular masses, and true epithelial 
"pearls" are generally to be observed; various differences are seen in 
the amount of fibrous stroma that exists, and the more fibrous stroma 
there is, the less is the malignancy of the growth, or perhaps it is better 
stated that the more fibrous stroma there is, the less rapid is the pro- 
gression of the growth. Mucoid degeneration has been described, and a 
single report of primary carcinoma myxomatodes is to hand (O. Fischer1). 
Site.-The commonest site has been a matter of endless debate and 
is very difficult to designate. The level of the bifurcation of the trachea 
seems to be affected oftener than any other place, and as to which third 
1 Prag. med. Woch., 1899, xxiv, pp. 30, 31. DISEASES OF THE (ESOPHAGUS 
101 
of the gullet is the most liable to carcinoma, a study of the literature 
indicates the lowest third; but this statement is made without conviction; 
it does not greatly matter, for it is a well-proved fact that no part enjoys 
any exemption. A favorite text-book statement is that the points of 
physiological narrowing are more liable to be attacked than are other 
parts, but this statement loses value when one finds that, according to 
Kraus, thirteen different points of narrowing have been described in the 
25 cm. length of the tube. It does seem possible to state, however, that 
a very small fraction, perhaps a tenth of all growths, lie in the neck, 
where they are readily accessible. 
Perforation.-This is surprisingly frequent; in Petri's series of 44 
cases, 27 perforated. The perforation may occur into different organs 
or areas, depending upon the site of the growth, but in by far the greatest 
number the ulceration is into the larger air passages, the larynx, trachea, 
or a bronchus; apart from these, into the mediastinal tissue, the pleura, 
the lung, or even, although a rarity, into the pericardium. Perforation 
is not of itself necessarily fatal, but death follows soon, as a rule, because 
the oesophageal contents set up aspiration pneumonia or gangrene. 
When the rupture occurs into the mediastinum, interstitial emphysema 
of the tissues of the neck may be seen, followed by cellulitis. When the 
pleura is densely adherent to the lung, the lung tissue itself may be 
directly invaded by the material escaping from the opening. Occasionally 
the perforation occurs into a bloodvessel. 
Extension to Neighboring Structures.-Many different structures 
may be invaded and damaged by the extension of the growth, chief 
among which are nearby arteries, the vagus or the sympathetic nerves, 
the recurrent laryngeal nerve, if the growth be left-sided, or even the 
thoracic duct and the brachial plexus. The vertebrae have been eroded, 
and an oesophageal carcinoma has been known to produce pressure on 
the spinal cord. In the case of the veins, the gradual pressure of the 
invading neoplasm leads to a thrombosis, so that by the time the wall 
is eroded the danger of hemorrhage is obviated. In the arteries, on the 
other hand, there may be no such protection, and fatal hemorrhage 
has occurred in a number of cases. Most of the important arteries near 
the oesophagus have been implicated by extension of oesophageal cancer; 
the carotids, the subclavians, the intercostal and vertebral arteries have 
been invaded, and of 50 cases of arterial implication collected by Knaut, 
32 occurred in the thoracic aorta. Those cases in which the heart, gen- 
erally the auricles, has been attacked by the growth, where particles 
have been broken off and carried to other parts of the body, are to be 
regarded rather as curiosities than as actual clinical probabilities. A 
growth at the cardiac end is very apt to spread to the peritoneum or 
into the diaphragm. 
For many years an impression prevailed that carcinoma of the oesopha- 
gus had not so great a tendency to form metastases as had carcinomas 
elsewhere, but this arises from no inherent peculiarity of the growth 
itself; it possibly happened that the secondary growths in the deep 
cervical glands were often overlooked; it is even more likely that the 
importance of the structures involved leads to a comparatively early 102 
DISEASES OF THE DIGESTIVE SYSTEM 
fatal result, at which time the lymphatic involvement, and especially 
extensive involvement of distant organs, is as yet not prominent. The 
comparatively short duration of carcinoma of the oesophagus is in favor 
of this explanation. Twelve cases at autopsy in the Royal Victoria 
series showed secondary growths in eight. 
Symptoms.-In the majority of cases the earliest symptom is a 
difficulty in swallowing, which at first occurs only with a hard or dry 
mouthful of food, with a feeling of discomfort at the site of the growth; 
as the patient describes it, there is "something there." A mouthful of 
fluid generally suffices at first to wash down the obstructed mass. In 
one case of our own series the stenosis at death was so great that the 
circumference of the gullet at the growth was 1.5 cm., yet the patient, 
having been living on fluids, never complained of dysphagia. The 
progress of the difficulty in swallowing is at times slow, but is constant; 
an exception to this is that sometimes late in the disease a piece of the 
growth may be broken away and the lumen widened. At first, merely 
hard pieces of food give difficulty or discomfort, then there is obstruction 
to soft foods, and finally to fluids, so that ultimately none, or at best, 
very little fluid can be taken. Attempts at swallowing excite cough, 
and frequently regurgitation occurs, which may be immediately after 
the food is taken, or delayed for hours. The higher up the stenosis, 
the more prompt is the regurgitation, and the lower, the longer delayed. 
Regurgitation of food is frequently preceded by severe retching, and the 
regurgitated food is generally alkaline, mixed with much mucus, and 
shows no peptonization. If the growth be ulcerated, the regurgitated 
material may be mixed with blood, and particles of the growth may 
be found; under these circumstances the breath is usually fetid. 
Commonly, discomfort or a feeling of oppression is felt under the 
sternum, localized to the site of the growth, although severe pain may 
be complained of; it is at times referred to the xiphoid region, instead 
of to the actual situation of the growth. The severe pains are of a tearing 
or piercing character, at times radiating widely to the back, neck, or 
shoulders. Such pains are often nocturnal, and may be independent of 
attempts to take food; although pain is, in most cases, a late symptom, 
it must not be forgotten that it may be the earliest indication of the 
disease, preceding even the difficulty in swallowing. Guarnaccia1 states 
that in all cancers of the upper third of the oesophagus, even in the early 
stage there is a progressive fixation of the tongue, so that it can be 
protruded only with difficulty and pain, and that it becomes almost 
impossible for the observer to draw it out. 
With the gradual increase in the difficulty of taking food there is great 
weakness; the loss of flesh is rapid, and may be extreme, while many 
patients complain of severe thirst, less frequently of hunger. The 
cervical and supraclavicular lymph nodes, when involved by secondary 
growth, are enlarged and at times palpable, especially on the left side. 
It is scarcely necessary to give in detail the symptoms that arise from 
pressure upon the various nerves which may be implicated. It is said 
1 Arch. Int. de Laryng., 1912, xxxix, p. 88. DISEASES OF THE (ESOPHAGUS 
103 
that in as many as a sixth of all cases there is a contraction of the corre- 
sponding pupil, with ptosis, falling in of the bulbus, and sluggish reaction 
to light (Hitzig); these pupillary changes are most often seen on the left 
side, and depend upon pressure on the sympathetic nerves; there need not 
be with it a paralysis of structures supplied by the recurrent laryngeal. 
The so-called Horner's complex-ptosis, miosis and enophthalmos-is 
occasionally noted as present. The involvement of the sympathetic 
means that lymph nodes have implicated the nerves, and does not tell 
the site in the oesophagus; especially is involvement of the right recurrent 
apt to be by lymph nodes, because on the left side the nerve lies so close 
that the primary tumor may affect it. When the recurrents are involved, 
there may be a very serious dyspnoea, which may come on even before 
dysphagia has become prominent. More common than any other single 
sign, probably, is paresis or paralysis of the vocal cords from interference 
with the recurrent laryngeal nerve. 
If no contra-indication exists (the presence of aneurism should always 
be excluded), a local examination by the use of the tube and bougies 
will determine if an obstruction really exists and its exact position. If 
bleeding is excited by the use of the tube, the further examination by 
bougies should be postponed, but should no such contra-indication exist, 
one can sometimes determine, by using bougies of diminishing calibre, 
at what level in the growth the stenosis exists, and may even guess at 
its extent. The greatest care should be used in passing the bougie to 
avoid perforating the wall, an occurrence by no means infrequent in 
careless hands. When using the tube, the contents of the eye of the 
tube should be noted, as pus, blood, or mucus may be found; more rarely, 
particles of the growth are obtained. The examination of the contents 
of the stomach is not of moment, for normal acidity, hyperacidity or 
anacidity may exist. 
Of great value, but of some difficulty of application, is the use of the 
oesophagoscope, by which the growth can be actually seen, and its nature 
and extent, at least as far as the stenosis, be accurately determined. 
The z-rays may enable a correct diagnosis to be made. Reference has 
been made to the zig-zag course sometimes taken by the narrowed 
lumen. 
Diagnosis.-This is well summed up as follows: "If there is steady 
loss of flesh, with increasing dysphagia, in a middle-aged or elderly 
person, suspect carcinoma; if the sound is arrested, the diagnosis is very 
probable; if there is slight bleeding with the use of the sound, it is all 
but certain." In its early stages the disease may be confounded with 
almost any oesophageal disease; it may preserve its likeness to benign 
stricture for a considerable time; an advanced case is generally recognized 
without difficulty. It is obvious how useful oesophagoscopic examination 
by a trained eye may be in an early case. 
Prognosis.-The duration of the disease varies between six months 
and two years from the appearance of the first symptoms, although at 
times its entire course is measured in weeks. In 104 cases, Lamy1 states 
1 Arch. des. Mal. de V App. Digest., Paris, August, 1910, iv, No. 8. 104 
DISEASES OF THE DIGESTIVE SYSTEM 
that the majority succumbed in less than twelve months. The prognosis 
is very bad; carcinoma of the oesophagus in an accessible part is but a 
small proportion of the whole, and even in these surgical treatment 
must admit a large mortality and a small percentage of cures. 
Treatment.-This is in most cases palliative, but in a few may be 
curative. The few cases in which the growth is early and accessible 
offer chances of success under surgical treatment, and even the intra- 
thoracic growths are now being attempted. In all cases other than the 
above the treatment can be only palliative; the principles of such treat- 
ment are simple, keep up the nutrition, feed by the mouth as long as is 
possible, counsel an cesophagostomy or gastrostomy, preferably the 
latter, when mouth-feeding is impossible or about to become so, and keep 
the patient as free as may be from pain. 
The preservation of nutrition is the most important factor, although 
difficult of accomplishment. Good judgment and the utilization of the 
patient's experience are requisite in the selection of articles of diet. The 
stringy mucus which so often troubles the patient is lessened by the use 
of solutions of sodium bicarbonate (1 to 10) as a wash for the mouth, or 
to be swallowed. A demulcent quality in the food is desirable. Lieber- 
meister1 states that when the oesophagus is obstructed by carcinoma, 
ease in swallowing may be obtained by the patient sipping a small 
quantity of 1 or 2 per cent, hydrogen dioxide solution. It may be neces- 
sary to give morphine or atropine hypodermically before each meal. 
Many physicians practise intubation of the stricture, for which various 
procedures have been devised. One of these is a tube, of which the 
upper end is fixed in the back of the mouth (by cords fastened around 
the ear or in other ways); it passes through the stricture to the stomach. 
Another method is the use of a short tube, with a projecting rim which 
rests on the stricture, which passes the narrowing. It is placed in position 
by a whalebone guide, and is also secured above by cords through the 
mouth. Care of the cords is necessary. If a fistula into the respiratory 
tract has occurred, the use of a tube is essential to the continuance of 
mouth-feeding, and at this point it may be stated that most clinicians 
are of the opinion that it is necessary to carry on mouth-feeding as long 
as possible, to utilize, for. one thing, to the full degree, the salivary 
secretions and their admixture with the food. 
With the gradual increase of stenosis further means need to be under- 
taken, lest the patient die rapidly from starvation; cesophagostomy 
below the stricture or gastrostomy is indicated, but for various reasons 
gastrostomy is the operation generally preferred. It is a difficult matter 
to counsel a gastrostomy at the right time; it is almost certain to be 
required, and if delayed too long the patient is apt to die from the effects 
of the operation, or the degree of starvation is so great that its good 
effects are not realized. On the other hand, the patient will often object 
to the operation so long as the oesophagus remains moderately patent. 
No rule can be laid down for a decision; a frank explanation of the 
circumstances to the patient and the patient's friends should be made. 
1 Liebermeister, Munch, med. Woch., September 19, 1911, Iviii, No. 38. DISEASES OF THE (ESOPHAGUS 
105 
If pain be severe, it should be treated. The application of a few drops 
of weak silver nitrate solution (1 or 2 per cent.), or 10 to 15 drops of a 
3 to 4 per cent, solution of eucaine, or 10 drops of a 1 per cent, solution 
of heroin, repeated thrice a day, will be found to relieve pain; if these 
prove inefficient, the hypodermic injection of morphine is the most satis- 
factory method. Ten drops of a 1 per cent, solution of the extract of 
mix vomica, taken thrice daily, is recommended; the astringent solutions 
of silver nitrate will at least assist cleanliness. 
The external use of the z-rays has not been of service, but Einhorn1 
reports benefit in retardation of the growth from the use of a radium 
vial in a hard-rubber capsule, which is screwed into the end of a flexible 
rubber tube and left in position for one-half to one hour at a time. 
Sarcoma of the oesophagus occurs rarely, but 24 cases have been collected 
by Hacker.2 Three-quarters of these were in males, and more than 
three-quarters in the thoracic part of the gullet. Metastasis was frequent. 
It cannot be differentiated during life from carcinoma, save by the 
microscopic examination of fragments of the growth. Its treatment 
is identical with that of the commoner neoplasm. 
NON-MALIGNANT GROWTHS OF THE (ESOPHAGUS 
Non-malignant new-growths of the oesophagus deserve only brief 
mention. The commonest is fibroma, or fibrous polyp, which not infre- 
quently is pharyngeal in origin, and as it grows hangs down into the 
oesophagus. Rokitansky reported one seven and a half inches in length 
and two and a half inches in thickness. An interesting case (Monro), 
coming from the Edinburgh Hospital in 1763, appeared in the Edinburgh 
Physical and Literary Essays of that time. By movements of vomiting 
and coughing it could be projected to the front teeth, but had to be 
swallowed almost immediately to prevent choking. A ligature was 
tied around it, it was reswallowed, and allowed to slough, the piece 
coming away per anum. Two years later it caused death. 
These growths may be sessile or pedunculated, the former being 
probably the earlier stage; they are elastic, firm, and are apt to be 
ulcerated; although generally single, they may be multiple. Myomata, 
fibromyomata, and lipomata3 also occur; finally, more frequently than 
any of the last named, are those proliferations of mucosa and submucosa 
celled papillomata, which are pedunculated, soft, and often multiple. 
They rarely give rise to symptoms of any degree of severity. All the 
signs of new-growth may fail with these neoplasms, provided they be 
not large enough to cause difficulty in swallowing, but if they are large, 
one may find, as in carcinoma, pain in the chest, radiating to the back 
and epigastrium, becoming accentuated on swallowing, especially if 
ulceration be present; the differential diagnosis rests upon the preserva- 
tion of nutrition if actual sight of the tumor by the oesophagoscope is 
not possible. Surgical treatment may become necessary. 
1 Jour. Amer. Med. Assoc., July 1, 1905, xlv. 
2 Mitth. a. d. Grenzgeb. d. Med. u. Chir., Band xix, Heft. 3. 
3 See Glinski, Virchows Archiv, 1902, Band 167. CHAPTER IV 
FUNCTIONAL DISEASES OF THE STOMACH 
JULIUS FRIEDENWALD, M.D. 
GASTRIC NEUROSES 
Introduction.-Gastric neuroses are those functional disturbances of 
the stomach manifesting symptoms of a nervous character and not 
based upon any anatomical pathological changes. A certain number of 
the so-called gastric neuroses, dependent without question upon some 
form of anatomical change, have up to the present time eluded our means 
of detection. With more and more exact methods of investigation, the 
number of gastric neuroses will gradually be lessened in number, and 
some of these diseases be placed upon a more definite anatomical basis. 
It is now but little understood in what manner the disturbances of 
innervation take place; it is well known, however, that the branches of 
the vagus and abdominal sympathetic carry the impulses to and from 
the stomach, and it is through these nerves that these disturbances of 
innervation occur; while we cannot trace the exact paths, it is generally 
believed that the impulses of motility, sensation, and secretion are 
transmitted by different nerves; since any of these disturbances may 
exist alone and independently of the other, wTe therefore believe in the 
existence of special nerves of motion, secretion, and sensation. 
It will not be out of place to briefly discuss a few points associated 
with the nervous mechanism of the stomach. Between the circular 
and longitudinal muscles there is a plexus of nerves (Auerbach's plexus) 
by means of which a local nervous mechanism is maintained. Intimate 
connection with the great nerve centres is had through the vagi, while 
in addition to these the sympathetic sends fibres to the stomach. It 
has not yet been entirely determined whether the rhythmic contractions 
of the stomach and intestines are entirely under nervous control, since 
this special process is regarded by some as being of muscular origin 
alone. Magnus1 considered these contractions of nervous origin. He 
succeeded in obtaining rhythmic movements of the muscles of the 
intestines taken from the body which still held the plexus of Auerbach, 
even after the removal of the plexus of Meissner and the mucosa. 
Through the researches of Langley, II. Meyer and Gaskell, much 
attention has been recently attracted to the functions of the vegetative 
or autonomic nervous system, which includes all of the efferent nerve 
fibres (outside of the cerebrospinal axis), excepting those supplying the 
voluntary muscles. There are two groups of fibres of the autonomic 
nervous system, which must be distinguished from each other. 
1 Die gesammte Physiologic, 1904, cii, 362. 
106 FUNCTIONAL DISEASES OF THE STOMACH 
107 
The first group, includes those fibres taking their exit from the thoracic 
and lumbar region of the spinal cord, and known as the sympathetic 
proper, which supply the bloodvessels, glands and smooth muscle fibres 
of the entire body, including those of the stomach and intestines, bile 
and pancreatic ducts, liver and pancreas, colon, sigmoid and rectum. 
The second group or autonomic proper (non-sympathetic), includes 
the nerves taking their exit from the mid-brain, hind-brain, and sacrum, 
supplying the glands and muscles of the gastro-intestinal tract, the 
oesophagus, stomach, intestines, liver, biliary passages, pancreas and 
ducts, colon, sigmoid and rectum. This group has been termed cranial- 
sacral autonomic system, or "the vagus system in the larger sense." 
Through the researches of Eppinger and Hess, the theory has been 
advanced that disturbances of the autonomic system leading to increased 
and decreased tonus or excitability, may be the cause of certain patho- 
logical changes, and that through this system, the activity of the glands 
of internal secretion are controlled and regulated. According to this 
theory the symptoms of nervous dyspepsia are due to disturbances of 
internal secretion in consequence of which increased or decreased excit- 
ability or increased or decreased tonus is transmitted by way of the 
autonomic system to the stomach and intestines. 
Eppinger and Hess have according to this plan evolved a clinical 
symptom-complex, which is based on the excitability or tonus of the 
autonomic system, and is termed by them vagotonus, and sympathetico- 
tonus. The effect of the increased tonus of the craniosacral system 
controlling the digestive organs consists in an increase in secretion of 
the stomach glands (hypersecretion and hyperacidity), increased gastric 
peristalsis (nervous vomiting), cardiospasm, pylorospasm, spastic con- 
stipation; increased intestinal peristalsis (nervous diarrhoea), mucous 
colitis, and spasm of the rectal sphincter. 
As forms of increased sympatheticotonus, may be mentioned, atony 
of the stomach, ptosis, atony of the intestines with increased constipation, 
achylia gastrica, nervous anacidity and relaxation of the anal sphincter. 
It is still doubtful whether or not the pylorus is partially under local 
nervous control, for Cannon1 has shown that destruction of either of 
the vagi or the sympathetic system does not prevent the passage of the 
chyme from the stomach into the intestines. There is no question, 
however, that the sphincters of the stomach are partially controlled by 
the central nervous system. With special reference to the cardia, 
Langley2 has shown that the vagus contains both inhibitory and accel- 
erator fibres, while Openchowski3 has demonstrated that stimulation of 
the sympathetic increases the contraction of the cardia. In reference 
to the pylorus, May4 has shown that the stimulation of the vagus causes 
at first an inhibition followed by an acceleration of the contraction of 
the pylorus. In regard to the nervous mechanism of other portions of 
the stomach, May has demonstrated that stimulation of the vagus 
caused at first an inhibition of the peristalsis of the pyloric portion, 
1 Am. Jour. Physiol., 1905, xiii, n. 22. 2 Jour. Physiol., 1898, xxiii, p. 407. 
3 Centralblatt fur Physiologic, 1889, S. 1. 4 Jour. Physiol., 1904, xxx. 108 
DISEASES OF THE DIGESTIVE SYSTEM 
with a lessened tone of the cardia, followed later by an acceleration of 
peristalsis in the pyloric region with increased tone in the cardia. Cannon1 
has shown that emotion plays an important role in the movements of 
the stomach by demonstrating that peristalsis ceases whenever "the 
animal manifests signs of rage, distress, or even anxiety." According 
to Cannon2 the stomach is divided into two parts that are physiologically 
distinct. The larger part is the cardiac area, the smaller the pyloric. 
During the process of digestion there are constant peristaltic movements 
running over the surface of the pylorus. Peristaltic waves are not present 
in the cardiac area. After the pylorus empties itself, however, the cardiac 
portion produces a tonic pressure, forcing its contents into the pyloric 
area; therefore, mixture with the gastric secretion takes place in the 
pyloric area. The food remains, however, for some time in the cardiac 
area, during which the salivary digestion is continued. According to 
Cannon the presence of free hydrochloric acid in the stomach occasions 
the relaxation of the pyloric sphincter, causing the pylorus to open and 
so permit the escape of the acid chyme into the duodenum. The presence 
of the acid in the duodenum produces a reflex stimulation of the pylorus, 
which closes and remains so until the contents of the duodenum have 
again become alkaline. 
Cannon, who has pointed out the importance of tonus in the activity 
of the alimentary canal, has shown that mechanical stretching stimulates 
activity in smooth muscles, and as this form of muscle surrounds the 
stomach, and intestines (which fill up and then empty), the effect of 
the distension becomes manifest. Thus when the muscle is in a state 
of tonus, stretching is followed by a contraction, but when the stomach 
is atonic, flaccid distension is not followed by contraction. According 
to Cannon "the view that tonicity of the neuromusculature of the 
alimentary canal is a fundamental necessity for the appearance of 
rythmical movements harmonizes many diverse observations." It 
accounts for the lack of motility in atony of the stomach, and gives an 
explanation for the existence and importance of extrinsic motor nerves. 
It also explains why worry, anxiety and distress inhibit gastro-intestinal 
movements, for such conditions accompanied by splanchnic impulses 
abolish tonus. 
Etiology.-Gastric neuroses may be primary or secondary; they are 
primary when the seat of the nervous disorder is inherent in the stomach 
itself, and secondary when the nervous mechanism of the stomach is 
reflexly affected either from the brain, spinal cord, or some other organ, 
such as the liver, kidneys, etc. Thus, a severe pain, such as kidney colic, 
may reflexly affect the stomach, causing vomiting; it is also a well- 
known fact that menstrual disorders, as well as sexual disorders in males, 
may have a marked reflex effect upon the gastric functions. It has 
been shown by Gould that severe eye-strain may also have a marked 
influence in this regard. On the other hand, gastric neuroses may in 
turn reflexly affect other organs, and we may find such symptoms as 
headache, palpitation, insomnia, and other manifestations. 
1 Am. Jour. Physiol., 1898. 
2 Ibid., 1904. FUNCTIONAL DISEASES OF THE STOMACH 
109 
Occurrence.-The writer has classified the cases of gastric neuroses 
occurring in his practice during a period of some years; in order to obtain 
a clearer view of these cases, the histories have been collected both from 
the records of private cases and hospital practice. This plan was deemed 
advisable because comparatively few forms of gastric neuroses are seen 
in the hospital wards. Of 2000 patients suffering with the various forms 
of gastric disease, 1592 (79.6 per cent.) represented one or more forms 
of nervous disorder, while 408 (20.4 per cent.) were affected with organic 
disease. In a smaller series of cases more recently analyzed, it has been 
observed that gastric neuroses are much less frequent now, than was 
formerly supposed, and that but 55 per cent, of the cases could be 
classified as neuroses, while 45 per cent, represented organic diseases. 
This change in the relation of two conditions, is due to the fact that 
many cases which were formerly classified as neuroses are known now 
to be due to some definite pathological change. 
In order that a gastric neurosis may exist, there must be present some 
predisposition, i. e., a neurotic condition in the individual. This is 
frequently first manifested by nervous symptoms directed to other 
organs, the stomach only later becoming involved. In this series of 
cases the early nervous manifestations were first noted in 38 per cent, in 
organs other than the stomach, while in 62 per cent, the stomach itself 
was first involved. The manner of development of these affections is 
often peculiar, at times beginning suddenly, often without any apparent 
cause or error in diet, persisting for a longer or shorter period of time, 
and then perhaps terminating abruptly, at other times coming on slowly, 
progressing rapidly, and terminating when least expected. Heredity 
plays an important role in the development of gastric neuroses. Among 
our observations 70 per cent, of the patients gave a history of either 
some functional or some organic hereditary nervous tendency. In 32 
per cent, the disorder was directly dependent upon some shock, anxiety, 
or vice, while in 18 per cent, no known cause could be discovered. 
Most of these affections are more frequently observed in females than 
in males, more often in men of the higher classes, and about equally in 
females of the lower and higher classes. In this series of cases 54 per cent, 
represents the number of females affected, while 46 per cent, indicates 
the number of males. The chief factor in the production of these con- 
ditions in males is overwork, worry, and excesses, especially overindul- 
gence in drink, 29 per cent, of the patients giving a distinct alcoholic 
history. The chief causes in women are disorders of menstruation and 
reproduction, anxiety, sorrow, and disappointments. The predominance 
in this sex is due to the mode of living and peculiar affections. 
Age.-The neuroses rarely begin in old age. They occur most fre- 
quently between the twentieth and fortieth year. The following table 
shows the age in the gastric neuroses in this series: 
Year. 
Cases. 
Per cent. 
1 to 20 
. . . . 232 
14.5 
20 to 30 
. . . . 354 
22.5 
30 to 40 
. . . . 404 
25.0 
40 to 50 
. . . . 339 
21.5 
50 to 70 
175 
11.0 
60 to 70 
. . . . 88 
5.5 110 
DISEASES OF THE DIGESTIVE SYSTEM 
The neuroses occur as frequently in the robust and well-nourished 
as in the broken-down and enfeebled individual. After persisting for 
some time neuroses interfere with the general health, frequently occa- 
sioning emaciation; this condition, however, is secondary in most instances 
and is not a predisposing factor in the etiology. The symptoms of a gen- 
eral neurosis are usually present, i. e., irritability, lassitude, insomnia, 
depression, and a feeling of malaise. Hyperesthesia or anesthesia often 
exists in certain parts of the body. The subjective symptoms are change- 
able and capricious, exhibiting protean changes in rapid succession. 
The digestion is usually, as Boas states, in a condition of "labile gastro- 
intestinal function." The digestive complaint is frequently independent 
of the quality and quantity of food ingested, and without any connection 
with its digestion; errors of diet are not necessarily followed by aggrava- 
tion of the symptoms. Periodic attacks of discomfort often alternate 
with unaccountable periods of well-being. Frequently sudden changes 
take place in the secretory or motor functions of the stomach, or in 
both, so that a superacidity may quickly give way to a subacidity and 
a motor insufficiency to a hypermotility. The pain which may be present 
is diffuse and often bears no relation to the digestion of food. 
Gastric neuroses are usually polysymptomatic, more rarely mono- 
symptomatic in character. In the first form there is a multiplicity of 
symptoms, while in the latter but one symptom is observed. Neuroses 
rarely present the same form during their entire period, and a mono- 
symptomatic neurosis is not infrequently converted into the poly- 
symptomatic form. A characteristic feature of gastric neuroses is the 
fact that the symptoms vary so frequently, which is often of great 
assistance in differentiating between this class and organic disease. 
Classification of Gastric Neuroses.-The classification into secretory, 
sensory, and motor neuroses, so often used, has by no means been found 
to be satisfactory, and Boas1 has suggested the following modification: 
Monosymptomatic Gastric Neuroses 
Irritative Group. 
Superacidity or hyperchlorhydria. 
Supersecretion or gastrosuccorrhoea. 
Gastromyxorrhoea. 
Bulimia. 
Parorexia. 
Gastralgokenosis. 
Gastralgia. 
Hyperesthesia. 
Rumination (merycism). 
Regurgitation. 
Eructatio nervosa. 
Vomitus nervosus. 
Nausea nervosa. 
Cardiospasm. 
Pylorospasm. 
Pneumatosis. 
Peristaltic unrest. 
Depressive Group. 
Subacidity or hypochlorhydria. 
Anacidity or achylia gastrica. 
Akoria. 
Anorexia. 
Sitophobia. 
Incontinence of pylorus. 
Atony. 
Polysymptomatic Gastric Neuroses 
Nervous dyspepsia. 
1 Deut. med. Wochenschrift, August 17, 1906. FUNCTIONAL DISEASES OF THE STOMACH 
111 
Diagnosis.-This may be very difficult, as frequently these conditions 
envelop some organic disease, the nervous symptoms being so much 
more prominent that the actual disease becomes entirely masked. In 
order to establish the nervous character of a gastric disorder, all organic 
diseases must be excluded, and this is frequently a most difficult task. 
In the monosymptomatic forms the diagnosis is usually simple, especially 
if the examination of the gastric contents and functions shows a normal 
condition. The patient frequently has a hereditary nervous tendency or 
a weakened nervous system or neurotic habit. The disease is frequently 
either characterized by peculiar periodical or paroxysmal attacks, with 
many unaccountable periods of well-being, or by an absence of subjective 
symptoms even upon the ingestion of indigestible food. 
The diagnosis of the polysymptomatic forms is more difficult. In 
these the symptoms that are frequently found in severe organic diseases 
may be interwoven and combined with the gastric neuroses; a further 
difficulty arises from the fact that organic disorders are often accom- 
panied by nervous symptoms, and a most careful investigation may be 
necessary. Nervous dyspepsia is the most typical example of the poly- 
symptomatic neuroses with a multiplicity of symptoms seldom found in 
its frequency in organic diseases of the stomach. The nervous dyspeptic 
himself often indicates the diagnosis of this condition, and one need 
only listen to his story attentively. Objective signs may be absent, 
or, when present, may mislead one; thus a slight dislocation of the 
kidney or a slight gastric atony would be insufficient to account for the 
symptoms present. In the diagnosis of these conditions the appearance 
of the attacks without apparent cause and the intervals of well-being 
are most striking. The fact that as a rule the complaints of the patient 
bear no relationship to the quantity and quality of food ingested, but 
are mainly dependent upon overexertion, mental disturbances, and 
excitement is of greater value in the diagnosis. The conditions are 
often relieved or improved by change of scene or relaxation. 
When it is impossible to gain a clear idea of the condition, Boas advises 
the functional testing of the stomach. The patient is given a very 
digestible diet, such as is usually prescribed during the third week of an 
ulcer treatment. The subjective symptoms are noted while the patient 
is on the diet, during a period of from three to four days; then additions 
are made gradually, such as sauces, vegetables, dessert, and raw fruits. 
An exact record is again made, and by comparing the symptoms during 
the first and second period the presence of an organic or nervous gastric 
disorder will be indicated. In the latter condition the symptoms not 
only often diminish, but frequently disappear entirely during the second 
period, while in the former they are apt to increase. Boas also advises 
the frequent testing of the motor and secretory functions of the stomach, 
which when found to be constantly normal are often alone sufficient 
evidence to indicate the neurotic nature of the disorder. 
Prognosis.-The prognosis in neuroses of the stomach is very favorable, 
provided the condition is treated early and the cause discovered and 
removed. Relapses, however, are frequent if care is not taken to regulate 
the daily regimen and maintain, so far as possible, a stable condition of 112 
DISEASES OF THE DIGESTIVE SYSTEM 
the general nervous system. It is not uncommon, when relapses do 
occur, that some nervous manifestation is produced other than that 
which was originally present. In the series of 1592 cases there were 752 
(47 per cent.) that gave a history of one or more relapses; of these, 321 
(20 per cent.) had one and 431 (27 per cent.) more than one relapse; in 
the remaining 840 no evidence of any former attacks could be obtained. 
Treatment.-In this it is necessary to remember that one is dealing 
with patients whose imagination is easily influenced in directions other 
than normal; for this reason the personal influence of the physician 
himself will have much to do with the patient's recovery. It is at first 
always important to make a most careful and complete examination 
to convince the patient that there is no organic disease. A change of 
scene is often important, and specific rules as to the mode of living and 
diet should be insisted on. In some cases a sanatorium treatment is 
most desirable. The diet should be carefully regulated, and especially 
in badly nourished patients the aim should be to strengthen the individual 
and add to his nutrition by increasing the body weight. For this purpose 
also the physical methods of treatment are most serviceable and must 
be resorted to, acting at the same time as suggestive measures. Of these, 
massage, cold and warm douches, packs, poultices, intragastric as well 
as external electricity, douching and lavage of the stomach play a most 
important role. 
Sadger1 extols hydropathic treatment for these conditions, and adapts 
the treatment to the constitutional weakness of the patient rather than 
to special symptoms. The treatment in this direction must be tonic 
and stimulant. He advises cold sponging with rubbing, cold compresses, 
the half or full cold bath, the Scottish douche, and Winternitz's compress. 
When sanatorium treatment is impossible or impracticable, a sojourn 
at the seashore or mountains, with specific directions as to the mode 
of living, rest, exercise, and diet, often proves serviceable. A cure at 
some mineral spring is often beneficial, provided the proper spring is 
selected and specific directions given as to drinking the water and the 
mode of living to be followed. In no instances should patients suffering 
with nervous stomach troubles be permitted to tell others of their con- 
dition. In severe forms a rest cure should be resorted to, as most remark- 
able results can often be achieved by this means. 
The nervous dyspeptic should be taught to rely more upon proper 
hygienic measures than upon drugs, as but few drugs have any marked 
influence in these cases. Of these remedies the bromides, preparations 
of valerian, arsenic, and codeine are most useful. 
HYPERACIDITY OR HYPERCHLORHYDRIA 
By the term hyperacidity is meant an excessive flow of gastric juice 
or, more correctly, an increase in the secretion of the hydrochloric acid 
produced by the gastric mucous membrane during the process of digestion. 
1 Archiv f. Verdauungskr., Bd. xii, Heft i. FUNCTIONAL DISEASES OF THE STOMACH 
113 
It has been questioned whether hyperchlorhydria should be termed a 
distinct disease, inasmuch as the excess of acid is simply a symptom 
observed in a number of gastric disorders and due to a variety of causes; 
yet the symptoms associated with this condition are so definite and so 
often embrace all subjective manifestations that we are forced to treat 
this condition as a special clinical entity. Yet it must be noted that 
although hyperchlorhydria is in many instances a secretory neurosis, 
in a large number of cases it is associated with some definite lesion. 
The question as to what is meant by an excess of hydrochloric acid 
has not yet been thoroughly agreed upon by all writers. According to 
Ewald, Einhorn, and others the normal percentage of free hydrochloric 
acid one hour after the Ewald test breakfast ranges between 0.1 and 
0.2 per cent. Any amount above 0.2 per cent, is to be considered a 
hyperacidity; on the other hand, many cases are met with having a 
greater acidity than 0.2 per cent, without symptoms of hyperacidity. 
In 14 of the patients in this series with free hydrochloric acid ranging 
between 0.21 and 0.29 per cent., and a total acidity varying from 70 
to 100, there were no evidences of any gastric disturbance whatever. 
On the other hand, symptoms of hyperacidity may exist even in cases 
of hypochlorhydria. This has occurred in 11 of the series. In the largest 
proportion of cases, however, any increase above 0.2 per cent, free 
hydrochloric acid represents a superacidity, and is usually accompanied 
by symptoms of this condition, although this is not always the case, 
for there are patients with acidities as high as 0.29 per cent, without 
any symptoms whatever, and others in whom free hydrochloric acid 
is entirely absent in whom symptoms of hyperacidity are manifested. 
The very same amount may indicate a hyperacidity in one individual 
and not in another, showing that individual variations may exist in the 
normal percentage, and that we cannot always draw a sharp line between 
the normal and the hyperacid state. The condition has been explained 
in two ways; according to some writers, the stomach of each individual 
has its own degree of acidity, and thus may perform its function with an 
acidity which is insufficient or more than sufficient for another. There- 
fore, any increase in this normal proportion of acid will render this 
particular gastric secretion superacid for this individual and occasion 
symptoms of hyperchlorhydria. Another explanation which seems to 
be more satisfactory was suggested by Talma.1 According to this 
observer the symptoms of hyperchlorhydria are due in these cases to a 
hypersensitiveness or hyperesthesia of the gastric mucosa to hydro- 
chloric acid. Stockton pointed out that the gastric mucosa is not only 
often intolerant to an excess of hydrochloric acid, but often to a normal 
or subnormal percentage of acid. Steele confirmed the observation, 
and went a step farther to show that the hyperacid condition of the 
gastric contents is not alone capable of producing the symptoms in 
hydrochlorhydria; according to him there must be some other condition 
present occasioning the gastric hyperesthesia, producing that condition 
in which the gastric mucosa cannot tolerate a normal or abnormal amount 
1 Zeitschrift f. klin. Med., 1884, Bd. xiii. 114 
DISEASES OF THE DIGESTIVE SYSTEM 
of acid, and, further, this hyperesthesia is due to ulcer, retention or 
hypersecretion on the one hand, or to a sensory neurosis on the other. 
Kaufmann also believes that some other factor must be involved to 
occasion the symptoms of hyperacidity besides merely the increased 
amount of the secretion. According to him, whenever the patient presents 
the symptoms of hyperacidity a second pathological factor must be 
sought, forming the connecting causal link between the chemical findings 
and the subjective disturbances. In many of these cases this factor is 
demonstrated in some ulceration, erosion, dilatation, and by far most 
frequently in an atony of the stomach. 
Etiology.-Hyperchlorhydria is the most frequent of all gastric disturb- 
ances. In the series of 2000 cases, representing organic as well as func- 
tional disturbances of the stomach, there are 1273 (63 per cent.) showing 
a hyperacidity; in the series of 1592 cases of gastric neuroses there are 
542 cases of hyperchlorhydria, or 34 per cent. 
The disease is frequently observed in young and middle-aged persons, 
while it is rarer in older individuals. It is found to a slight degree more 
frequently in females than males. Hyperchlorhydria is found more 
frequently among the better and wealthier classes than among the poor. 
This is due to the fact that mental strain and worry are often direct 
factors in the production of this disorder. Jaworski points out its fre- 
quency among the Polish Jews; we have observed it as a most frequent 
condition among the Hebrews of this vicinity. The following etiological 
factors in its production may be noted: 
1. Mental strain, mental overwork, prolonged worry, and mental 
fatigue are important. Nervous individuals and persons who have 
undergone severe mental strain are especially prone to this disorder; 
Van Noorden has found it frequently in patients suffering with melan- 
cholia. Neurasthenia and hysteria are also important causative factors; 
of the 542 cases of hyperchlorhydria, 186 belong to this class. 
2. Gastro-intestinal atony is a marked etiological factor, especially 
those forms associated with chronic constipation. It occurred in 164 
of this series, mainly in young females. 
3. Indiscretions in diet, such as the use of food of a very heavy char- 
acter, as well as the abuse of alcoholic drinks and tobacco, are the cause 
of the largest proportion of cases of hyperchlorhydria. This condition 
is frequently found in persons who masticate their food imperfectly, 
who eat too quickly, who drink foods too hot or too cold, or take their 
foods too highly seasoned. This class is represented by 186 cases. 
4. Among other conditions that bear some etiological relationship 
are ulcer of the stomach, chlorosis, cholelithiasis, nephrolithiasis and 
appendicitis but it is not our province to discuss the connection between 
ulcer and hyperchlorhydria here. Oswald pointed out the association 
of hyperacidity with chlorosis; in 85 per cent, of his cases a hyper- 
chlorhydria existed. In 34 cases of this series with chlorosis and gastric 
disturbances, hyperacidity was found in 24, normal acidity in 8, and 
subacidity in 2 cases. Cholelithiasis is frequently accompanied by 
hyperacidity and any condition leading to biliary retention may produce 
this condition. FUNCTIONAL DISEASES OF THE STOMACH 
115 
The following table represents the cases of hyperchlorhydria, tabulated 
according to age and sex, presenting the various etiological factors: 
Causes. 
No. 
Males. 
Females. 
Ages in years. 
10-30. 30-50. 50-70. 
1. Mental overwork and fatigue, 
neurasthenia 156 
89 
67 
44 71 41 
2. Gastro-intestinal atony 
chronic constipation . 
with 
. . 164 
54 
110 
73 54 37 
3. Indiscretions in diet, 
drink, and tobacco . 
food, 
. . 186 
105 
81 
95 57 34 
4. Indefinite and unknown causes 36 
15 
21 
Pathology.-As hyperchlorhydria is largely a sensory neurosis, no 
anatomieal lesion is present in the greater proportion of cases. Oester- 
reich1 found the gastric mucous membrane perfectly normal with the 
exception of a few slight erosions in a patient suffering from hyper- 
chlorhydria dying of an intercurrent pneumonia. According to Hem- 
meter,2 who has examined fragments of mucosa found accidentally in 
the wash water, there is in more than one-half the cases of hyperacidity 
"a proliferation of the glandular elements and increase of oxyntic or 
border cells." Straus3 described similar lesions. 
Symptoms.-The subjective symptoms usually appear gradually; 
they consist of acid eructations, heartburn, and pain and burning in the 
stomach. Acid eructations usually appear at the height of the paroxysms 
of gastralgia, and their appearance is accompanied by a passing relief 
from pain. If portions of the acid secretion of the stomach are eructated, 
the mucous membrane of the oesophagus is subjected to this irritation, 
and heartburn develops. This symptom usually appears after eating 
acid foods, and is frequently relieved by taking milk, meats, and eggs. 
The pain may vary from a severe pressure in the stomach to a very acute 
pain, and may extend into the back between the shoulder-blades and 
pass under the sternum to the pharynx (pyrosis hydrochlorica). It is 
not continuous, but appears at certain periods with intervals of complete 
relief, usually from two to four hours after meals, depending upon the 
quality and quantity of food taken. In a very small number of cases 
the pain supervenes immediately upon eating, as occurred in 9 of the 
series (1.6 per cent.). The symptoms continue for a variable period 
of time, disappearing in the course of an hour or persisting for many 
hours. Pain is much more easily induced by starchy foods than by 
protein foods, more quickly by light meals than by heavy ones, and is 
usually relieved by the ingestion of food or by neutralizing the acid by 
means of some alkali. Paroxysms of pain (gastralgia) occur in a certain pro- 
portion of cases; they develop gradually, beginning as a feeling of pressure 
and becoming more severe. As a rule, the pain disappears at night upon 
lying down, and does not begin again until several hours after breakfast. 
The severe gastralgic paroxysms are not commonly found after every 
meal. They are accompanied not only by intense pains in the epi- 
gastrium, but also in the back; they are partially relieved by the acid 
1 Deut. med. Wochenschrift, 1895, Nr. 21. 
2 Archiv f. Verdauungsk., Bd. iv, S. 23; Diseases of the Stomach, third edition, p. 814. 
3 Virchows Archiv, 1898, Bd. cliv. 116 
DISEASES OF THE DIGESTIVE SYSTEM 
eructations and entirely by the vomiting of the acid secretion, which 
burns the throat and numbs the teeth as it passes over them. In some 
cases the seizures may be very mild, and in other cases they recur irregu- 
larly at intervals of days. In this series of 542 cases, gastralgic seizures 
occurred in 176, i. e., 32 per cent. A sensation of burning in the stomach 
is frequently observed; this is felt in the epigastrium, and may extend 
to the back. It is relieved by the same measures as those which relieve 
the pain, namely, by alkalis or the taking of some form of food. In 
this series there were 221 that complained of this sensation, i. e., 40 per 
cent. The appetite is usually good, and as eating usually relieves the 
symptoms, the patient often accustoms himself to eat frequently; small 
quantities will, however, often satisfy the patient. In 124 (21 percent.) 
of the cases the appetite was increased, in 357 (66 per cent.) it was 
normal, and in 61 (13 per cent.) it was diminished. The thirst is not 
greatly increased, although the reverse is stated by most authorities. 
In this series thirst was only increased in 31, i. e., 6 per cent. 
The bowels are frequently constipated, as occurred in 164 of the 
series, or 30 per cent. Occasionally constipation alternates with diar- 
rhoea, as occurred in 7 of the cases (1.3 per cent.). 
The objective symptoms may be divided into two classes, those 
presented by the physical examination and those obtained by the exami- 
nation of the vomited material and gastric contents. The patient, as 
a rule, is in good general health, has lost but little flesh, and the general 
nutrition is not usually disturbed; the abdomen is not usually sensitive 
to pressure, and painful areas are not apparent except perhaps during 
the attacks of pain, when the stomach may be found distended and 
sensitive to pressure. Vomiting is not frequent; it usually occurs when 
the paroxysms of gastralgia are present, and then at the height of the 
attack; relief is obtained by vomiting, and the pain disappears. This 
symptom occurred in 86 of the cases, or 15 per cent. The vomited 
matter is very acid, which is detected even by the patient himself; on 
examination this material is found to contain large quantities of free 
hydrochloric acid. The examination of the gastric contents after a 
test meal usually reveals normal or hypermotility. Six hours after a 
Riegel test dinner the stomach is usually empty; one hour after a test 
breakfast it contains only a small quantity of gastric juice. In 30 per 
cent, of this series there was an atony of the stomach in which more or 
less retention was observed. The gastric juice shows a very high degree 
of acidity; the starch digestion is imperfect, and rather large quantities 
of amidulin are found. On the other hand, the protein digestion in 
the stomach is complete and peptonization is more rapid than under 
normal conditions, so that none or but few undigested meat fibres are 
found in the gastric contents. 
Schiller1 has pointed out that the specific gravity of the gastric juice 
is diminished in hyperchlorhydria. According to this observer it is 
usually below 1.016, the normal specific gravity varying between 1.016 
to 1.020. The observations in 14 cases as to the specific gravity of the 
1 Deut. med. Wochenschrift, May 1g, xOOO. FUNCTIONAL DISEASES OF THE STOMACH 
117 
gastric contents in this condition are, on the whole, in accord with those 
of Schiiler, ranging between 1.008 and 1.014, although occasionally higher 
figures are found, as in 3 of this series between 1.019 and 1.022. 
Absorption in the stomach is said to be more rapid in hyperchlorhydria 
than under normal conditions. 
The urine is at times alkaline and contains a precipitate of phosphate, 
especially after severe attacks of vomiting. The acidity of the urine is 
diminished proportionately to the increase in acidity of the gastric 
juice, and the chlorides are also diminished in quantity. 
Diagnosis.-This is established by careful investigation into the sub- 
jective symptoms together with the results obtained from analysis of 
of the gastric contents. These symptoms consist of acid eructations, 
heartburn, burning and pains in the stomach, the pain appearing from 
two to four hours after meals, relief being obtained by the ingestion of 
food and by neutralizing the acid with alkalis. The examination of 
the stomach contents after a test meal reveals an increase in free hydro- 
chloric acid; wdiile on fasting, the stomach is found nearly or almost 
completely empty. Hyperchlorhydria must be differentiated from 
chronic hypersecretion, ulcer, acid gastritis, atony, and cholelithiasis. 
Chronic hypersecretion is distinguished by the intense gastric pains 
appearing frequently at night, the more frequent vomiting, and the 
appearance of large quantities of gastric juice (100 cc. and more) in the 
fasting stomach. Ulcer of the stomach (without hemorrhage) is differ- 
entiated by the presence of the circumscribed epigastric and dorsal 
areas of pain. The pain in ulcer is proportionate to the quality and 
quantity of the food taken, which is not usual in hyperchlorhydria. 
Occult blood is frequently found in the feces in ulcer, but not in hyper- 
chlorhydria. Duodenal ulcer is distinguished by the characteristic 
remissions in pain, extending over longer or shorter periods; by the pain- 
ful area which is absent in hyperacidity, and by the presence of occult 
blood in the stools. The differential diagnosis between these two con- 
ditions is very difficult at times, as hyperacidity usually accompanies 
ulcer of the stomach and duodenum; the greater irregularity of the 
symptoms in hyperchlorhydria and presence at least of some of the 
definite symptoms of ulcer will usually lead to a correct diagnosis. In 
doubtful cases, Boas advises that the patient undergo the rest treatment 
for ulcer; a favorable outcome rather indicates the presence of ulcer. 
Hyperchlorhydria is distinguished from an acid gastritis by the constant 
absence of mucus in the gastric contents, and from atony by the absence 
of symptoms of retention. In a certain proportion of cases of hyper- 
chlorhydria, however, atony is present (30 per cent.) and the symptoms 
of both conditions become marked. In cholelithiasis the pains are not 
relieved by the ingestion of food or the administration of alkalis, and 
radiate to the right toward the hypochondriac region and are in no wray 
dependent upon the time of the ingestion of food, whereas the pains of 
hyperchlorhydria usually appear at the height of digestion, i. e., from 
two to four hours after meals. 
Prognosis.-This is usually quite favorable as to the relief of the 
symptoms, especially if the condition is of recent origin; in protracted 118 
DISEASES OF THE DIGESTIVE SYSTEM 
cases the prognosis is less favorable, and even when patients have been 
apparently cured of this condition relapses are not infrequent, probably 
due in many instances to the fact that while at first the acidity of the 
gastric secretion may be reduced, a permanent reduction is not usually 
effected. In personal observations in 9 patients in whom we have been 
able to make gastric analyses more or less frequently during the time of 
treatment, i. e., for a period of six months, and again after the first and 
second years, during which symptoms of hyperacidity no longer existed 
and treatment was no longer instituted, it is evident that while the 
patient is under treatment and the acidity of the gastric juice can be 
reduced, this reduction is not permanent, and that while the patient 
may be free of all symptoms of hyperacidity an excess of acid secretion 
still exists. This points to the fact that our treatment is only effectual 
in reducing the gastric hyperesthesia and not the acidity. 
In those instances in which the hyperacidity is symptomatic of other 
conditions the prognosis depends upon the relief of the primary disease. 
In the series of 542 cases of hyperchlorhydria in which it was possible to 
follow 48 cases for a period of at least three years or more, 31 were cured 
(65 per cent.), 10 were relieved (21 per cent.), and 7 were not benefited 
(14 per cent.); relapses occurred in 5 cases (10 per cent.). 
Treatment.-In this the diet plays the most important role, it being 
essential that the food should be given in such a form as not to produce 
any irritation to the mucous membrane of the stomach. As the gastric 
hyperesthesia is mainly responsible for the hyperacidity, the treatment 
should be directed to this condition. This would include the removal 
of all causes of irritation, the prohibition of alcoholic stimulants; all 
acids, including organic acids, should be forbidden; all spices and con- 
diments, such as ginger, pepper, mustard, and horse-radish, should be 
prohibited. All foods to which vinegar or lemon-juice have been added 
should be interdicted; all hard substances which are apt to irritate the 
stomach, such as nuts, should be avoided; food must be thoroughly 
masticated and should be taken neither too hot nor too cold. Formerly 
a diet consisting almost exclusively of proteins was recommended in 
order to neutralize as much acid as possible as the proteins possess the 
power of combining with free hydrochloric acid. On the other hand, 
it was soon discovered that while the proteins possess this power, they 
nevertheless again stimulate the flow of acid; some, such as raw beef, 
beef-juice, and beef extract, more than others, such as well-cooked meat. 
More recently various authors have recommended a carbohydrate diet 
in preference to a protein one. Some prefer a liberal mixed diet, consist- 
ing of proteins, fats, and carbohydrates. The following table taken from 
Bickel presents the food which slightly and the food which strongly 
excites gastric secretion: 
Foods slightly exciting acid secretion. 
Liquids: Water, alkaline water, tea, cocoa (rich in fats), milk (rich in fats), 
cream, and egg-albumen. 
Condiments: 0.9 per cent, of salt solution. 
Solids: Cooked meats, fats of all kinds, cooked vegetables, such as potatoes, 
asparagus, cauliflower, spinach, white beets (all in puree), starch, sugar. FUNCTIONAL DISEASES OF THE STOMACH 
119 
Foods strongly exciting acid secretion. 
Liquids: All alcoholic and carbonated drinks, coffee, cocoa (poor in fats), 
skimmed milk, beef-tea, beef extract, strongly seasoned soups, yolk of eggs, 
hard-boiled eggs, beef solution. 
Condiments: Pepper, cinnamon, mustard, cloves, paprika, salt in concentration. 
Solids: Raw or slightly cooked beef, dark meats, salted meats (pork, pickled 
meats, smoked fish), dark breads. 
The carbohydrate foods which are allowable are the more digestible 
vegetables, such as mashed potatoes, spinach, asparagus, peas, and 
carrots, strained and eaten in the form of purees, also the digestible 
farinaceous foods, such as rice and grits. Strauss1 has recommended 
the administration of a solution of sugar; this food can be best given in 
most instances in the form of some baked cake in which part of the 
starch has become dextrinized by baking or roasting. Strauss and 
Aldor have advised the use of fats, inasmuch as they tend to lessen the 
acidity of the gastric secretion. They are best given in the form of 
butter, cream, olive oil, and the like. Of the fluids, milk, cocoa, and 
alkaline mineral waters, such as Apollinaris, Vichy, and Seltzer, are 
especially useful; the carbon dioxide produces a sedative effect and 
lessens the secretion of acid. These waters may be used to dilute milk. 
In arranging the diet it has been found best in dealing with patients 
taking but little nourishment to allow them to eat at frequent intervals; 
if, however, large meals are consumed, it is advisable to permit only 
three meals a day, allowing the stomach to rest in the intervals. In 
marked forms of nervous hyperchlorhydria a purely vegetable or milk 
and vegetable diet has been recommended by certain writers; the vege- 
tables should be eaten in the form of purees. Laufer, Vincent, Euriquez, 
and others attach great importance to a salt-free diet in hyperchlorhydria, 
believing that a high percentage of muriatic acid may be reduced by a 
diet free of salt. Zweig comes to similar conclusions, and urges a salt- 
free diet in the treatment of gastric hyperacidity. In advanced cases, 
with marked emaciation and prominent nervous symptoms, an absolute 
or modified rest cure will accomplish excellent results; in these cases 
milk and egg-albumen should be the only food given at first, gradually 
increasing, and finally allowing easily digestible solid food. 
The following list, taken from Friedenwald and Ruhrah,2 gives the 
foods which are allowable and those which are forbidden in hyperchlor- 
hydria: Allowable: Eggs, soft boiled, hard boiled, or poached. Meats, 
boiled or broiled; brains, raw scraped beef, boiled or broiled beef, broiled 
steak, roast mutton, broiled chops, roast lamb; boiled, broiled, or roasted 
chicken; broiled or roasted squab, roast turkey, broiled or roasted birds. 
Farinaceous food: Rice, cornstarch, sago, tapioca, arrowroot, hominy, 
grits, vermicelli, cream of wheat, stale wheat bread, toast corn bread, 
pulled bread, zwieback. Fruits: Baked or stewed apples, stewed 
apricots, stewed peaches, stewed pears, stewed prunes. Fatty foods: 
Butter, cream, pure olive oil. Drinks (taken mainly between meals): 
Milk, buttermilk, malted milk, peptonized milk, milk with lime-water, 
milk with Vichy, milk flavored with tea, milk flavored with coffee, kefir, 
1 Zeitschrift f. klin. Med., vol. xxix. 
2 Diet in Health and Disease, fourth edition, p. 810. 120 
DISEASES OF THE DIGESTIVE SYSTEM 
koumyss, junket, whey, cocoa, albumin-water, water (not with meals), 
hot water. Vichy, Apollinaris, Poland, Lithia water, Carlsbad. 
They must not take: Soups, fried foods, pork, veal, stews, hashes, 
corned meat, liver, kidney, duck, goose, sausage, crabs, lobsters, preserved 
fish, smoked fish, salmon, salt mackerel, sardines, cauliflower, celery, 
cocoa, radishes, cucumbers, sweet potatoes, beets, tomatoes, acid fruits, 
salads, hot bread or cakes, nuts, candies, pies, pastry, strong tea, coffee, 
alcoholic stimulants, ice-water, ice-cream. 
Hygienic Measures.-These should never be neglected in the treatment 
of hyperchlorhydria. Those patients who have been fatigued by over- 
work should be ordered rest, and those who are worn out by mental 
strain and excitement are often best ordered away to the country, sea- 
shore, or mountains; physical exercises, out-door life, and cold sponge 
baths are often serviceable adjuvants; warm poultices or Preissnitz 
compresses are frequently useful in the relief of pain. 
Gastric lavage is rarely necessary in the simple cases although it is 
often of benefit in severe and obstinate forms. It is best practised late 
in the evening, three or four hours after the last meal, or on an empty 
stomach in the morning; douching of the stomach with a solution of 
silver nitrate is often beneficial; 500 cc. of a 1 to 2000 solution is allowed 
to enter the stomach and again washed out thoroughly with normal 
salt solution. Electricity often exerts a very beneficial effect in some 
cases of hyperchlorhydria, and can be used either as the intragastric 
faradization or galvanization. The faradic current is useful in most 
instances, but in painful conditions the galvanic current is to be preferred. 
The chronic constipation often associated with hyperchlorhydria is 
frequently relieved by this mode of treatment. 
Medicinal Treatment.-Alkalis are employed to neutralize the excess 
of acid. Of these, the bicarbonate of soda, calcined magnesia, magnesia 
carbonate, calcium carbonate, and the phosphate of soda are most 
frequently utilized. Calcined magnesia has an advantage over bicar- 
bonate of soda, as the former neutralizes four times as much acid as 
the latter; it has the additional advantage in that it is distinctly laxative 
and is therefore especially useful when constipation is present; the doses 
of the alkali should be, so far as possible, proportioned to the heaviness 
of the meal as well as the degree of hyperacidity. The alkalis should 
be administered when the discomfort begins to manifest itself, i. e., about 
two hours after meals. Of other drugs found useful are: 
1. Atropine, which inhibits gastric secretion. This remedy can be 
administered in the form of the extract of belladonna or atropine. 
2. Nitrate of silver in solution, which tends to diminish the gastric 
hyperesthesia. 
3. Bismuth subnitrate and carbonate, which may be administered in 
large doses and which exert a beneficial, largely mechanical, effect on 
the gastric mucosa. 
4. Hydrogen peroxide is also useful and may be given in one-tea- 
spoonful doses in a glass of water after meals. Magnesium peroxide, 
known under the trade name as magnesium perhydrol, has also been 
found beneficial. FUNCTIONAL DISEASES OF THE STOMACH 
121 
5. The nerve sedatives, such as the bromides, valerianates, and 
sumbul, which relieve the gastric hyperesthesia. In those cases in which 
symptoms of hyperacidity exist and in which the gastric secretion shows 
a normal or lessened amount of acid the sedatives are more valuable 
than the alkalis. 
6. Nux vomica: While the bitter tonics are to be avoided, as a rule, 
in hyperchlorhydria, Musser1 advised the administration of nux vomica 
in ascending doses in those cases in which the symptoms of hyperacidity 
are due to a sensory neurosis; he had uniformly good results from this. 
7. Olive oil: Cohnheim2 has recommended olive oil very highly in 
the treatment of this condition. It may be given in tablespoonful doses 
before meals or about two hours after meals. 
Inasmuch as constipation is sometimes the cause of hyperchlorhydria, 
a correction of this will often give permanent relief and this is often 
best accomplished by diet rather than by drugs. 
Of the watering places for the treatment of hyperchlorhydria, Carlsbad, 
Vichy, Neuenahr, and Bedford and Saratoga (Vichy) are to be most 
highly recommended. 
Larval Hyperacidity.-Straus3 was the first to point out that symptoms 
of hyperacidity may exist without an actual increase in hydrochloric 
acid, and Roth and Straus4 explain this by assuming that there is an 
actual hyperacidity which is not revealed, because the examination of 
the gastric contents is made an hour after the test breakfast is given, 
and that two elements exist in the formation of the gastric secretion- 
an inactive diluting fluid and an active form whose specific action is to 
digest proteins. The active digestive secretion is gradually diluted by 
the diluting fluid. It is, therefore, easily conceived how, if the diluting 
fluid be secreted rapidly, a gastric juice which is hyperacid when first 
secreted may be rapidly reduced to normal or subnormal. 
According to our observations5 the symptoms are largely those of a 
neurasthenia, evincing at the same time special manifestations of hyper- 
chlorhydria, consisting of pain and pressure in the region of the stomach 
one hour after meals, and extending over a period of from one to one and 
one-half hours, and usually relieved at the end of this time, or at any 
time, by the ingestion of food. Of the other symptoms, acid eructations, 
heartburn, nausea, and occasionally vomiting of acid material are most 
prominent. The appetite is usually increased, though on account of the 
pain induced by the ingestion of food there is usually fear of eating. 
An epigastric painful area is not present and occult blood is always 
absent in both gastric contents and in the stools. In all instances general 
nervous symptoms are manifested, as headaches, insomnia, lassitude, 
irritability, and depression, with periods of discomfort alternating with 
accountable periods of well-being, the periods of discomfort often being 
induced by nervous influences. The quantity of gastric contents obtained 
1 Transactions of the Association of American Physicians, 1905, p. 193. 
2 Zeitschrift f. klin. Med., vol. iii, S. 110. 
3 Dent. Archiv f. klin. Med., 1896, Band Ivi, S. 120. 
4 Zeitschr. f. klin. Med., Band xlvii. 
5 Am. Jour. Med. Sci., 1911, cxlii, p. 157. 122 
DISEASES OF THE DIGESTIVE SYSTEM 
is always large, varying between 215 and 368 co., always a most significant 
feature of this condition. The appearance of the contents is also char- 
acteristic, consisting largely of a watery secretion containing but little 
sediment. On standing, two layers are formed-a lower, slight in amount, 
but with solid sediment, and above a clear layer, larger in quantity. The 
total acidity as well as the percentage of free hydrochloric acid is always 
normal, though in the earlier period of digestion a high total acidity 
as well as a marked hyperchlorhydria is always manifested. The amidulin 
reaction is present in all instances. 
The diagnosis of larval hyperacidity does not usually present any 
difficulty. The symptoms of hyperacidity which arise early in the 
period of digestion, together with the characteristic features of the 
gastric contents, the large amount obtained consisting mainly of a 
watery secretion, with a low specific gravity, and with a normal acidity, 
and presenting the amidulin reaction distinguish this condition from 
the usual forms of hyperchlorhydria. The absence of an epigastric 
painful area/ as well as the absence of occult blood in the stools, dis- 
tinguishes it from gastric ulcer. Larval hyperacidity is differentiated 
from digestive or alimentary hypersecretion of gastric juice, with which 
it has many symptoms in common, by the presence of a hyperacidity 
during the early period of digestion, but which tends to become normal 
at that period when test meals are ordinarily withdrawn. The treatment 
should be largely directed toward the management of the nervous 
system. In emaciated individuals the best results are obtained by means 
of a systematic rest-cure treatment. The diet should consist largely 
of three meals a day, together with intermediate feedings of liquid food. 
The dietary should contain an excess of proteins and fats, and but a 
moderate quantity of carbohydrates. Of the various protein foods, 
milk, eggs, and fish are to be preferred. 
Fats have a tendency to decrease the gastric hyperacidity, and are to 
be recommended. Of these, butter, cream, and olive oil are especially 
useful. The carbohydrates are only permissible in the most digestible 
forms, and vegetables should be mashed and strained and taken in the 
puree form, free of all cellulose. Water is usually well borne, and may 
be administered in large quantities, with benefit. All acid food, as well 
as stimulants, should be avoided. The alkalis, together with belladonna, 
are of great service. Good results are usually obtained from the use of 
hydropathic measures, as well as from massage. 
GASTROSUCCORRHCEA OR HYPERSECRETION OF GASTRIC JUICE 
This is a condition in which a constant excessive flow of gastric juice 
is secreted. The stomach pours out this secretion even when free from 
food, so that large quantities of gastric juice may be found even in the 
morning before the ingestion of any nourishment. This disease was first 
described by Reichmann1 in 1882, and afterward more fully elucidated 
by Riegel in various communications between 1884 and 1893. 
1 Berl. klin. Wochenschrift, 1882, No. 40. FUNCTIONAL DISEASES OF THE STOMACH 
123 
The disease is found in three forms: gastrosuccorrhoea continua 
periodica, gastrosucchorrhoea continua chronica, and digestive gastro- 
succorrhoea. There has been considerable diversity of opinion among 
various authors whether gastrosuccorrhoea should be placed in the 
category of organic diseases or among the neuroses. There is no question 
that in most instances this condition is a result of some marked organic 
gastric affection, as ulcer with obstruction, dilatation, or atony. On the 
other hand, in a small number of cases the condition can only be looked 
upon as neurotic; this is more frequently the case with the form known 
as gastrosuccorrhoea continua periodica than the continua chronica. 
Gastrosuccorrhoea Continua Periodica.-By this is meant that condi- 
tion in which, in addition to the appearance of the acute attacks with 
a constant secretion of gastric juice, severe gastric pains and vomiting 
are present. Rossbach1 called attention to a condition which is closely 
related to periodical hypersecretion, but in which the attack takes its 
onset with violent headaches and which he terms gastroxynsis. Periodical 
hypersecretion may be present as a simple gastric neurosis or as a reflex 
neurosis, secondary to disease of the brain or spinal cord, i. e., progressive 
paralysis, tabes dorsalis, or myelitis. 
Etiology.-The causes are various, among which may be mentioned 
excessive mental strain, excitement, anger, overindulgence in food, and 
the abuse of tobacco. At times this condition is found in connection 
with the crises of locomotor ataxia, accounted for by the fact that the 
nerve fibres leading to the gastric glands regulating the flow of hydro- 
chloric acid are unduly stimulated. 
The patient suffering with this condition usually presents other 
nervous symptoms indicating the nervous origin of the disorder. The 
disease occurs usually in young people, and more frequently in males 
than in females. In a series of 1592 cases, 21 suffered with intermittent 
hypersecretion (1.5 per cent.). 
Symptoms.-The characteristic signs of this condition are not only 
the paroxysmal appearance of the attacks, which take their onset in 
the midst of perfect health, but also the special character of the gastric 
contents and vomitus. The attack has its onset early in the morning, 
usually with lassitude, malaise, headache, loss of appetite, thirst, and 
pains in the stomach, which become intense and are accompanied by 
heartburn and acid belching. The pains become spasmodic and more 
intense, and finally vomiting sets in. The vomited matter is very acid, 
at first consisting of food and then of gastric juice. The attacks may 
thus be entirely recovered from, or after a short period of relief others 
may set in, extending over a period of from a few hours to several days. 
The vomiting can be prevented at times by the drinking of large draughts 
of water or by the administration of large doses of alkalis. The quantity 
of the vomited matter is usually very large in amount, often from 200 
to 500 cc., containing at first food particles and afterward consisting 
of pure gastric juice, which is tinged yellowish or greenish with bile. 
The material first vomited is usually very acid, often containing 0.3 per 
1 Deutsch. Archiv f. klin. Med., 1885, Band ccclvii. 124 
DISEASES OF THE DIGESTIVE SYSTEM 
cent, or more free hydrochloric acid, but afterward, when admixed with 
bile, the acidity is greatly reduced to or below normal. The vomited 
material may contain slight traces of blood, which has no special signi- 
ficance. During the attack, besides the intense pain there is a total 
loss of appetite, great thirst, and general feebleness; the pulse becomes 
weak and the patient presents the appearance of great suffering; he 
becomes pale and breaks out in a cold perspiration. The urine is 
greatly diminished in quantity and of a high specific gravity, while the 
bowels are constipated. The attacks vary greatly both as to intensity 
and duration, sometimes terminating gradually, sometimes suddenly. 
Between the attacks the patient is usually in good health, free of all 
disturbances, although at times moderate gastric disturbances exist, 
such as discomfort in the stomach, acid eructations and heartburn. 
Gastric analysis at this time usually reveals a hyperacidity, even though 
symptoms of hyperchlorhydria are not present. The condition known 
as gastroxynsis differs from periodic hypersecretion only in that the 
headache is a most important and persistent symptom. The other 
symptoms of gastroxynsis are so similar to those of periodic hypersecretion 
that these cases should be classed in the same category. 
Diagnosis.-This is made by the appearance of the symptom-complex 
described, as well as by the finding of large quantities of gastric juice 
in the stomach at a time when no ingesta are present. The differential 
diagnosis must be made from periodic vomiting and the vomiting occur- 
ring in the gastric crises of locomotor ataxia. Periodic hypersecretion 
is distinguished from periodic vomiting by the irregular appearance of 
the attacks and by the vomiting of large quantities of pure gastric 
juice, whereas, in periodic vomiting, the attacks appear at regular 
intervals and the vomited material consists of mucus and bile. From 
the vomiting occurring in the gastric crises periodic hypersecretion is 
also differentiated by the appearance of large quantities of acid gastric 
secretion in the vomit and by the fact that the attacks persist during 
the night, neither of which is usual in the crises of locomotor ataxia. 
Prognosis.-The duration varies greatly; some attacks are short, 
lasting but a few hours, others extend over a period of days. Sometimes 
the patient becomes greatly weakened and prostrated by the effect 
of the attack; in other instances his general health will in no way be 
impaired. If the primary cause can be determined and relieved the 
prognosis is favorable; on the other hand, this is impossible in many 
instances, and the attacks reappear at varying intervals. 
Treatment.-This is, so far as possible, to seek out and relieve the 
cause. If due to overanxiety or mental strain, the patient should be 
ordered to the mountains or seashore. Physical exercises should be 
insisted on, and overindulgence in food and drink and in the use of 
tobacco prohibited. Hydrotherapy exerts a favorable influence. 
In a number of our cases relief was afforded by means of intragastric 
electricity. In those instances in which the attacks have their origin 
from a hyperchlorhydria this condition must be treated. For the attack 
itself the mode of treatment advised by Einhorn1 is often found service- 
1 Diseases of the Stomach, fourth edition, p. 362. FUNCTIONAL DISEASES OF THE STOMACH 
125 
able; that is, to administer a moderate dose of bromide just as the attack 
begins; this method will at times abort an attack. As soon as the attack 
sets in the stomach should be thoroughly washed out with an alkaline 
solution, and this may be repeated a number of times during the attack. 
For the severe pain one is often forced to administer morphine hypoder- 
mically, this being the only remedy to be relied upon at times to produce 
even temporary relief. During the attack the patient should be allowed 
but small quantities of fluids, water, milk, and egg-albumen; bits of ice 
may be administered to relieve the thirst; also enemata of normal salt 
solution may be given. 
Gatrosuccorrhoea Continua Chronica.-This is also known as Reich- 
mann's disease, or chronic hypersecretion, and also as chronic continuous 
secretion of gastric juice. It is characterized by a chronic continuous 
secretion of gastric juice, even in the absence of food in the stomach, 
that is in the fasting stomach. This condition may be primary or 
secondary. It is primary when it occurs as a gastric neurosis independent 
of any known anatomical change in the stomach; it is secondary when 
it occurs as the result of some other gastric disturbance, such as ulcer, 
dilatation, or atony. As continuous hypersecretion is most frequently 
associated with dilatation, and as the symptoms of both conditions are 
very similar, many authors deny the existence of this condition as a 
separate entity and believe that it is simply a form of dilatation. It 
cannot be denied that most cases are secondary to dilatation. 
The difficulty in differentiating between continuous hypersecretion 
and dilatation is more evident when we observe that of the six cases 
of this disease originally reported by Reichmann,1 but one can be counted 
a case of chronic hypersecretion, the remainder presenting symptoms 
of hypersecretion secondary to pyloric stenosis. Riegel believes that 
continuous hypersecretion is in some instances a perversion of function 
and really of a neurotic type, in which no organic lesion can be detected. 
M. Pickardt2 has reported three cases in which this condition was primary 
and existed as a pure neurosis, and in which careful investigation failed 
to present any organic disease of the stomach or motor insufficiency. 
Etiology.-The causes are much like those of intermittent gastro- 
succorrhoea, namely, great mental anxiety and excitement, indiscretion 
in the use of food, and the abuse of drink extending over long periods 
of time. Secondary continuous hypersecretion may arise as a result of 
dilatation, atony, or ulcer. Primary continuous hypersecretion is a 
rare disease; it does not occur as frequently as intermittent hyper- 
secretion. In this series of 1592 cases there were 10 cases of primary 
continuous hypersecretion (0.63 per cent.), 7 in males and 3 in females; 
4 were between twenty and thirty years of age, 3 between thirty and 
forty, and 3 between forty and fifty. 
Pathology.-The anatomical changes in these conditions are not 
always uniform. Korezynski and Jaworski,3 who investigated the 
subject most carefully, find no anatomical changes whatever in a certain 
' Berliner klin. Wochenschrift, 1882, No. 40; 1884, Nr. 48; 1887, Nr. 12. 
2 Ibid., October 30, 1905. 
3 Deut. Archiv f. klin. Med., vol. xlvii. 126 
DISEASES OF THE DIGESTIVE SYSTEM 
number of cases. In others a special form of gastritis existed, associated 
with a degeneration and destruction of the peptic cells, while the parietal 
cells remained normal. Interstitial changes were also observed. 
Symptoms.-The subjective symptoms of chronic hypersecretion are 
pain, burning in the epigastrium, heartburn, acid eructations, nausea, 
vomiting of large quantities of gastric juice, and increased thirst. These 
make their appearance gradually, and many patients complain of mild 
dyspeptic symptoms for years before the true nature of the disease is 
Revealed. At first there is but a slight degree of burning in the epi- 
gastrium and heartburn, which gradually intensifies, then pain appears, 
coming on several hours after meals which is relieved by the ingestion 
of food. The pain also appears in attacks during the night, a rather 
characteristic symptom. After the pain has existed for some time, 
vomiting sets in, the vomitus consisting of a large quantity of a very 
acid gastric juice. 
These symptoms may be mild in some patients and very severe in 
others; they are apt to appear for a certain length of time and disappear, 
to recur after weeks or months; in severe attacks the symptoms are 
present almost daily, and vomiting may occur four or five times a day. 
The patient loses flesh, the tongue and skin become dry, the appetite 
is increased in some cases, diminished in others. The attacks of pain 
can be often lessened by the ingestion of protein food, such as boiled 
eggs or milk. Constipation is usually present, and the quantity of urine 
is diminished, the chlorides decreased, and the phosphates increased. 
The objective signs consist in demonstrating hyperacidity as well as 
the presence of large amounts of gastric juice in the fasting stomach. 
The acidity of the gastric juice after a test breakfast may amount to 
80, 90, 100, or more, and the free hydrochloric acid to 0.25 to 0.3 per 
cent. The protein digestion is good, showing a perfect peptone reaction, 
while the starch digestion is imperfect, the continuous flow of acid imped- 
ing amylolysis. The most important and characteristic symptom is 
the finding of gastric secretion in a fasting stomach; under normal 
conditions small quantities of gastric juice may be found in the stomach, 
but when quantities of 100 cc. or more are present the condition of 
hypersecretion must be considered, and especially so if it is discovered 
at a number of examinations. Even with smaller quantities than 100 cc. 
providing the other symptoms are present, such cases must be classified 
under the head of chronic continuous gastrosuccorrhoea. 
In order to arrive at a more certain diagnosis, lavage should be given 
the evening before; the next morning the stomach is tested, fasting, so 
that no portions of former meals may be retained. The gastric secretion 
obtained from the fasting stomach is usually watery and often contains 
a small trace of bile; it is of a high total acidity and contains an excess 
of free hydrochloric acid, the peptone reaction being good, the dextrin 
reaction absent. In the secondary form of gastrosuccorrhoea continua 
chronica, dilatation or atony of the stomach is usually present. 
Sequelae.--Of the sequelae or complications, atony and dilatation of 
the stomach, with or without ulcer, are the most common. Atony and 
dilatation often appear after the gastrosuccorrhoea has existed for a 127 
FUNCTIONAL DISEASES OF THE STOMACH 
considerable period of time; it is only in the earlier stages that the primary 
nature of the chronic hypersecretion can be determined; when the 
patient is seen late in the course of the disease, when both conditions 
are marked, it is often impossible to determine which is primary. 
Diagnosis.-This is suggested by the symptoms, i. e., excessive pain 
occurring several hours after meals and also during the night, with 
vomiting of large quantities of gastric juice. In addition there is burning 
in the epigastrium, heartburn, acid eructations, and increased thirst. 
The diagnosis is made certain by examining the stomach in the fasting 
state, when large quantities of gastric juice, usually over 100 cc., are 
obtained, showing an entire absence of amylolysis. It is important to 
practise lavage on the evening before the morning that the fasting 
stomach is tested. It is often important to exclude atony and dilatation, 
which, however, are often associated with gastrosuccorrhoea. In atony 
a motor insufficiency is observed, while in dilatation the motor insuffi- 
ciency is so great that food particles are still present in the fasting 
stomach. This is not the case in gastrosuccorrhoea unless the condition 
is accompanied by dilatation. Ulcer will be excluded by the absence 
of occult blood in the feces and of a circumscribed painful area, and the 
presence of large quantities of gastric juice in the fasting stomach. 
Prognosis.-This depends largely upon whether the condition is 
primary or secondary. If it is secondary to a dilatation, the prognosis 
is not as favorable as if it were primary, unless some radical procedure 
is undertaken, such as a pyloroplasty or gastro-enterostomy. When 
primary, the prognosis is usually not unfavorable, especially if rational 
treatment is undertaken. Frequent relapses are common, while certain 
severe cases are often very protracted and may continue indefinitely, 
notwithstanding the most rigid form of treatment. 
Treatment.-This consists in relieving the irritation of the gastric 
mucosa and thus diminishing the flow of gastric secretion. Diet is of 
primary importance and should consist of small but frequent meals, 
given at intervals of from three to four hours. The patient should be 
required to eat slowly and masticate his food thoroughly; all irritating 
substances such as pepper, mustard, onions, and highly seasoned foods 
should be interdicted. As motor disturbances are apt to occur in this 
condition, fluids should be administered sparingly. The diet should be 
made up mainly of proteins, since these foods are well borne. The car- 
bohydrates are poorly digested, and hence must be given only in small 
quantities and in the most easily digestible forms. All forms of meat 
are allowable, roast beef, lamb chops, chicken, and broiled steak, but 
should be finely minced. Of the carbohydrates the best are oatmeal, 
zwieback, Nestle's food; puree of potatoes, spinach, etc., may also be 
allowed. Fats may be permitted to a greater or less degree in the form 
of good butter, cream, or olive oil. Milk is excellent, and may be taken 
either alone or mixed with small quantities of tea, coffee, or cocoa. It 
may also be given with eggs. The foregoing regulations as to diet apply 
to chronic hypersecretion without dilatation; when ectasia exists the 
dietetic rules described under this head must be followed. 
Lavage of the stomach is a most efficient means of relieving pain and 128 
DISEASES OF THE DIGESTIVE SYSTEM 
irritation. This is best practised in the morning before the ingestion 
of food. Instead of lavage Boas recommends emptying the stomach 
in the fasting state (expression) by means of the tube; while Reichmann 
believes in lavage of the stomach with solutions of nitrate of silver 1 or 
2 to 1000. Penzoldt advises douching with a solution of boric acid, and 
Einhorn sprays the stomach with nitrate of silver. 
The alkalis play a most important role in the treatment of the disease; 
of these, bicarbonate of soda, calcined magnesia, phosphate and citrate 
of soda are most commonly employed. These are best administered 
two or three hours after meals, i. e., at the height of digestion. Other 
remedies which are useful at times are bismuth subnitrate, given in 
large doses (half a dram), belladonna, and nitrate of silver in solution. 
Einhorn recommends the use of direct galvanization of the stomach. 
Digestive Gastrosuccorrhoea.-Straus1 first pointed out that in certain 
cases of hyperacidity relatively large quantities of a thin, watery, gastric 
secretion were obtained one hour after a test breakfast. He called this 
condition digestive or alimentary hypersecretion. Zweig and Calvo2 
investigated this subject more fully, and discovered that the large 
amounts of contents obtained after the test breakfast do not depend 
upon motor disturbances of the stomach, such as atony, but rather upon 
increased gastric secretion. Elsner3 and Friedenwald4 have also called 
attention to this condition. Boas5 has investigated this question, and 
considers the name digestive gastrosuccorrhoea more appropriate than 
alimentary gastrosuccorrhoea, because the increased gastric secretion 
is dependent upon the act of digestion in contradistinction to continuous 
hypersecretion. In the latter the secretion extends beyond the digestive 
act, and more or less gastric juice is found in the fasting stomach. 
Etiology.-This disease occurs most frequently in males. The 12 
cases of Boas all occurred in males. In our 14 cases there were 12 males 
and 2 females, the ages varying between eighteen and sixty-four years. 
Symptoms.-An important symptom is extreme emaciation, a loss 
of from ten to fifteen pounds being not unusual. This loss of flesh is a 
most important sign, especially since it appears without the slightest 
tendency to any disturbance of motility of the stomach. The appetite 
and quantity of food taken may be normal; occasionally, however, 
both may be decreased. The great loss in weight must be dependent 
upon the loss of gastric secretion. Amylolysis is extensively diminished 
and constipation very marked. The subjective signs are of much the 
same character as those found in nervous dyspepsia. Patients complain 
of various sensations in the stomach, pressure, fulness, eructations, 
excessive flow of saliva; occasionally violent pains; very rarely, if ever, 
heartburn. Nausea or vomiting occurs exceptionally. Marked splashing 
is observed in the region of the stomach; tender spots painful to pressure 
are, however, not observed; the abdomen is occasionally distended with 
1 Deut. Archiv f. klin Med., Bd. Ivi, S. 120. 
2 Archiv f. Verd., Bd. ix, S. 262. 
3 Berlin, klin. Wochenschrift, 1904, Nr. 25. 
4 Am. Jour. Med. Sci., 1910, cxl, 318. 
6 Deut. med. Wochenschrift, 1907, Nr. 33, S. 135. FUNCTIONAL DISEASES OF THE STOMACH 
129 
gas. A diminution in the chlorides and an increase in indican are fre- 
quently observed in the urine. This disease is much like atony, and 
Boas believes that there can be no question but that it has in many 
instances been mistaken for atony or nervous dyspepsia. In order to 
determine the presence of this condition, Boas advises a dry test meal. 
Inasmuch as bread contains 35.5 per cent, of water, he uses Albert cakes 
containing but 8.9 per cent, of water. If five Albert cakes are given as 
a test meal and removed from the stomach at the end of an hour under 
normal conditions, but a small residue will be obtained. In digestive 
gastrosuccorrhoea, however, 100 to 200 cc. of fluid will be obtained. 
On standing it forms into two layers, a lower layer slight in amount 
precipitated to the bottom, and above it a clear or slightly cloudy fluid 
three or four times as large in amount. The secretion generally shows 
a total acidity and percentage of free hydrochloric acid, usually not 
above and often below normal. 
In a large proportion of our cases the total acidity varied from 40 to 
56 and free hydrochloric acid 35 to 45, which indicates that while in this 
condition there may be no excess in the acids of the gastric secretion, 
the secretion is greatly increased in quantity. In other words, there is 
a hypersecretion but no hyperacidity. The average specific gravity 
of the gastric juice is 1.006. The secretion presents a more or less marked 
biuret and sugar reaction, while albumin is not present; erythrodextrin, 
amidulin, and also the amylum reactions are usually marked. By means 
of the dry diet the diagnosis is made positive. If the bottom layer of 
the secretion is large, there must be a motor disturbance present. 
Diagnosis.-The symptoms do not wholly point to the condition; the 
most marked ones are those of chronic nervous dyspepsia with marked 
emaciation, succussion in the region of the stomach a considerable period 
of time after meals and after small meals. The symptoms often point 
to atony, therefore, in order to make an exact diagnosis, three forms of 
examinations must be used: 
I. Examination of the fasting stomach. 
II. Examination of the gastric contents one hour after the dry test 
meal. 
III. Examination of the gastric contents one hour after a test breakfast. 
Prognosis.-This is not unfavorable. Alimentary gastrosuccorrhoea 
is a gastric affection of nervous origin, which is apt to extend over a 
long period of time, presenting great variability of symptoms, and with 
days and weeks of apparent perfect health giving place suddenly to 
periods of severe distress. That this disorder is purely a form of gastric 
neurasthenia is manifested by the fact that when the patient is restored 
to good health the increased secretion is apt to disappear. 
Treatment.-The therapeutic indications are to increase the body 
weight, to avoid foods that increase the quantity of gastric secretion, 
and, finally, to counteract the imperfect starchy digestion, all three 
indications being corrected by the diet. It is also necessary to overcome 
the constipation, and this can be accomplished by the same means, 
namely, by a protein, fat and sugar diet, with a small proportion of 
carbohydrate. In place of sugar, dextrinized food can be utilized as 
vol. m-9 130 
DISEASES OF THE DIGESTIVE SYSTEM 
bread; the crust of wheat bread is to be preferred. Fluids should be 
given plentifully in order to avoid the irritation of the gastric juice 
upon the mucous membrane of the stomach. Alkaline drinks should 
be taken plentifully during meals. Soups, alcohol, black coffee, and tea 
should be avoided. Excellent results are obtained by a rest cure of some 
weeks. Of medicinal remedies, belladonna or atropine may be utilized; 
on the other hand, alkalis are most beneficial. 
GASTROMYXORRHCEA 
By gastromyxorrhoea is meant a flow of mucus from the stomach. 
While various observers as Ewald, Riegel, Martins, have shown that 
small quantities of mucus were occasionally found in the fasting stomach, 
but little attention was paid to this condition until Dauber1 pointed out 
that under abnormal conditions considerable quantities of mucus were 
secreted by the stomach and found in the fasting state. He called the 
disease chronic hypersecretion of mucus or gastrosuccorrhoea mucosa. 
Kuttner2 investigated the subject farther, and found that the condition 
exists not infrequently, and is often observed in certain patients if lavage 
is practised on the fasting stomach. Friedenwald3 reported 12 cases. 
The appearance of small quantities of mucus in the fasting stomach may 
be regarded as normal; it is important, therefore, to fix a limit to the 
quantity to be considered normal, and any amount beyond this must 
be looked upon as pathological. Kuttner regards the recovery of more 
than 5 cc. of mucus from the fasting stomach pathological, but con- 
siders the condition one of gastromyxorrhoea when more than 25 cc. are 
obtained. The condition can only be considered present if the secretion 
of mucus is constant or reappears at certain intervals. It is important, 
however, to consider the method by which the mucus is obtained. The 
patient should be accustomed to the use of the tube, as otherwise the 
mixture of saliva with the mucus will be so great as to vitiate the results. 
The method of moving the tube to and fro to induce the expulsion of 
mucus and the long continuance of the examination will increase the 
quantity of mucus. In order to arrive at a definite decision that there 
is an abnormal secretion, repeated examinations should be made. It 
is perfectly possible, too, that by swallowing saliva and pharyngeal 
mucus, secretion in the stomach may be excited; on the other hand, 
there must be a pathological disposition to secrete mucus in such cases, 
as the mucous membrane of the stomach would hardly react thus to 
so slight an irritation. Kuttner concludes that an increased secretion 
of mucus occurs in the fasting stomach, in gastromyxorrhoea. 
Intermittent Gastromyxorrhoea.-This occurs rarely. Many cases 
are probably not recognized, as the discomfort is not lasting and the 
attention of the physician is not called to the condition. In this the 
increased secretion of mucus occurs at irregular intervals. 
1 Archiv f. Verdauungskr., Bd. ii, S 167. 
2 Berlin, klin. Wochenschrift, October 30, 1905. 
3 Boston Med. and Surg. Jour., 1908. FUNCTIONAL DISEASES OF THE STOMACH 
131 
Etiology.-Kuttner was unable to find any evidences of locomotor 
ataxia in the patients whom he investigated. In 2 the attack took its 
onset with disturbances in the secretions of the nose. He believes, 
therefore, that there is connection between the affection of the nose and 
that of the stomach; the mucus of the stomach, however, is not simply 
swallowed, but in large part due to secretion. 
Symptoms.-The attack may begin with prodromal symptoms, head- 
ache, loss of appetite, nausea, etc., but more usually in the midst of 
perfect health, often early in the morning, soon after awakening. The 
most striking symptoms of this paroxysmal attack is severe vomiting, 
which is intractable in the true sense of the word, as it cannot be success- 
fully checked by any remedy. The vomited matter consists of large 
quantities of tough, slimy liquid, finally of bile and intestinal juices, 
but contains no food remains. Pain in the region of the stomach is 
not present, or if so it is of no moment. During the attack the stomach 
refuses to retain food, drink, or medicine. The patient feels wretched, 
the abdomen is retracted, the pulse small, the tongue dry, and the 
quantity of urine much diminished. The attack may extend over a 
period of one day, or may continue from three to five or even twelve 
days. The attack usually ceases quite suddenly, and after the cessation 
of the vomiting the patient can again take food without any annoyance. 
The patient enjoys good health during the interval of the attacks, and 
often has no or slight dyspeptic symptoms. The gastric contents after 
a test breakfast in the interval generally show a normal percentage of 
hydrochloric acid and only a slight amount of mucus. 
Treatment.-A distinction must be made between the attack and the 
patient's general condition. In the beginning of the attack thorough 
lavage may terminate the symptoms at once, although 'when they are 
at their height lavage is valueless, and but little is to be gained by the 
internal administration of medicine. A hypodermic injection of morphine 
with atropine is sometimes useful. A condition of collapse accompanying 
a severe attack may be so serious, especially in patients with a weak 
heart, as to demand subcutaneous injections of camphor, enemata of 
normal salt solution, or a subcutaneous infusion. Treatment of the 
underlying condition is mainly directed to the removal of the neurotic 
tendency. At times a change of climate and atmosphere, hydrotherapy, 
massage, electricity, iron, and arsenic may produce a favorable influence 
upon the disease. Search should be made for a possible cause, either 
in the stomach itself or in other organs, such as the nose, and treatment 
should be directed to these conditions. 
Continuous Gastromyxorrhoea.-The chronic or continuous form is 
more frequent than the intermittent. 
Etiology.-This condition may be associated with hypersecretion of 
acid or with various organic diseases, or may exist as an independent 
functional neurosis. Kuttner has found it associated most frequently 
with chronic catarrh, as well as with those nervous affections of the 
gastric mucosa in which there is a marked diminution or entire absence 
of hydrochloric acid. He also observed it in typical cases of gastric 
ulcer with or without pyloric obstruction. These diseases seem to be 132 
DISEASES OF THE DIGESTIVE SYSTEM 
rather favored by the ingestion of starchy food. The seat of origin of 
the mucus is not known, but it is probably a mixture of the secretion 
of the superficial epithelium and of the mucous glands, coming in largest 
measure from the glands of the pylorus. 
It is impossible to determine whether this condition is always accom- 
panied by a definite lesion of the mucous membrane, but as it is frequently 
associated with hypersecretion of acid, it may depend purely upon 
nervous influences. Twelve cases of this disease have come under the 
writer's observation,1 nine in females, and only three in males. 
Symptoms.-There are no characteristic symptoms, and the condition 
may be discovered in some cases in which there are no subjective symp- 
toms. The diagnosis is established by the discovery of large quantities 
of mucus in the fasting stomach, shown to be the product of the gastric 
mucous membrane and not to come from other sources, such as the 
nose, mouth, or pharynx. 
Treatment.-Lavage should be practised for the removal of the mucus, 
provided there is no contra-indication to the procedure; instead of this 
method of treatment, mineral waters may be utilized, being chosen with 
reference to the nature of the associated disease, the general condition 
of the patient, and the various gastric functions. 
In contradistinction to gastromyxorrhoea, Kaufmann2 described a 
frequent finding in the gastric contents, that is a complete lack of 
mucus, which he terms amyxorrhoea gastrica. This may be due to 
different causes. Kaufmann calls attention to the fact that the mucus 
is a protective agent of the gastric mucosa, and that in some of the cases 
presenting symptoms of hyperacidity, and in which the stomach contents 
shows no excess of acid, but normal or even subnormal figures of acidity, 
the lack of sufficient mucus is the principal cause, rendering the mucosa 
hypersensitive even to secretions of a normal or moderate degree of 
acidity. The symptoms of hyperacidity disappear under treatment 
with nitrate of silver, which increases the amount of mucus. 
BULIMIA 
Bulimia is that condition characterized by an abnormal increase in 
the sensation of hunger. It has also been termed hyperorexia, cynorexia, 
and lycorexia. Rosenthal believes this disorder is due to an excitation 
of the hunger centre, and this is probably true in cases of the affection 
following brain diseases. Stiller considers it due to irritation of the 
peripheral nerve endings in the stomach itself. It is probable that there 
are some forms due to lesions of the brain, while others are due to 
excitation of the nerves in the stomach itself. It has been stated that 
the sensation of hunger is due to stimulation of the hunger centre in 
the medulla by blood impoverished in the nutritive substances, and 
that this condition is overcome when the nutritive value of the blood 
is increased. That this will not entirely account for the sensation is 
shown by the statement that the appetite is satisfied as soon as the 
1 Boston Med. and Surg. Jour., 1908. 
2 Am. Jour. Med. Sei., 1908, cxxxv, p. 207. FUNCTIONAL DISEASES OF THE STOMACH 
133 
stomach is filled with food, long before the nutritive material has reached 
the centres of the brain. On the other hand, Leo has stated that increased 
appetite is due to the rapid evacuation of the stomach, which must be 
accompanied by a pyloric insufficiency; yet Ewald and Fleischer have 
observed cases in which an increased motility of the stomach did not 
exist. Recently, Cannon has advanced the theory that the sensation 
of hunger is produced by tonic contractions of the empty stomach. 
Etiology.-Bulimia may exist as a primary neurosis or may be second- 
ary to diseases of the stomach or other organs. As a primary neurosis, 
it is found in neurasthenia and hysteria. It occurs in cerebral tumors, 
Basedow's disease, pulmonary tuberculosis, diabetes, syphilis, intestinal 
worms, in ulcer and dilatation of the stomach, and in many other con- 
ditions. Bulimia is most frequently observed in females between the 
fifteenth and fortieth years. In the series of 1592 cases of gastric neuroses 
bulimia occurred in 24 cases (1.5 per cent.). 
Symptoms.-This condition usually occurs in attacks at irregular 
intervals, although at times they may appear periodically and extend 
over a long period of time or may be of short duration and be followed 
by an attack of anorexia. The disorder comes on as a violent sensation 
of hunger occurring after meals, in consequence of which the patient 
becomes exhausted, feels faint, has gastric pains, ringing in the ears, 
and suffers with vertigo and cold extremities. This continues until 
some food is taken. A very small quantity of food will at times overcome 
the sensation for a longer or shorter period of time; occasionally very 
large quantities must be ingested to relieve the condition. In one case 
of this series a quantity of food representing 6250 calories was consumed 
daily. In consequence of the inordinate amount of food, other disturb- 
ances of digestion are apt to follow, such as atony, gastritis, and disturb- 
ances of the intestines. The gastric contents were examined in 21 of 
24 cases; normal acidity was found in 15 (72 per cent.), hyperacidity in 
3 (14 per cent.), and subacidity in 3 (14 per cent.); hypermotility was 
present in 6, normal motility in 12, and atony in 3 cases. 
Diagnosis.-Bulimia must be differentiated from acoria and poly- 
phagia. In bulimia there is an abnormal desire for food, but the desire 
can be satisfied, while in acoria there is an absence of the sensation of 
satiation. In polyphagia or gluttony, while the appetite remains good, 
the feeling of satisfaction is delayed to such an extent as to create a 
constant desire for more food. 
Prognosis.-This depends upon the cause, whether it is primary or 
secondary to some other disorder. The primary form due to neurasthenia 
or hysteria may be protracted or may disappear suddenly; when second- 
ary, the prognosis depends upon the nature of the primary disease. 
Treatment.-In treatment special attention should be directed toward 
the primary disorder. In those forms due to neurasthenia and hysteria 
the nervous system in general should receive special attention. In 
many cases rest, change of scene, hydrotherapy, electricity, massage, 
and psychotherapy are effectual means of combating this condition. 
The diet should be carefully regulated. Patients should be required 
to eat slowly and masticate the food thoroughly. Nourishment should 134 
DISEASES OF THE DIGESTIVE SYSTEM 
be taken at frequent and regular intervals, such as every two hours. 
The food should consist largely of milk, eggs, cereals, boiled fish, the 
lighter meats, and green vegetables. Fried foods and sweets should be 
avoided. Intragastric galvanization has proved effectual in some cases, 
while at times the intragastric douche has been used with some success. 
The bromides have been used advantageously, the bromide of strontium 
in 15-grain (1 gm.) doses taken three or four times a day, being most 
useful. Arsenic, codeine, and opium have also been recommended. 
PAROREXIA 
Parorexia is that condition characterized by a perversion of the 
appetite. According to the character of the perversion we have: (1) 
Pica, desire for articles which are not foods, such as chalk and earth. 
(2) Malacia, desire for spiced food, vinegar, mustard. (3) Allotriophagia, 
desire for disgusting substances, such as urine and fecal matter. 
Pica and malacia are often observed in the same individual. Parorexia 
is found in neurasthenia and hysteria, occasionally in disturbances of 
the digestive tract, helminthiasis and gastralgia, and often in the insane. 
Malacia is frequently observed in chlorotic girls and pregnant women, 
while allotriophagia is found in the insane. In this series of 1592 cases 
there were 8 cases of parorexia (0.5 per cent.), 6 being in males and 
2 in females; 3 were from ten to twenty, 2 from twenty to thirty, 2 
from thirty to forty, and 1 from forty to fifty years of age. 
GASTRALGOKENOSIS (PAINFUL GASTRIC EMPTINESS) 
Boas has introduced this term to indicate that neurosis characterized 
by the appearance of pain in the stomach, occurring when the stomach 
is empty, and which disappears as soon as food is taken. It may occur 
as a permanent neurosis, or come on periodically. According to Boas, 
this condition is produced by severe contractions of the pylorus, and is 
relieved when food is present in the stomach. 
Etiology.-This condition is found in neurasthenic individuals who are 
subject to worry and anxiety, or who have been leading an irregular 
life. Examination of the gastric functions shows normal conditions 
both as to secretion and motility. This affection occurred only in males 
in 7 of this series (0.5 per cent.); of these, 3 were between twenty and 
thirty, 3 between thirty and forty, and 1 between forty and fifty years. 
Symptoms.-The condition manifests itself by the appearance of pain, 
which at times becomes intense, from one to two hours after meals. An 
attack may appear during the day or night, and last from fifteen to 
thirty minutes. The pain is immediately relieved by taking food. 
Treatment.-This consists in properly looking after the underlying 
neurasthenia. Patients should be taught not to allow the stomach to 
become empty, and for this reason should be encouraged to take food 
every two hours. Boas has obtained good results by the use of opium. FUNCTIONAL DISEASES OF THE STOMACH 
135 
GASTRALGIA NERVOSA 
Gastralgia nervosa is the condition characterized by periodic or 
spasmodic attacks of pain in the stomach, appearing independently 
of the ingestion of food and not associated with any organic disease. 
The pains of a gastralgic type present in ulcer, cancer, dilatation, and 
in some forms of gastritis are accompanied by organic changes, and 
cannot be properly classified under the head of gastralgia nervosa. 
Etiology.-Gastralgia is usually considered as a neurosis of the vagus, 
and only a marked increase in the condition to be described as gastric 
hyperesthesia. Einhorn divides gastralgias into five varieties: (1) Of 
gastric origin; (2) of central origin; (3) of neurotic origin; (4) of con- 
stitutional origin; and (5) of reflex origin. 
1. Gastralgias of gastric origin. In this class are found the neuralgic 
pains present in cancer and ulcer of the stomach, in certain forms of 
gastritis, and produced by adhesions from the stomach to other organs. 
2. Gastralgias of central origin. In this class are the attacks of pain 
observed in the gastric crises of locomotor ataxia, and the gastric pains 
in cerebral tumors and myelitis. 
3. Gastralgias of neurotic origin. This is often observed in hysteria 
and neurasthenia, and usually simultaneously with other symptoms. 
4. Gastralgias of constitutional origin. Gastralgia may be due to 
some change in the blood, as in lead-poisoning, anemia, and gout. 
5. Gastralgias of reflex origin. This form is due to disease of other 
organs, as the generative system, and enteroptosis. 
Gastralgia is more frequent in women than in men. In this series of 
1592 cases of gastric neuroses, there were 24 cases of gastralgia (1.5 per 
cent.), 17 being in females and 7 in males. 
Symptoms.-The attacks of pain, as a rule, appear suddenly; occa- 
sionally they are preceded by premonitory symptoms, such as fulness 
in the stomach, nausea, vomiting, and headache. The pain may be 
burning, boring, tearing, cutting, or gnawing, and is usually felt in the 
epigastrium; at times it radiates throughout the entire abdomen or even 
to the back, and may be so intense as to cause weakness and collapse, 
the patient having a thready and irregular pulse, with pallor, cold 
extremities, and cold perspiration. Often the pains are relieved by 
pressure; at times these symptoms are accompanied by nausea, vomiting, 
and hysterical manifestations, such as globus hystericus and nervous 
chills. The duration varies, the attacks may last from a few moments 
to many hours, and the intervals between may be days, weeks, or months. 
In the gastric crises of locomotor ataxia the attacks of gastralgia are 
usually ushered in with pains in the legs and arms, nausea and vomiting. 
These crises may precede the classic signs of locomotor ataxia by months 
or years. Boas calls special attention to the gastralgic pains occurring 
in neurasthenic females at the menstrual period. 
In most instances this condition bears no relation whatever to the 
character of the food taken. The pains begin in the epigastrium, remain 
localized, and are burning and boring in character. The attacks last 
from fifteen to thirty minutes, and are repeated several times during 136 
DISEASES OF THE DIGESTIVE SYSTEM 
the day, while at night the pain is absent. Another form is that pro- 
duced by open inguinal or femoral rings, occasioning small or occult 
hernia, also by hernia of the abdominal walls. These are observed 
most frequently along the linea alba. The pain is colicky, and ceases 
when the patient reclines. Neurasthenic symptoms are almost always 
present. 
Diagnosis.-This is made by the character of the attacks with paroxys- 
mal pain, bearing no relation to the ingestion of food, and at the same 
time not associated with any organic or other functional disease of the 
stomach. As gastralgia is usually due to some other condition, care 
should be taken to determine as far as possible its etiological relation. 
Gastralgia must be differentiated from ulcer. In ulcer there is a circum- 
scribed painful area in the epigastrium and in the back to the left of 
the eleventh or twelfth dorsal vertebra. The pain is proportionate to 
the quality and quantity of food ingested, and is accompanied by nausea 
and vomiting; is relieved by vomiting; occult blood is found in the feces 
at times. When there is still doubt Leube recommends the ulcer rest 
cure in order to determine from the result of the treatment the presence 
or absence of ulcer. Gastralgia is differentiated from chronic gastritis 
by the slower appearance of the pains after the ingestion of food, by the 
presence of the paroxysms of pain, and by the absence of any change 
in the gastric secretion. It is differentiated from cancer by the absence 
of the usual signs; the pain usually not being paroxysmal in cancer. 
Intestinal colic may be mistaken for gastralgia, but in it the intestine 
is inflated with gas, and the pain is relieved by the passing of gas or a 
movement of the bowels, which frequently contains mucus. The pain 
of intestinal colic changes its position, while in gastralgia it is localized, 
as a rule, in one area. Intercostal neuralgia is distinguished from gastral- 
gia by the fact that in the former condition the intercostal area is painful 
to pressure along the course of the nerve. Gall-stone attacks may be 
mistaken for gastralgia. In these the pain is generally to the right of 
the median line, the attack is accompanied by fever, and there is often 
a sensitiveness of the liver. In some cases the diagnosis is most difficult, 
especially when the more important symptoms of cholelithiasis are 
absent. Nephritic colic is differentiated from gastralgia by examination 
of the urine. The pain in nephritic colic radiates toward the bladder. 
Treatment.-It is important to direct our attention to the under- 
lying cause. The form due to anemia should be treated with iron and 
arsenic; that due to malaria by means of quinine; and that from nicotine 
poisoning by cautioning against the use of tobacco. Reflex gastralgia 
must be handled by treating the primary disease. That due to neuras- 
thenia and hysteria should be treated by change of scene, rest, electricity, 
and massage. In patients much run down a systematic rest cure will 
produce excellent results. The attacks of pain are treated as follows: 
hot applications in the shape of a hot-water bag or hot poultices or 
packs are placed on the abdomen and the patient given half a grain 
(0.03 gm.) of codeine or 20 to 30 drops (1.5 cc.) of Hoffman's anodyne. 
Belladonna and chloroform water have also been recommended, as 
well as phenacetin and antifebrin. If the attacks of pain are intense, a FUNCTIONAL DISEASES OF THE STOMACH 
137 
hypodermic injection of morphine must be administered or opium and 
belladonna given by rectum. The galvanic current is of considerable 
value, the anode being placed on the epigastrium and the cathode on 
the spinal column. Strong currents are used. At times better results 
may be obtained by means of intragastric galvanization. 
HYPERESTHESIA GASTRICA 
By gastric hyperesthesia is meant that condition in which the mucous 
membrane of the stomach is unduly sensitive, even to its normal contents. 
The lightest forms of foods will often cause distress in spite of the fact 
that the stomach presents neither secretory nor motor disturbances. 
The character of the discomfort may be pain, fulness, burning, or sen- 
sations of cold occurring after meals. In some instances, not only does 
the food cause discomfort, but the normal amount of hydrochloric acid 
will cause pain, similar to that found in hyperacidity, and it may exist 
even when the acid is diminished or absent. 
Under the subjects of achylia gastrica and hyperchlorhydria, it was 
shown that symptoms of hyperacidity occasionally exist in achylia 
gastrica; in these cases there is evidently a hyperesthesia of the gastric 
mucous membrane, which is so sensitive that it cannot tolerate even 
the normal amount of acid. Again, a condition is often observed in 
which the percentage of acid may be far in excess of normal, and yet 
the individual have perfect health without gastric disturbances. 
Etiology.-As a primary affection, hyperesthesia is found in neuras- 
thenia and hysteria, and frequently in anemic females; it occurs secondary 
to affections of various organs, such as ulcer of the stomach, chronic 
gastritis, and disease of the kidneys (uremia). It may be produced by 
excesses in food and drink, the abuse of coffee, tea, alcohol, indulgence 
in highly seasoned food and tobacco, or it may come from drug habits, 
such as opium or cocaine. The taking of sufficient food, fasting, living 
on an exclusive diet, or eating irregularly are also etiological factors. 
Hyperesthesia is the affection from which conditions such as anorexia 
nervosa, nervous nausea and vomiting, gastralgia, and sitophobia often 
take their origin. In this series of 1592 cases there were 31 cases of 
hyperesthesia (2 per cent.). 
Symptoms.-The sensation produced is that of mild pain, fulness, and 
burning, appearing soon after meals and continuing during digestion, 
and ceasing when the stomach is empty. In some cases the pain is 
greater, and may cause nausea and vomiting. The disturbance is often 
greater from liquid than from solid food. On account of the discomfort 
produced, much food is discarded and the patient emaciates and loses 
strength. Some of the cases manifest the symptoms of hyperchlorhydria, 
notwithstanding that the acidity may be normal or subnormal. In 
these cases the discomfort appears several hours after meals and dis- 
appears on the ingestion of food or the.taking of alkalis. On palpation 
the whole gastric area may be sensitive to pressure but free from localized 
painful points. The gastric secretion shows a normal percentage of 138 
DISEASES OF THE DIGESTIVE SYSTEM 
free acid, with occasional slight variations. The motor function of the 
stomach is not disturbed. 
Diagnosis.-This is usually made with ease, provided the symptoms 
above described are present together with a normal gastric secretion. 
Hyperesthesia must be differentiated from ulcer and chronic gastritis. 
In ulcer there is a localized painful area and the pain is proportionate 
to the quality and quantity of food ingested. In chronic gastritis there 
is usually a diminution of gastric secretion, together with the presence 
of mucus, while the symptoms of distress do not appear immediately 
after meals, but some time later. 
Treatment.-In all instances the patient should be required to remain 
in bed, at first on a milk or egg-albumen diet, and, if possible, combined 
with a systematic rest cure, the food being increased gradually until 
solid food is taken. In serious cases, rectal alimentation must be practised 
for a few days at the onset. Cold compresses should be applied to the 
abdomen. Galvanization is efficacious in some cases. Nitrate of silver 
may be given by mouth, grain | (gm. 0.008) in solution, three times 
daily, or administered by means of the stomach douche. At times the 
bromides, valerianates, and sumbul prove useful, especially in those 
forms due to neurasthenia and hysteria to which attention must always 
be directed. In the cases dependent upon anemia, iron is indicated. 
Gastric Idiosyncrasies and Abnormal Sensations.-There are certain 
individuals who manifest an idiosyncrasy toward certain foods which 
when taken produce gastro-intestinal disturbances or some eruption 
on the skin. Among the foods causing this class of symptoms are fish, 
berries, cheese, etc. Fever, headache, gastric pain, nausea, vomiting, 
and urticaria are accompanying symptoms. The writer has constantly 
noticed the condition in a certain patient after eating eggs. The only 
means of preventing it is to order the individual to abstain from the food 
that causes this discomfort. There are abnormal sensations met with 
in neurotic individuals, such as cold, heat (stomach burn), epigastric 
pulsations, constrictions, and sensations of a foreign body in the stomach. 
The gastric secretion is normal in all these instances, and there are 
usually other neurasthenic symptoms present that indicate the nature 
of the disorder. The treatment must be directed to the nervous system 
in general. The bromides and belladonna are at times of value. 
MERYCISM OR RUMINATION 
By merycism is meant that condition in which there is a regurgita- 
tion of food into the mouth which is again masticated and then either 
reswallowed or spat out. This act is accompanied by a more or less 
pleasurable sensation and without nausea or effort, and occurs some 
time after meals. Rumination in man is comparable to the same con- 
dition found in certain animals. Some authorities attribute this disorder 
to a paresis of the cardia, while others consider it a reflex neurosis causing 
a temporary relaxation of the cardia. Rosenthal holds it is due to an 
irritation of the vagus, producing an opening of the cardia through 
Openchowski's dilator fibres, occasioning an antiperistalsis of the FUNCTIONAL DISEASES OF THE STOMACH 
139 
oesophagus. There are two classes of phenomena aiding in the production 
of the disorder, one active, the other passive; the active consists in 
depression of the diaphragm and contraction of the muscles of the 
abdomen, both of which produce a void in the thoracic cavity; and con- 
traction of the abdominal muscles which compress the stomach. "The 
passive phenomenon consists in the elongation and widening of the 
oesophagus and the diminution of the lumen of the stomach" (Spivak). 
Etiology.-Heredity plays a role in a number of cases which have been 
reported. The writer has observed the condition in a father aged fifty-one 
and a daughter aged fourteen years. In many cases other neurotic and 
hysterical tendencies have been observed. At times the condition is 
acquired by imitation. 
Among the causes to which rumination is said to be due are rapid 
eating, worry, fear, nervous strain, and sudden shock. A large number 
of cases occur among idiots and the insane. The disease is observed 
more frequently among men than women. It is found at all ages, and 
is most common in highly intellectual men. In the series of 1592 cases 
of gastric neuroses there were 24 cases of merycism (1.5 per cent.). 
Among them were five students, one artist, two lawyers, three physicians, 
five clergymen, two merchants, one baker, and one mechanic. The 
gastric contents were examined in 19 of the 24 cases of this series; a 
normal acidity existed in 11, hyperacidity in 3; subacidity in 2; anacidity 
in 1; and heterochylia in 2 cases. Atony was found in 3 cases, while 
in the others the motor function was normal. 
Symptoms.-Rumination usually begins as a voluntary process in an 
insidious manner; on account of gastric discomfort the food is first 
regurgitated, producing a pleasurable sensation it is again reswallowed, 
and finally the condition of merycism is established as an involuntary 
process. The regurgitation usually takes place during the early period 
of gastric digestion; it rarely occurs in the fasting stomach; the remastica- 
tion continues as long as the regurgitated food has a pleasant taste; as 
soon, however, as it becomes acid (during the late period of digestion) 
it is either swallowed at once or ejected. Rumination may take place 
after every meal and last for a very short period of time or extend over 
hours. Merycism occurs alone or may accompany other gastric disorders; 
it is occasionally associated with atony and dilatation of the stomach. 
As a rule, the general nutrition of patients suffering with this disorder is 
good; although when large portions of all meals are not reswallowed 
emaciation is produced and the general nutrition affected. 
Diagnosis.-This is made without difficulty. It differs from regurgita- 
tion in that the food is again masticated, while in the latter this process 
does not take place. In vomiting, nausea and retching are present, while 
merycism is accompanied by pleasurable sensations. 
Prognosis.-This is often good, especially if the patient makes the effort 
to overcome the habit. This condition may extend over a long period of 
time, being present occasionally during the entire life, or it frequently 
disappears for a period, to recur following some strain or shock. 
Treatment.-This consists essentially in an autosuppression. In a 
certain number of cases the patient can be taught to overcome this 140 
DISEASES OE THE DIGESTIVE SYSTEM 
disease. He should be required to eat slowly and masticate thoroughly; 
3 patients of this series were cured in this way. The state of the gastric 
secretion occasionally gives a clue as to treatment. Hydrochloric acid 
is useful in cases of subacidity while alkalis are of benefit in superacidity. 
Intragastric electricity has been recommended, and was of great benefit 
in 2 patients. In those who are much run down and weakened by disease 
a thoroughly regulated rest cure with psychotherapy is most effective; 
3 patients were cured in this way. Strychnine and quinine have been 
recommended, inasmuch as their taste destroys the desire to remasticate. 
Lavage has been used by Johannessen and gavage by Jurgensen. 
REGURGITATION 
By regurgitation is meant that condition observed in hysterical and 
nervous individuals when food is brought up in small quantities from 
the stomach into the mouth and usually ejected. This disorder is much 
like rumination, except that food is not remasticated; rumination, 
however, may develop from long-continued regurgitation. 
Etiology.-This is the same as that of rumination. The condition is 
usually found in neurasthenic and hysterical individuals, and is at times 
voluntary; however, as the habit becomes established it becomes invol- 
untary. Regurgitation may be occasioned by a nervous strain or shock, 
or may be secondary to some other gastric disturbance, such as dilatation, 
catarrh, or hyperchlorhydria. This disorder is also largely found in 
adult males, and more frequently in individuals pursuing intellectual 
pursuits. It occurs more frequently than rumination. In the series 
of 1592 cases of gastric neuroses it was present in 32 cases (2 per cent.), 
26 being in males and 6 in females. Among those suffering from this 
affection, there were two artists, three students, three physicians, six 
lawyers, five ministers, four teachers, three merchants, one mechanic, 
and one laborer. The gastric secretion is usually normal. In the series 
of 32 cases the gastric contents were examined in 29, and normal acidity 
was found in 23 (79 per cent.), hyperacidity in 3 (10 per cent.), sub- 
acidity in 2 (8 per cent.), and heterochylia in 1 (3 per cent.). The motor 
function was usually normal, a slight atony existing in five. 
Symptoms.-The onset is gradual, and consists in the regurgitation of 
food from the stomach soon after eating and persisting during the entire 
period of digestion. It is not preceded or accompanied by nausea, and 
if it occurs early in the process of digestion, the regurgitated material 
has the same taste as the food swallowed. Later it becomes sour from 
the mixture of the acid of the gastric juice. At times this process can 
be suppressed, at other times not. The food is not remasticated and 
swallowed with pleasure, as in the cases of rumination. Regurgitation 
may occur after any meal, or only after certain ones; it may disappear 
for a time, to recur after some mental strain or excitement. When 
large portions of all meals are habitually regurgitated and ejected, the 
general nutrition of the patient is likely to suffer. 
Diagnosis.-Regurgitation is differentiated from vomiting by the 
absence of the usual signs of the latter, nausea, retching, salivation, etc. FUNCTIONAL DISEASES OF THE STOMACH 
141 
It is distinguished from oesophageal regurgitation due to stenosis of the 
oesophagus by the presence of the gastric secretion in the regurgitated 
matter. The difficulty or inability to pass the tube in oesophageal stenosis 
aids in differentiating this from gastric regurgitation. 
Prognosis.-This is usually favorable, provided the patient will assist 
in the act of suppression of the condition; the health becomes seriously 
affected only in those instances in which all food is constantly regurgitated. 
Treatment.-The general condition should be looked into and the 
associated neurasthenia or hysteria treated. An important factor 
consists in teaching the patient voluntary suppression. In emaciated 
individuals this may be assisted by a rest cure with isolation. The 
patient should be required to eat slowly and masticate his food thor- 
oughly. Intragastric electricity is valuable in some cases. Strychnine 
and the bromides have been used with good results. 
ERUCTATIO NERVOSA 
Eructatio nervosa is a condition characterized by periodic or parox- 
ysmal attacks of noisy belching; it occurs in neurasthenic and hysterical 
individuals. The question of the origin of the gas expelled has attracted 
much attention. The following sources have been suggested: The 
fermentation or putrefaction of food, causing the formation of gases, or 
the swallowing of air (aerophagia). It is now generally admitted that 
the gas which is expelled in eructatio nervosa is swallowed, and that the 
air passes into the stomach by an act of deglutition. The swallowing 
of small quantities of air is a natural phenomenon accompanying the 
deglutition of food. Aerophagia, on the other hand, occurs as a voluntary 
act, induced to relieve an uncomfortable sensation in the stomach or 
oesophagus by the expulsion of gas that has been swallowed. Convulsive 
deglutition is accompanied by forcing air into the oesophagus and 
stomach, while expulsion is occasioned by contraction of the oesophagus 
expelling the accumulated air with a loud characteristic sound. Oser1 
ascribes this condition to aspiration, air being suctioned in and expelled 
through the oesophagus by expansion and contraction of the stomach. 
Linnosier believes that aerophagia is much like regurgitation, and that 
while in regurgitation there is an expulsion of food, in aerophagia there 
is an expulsion of gas. In some cases, as Ewald points out, the belching 
has no connection with the stomach, but originates from the oesophagus 
by contractions of the muscles of the neck. 
Etiology.-Eructatio nervosa is usually found in hysterical or neuras- 
thenic individuals. It is more common in females, and in younger than 
in older persons. In the series of 1592 cases of gastric neuroses there 
were 54 cases of eructatio nervosa (4 per cent.), 42 in females and 12 
in males. While this condition is usually a simple gastric neurosis pro- 
duced by some mental excitement, such as anger, worry, or great sorrow, 
yet it may occur as a result of some other gastric disturbance. Catarrh, 
1 Die Neurosen des Magens, 1885, S. 137. 142 
DISEASES OF THE DIGESTIVE SYSTEM 
gastroptosis, or a reflex condition secondary to disturbances of other 
organs, such as the genito-urinary organs and heart, may produce it. 
Symptoms.-This disorder usually develops suddenly and is accom- 
panied by noisy eructations, which vary in duration and intensity, the 
paroxysm lasting from a few hours to days. Frequently there is a 
period of quiescence between the paroxysms, the attack presenting no 
definite relation to the quality and quantity of food taken. The number 
of eructations varies greatly. Spivak1 calls attention to two forms of 
nervous eructations, voluntary and involuntary. In the first variety 
the patient controls the condition, and is able to inhibit this habit at 
will; in the second, which generally occurs during an attack of hysteria, 
he is unable to do so. The attack is spasmodic in character and cannot 
be controlled. The paroxysm usually disappears suddenly and ceases 
during sleep. On examination, patients suffering with nervous eructations 
present a rather increased sensibility to pressure in the epigastric region. 
These areas on pressure occasion eructations (aerophagenic points, 
Bandouin). Examination of the gastric contents may or may not reveal 
normal conditions. In this series of 54 cases the gastric contents were 
examined in 51; normal acidity existed in 42 cases (82 per cent.), super- 
acidity in 6 (12 per cent.), and subacidity in 3 (6 per cent.). 
Diagnosis.-This is not usually difficult. The characteristic paroxys- 
mal attacks can scarcely be mistaken. There is usually an absence of 
organic disease; the gastric contents are frequently normal (82 per cent, 
of this series); the gas expelled is atmospheric air and shows no signs 
of fermentation, while the examination usually reveals other neurasthenic 
or hysterical symptoms. 
Treatment.-Mild forms of the disorder may be combated by explain- 
ing its nature to the patient and urging him to control the attack. Some- 
times, however, this is difficult, and we must content ourselves with 
the treatment of the neurasthenic condition. This may be accomplished 
by hydrotherapeutic measures, electricity, and change of scene. In 
persons who are much run down and have lost much flesh nothing 
will accomplish such excellent results as a well-regulated rest cure. At 
times good results may be obtained by means of lavage, douching the 
stomach, or by means of intragastric electricity. Drugs are usually of 
little value. Among those employed in this condition with more or less 
effect are the bromides, chloral, codeine, and belladonna. 
NERVOUS VOMITING (VOMITUS NERVOSUS) 
The act of vomiting is a very complicated process; not only does the 
nervous system play a part in the act, but also the muscles that govern 
the movements of the stomach. In addition to the centres governing 
the stomach movements there is a coordinated action of the vomiting 
centre from which this act takes it origin. The vomiting centre is in 
the medulla in the vagus nucleus in close proximity to the centres trans- 
mitting impulses to the muscles of the stomach, diaphragm, and pharynx. 
1 New York Medical Record, April 29, 1905. FUNCTIONAL DISEASES OF THE STOMACH 
143 
Etiology.-Vomiting may be due to one of three conditions: to some 
abnormal state of the food, to some disease of the stomach itself, or to 
some disturbance of the nervous system. The form with which we are 
here concerned comes under the latter head. It may be divided into 
three groups: (1) Cerebrospinal vomiting due to a lesion or functional 
disturbance of the nervous centres. (2) Nervous vomiting proper, or 
vomiting due to neurasthenic or hysteria. (3) Reflex vomiting. 
Stiller1 points out the following features as characteristic of this form: 
(a) The ease of the vomiting. (6) Its non-dependence upon the quality 
and quantity of the ingested food, (c) The capriciousness with which 
very bizarre articles of food are retained to the exclusion of others, 
(d) The occasional elective vomiting that consists in selecting only 
one form of food which is separated from the chyme, (e) The ease 
with which patients bear this condition even for a long period of time. 
(J) The very slight degree of inanition produced by the habitual vomit- 
ing. (^) The extraordinary influence of the slightest external or internal 
causes that react on the patient's temperament. (A) The occurrence 
of vomiting frequently, even on a fasting stomach, and the appearance 
of this condition independently of the meal, (i) The presence of other 
nervous symptoms associated with the vomiting or alternating with it. 
In this series of 1592 cases of gastric neuroses there were 49 of nervous 
vomiting (3 per cent.), 34 in females and 15 in males; as to age, 6 were 
in the first decade, 6 in the second, 14 in the third, 11 in the fourth 8 
in the fifth, 3 in the sixth, and 1 in the seventh. 
1. Cerebrospinal Vomiting.-The cause of this form (also known as 
central vomiting) is found in the brain, spinal cord, or the membranes 
covering these structures. The condition has been observed as a symp- 
tom of inflammatory disease of these structures. It is found in menin- 
gitis, encephalitis, apoplexy, abscess, cerebral tumors, not infrequently 
after brain anemia or hyperemia, concussion, intoxication from ether, 
chloroform, opium, tobacco, or septicemia and auto-intoxication. Spinal 
vomiting due to disease of the cord is rather infrequent; it occurs most 
commonly in the gastric crises of locomotor ataxia and occasionally in 
transverse myelitis. The gastric crises are characterized by the occur- 
rence in the midst of well-being, of sudden attacks of intense pain appear- 
ing in the epigastrium radiating toward the sides and back. They are 
followed by the vomiting of large quantities of food, mucus, bile, and 
finally of intestinal juices and occasionally of blood. After copious 
vomiting temporary relief is afforded, and the attack ceases, especially 
during the night, to return on the following day. It may continue at 
intervals from six to eight days, or may last even longer. The vomiting 
may cease as suddenly as it appeared, the appetite may return, and 
the general condition of the patient improve. 
During an attack the patient becomes weak and prostrated, the pulse 
is feeble and rapid, the appetite disappears, the bowels become con- 
stipated and the thirst intense, while the abdomen is much retracted. 
The examination of the vomited matter for free hydrochloric acid may 
1 Die nervose Magenkrank, 1884, S. 151. 144 
DISEASES OF THE DIGESTIVE SYSTEM 
reveal a normal, subnormal, or hyperacid secretion. The diagnosis of 
locomotor ataxia is made by the presence of the other characteristics 
of this disease, but inasmuch as gastric crises may occur as early symp- 
toms of tabes, the diagnosis may be difficult. 
2. Nervous Vomiting Proper.-This form of nervous vomiting is most 
frequently associated with neurasthenia or hysteria. It is found mainly 
in hysterical females; in this series it occurred in 19 females to 4 males. 
The vomiting is often accompanied by pains in the stomach, and comes 
on more or less frequently every day or every few days and is often 
observed after some severe mental strain or excitement. Nausea is 
frequently absent in these cases, the vomiting occurring without any 
effort whatever; other symptoms of neurasthenia or hysteria are either 
associated with the vomiting or alternate with it. The diagnosis of 
nervous vomiting is established by the presence of associated nervous 
symptoms, and by its non-dependence on the quantity and quality of 
food taken; further by its irregularity, the expulsion of either only 
solids, or only liquids, or only one particular form of food, or only a 
portion of the meal, and the very slight loss in strength and weight. In 
this condition the skin is usually dry; the quantity of urine excreted is 
small, with a marked diminution in urea. The vomiting may continue 
for days or months and then disappear suddenly without apparent 
cause. 
Periodical Vomiting.-This condition was first described by von 
Leyden, and is characterized by vomiting occurring at regular intervals; 
between the attacks the patient is in normal health, and complains 
neither of gastric distress nor disturbance of the nervous system. The 
attacks come on abruptly and disappear as suddenly, lasting from a 
few hours to twelve or fourteen days, the attack as well as the interval 
having a constant and definite duration. The attack is usually ushered 
in abruptly by nausea, gastralgic pain, and headache, followed by 
vomiting, at first of gastric contents and mucus, and then of bile. The 
vomiting is excessive, no food, not even fluids, being retained by the 
stomach during this period. The patient becomes weakened and pros- 
trated, the pulse weak, the tongue dry, severe, lancinating pains often 
occur in the extremities, constipation becomes marked, and the urine 
is diminished. The vomiting ceases suddenly and the attack gradually 
passes off, to be repeated again at an interval of from two to four or 
six weeks or even several months. When the attacks occur at short 
intervals emaciation may be extreme, and the disease becomes most 
serious, in consequence of the extreme inanition produced. A distinctive 
feature is the typical periodicity by which it can be distinguished from 
the gastric crises of tabes. An examination of the stomach contents 
in these cases usually reveals normal conditions. 
Psychic Vomiting.-This is generally due to some form of shock, 
fright, or sudden mishap. It may be mild or intense. In mild forms 
only portions of the food are vomited for a certain period of time, and 
the attack then disappears, the general nutrition not being markedly 
impaired; in the severe form the inanition may be so great that the dis- 
ease may become extremely serious, or even fatal. 145 
FUNCTIONAL DISEASES OF THE STOMACH 
Juvenile Vomiting'This form of vomiting occurs in young school 
children who have been subjected to overstudy. In addition to the 
vomiting, other symptoms, as a rule, present themselves. The disorder 
usually begins with gastric pains and vomiting, to which such symptoms 
as headache, pallor, dilated pupils, a slowing of the pulse, and constipation 
are added. In these cases improvement always follows when the patient 
is allowed to discontinue his school work. 
Periodic Vomiting in Children.-A peculiar form of periodic vomiting, 
differing from the form described as juvenile vomiting, occurs in young 
children. It comes on usually at the age of from two to three years, 
and generally passes off as the child becomes a few years older. The 
condition has been fully described by Snow, Griffith, and others. The 
attack is characterized by a sudden onset, in the midst of good health, 
of intense vomiting, accompanied by fever and great depression, that 
ceases as suddenly as it began. In a certain number of cases the attacks 
appear with a distinct periodicity at intervals of every few weeks or even 
months. In at least some Snow has shown that the gastric irritability is 
due to an intermittent hyperchlorhydria, a secretory gastric neurosis. 
The cause of this recurrent vomiting is unknown, but it is probably a 
transitory auto-intoxication that affects the nerve centres governing 
gastric secretion and motion. 
3. Reflex Vomiting.-This is a very common«form of nervous vomiting, 
and may be produced by various diseases affecting the stomach and 
other organs. It is found as one of the symptoms of disease of the middle 
ear, disturbances of the eye, pharynx, larynx and tonsils. To these 
may be added diseases of the lungs and abdominal organs. Reflex 
vomiting is also common during pregnancy. 
Gould and others have pointed out the frequent dependence of this 
as well as other gastric neuroses upon eye-strain, while Brav has found 
astigmatism a common cause of vomiting in school children. The 
vomiting of pregnancy is often a reflex neurosis of the sympathetic 
nerves. In another form vomiting is due to some hysterical or neuras- 
thenic tendency. In these cases the neurotic nature is indicated by 
the fact that a cure frequently follows the employment of perfectly 
useless and unphysiological procedures. Many of these cases, therefore, 
may be cured by rest or simple suggestive means. A third variety of 
vomiting of pregnancy is the toxemic form, which is a very serious 
disease and is produced by a marked disturbance of metabolism. 
Diagnosis.-The diagnosis between the various forms of nervous 
vomiting is not always a simple matter. After establishing the nervous 
origin of the vomiting it is most important to determine its exact cause, 
whether, for example, it is reflex or due purely to neurasthenia. These 
facts, as a rule, can be elicited by a complete investigation into the 
history and a rigid examination of the patient. 
Prognosis.-This depends largely upon the cause. In the cerebro- 
spinal vomiting it is usually bad, although in the gastric crises the 
vomiting may abate entirely, notwithstanding the continued progress 
of the disease. In the form with neurasthenia or hysteria the prognosis 
is usually favorable when under proper treatment, but occasionally a 
vol. in-10 146 
DISEASES OF THE DIGESTIVE SYSTEM 
fatal outcome is met with, due to exhaustion occasioned by the continued 
and prolonged vomiting. Three cases of this character have come 
under the observation of the writer. In the reflex form the prognosis 
is favorable provided the cause can be removed. 
Treatment.-The chief aim is removal of the cause. Inasmuch as this 
is not always possible, many patients must be treated symptomatically. 
In the milder forms, change of scene, avoidance of mental excitement, 
and rest will overcome this condition. In severe cases patients should 
always be placed in bed in a hospital under rigid isolation and rest-cure 
treatment. In seven of this series the writer is convinced that the lives 
of the patients were saved by this plan of treatment. 
As regards diet, the patient should be fed on liquid food, given in very 
small quantities, such as champagne, ice-cold milk, elam broth, or cold 
egg-albumen. In severe forms the patient must be fed for some days 
exclusively by the rectum and the thirst relieved by saline enemata. 
Duodenal alimentation by means of Einhorn's duodenal tube has proved 
highly efficacious in a number of cases under the writer's care. In 
some cases solid foods are wTell borne when liquids cannot be taken. 
These should be given in very small quantities; scraped beef, eggs, rice, 
and toast are especially useful. Hydrotherapy may be practised with 
good results in some cases. Electricity has a beneficial effect in some 
instances, the galvanic cucrent being used with the anode in the stomach 
and the cathode on the spinal column. The writer has had good results 
at times from lavage with solutions of nitrate of silver, at other times 
with solutions of menthol. As to the drugs used with more or less 
effect the following may be mentioned: Morphine given hypodermically, 
oxalate of cerium, cocain, menthol, the bromides, chloral, validol, and 
orthoform. Boas recommends iodide of potassium and bromide of 
sodium in the gastric crises, and rectal suppositories of opium and bella- 
donna are useful in attacks of periodic vomiting. In the periodic vomiting 
of children Rachford suggests the use of calomel and bicarbonate of 
soda, followed* by a saline laxative, and then benzoate of soda in from 
3 to 8 grain (0.2 to 0.5 gm.) doses every two or three hours. Snow also 
recommends an alkaline treatment in these cases. 
NAUSEA NERVOSA 
Nausea is observed in many gastric affections, as well as in diseases of 
other organs. There is, however, a purely functional form of nausea 
which is entirely of nervous origin and is due to hysteria or neurasthenia. 
Etiology.-Nausea nervosa is often found in anemic and chlorotic 
females; it is also observed with menstrual disturbances and frequently 
at the menopause. It begins, as a rule, after great excitement, worry, or 
anxiety in neurasthenic or hysterical individuals. This disorder is most 
often observed in women and rarely in men. In the series of 1592 cases 
of gastric neuroses there were 40 cases of nausea nervosa (2.5 per cent.), 
30 in females and 10 in males. As to age, 13 were in the second decade, 
9 in the third, 7 in the fourth, 7 in the fifth, and 1 in the sixth. 147 
FUNCTIONAL DISEASES OF THE STOMACH 
Symptoms. - Nausea may be intermittent or continuous. In the 
intermittent form it appears any time of the day or night and bears no 
relation to the ingestion of food, its quantity or quality. In the contin- 
uous form it persists for days and months in varying degrees of severity, 
sometimes slight, at other times so intense as to cause vomiting. The 
nausea is not dependent upon the quantity or quality of the food ingested, 
yet it causes a loss of appetite, and the patients, as a rule, live upon a 
very limited diet, the result being great emaciation. Examination of the 
gastric contents showed a normal acidity in 34 and in 6 a hyperacidity. 
The gastric motility was normal in all. 
Diagnosis.-All organic diseases accompanied by nausea must be 
excluded, such as tuberculosis, diseases of the genital organs, arterio- 
sclerosis, uremia, and organic diseases of the stomach. 
Treatment.-In many cases due to anemia or chlorosis appropriate 
treatment will relieve the condition. Attention should be paid to repair 
of the nervous system, especially by massage, electricity, and hydro- 
therapy. In those cases accompanied by marked anemia and great 
loss of flesh splendid results are obtained through a well-conducted 
rest cure. Complete isolation is always necessary in severe forms. 
Duodenal feeding may be practised at times with advantage. Relief 
is shown in some cases by means of the bromides, valerian, sumbul, 
and chloral. Validol for milder forms has been of great service in the 
writer's experience. 
CARDIOSPASM 
Cardiospasm is characterized by a spasmodic contraction of the 
cardia not due to any organic disease. Under normal conditions there 
is a spasmodic contraction of the cardia by which not only solids but 
also liquids are somewhat delayed in their passage into the stomach. 
This contraction may be increased both when the cardia is the seat of 
an organic disease or as a condition accompanying hysteria or neuras- 
thenia. As a result of the cardiospasm a diffuse dilatation of the 
oesophagus is often produced. The etiology of cardiospasm and diffuse 
dilatation of the oesophagus has been a matter of dispute. According 
to Mikulicz and Meltzer, it is due to a failure of the central inhibitory 
influences controlling contraction of the cardia. Rosenheim believes 
that the predisposition to idiopathic dilatation is due to a weakness of 
the muscular coats; while Krause views it as a functional disturbance 
of the innervation of the oesophagus causing cardiospasm as well as a 
weakness of the muscular wall (Tyson). 
Etiology.-Cardiospasm is found at times accompanying hysteria and 
neurasthenia. It occurs after swallowing food that is hard and not 
sufficiently masticated, or after swallowing food too rapidly or too highly 
seasoned. Excitement is occasionally a causative factor. It occurs at 
times after habitual air swallowing. If the air collects, it expands and 
produces a dilatation of the stomach, and with it a spasm of the cardia, 
often complicated at the same time w'ith pylorospasm. It occurs at 
any age, most frequently in females. In this series of 1592 cases of 
gastric neuroses there were 25 cases of cardiospasm (1.5 per cent.), 17 148 
DISEASES OF THE DIGESTIVE SYSTEM 
being females and 8 males. As to age, 6 were in the second decade, 9 
in the third, 7 in the fourth, 2 in the fifth, and 1 in the sixth. 
Symptoms.-Cardiospasm occurs in two forms, as the acute or chronic 
variety. The acute form is only of a few days' duration, the onset being 
sudden. The attack is accompanied by a burning sensation, with pressure 
or pain behind the sternum, and dysphagia; as the food accumulates in 
the oesophagus an effort must be made to force it into the stomach; when 
this is impossible, the food is regurgitated, causing at times some dyspnoea. 
At other times it is impossible to swallow food. Regurgitation of the 
food causes relief of all symptoms. This condition comes on periodically, 
and during the interval the patient is free from discomfort. In the 
chronic form there is also a marked dysphagia. Foods are forced into 
the stomach by the patient with great effort, by taking a deep inspiration 
and compressing the chest by muscular action while holding the breath. 
Liquids and semisolids are most easily swallowed. The solid foods must 
be thoroughly masticated, and are often swallowed by taking small 
quantities of water at the same time. After a time a diffuse dilatation 
of the oesophagus takes place, which may hold several hundred cubic 
centimeters. At times less difficulty occurs in swallowing, and occa- 
sionally the patient can take a solid meal; however, after the diffuse 
dilatation of the oesophagus has taken place, the dysphagia becomes 
constant. If the air swallowed during a meal cannot be eructated, the 
stomach becomes distended, and on account of the cardiospasm it is 
impossible for vomiting to take place. Pain and pressure behind the 
sternum are common, the patient complaining of a sensation as though 
food were lodged at this point. The dilated lower part of the oesophagus 
retains the food and regurgitates it after a certain length of time. The 
contents contain no free hydrochloric acid. The second deglutition 
murmur is absent. Examination with the bougie reveals important 
conditions; on introducing it one feels a resistance, which is felt more 
plainly with the large than with the small-sized bougies; after gentle 
pressure the resistance gives way and the bougie passes into the stomach. 
The presence of a diffuse dilatation of the oesophagus above the position 
of the cardiospasm is demonstrated as follows: A tube is passed in the 
oesophagus to a point at which food mixed with mucus is withdrawn 
through the tube. A second tube is now passed into the oesophagus 
beside the first, but is forced through the resistance; through this tube 
gastric contents are obtained; if eosin-stained water is introduced through 
the first tube and plain water through the second, it can be demonstrated 
that there is no communication between the tubes, as is observed by 
the return of the fluids separately and not mixed (Rumpel's double 
tube test). Owing to the lack of nourishment, the general health fails. 
Diagnosis.-In the acute form this is made by the variations in the 
degree of dysphagia, by the introduction of an oesophageal bougie with- 
out difficulty, by the resistance being less from a bougie of large caliber 
than from a small one, by the absence of the second deglutition murmur, 
and by the inability of the patient to vomit. In the chronic form the 
dysphagia lasts over a longer period of time, while svmptoms of dilatation 
of the oesophagus become evident. The condition is recognized by the FUNCTIONAL DISEASES OF THE STOMACH 
149 
test of Rumpel, already described. In addition, the examination by 
means of the bougie reveals a condition similar to that found in the 
acute form. In those cases accompanied by dilatation the diagnosis may 
be confirmed by means of oesophagoscopy and an x-ray examination. 
Cardiac carcinoma is differentiated by the fact that it occurs in advanced 
age, that often traces of blood and pus, together with carcinomatous 
particles, are obtained by the bougie, and that small-calibered bougies 
pass more easily than larger ones. In cardiac cancer there is usually 
an absence of free hydrochloric acid in the gastric secretion, while in 
cardiospasm there is either a normal or a hyperacid secretion. 
Treatment.-In the acute forms special attention should be paid to the 
nervous system and the general nutrition of the patient looked into. 
In order to overcome the cardiospasm large bougies should be introduced 
into the stomach and allowed to remain for a considerable length of 
time. Internally belladonna, the bromides, morphine, and cocaine are 
used with a variable degree of success. Rosenheim recommends the 
injection at the seat of the affection of a 3 to 5 per cent, eucaine solution, 
at first twice daily, then less frequently. In the treatment of the chronic 
form only liquid or semisolid food should be taken; in those cases in 
which the constriction is marked food must be administered through a 
tube; before proceeding with the feeding, lavage of the oesophagus is 
first practised with the same tube, in order to rid it of mucous masses, 
food remains, etc. Large bougies should also be introduced and allowed 
to remain for a considerable length of time. In order to produce a 
forcible dilatation of the contracted oesophagus and cardia, Sippey's, 
Plummer's, Einhorn's or Meyer's dilators are employed with much 
success. 
PYLOROSPASM 
By pylorospasm is meant a spasmodic contraction of the pylorus not 
due to organic disease. It is usually due to some severe irritation of 
the mucosa of the pylorus, such as that produced by the acid in super- 
acidity or supersecretion; or it may be due to an ulcer, erosions, fissures, 
or cancer at the pylorus, while there are other forms entirely of nervous 
origin. Cases of the latter form have been described in infants. In a 
female, aged twenty-three years, observed by the writer, in whom all 
the symptoms of pylorospasm were manifested and who was operated 
on by Finney, no anatomical changes were observed, but entire relief 
was afforded by pyloroplasty. 
Etiology.-In the series of gastric neuroses only 4 cases could be 
definitely classified as primary pylorospasm (0.3 per cent.); 3 of these 
were observed in females and 1 in a male. 
Symptoms.-At the height of digestion, the pylorus suddenly becomes 
spasmodically contracted with intense pain in its region, together with 
eructations and often vomiting. At first the spasm appears periodically, 
but as the disorder progresses it may become continuous and produce 
a spastic contraction of the pylorus, with tendency to dilatation and 
retention of food. The food is vomited under these conditions, and 
possesses all the characteristics of that observed in a dilated stomach. 150 
DISEASES OF THE DIGESTIVE SYSTEM 
Relief is afforded by the vomiting for a period of time varying from one 
to three or four days, when the same disturbance is again produced. The 
symptoms found in dilatation are then observed-emaciation, intense 
thirst, and constipation. The pyloric area, as a rule, is tender to pressure, 
and contraction may take place near the pylorus, producing a firm mass 
on palpation, which may gradually disappear. The secretion of acid 
may be normal or increased, but becomes normal when the motor func- 
tion is again restored. Chronic gastrosuccorrhoea is frequently observed 
in these cases and occasionally tetany. 
Diagnosis.-This is made by the exclusion of all organic disease and the 
appearance of the spasmodic attacks of pain in the region of the pylorus, 
with the appearance of intermittent stagnation. 
Treatment.-This consists primarily in properly looking after the 
underlying neurasthenia. For this purpose change of scene, massage 
and electricity, or a rest cure, may be found advisable. The diet should 
be carefully regulated, all irritating foods being avoided, and the meals 
should be small, easily digested, and given at regular intervals. The 
administration of olive oil has been found of great service. When 
retention is present, gastric lavage with plain water or nitrate of 
silver solution must be given. For the pain codeine combined with 
belladonna is serviceable; hot applications to the abdomen and a 
thorough lavage usually afford most relief from the pain. Einhorn 
has recommended the dilatation of the pylorus by means of his 
pyloric dilator. If after faithful trial no relief can be obtained from 
these measures described, the writer has observed excellent results 
from pyloroplasty. Some authorities recommend gastro-enterostomy. 
PNEUMATOSIS 
By pneumatosis is meant that condition in which the stomach is 
distended with air and in which expulsion of the same is impossible, 
causing unpleasant expansion of the stomach and dyspnoea (asthma 
dyspepticum, Henoch). In a large proportion of cases this condition 
is partly due to a simultaneous cardiospasm and pylorospasm. Relief 
is at once afforded when the spasm ceases and the air escapes. Pneu- 
matosis is found secondary to certain gastric disturbances, such as 
atony and dilatation, or is a primary neurosis accompanying neurasthenia 
and hysteria. It occurs as a continuous or periodic affection, and appears 
after nervous anxieties or mental strains. 
Etiology.-Pneumatosis is found more often in males. In this series 
it occurred in 8 cases (0.5 per cent.); of these, 6 were males and 2 females. 
Symptoms.-Pneumatosis occurs in one of two types: In the first it 
appears in an acute form intermittently with alarming symptoms causing 
dyspnoea, collapse, rapid and irregular pulse, and cyanosis. The region 
of the stomach isgreatlydistended,often balloon-shaped, and is tympanitic 
on percussion. The patient is unable to relieve himself by eructating. 
In the second type the attacks either come on immediately after meals 
or some time later, or after some exertion; the symptoms are much like FUNCTIONAL DISEASES OF THE STOMACH 
151 
those of the acute form, but may become alarming. The gastric contents 
are usually normal; occasionally there is a hyperchlorhydria, and again 
at times hypochlorhydria. 
Diagnosis.--This is ordinarily made by observing the symptoms 
described; all organic conditions such as dilatation or atony must be 
excluded. It is sometimes mistaken for angina pectoris, but in angina 
there is no continuous distension of the stomach and the expulsion of 
the gas does not afford relief. 
Treatment.-Special attention should be paid to the nervous system. 
Change of scene, hydrotherapy, and massage will often do much to 
restore the patient to health. Of the medicines used to give relief the 
most important are the bromides, cocaine, or morphine. Boas advises 
the use of the extract of physostigmine, grain (gm. 0.01), combined 
with the extract of nux vomica, grain (gr. 0.02), three times daily. 
In acute attacks the stomach tube will afford instant relief. 
PERISTALTIC UNREST (TORMINA VENTRICULI NERVOSA) 
Peristaltic unrest is characterized by an excessive and visible peristalsis 
of the stomach. This condition was first described by Kussmaul as 
occurring in neurasthenic individuals in whom excessive peristalsis 
caused annoying sensation and unpleasant contractions of the stomach. 
In the cases described by Kussmaul the peristaltic movements were 
visible, as a gastroptosis was present at the same time. Peristaltic 
movements usually take their origin at the fundus of the stomach and 
run toward the pylorus; the wave, however, may be antiperistaltic 
also and run in the opposite direction; occasionally antiperistaltic 
movements exist alone; cases have also been observed in which peri- 
staltic movements of the intestines were present at the same time. 
Etiology.-Peristaltic unrest may occur in one of two conditions: First, 
due to an obstruction of the pylorus, the stomach exerting itself to 
overcome the difficulty produced in emptying its contents into the 
intestines; second, the unrest may occur as a pure neurosis, accompanying 
neurasthenia or hysteria; as a neurosis it is an exceedingly rare affection, 
but one case occurring in the series (0.06 per cent.). 
Symptoms.-The important symptom is the peristaltic movement of 
the stomach running from the fundus to the pylorus and at times accom- 
panied by antiperistaltic movements. These movements are usually 
visible and are felt by the patient. When the stomach is in its normal 
position the patient may be conscious of the movement, but it cannot 
be seen. Other symptoms are often present, such as eructations, nausea, 
anorexia, and the too rapid evacuation of the stomach (hypermotility). 
General symptoms of neurasthenia are ordinarily present. 
Diagnosis.-This is simple if organic obstruction of the pylorus pan be 
excluded, which is usually readily done. 
Treatment.-This should be directed mainly toward the neurasthenic 
condition by change of scene, massage, and hydrotherapy. At times, 
when the patient is anemic, the best results have followed a well-regulated 152 
DISEASES OF THE DIGESTIVE SYSTEM 
rest cure. Kussmaul recommends internal and external application 
of the faradic current. Good results have been obtained by the admin- 
istration of the bromides, codeine, and belladonna. 
SUBACIDITY OR HYPOCHLORHYDRIA 
By subacidity or hypochlorhydria is meant that form of neurosis in 
which the amount of hydrochloric acid as well as the other constituents 
of the gastric secretion is lessened. While there are still small quantities 
of hydrochloric acid secreted in this condition, the quantity is so small 
that it at once combines with the protein foods. Subacidity is present 
in certain organic diseases of the stomach, as chronic gastritis and cancer, 
also during the height of acute febrile diseases. The term nervous sub- 
acidity, however, can only be applied to those conditions in which all 
signs of organic disease of the stomach can be excluded. The condition 
is frequently found accompanying neurasthenia or hysteria, and is 
present also in certain lesions of the spinal cord, as tabes dorsalis. In 
this series of 1592 cases, 80 (5 per cent.) represent the number of cases 
of subacidity or hypochlorhydria; of these, 34 were males and 46 females. 
Symptoms.-Many cases run their course for a considerable period of 
time without symptoms; this is especially true as long as the motor 
function of the stomach is normal, but as soon as this is impaired fermen- 
tation begins in the intestines and distension from gas takes place. 
The symptoms of this condition, however, are not distinctive, and a 
diagnosis cannot be made until the gastric secretion is examined. As 
long as the intestinal digestion is normal, symptoms of gastric disturb- 
ances are absent and the patient can maintain his normal weight and 
strength; as soon,1 however, as the intestinal functions become disordered 
by inflammation, diarrhoea sets in and the patient becomes weakened 
and emaciated. A symptom in 7 cases was burning with pain about 
two hours after meals, relieved by alkalis or food and presenting symp- 
toms of acidity. 
Diagnosis.-This is arrived at by examination of the gastric con- 
tents and finding a diminution of hydrochloric acid; at the same time 
hysterical or neurasthenic symptoms must be present. By continually 
observing cases of nervous subacidity one is frequently surprised by the 
various changes this condition undergoes, often to a normal acidity or 
even to hyperacidity. Hemmeter termed this condition heterochylia. 
Treatment.-The diet should consist largely of carbohydrates. Meat 
should be given, however, in the most digestible form and finely divided; 
the food should be given in small quantities at frequent intervals. Much 
attention should be paid to the general health and special treatment 
should be given to the nervous system. Hydrochloric acid administered 
in 10- to 20-drop (1 cc.) doses after meals is a useful adjuvant. Lavage 
of the stomach is rarely necessary unless the motor function is markedly 
disturbed and at the same time leads to fermentation. The use of 
massage and electricity (intragastric) is also serviceable in many cases. 
The saline waters, such as Kissingen or Wiesbaden, are useful so long 
as the motor function is normal; as soon as this is disturbed their use 
should be discontinued. FUNCTIONAL DISEASES OF THE STOMACH 
153 
ANACIDITY OR ACHYLIA GASTRICA 
The term achylia gastrica was first introduced by Einhorn1 to indicate 
a condition in which there is an absence of gastric secretion. The term 
is simply meant to designate a symptom, the condition underlying the 
same being a severe form of chronic gastritis or atrophy of the mucous 
membrane or some condition wholly neurotic in origin. * It is not our 
province to discuss here the cases which are accompanied by a complete 
atrophy of the gastric mucous membrane. Fenwick2 first described 
this condition in certain cases of pernicious anemia. The use of the 
term achylia gastrica is best restricted to those cases for which Einhorn 
first adopted it. In these there is a complete lack of gastric secretion, 
which persists for many years without ending fatally, and in which the 
general condition of health frequently improves. The patient often 
presents no subjective symptoms whatever, and can take many forms 
of food without the slightest discomfort, the small intestine vicariously 
assuming the function of the stomach. In a case of the writer's this 
condition persisted for twelve years, with gain in weight and with but 
few attacks of intestinal disturbance. 
Etiology.-It seems doubtful in most instances whether a complete 
absence of gastric secretion is due to a neurasthenic condition alone, 
because, while the neurasthenic condition may improve and disappear, 
the gastric secretion remains absent permanently. According to many 
writers it is probable that a more or less pronounced chronic gastritis 
is present in a large proportion of cases of achylia gastrica. According 
to Martins, achylia gastrica is produced by two conditions: First, simple 
achylia gastrica, a primary secretory debility of the stomach that may 
be either congenital or developed early from hereditary predisposition; 
and second, atrophy of the gastric mucosa producing a secondary achylia 
gastrica. Simple achylia gastrica is found in neurasthenic patients, 
and is associated with inherited weakness of the nervous system. It 
may remain latent without making serious inroads upon the general 
health, especially in those patients in whom the motility of the stomach 
remains normal and the intestinal functions are undisturbed. There are 
transitions from the simple forms of achylia gastrica in which there are 
none or but the slightest changes in the mucous membrane to that form 
ending in complete gastric atrophy. 
According to Stockton, the belief that achylia gastrica may in some 
instances begin as a simple depression of the functional activity of the 
secretory glands of the stomach, the result in some cases of neurasthenia, 
in others as reflex irritation, appears to be gaining rather than losing 
ground. According to this observer, with the improvement in health 
gastric secretion is increased, and disappears again with nervous strain. 
When it is absent for any length of time, it is probable that considerable 
atrophy of the mucous membrane has appeared, and yet in certain cases 
Stockton observed the secretion appearing after it had been absent for 
a period of a year or more. From an observation of some patients for 
1 New York Med. Rec., June 11, 1892, 
2 Lancet, July, 1877. 154 
DISEASES OF THE DIGESTIVE SYSTEM 
at least fifteen years, Stockton1 believes that, in the absence of or with 
a very low standard of gastric secretion, individuals are always found 
to have impaired health, even with relatively good intestinal digestion. 
Achylia gastrica is usually found after the thirtieth year of age; it is 
rarely found in younger persons. There is apparently no difference in 
the frequency of occurrence in males or females. In this series the 
number of casfes of achylia gastrica is 114; of these, 2 represent that form 
known as atrophy of the stomach, and cannot be considered here, leaving 
112 cases (7 per cent.) in all, 57 being females and 55 males. As to age, 
2 were below twenty, 13 in the third decade, 19 in the fourth, 33 in the 
fifth, 35 in the sixth, and 10 in the seventh. 
Pathology.-There have been so few cases in which autopsies have 
been performed that it is not known whether lesions occur in all cases. 
According to Martins and Lubarsch, and Strauss,2 a more or less marked 
gastritis exists in a large proportion of cases of achylia, but there is no 
means of determining whether the gastritis is the cause or the result of 
the achylia. Einhorn maintains that there are many cases of achylia 
in which the mucous membrane of the stomach presents no pathological 
change whatever, which accounts for the fact that a repair of the con- 
dition is sometimes found. Small fragments of the mucous membrane 
that are broken off by the stomach tube usually present some degenerative 
change. The glands show granular degeneration with considerable 
round-cell infiltration presenting the picture of a glandular gastritis. It 
is generally believed by most authorities that notwithstanding the 
impossibility of judging the general condition of the mucous membrane 
from fragments of a small area, in the largest proportion of cases of 
achylia gastrica there is some degeneration in the mucous membrane 
of the stomach, and there is no great amount of evidence at present to 
indicate that this condition can occur without some anatomical change. 
Symptoms.-Einhorn3 divides achylia gastrica into three groups: 
(1) In individuals having no gastro-intestinal symptoms whatever, and 
who are in good general health. (2) Patients presenting a greater or 
less number of gastric symptoms. (3) Patients having apparently no 
gastric symptoms, but presenting marked intestinal disturbances. The 
smallest number of cases are contained in the first group, in which all 
subjective symptoms are absent. The individual presents no loss of 
weight, the appetite remains unimpaired, and the diseased condition 
is usually noted by accident. In this series of 112 cases, only 8 can be 
counted in this group. 
The largest proportion of cases is found in the second group, in which 
the symptoms are mainly gastric; in this series of 112 cases, 69 belong 
to this group. The symptoms are loss of appetite, sensations of pain 
and pressure in the region of the stomach, and occasionally vomiting. 
The pains are generally mild, often merely a sensation of burning and 
pressure occurring soon after meals and persisting for some time; in 
some cases there may be no pain whatever, while in others it may occur 
1 New York Medical Journal, February 17, 1906. 
2 Vircnows Archiv, Bd. cliv. 
3 Diseases of the Stomach, fifth edition, p. 352. FUNCTIONAL DISEASES OF THE STOMACH 
155 
with great severity. Nausea and vomiting occur rarely-in but 17 cases 
of this series. The vomited matter usually contains undigested food 
particles. Eructations and pyrosis are observed at times; occasionally 
symptoms are presented which are similar to those found in hyper- 
chlorhydria; that is, the appearance of pain one or two hours after meals, 
relieved by the ingestion of food. This symptom was noted in 11 cases 
in this series. Nervous symptoms are also frequently present. 
The third group contains those patients having apparently no gastric 
disturbance but presenting intestinal disturbances. In the series of 
112 cases these number 35. The most prominent symptom is diarrhoea. 
The patient complains of little or no disturbance of the stomach, but 
is affected with symptoms apparently referable to marked disturbance 
of the intestines, gurgling in the bowels and intestinal colic. Frequently 
diarrhoea alternates with constipation. The diarrhoea is probably 
occasioned by the undigested food mechanically stimulating peristalsis. 
In addition, a large number of bacteria pass through the stomach and 
cause decomposition in the bowels. 
Examination of the gastric contents is of the greatest importance. 
The following are the characteristics: the amount is very small, only a 
small quantity of fluid, with bits of unaltered bread; in the morning 
before the ingestion of food the stomach is entirely empty, with no 
traces of food from the previous day. The gastric contents are neutral 
or slightly acid, the total acidity varying between 2 and 6. Hydrochloric 
acid is not present, pepsin and rennin are entirely absent, although the 
rennet zymogen may still be present; the test for propeptones and pep- 
tone reveals negative results, and there is an absence of mucus. Frag- 
ments of mucous membrane often appear in the contents, indicating the 
great vulnerability of the mucous membrane. The motor function of 
the stomach is usually increased. 
Diagnosis.-For the most part this is not difficult from the examination 
of the gastric contents; repeated examinations are necessary to confirm 
it. The most important signs are an entire and constant absence of 
hydrochloric acid, an almost entire absence of the ferments, and a very 
low total acidity. As in nearly all of the cases some alteration has taken 
place in the gastric mucosa, it is difficult in many instances to distinguish 
this condition from a chronic gastritis. One must rely mainly upon 
the presence of nervous symptoms and the complete absence of mucus; 
a fluctuation in the gastric secretion will occasionally indicate the nervous 
origin. This condition is distinguished from carcinoma by the absence 
of the typical signs of cancer. The degree of acidity is much higher in 
carcinoma even when free hydrochloric acid is absent; lactic acid is 
usually present as well as the Oppler-Boas bacillus; the latter is not 
found in achylia. There is a constant finding of occult blood in car- 
cinoma never observed in achylia; in 50 examinations from 24 cases of 
achylia in this series, occult blood was never found in the feces. Hemor- 
rhages are never observed in achylia. When cancer is advanced, no 
difficulty is presented in making the diagnosis. 
Course and Prognosis.-Patients suffering from achylia gastrica may 
be affected for many years without having serious inroads made in their 156 
DISEASES OF THE DIGESTIVE SYSTEM 
general health. They may even gain flesh when the course is latent for 
a long period of time. As long as the motor functions of the stomach 
remain normal and the intestine takes up the functions of the stomach 
vicariously, no serious results are produced; when, however, one or other 
of the functions are disturbed, the symptoms of achylia begin to manifest 
themselves and the general nutrition becomes markedly disturbed. 
Since a chronic gastritis is present in most instances, an absolute cure 
is impossible, even though the symptoms are entirely relieved. 
Treatment.-This is mainly dietetic, and although it is necessary to 
restrict the diet materially, it is most important to insist on the ingestion 
of sufficient food, as many of these patients are weak and have lost flesh. 
The question as to quantity of food should be carefully considered with 
an attempt to increase the general nutrition as well as the body weight. 
In accomplishing this object these facts should be held in mind, namely, 
to maintain the motor function of the stomach in its normal condition, 
as well as to prevent any disturbance of the intestinal canal, since the 
intestine acts vicariously and digests the food for the stomach. It is 
important to arrange the diet so that it can be acted upon easily by the 
intestinal juices. The food must be broken up into as fine particles as 
possible and should to a large extent be given in liquid and semiliquid 
form. Of the liquids, broths, such as barley, rice, or chicken, are to be 
recommended. Vegetables are usually well taken; cereals should be 
eaten after the cellulose has been removed. Peas and beans strained 
and eaten in puree form, as in broth, are especially useful, since they 
contain quite a large percentage of protein. Potatoes and rice should 
be eaten cooked with broth or milk, or as a mush. Eggs are best taken 
soft boiled. Meats must be given in the most digestible forms, i. e., 
brains, scraped beef, boiled sweetbreads, and these only in small amount; 
raw oysters and boiled fish are also permissible. Milk is occasionally 
imperfectly digested and cream, kefir, koumyss, or matzoon may be 
substituted. Butter may be eaten on crackers, stale bread, or toast. 
Such beverages as tea, coffee, cocoa, and small quantities of wine may 
be allowed. When symptoms of hyperchlorhydria are manifested, the 
taking of liquids from one to two hours after meals will afford relief. 
Lavage and intragastric faradization may be resorted to in those 
instances in which the gastric motility is somewhat impaired. Drugs 
are not always required; in some cases dilute hydrochloric acid may 
be given, well diluted in 15-drop (1 cc.) doses, three or four times at 
intervals of fifteen minutes after meals with benefit. For anorexia 
strychnine combined with the bitter tonics is recommended. In those 
instances in which the general nutrition has become very much depressed, 
and in which diarrhoea is or is not present, excellent results may be 
obtained by a systemic rest-cure treatment. 
ACORIA 
By acoria is meant that condition in which there is an absence of 
the sensation of satiety. The patient does not feel that he has eaten 
enough, no matter whether he partakes of a large or a small meal; the FUNCTIONAL DISEASES OF THE STOMACH 
157 
appetite is not increased; it may even be diminished. The cause has 
not been determined; it has been stated that acoria is due to an over- 
stimulation of the hunger centre, but this theory is untenable. The 
condition may be due to loss of sensation in the stomach itself. 
Etiology.-Acoria occurs as a primary disorder associated with neuras- 
thenia or hysteria, or is observed secondary to other diseases, such as 
diabetes or disorders of the male sexual organs. Sorrow, sudden shock, 
or excitement are among the etiological factors concerned in its produc- 
tion. In this series of 1592 cases it occurred five times (0.3 per cent.); 
of the 5 cases, 3 occurred in males and 2 in females. 
Symptoms.-The affection is characterized by an absence of the sensa- 
tion of satiation, no matter how large the meal may be. In consequence 
of the inordinate eating, atony and gastritis may develop. Acoria may 
at times be transformed into bulimia. The gastric secretion is usually 
normal; in this series normal acidity existed in 4 and subacidity in 1; 
the gastric motility was normal. 
Diagnosis.-Acoria must be differentiated from polyphagia and 
bulimia; in acoria there is an entire absence of the sensation of satiation, 
while in polyphagia the feeling of satisfaction is delayed to such an 
extent as to create a constant desire for more food. In bulimia there 
is an abnormal desire for food, but this desire can be satisfied. 
Treatment.-This must be directed toward the cause, which in most 
instances involves treatment of the general neurasthenia by means of 
rest, change of scene, hydrotherapy, massage, and electricity. Entire 
relief was effected in two cases by a rest cure combined with psycho- 
therapy. The meals should be carefully regulated; the patient should 
be required to eat slowly and masticate thoroughly. Strychnine in 
ascending doses has been used with some success. 
ANOREXIA NERVOSA 
Anorexia is characterized by a marked diminution in or the absence 
of the sensation of hunger, combined with a complete loss of appetite. 
Penzoldt points out that the terms hunger and appetite should be 
separated, as they are not synonymous; according to this author, hunger 
is defined as the warning for food, while appetite is the pleasure in par- 
taking of it. Anorexia may accompany various organic or functional 
diseases, or may be a primary neurosis accompanying neurasthenia or 
hysteria (anorexia nervosa). In this condition the loss of appetite may 
be so great as to cause a most marked disgust or repugnance for food. 
The cause of nervous anorexia has been attributed to a depressed state 
of the hunger centre, while it is generally believed that this affection is 
produced by a "special hyperesthesia" of the mucous membrane of the 
stomach (Rosenthal). 
Etiology.-Anorexia may be primary or secondary. It is primary as 
a manifestation of hysteria and neurasthenia; it is secondary to such 
diseases as cancer of the stomach, chronic gastritis, gastroptosis, acute 
febrile conditions, chronic nephritis, and other organic diseases. Anorexia 
nervosa usually begins after some great mental strain, excitement, or 158 
DISEASES OF THE DIGESTIVE SYSTEM 
anxiety. It is not uncommonly found in men with sexual disorders 
(Peyer) and in women affected with uterine disease, and is often observed 
in a most aggravated degree in the insane (anorexia mentale). Opium 
habitues are commonly affected with this disorder. It is most frequently 
observed in females, and especially between the ages of fifteen and 
forty years. In this series of 1592 cases there were 48 cases of nervous 
anorexia (3 per cent.), 11 being males and 37 females. As to age, 19 
were in the second decade, 12 in the third, 10 in the fourth, 4 in the fifth, 
and 3 in the sixth. 
Symptoms.-After some great mental strain or worry a loss of appetite 
begins to manifest itself; the digestive powers are still normal but the 
patient shows a lack of desire for food. This lack of appetite becomes 
more and more decided until the stage of absolute repugnance for food 
is reached, and the patient loses weight and strength, becomes anemic 
and pale, the pulse becomes slow and weak, the urine scanty, and marked 
constipation is evident. With these symptoms, others of a nervous 
character manifest themselves, and the patient becomes irritable, restless, 
and sleepless, and, if forced to take food, vomits. If the condition still 
progresses, symptoms of a very serious character arise, such as inanition 
with delirium, slight fever, and exhaustion, and the patient may die. 
When the disease is well marked the patient presents the appearance of 
having tuberculosis; the skin is dry, the abdomen is markedly retracted, 
the eyes are sunken, the pupils are dilated, and the mucous membranes 
are pale. Death may be due to exhaustion, pneumonia, or infection. 
Diagnosis.-The presence of other nervous manifestations, together 
with the anorexia and absence of all organic disease, easily leads to a 
correct diagnosis. In all cases, in arriving at a diagnosis organic diseases 
acconlpanied by anorexia must be excluded. 
Treatment.-In the milder forms much can be accomplished by insist- 
ing that the patient take sufficient nourishment. In order to make this 
possible the food should be varied and the patient's taste so far as possible 
be consulted. The bitter tonics at times play an important role; of 
these, gentian, colomba, quinine, and strychnine are often useful, espe- 
cially when combined with dilute hydrochloric acid. Lavage with a 
bitter infusion, or with a 0.5 per cent, solution of sodium chloride, has 
been recommended by Kussmaul and Fleiner. The nervous system 
should be built up by means of massage, hydrotherapy, and electricity. 
In all serious forms the patient should be isolated in a hospital or sanita- 
rium and placed under a strict rest cure, with forced feeding. The 
writer feels confident that the lives of a large number of his patients were 
saved by insisting upon this method of treatment. In those instances 
in which the patient still refuses to take food, gavage should be practised. 
When improving, some form of iron is useful. 
SITOPHOBIA 
This term was first introduced by Einhorn to indicate a special neurosis 
of the stomach manifested by marked fear of food. He declared 
that if this condition continued the dyspeptic symptoms gradually FUNCTIONAL DISEASES OF THE STOMACH 
159 
increased, even after taking the smallest quantities of food. In conse- 
quence the patient loses much flesh, becomes anemic, and develops 
other neurasthenic symptoms, such as dizziness, headaches, lassitude, 
etc. The fear is due to the unpleasant sensation and pain which occur 
after eating, in consequence of which the patient gives up one form of 
food after another until extremely small quantities of nourishment are 
taken and signs of inanition are produced. 
Etiology.-Sitophobia may exist secondarily to organic or functional 
disorders of the gastro-intestinal tract, or be a neurosis due to hysteria 
or neurasthenia. As a secondary condition it is found in ulcer, chronic 
gastritis, cancer of the stomach, chronic constipation, chronic diarrhoea, 
gastralgia, and enteralgia. In the series of 1592 cases of gastric neuroses 
there were 24 cases of sitophobia (1.5 per cent.), 18 being females and 6 
males. As to age, 4 were in the second decade, 7 in the third, 3 in the 
fourth, 6 in the fifth, 3 in the sixth, and 1 in the seventh. 
Symptoms.-On account of pain or uncomfortable sensations in the 
stomach the patient gives up one food after another until he subsists 
on a very small quantity of liquid food; in consequence of which the 
symptoms of inanition are produced. These are indicated by severe 
headaches, nervous manifestations (vertigo, general aches and pains), 
great loss of strength and flesh, and marked anemia. Many of these 
patients consume only from 400 to 1000 calories per day; if this persists, 
the emaciation continues until the patient finally succumbs. 
Treatment.-It is necessary to insist that the patient make every effort 
to take nourishment, even though it produces pain. In following out 
this plan he will observe that food which at first occasioned uncomfortable 
sensations gradually loses this effect and can be taken without fear of 
distress. At first liquid food alone should be given in the form of milk 
or egg-albumen, and gradually the diet should be increased to the soft 
and then to the solid form. In severe cases marked results are obtained 
by a well-regulated rest cure. It is an excellent plan to persist with 
liquid food, such as milk and eggs, for from ten to twelve days of the 
rest treatment, then increasing to very large quantities, and later suddenly 
placing the patient upon a generous diet without attracting his attention 
to the same. The patient gradually gains much in weight and strength 
by this plan of treatment. Occasionally the bromides, belladonna, and 
hyoscyamus are useful in reducing the sensitiveness of the stomach. 
INCONTINENCE OF THE PYLORUS 
Attention was first called to insufficiency or incontinence of the pylorus 
by de Sere and later by Epstein. The pylorus is insufficient when, during 
digestion, it is incontinent and fails to prevent the chyme from proceeding 
into the intestines at a too rapid rate. 
Etiology.-The condition may be due to an organic disorder, or may 
exist as a neurosis. The organic conditions that may produce the insuffi- 
ciency are carcinoma or ulcer of the pylorus or chronic gastritis. Boas 
has observed it in duodenal stenosis in which the pylorus was dilated 
by the material accumulating above the stenotic area. As a neurosis, 160 
DISEASES OF THE DIGESTIVE SYSTEM 
incontinence of the pylorus is a very rare affection. In the series studied 
there were but two cases (0.1 per cent.), one in a male aged twenty-seven 
years, the other in a female aged forty-one years. 
Symptoms.-This condition becomes evident by the fact that on 
inflation of the stomach this organ does not become filled and distended, 
but instead a gurgling takes place at the pylorus, the escape of air causing 
increased intestinal tympany. In addition, the stomach empties itself 
too rapidly after test meals and other meals, and there is a reflux of con- 
siderable quantities of intestinal contents, bile, and pancreatic secretion 
into the stomach. This is observed in almost every lavage. Because 
of the very rapid evacuation of the stomach, diarrhoea is common. 
Treatment.-Because of the passage of the undigested food into the 
intestines and the diarrhoea, food should be given in a very digestible 
form. Einhorn recommends direct gastric faradization and occasional 
lavage. In some instances strychnine has been of service. 
ATONY 
Atony of the stomach is that condition in which the muscular walls 
have lost their tonicity, with a resultant motor insufficiency, in conse- 
quence of which the stomach is unable to pass its contents into the 
intestine at the normal rate. Although this condition has long been 
recognized, great confusion still exists concerning its significance. By 
some authors it is classified as a purely nervous disorder, by others as 
a form of gastrectasis, while some pass it by in a cursory manner. Kuss- 
maul1 was among the first to make a distinction between atony and 
dilatation. He showed that in gastrectasia due to stenosis of the pylorus 
or of the duodenum, vomiting is very frequent during the entire course 
of the disease and is a characteristic sign, while in atony it rarely occurs. 
Oser2 attempted to distinguish between dilatation and atony, and 
stated that in actual dilatation lavage is of great benefit, but that in 
atony it is of little value. Naunyn3 laid stress on fermentation in dilata- 
tion of the stomach, and showed that in muscular insufficiency fermenta- 
tion is usually produced. Minor forms without fermentation, he believes, 
should be excluded from the chapter of true gastrectasia. For clearer 
views concerning this subject we are much • indebted to Boas,4 who 
described this disorder at length as a separate pathological condition, 
devoting a special chapter to it and calling it myasthenia (muscle weak- 
ness) or muscular insufficiency of the first degree. 
Etiology.-As regards causation, atony may be of two kinds, primary 
and secondary. Primary atony is found in persons who have been in 
the habit of consuming large quantities of indigestible food; the excessive 
use of fluids especially predisposes to this disorder; frequently, however, 
no such cause is assignable. Atony may be secondary to many other 
1 Volkmann's klinische Vortrage, 1880, Nr. 181. 
2 Ursachen der Magenerweiterung, Wiener Klinik, 1881. 
3 Deut. Archiv f. klin. Med., Bd. xxxi, 1882, S. 225. 
4 Specielie Diagnostik und Therapie der Magenkrankh., ii Theil, iv Auflage, S. 89. FUNCTIONAL DISEASES OF THE STOMACH 
161 
diseases, such as those of the brain and cord, typhoid fever, anemia, 
tuberculosis, and diseases of the gastro-intestinal tract, such as gastrop- 
tosis, enteroptosis, chronic constipation, chronic gastritis, and nervous 
dyspepsia. Cholelithiasis is not an infrequent cause (Boas). According 
to Peyer, it is often found as a neurosis secondary to disease of the gen- 
erative organs in males. Bamberger finds it frequently congenital, and 
according to Zweifel it is not uncommon in children, due in many cases to 
improper feeding. Pfungen has shown that atony of the stomach often 
originates during the period of puberty. It is not improbable that the 
precocious appetite at this age, leading to the consumption of much indi- 
gestible food, is the cause. No age seems to be exempt and it appears 
with equal frequency in males and females. In the series of 1592 cases 
there were 147 cases of atony of the stomach (9.25 per cent.), 79 being 
females and 68 males. As to age, 7 were in the first decade, 26 in the 
second, 26 in the third, 30 in the fourth, 25 in the fifth, 19 in the sixth, 
and 14 in the seventh. 
Symptoms .-Most patients complain of a loss of appetite, although in 
rare instances the appetite may be fully maintained, at least in the first 
stages. When the condition is secondary to nervous disorders the 
appetite may even be increased (Peyer). A feeling of pressure or fulness 
comes on, usually during or after meals, and this is especially marked 
after the ingestion of fluids. In light forms the distress reaches its height 
immediately after meals, and gradually passes off during the next hour, 
to be again aggravated by the smallest amount of food. In severer 
forms it may be so great as to continue with intensity for hours after 
meals, and become still more aggravated when food is taken again. This 
feeling of pressure is accompanied by heart-burn, pyrosis, and eructations 
of gas, but rarely by vomiting. The quality as well as the quantity of 
food ingested is productive of this symptom; fluids are most likely to 
induce pressure. Constipation is almost a constant feature, and head- 
ache of a dull character is often present and may at times lead to actual 
vertigo. Nervous symptoms of various kinds may be present, such as 
palpitation of the heart and indefinite pains, and on this account the 
disorder is frequently mistaken for neurasthenia. 
On physical examination the stomach is found to be enlarged, so that 
the greater curvature reaches to or below the level of the umbilicus. 
Peristaltic and antiperistaltic movements of the walls of the stomach 
may occasionally become visible. With but small quantities of fluid 
(from 250 to 300 cc.) in the stomach, splashing sounds may be readily 
produced. In atony the stomach is not only enlarged but its motor 
function is also markedly impaired, and it does not propel its food into 
the intestine at the normal rate. Under normal conditions the stomach 
will be found empty in from six to seven hours. Should particles of 
food still be present after this time the motor function of the stomach is 
much impaired. A most important test is the condition of the stomach 
before the ingestion of food (Boas). If the contents of the stomach be 
expressed in the morning before taking food, the stomach will be found 
entirely empty and free from all food remains. This is not so in cases 
of gastrectasia, in which greater or smaller quantities of food will be 
vol. in-11 162 
DISEASES OF THE DIGESTIVE SYSTEM 
found. Boas has devised still another test which has proved of great 
service. The test supper of Boas consists of white bread with butter, 
cold meat, and two cups of tea taken at 8 p.m. In atonic conditions the 
stomach will be empty the next morning, but in gastrectasis it will still 
contain food remains at that time. 
Examination of the gastric contents is of great importance. The 
expression one hour after an Ewald test breakfast shows large quantities 
of solid contents, not separating into the characteristic three-layered 
fluid of gastrectasis and not containing yeast spores or sarcinae. Upon 
chemical examination the contents show in most cases a normal propor- 
tion of hydrochloric acid, pepsin, and casein ferment. According to 
Boas, at the very beginning of atony of the stomach, through constant 
mechanical irritation of food upon the walls of the stomach, an increased 
acid production results; in fact, the irritation may be so great that even 
hypersecretion may be produced. In other cases there may be a condition 
of subacidity. The findings in this series were hyperacidity, 36; normal 
acidity, 60; subacidity, 20; anacidity, 14; and alternating acidity in 17. 
Among the frequent complications may be mentioned dislocation of the 
stomach (gastroptosis), of the bowel (enteroptosis), and of the right 
kidney. Litten endeavored to demonstrate that dilatation of the stomach 
may cause the liver to move downward, carrying with it the right kidney, 
but very few accept this explanation and Nothnagel claimed that Litten's 
cases were for the most part really atony. Although dislocation of the 
right kidney is quite commonly associated with atony, he maintained 
that this association was merely a coincidence. It is probable that the 
atony in these cases is secondary to a gastroptosis. Atony of the intestine 
is not an infrequent concomitant of atony of the stomach; indeed, both 
may be present for years, and it may be difficult to tell which is the 
primary trouble. Gastric vertigo, the vertigo dyspeptica of Trousseau, 
which this writer believed to be caused by chronic gastritis, probably 
depends in most cases upon atony (Boas). According to Boas1 the 
so-called asthma dyspepticum is not uncommonly found in atony of 
the stomach. 
Diagnosis.-Atony must be differentiated from nervous dyspepsia and 
gastrectasis. According to Bamberger2 the variability and rapid change 
of symptoms, the presence of other nervous symptoms, the normal and 
increased appetite, and the absence and rapid disappearance of the 
gastric disturbance, distinguish nervous dyspepsia from atony. At 
times a diagnosis is difficult and sometimes impossible. It must not be 
forgotten that atony is frequently a complication of nervous disorders. 
From gastrectasia, atony is diagnosed by the absence of food remains 
in the stomach in the morning before taking food; by the absence of the 
three-layered fluid of gastrectasia, and by the absence of sarcinae and 
yeast spores. There is a marked diminution in the secretion of urine 
in gastrectasia but not in atony. 
Prognosis.-Atony of the stomach is a chronic disorder and may last 
for years. It is quite amenable to treatment, and, although it may not 
1 Archiv f. Verdauungskr., 1896, Bd. ii, S. 444. 
2 Krankh. der Chylopoet. Systems, Virchows Handbuch, Bd. vii, I, 1855, p. 270. FUNCTIONAL DISEASES OF THE STOMACH 
163 
be perfectly cured, the patient may be relieved of all suffering. It may 
pass into gastrectasia years after, but this is a rather rare occurrence. 
Treatment.-Since atony is frequently caused by injudicious and too 
rapid eating, people with feeble digestive powers should exercise special 
caution to eat slowly, masticate thoroughly, and avoid indigestible food. 
Persons suffering from atony of the stomach should eat small quantities 
of food at frequent intervals. Since water is not absorbed in the stomach 
to any extent, it is advisable that the quantity of fluids taken should 
not exceed 1| liters a day; this amount should include all fluids. If the 
thirst is very great, enemata of water may be administered. 
The use of milk in large quantities has been recommended, but is not 
to be advised when the patient is able to go about, since the weight of 
large quantities of milk may overdistend the stomach; when, however, 
a rest cure is instituted, milk is often well borne, even in very large 
quantities. The diet in atony of the stomach varies according to the 
nature of the gastric secretion. In cases of superacidity a liberal meat 
diet, consisting especially of chicken, beef, mutton, is recommended; 
fish, eggs, hard and soft boiled, are also permissible; the vegetables 
should be selected with care; carrots, peas, and cauliflower may be given, 
but must be mashed and strained so as to rid them of cellulose. Potatoes, 
rice, and grits are also allowed. Butter is the best form of fat. 
Alcoholic stimulants are, as a rule, not well borne, and their use should 
be prohibited; in a limited number of cases alcohol in the form of a 
light wine acts as a stomachic and may be prescribed. In those cases 
in which there is an absence or a diminution of acid in the gastric secretion 
the lighter forms of meat, such as the white meat of chicken or fish, 
sweetbreads, stewed chicken, or raw scraped beef, should be allowed; vege- 
tables, on the other hand, must be given in somewhat larger quantities. 
The treatment of chronic constipation requires special mention. In the 
treatment the main reliance must be placed on the diet. Such forms 
of food should be given as in the course of digestion produce substances 
to excite intestinal peristalsis; among these foods are Graham bread, 
certain vegetables, such as carrots, beans, tomatoes, peas, turnips, 
macaroni, stewed and raw fruits, buttermilk, honey, and cider. This 
form of diet will often overcome the constipation without the aid of 
drugs. When the treatment just described proves ineffectual, injections 
of various kinds, especially of oil, may prove beneficial. 
In atony lavage is quite superfluous, and is not to be recommended. 
The use of the stomach douche is of greater benefit, especially in those 
cases depending upon the various gastric neuroses. Still more beneficial 
is the use of electricity, which may be applied either extraventricularly 
or intraventricularly. The best results are obtained by the intraven- 
tricular method. The tonicity of the muscular walls of the stomach is 
influenced by the faradic current. Painful conditions are alleviated 
by the galvanic current, the cathode being used intraventricularly, 
the anode placed upon the fundus of the stomach. To this may be added 
massage of the abdomen, the effect of which is to increase the peristalsis 
of the intestine and to strengthen the abdominal walls. In regard to 
the medicinal treatment, preparations of strychnine seem to serve the 164 
DISEASES OF THE DIGESTIVE SYSTEM 
best purpose. Either strychnine sulphate or the extract of nux vomica 
may be given in pill form. To allay the feeling of pressure, which is a 
constant and annoying symptom, the extract of belladonna is prescribed. 
When there is a diminished secretion of hydrochloric acid, 15-drop doses 
of dilute hydrochloric acid, given according to the method of Ewald 
several times after meals, is indicated. In cases of increased acidity, 
sodium bicarbonate should be ordered after meals. 
POLYSYMPTOMATIC NEUROSES. NERVOUS DYSPEPSIA (LEUBE) 
OR NEURASTHENIA GASTRICA (EWALD) 
The polysymptomatic neuroses are characterized according to Boas by 
the presence of an unusual multiplicity of symptoms, in contradistinction 
to the monosymptomatic forms, in which one symptom is prominent or 
alone observed. The most important and typical example of a poly- 
symptomatic neurosis is nervous dyspepsia, in which the symptoms are 
manifold and yet no organic changes can be detected. According to 
Leube's original conception, the term nervous dyspepsia was intended 
to cover that group of cases in which the secretory and motor functions 
of the stomach were normal while the patient was suffering from manifold 
subjective symptoms following the ingestion of food. More recently 
Leube included in this class a group of cases manifesting changes in 
the gastric secretion and motility. 
There are two forms of nervous dyspepsia: (1) That in which no 
anatomical changes can be detected in the stomach. (2) That in which 
the nerves supplying the stomach are involved in anatomical changes, 
together with consequent changes in the gastric secretion. Boas describes 
a third form originating "reflexly from other organs, such as from the 
kidneys, uterus, ovaries, male generative organs, and particularly in 
the intestines." In addition constitutional diseases, such as diabetes, 
tuberculosis, and syphilis may form a basis for the production of this 
condition. Nervous dyspepsia is also characterized by the fact that 
all the functions of the stomach, motor, secretory, and sensory may 
be disturbed at the same time. It is a well-known fact that nervous 
dyspepsia, accompanying organic diseases of the stomach, can be so com- 
bined with it that a most careful investigation may be necessary in order 
to differentiate between the primary and secondary affection. 
Etiology.-As nervous dyspepsia is frequently associated with general 
neurasthenia, all conditions bearing an etiological relationship to neuras- 
thenia are causative in the production of this disorder. A large number 
are due to worry, anxiety, reverses, overwork, sexual and alcoholic 
excesses, and also to the abuse of tea, coffee, and tobacco. Certain 
cases come from diseases of the blood, constitutional diseases or such 
other diseases as pulmonary tuberculosis and diabetes; other cases occur 
reflexly, the primary cause being eye-strain, genito-urinary disturbances, 
mental disturbances, or the puerperal state. In this series of 1952 cases 
of functional gastric disorders there are 268 (16.5 per cent.) cases of 
nervous dyspepsia, 154 being males and 114 females. As to age, 33 
were in the second decade, 55 in the third, 55 in the fourth, 68 in the FUNCTIONAL DISEASES OF THE STOMACH 
165 
fifth, 38 in the sixth, and 19 in the seventh. It occurs more frequently 
in males than in females. 
Pathology.-In 41 patients suffering with nervous dyspepsia Jurgens1 
discovered a total degeneration of Meissner's and Auerbach's plexuses 
after death; so that in a certain number of cases there appears to be an 
anatomical basis for this condition. 
Symptoms.-It is characterized by the multiplicity of its symptoms, 
varying greatly in intensity, mode of onset, and frequency. The most 
prominent sign is the gastric discomfort present after meals, although 
the distress is not dependent upon the quality and quantity of food 
ingested, but rather upon mental strain, worry, or excitement. It often 
happens that the most digestible food causes distress, while the most 
indigestible food is borne without discomfort. The gastric distress is 
characterized by pressure, fulness, eructations, distension, flatulency, 
peculiar sensations in the stomach, and heartburn. One food after 
another is discarded on account of the discomfort produced by eating 
until the condition of sitophobia is produced with symptoms of marked 
inanition. In addition manifestations of neurasthenia are often present, 
headache, depression, vertigo, palpitation of the heart, lassitude, loss 
of strength, globus hystericus, and insomnia. The appetite is usually 
capricious, developing into a bulimia, and followed quite suddenly by 
complete anorexia. The general condition of the patient is not usually 
affected, although in some instances the emaciation may be so extreme 
as to suggest a serious organic disease. The periods of well-being, 
alternating with those of discomfort, are rather characteristic as also 
are the variations in the intensity of the symptoms from day to day. 
The abdomen is usually found sunken, occasionally distended with gas, 
accumulating often in the region of the cecum and in the colon at the 
splenic flexure; the abdomen is often tender at the distended areas, 
but the pain is relieved by the expulsion of the gas. The bowels are, 
as a rule, constipated. 
In the larger proportion of cases the gastric secretion is normal; 
occasionally there is a subacidity and less often a hyperacidity. A 
characteristic feature is the fact that when anacidity exists the ferments 
are not generally diminished in quantity; not infrequently marked 
variations in the state of the secretions are met with (heterocbylia). In 
this series the gastric analysis showed normal acidity in 163, subacidity 
in 57, hyperacidity in 35, and heterochylia in 13. As a rule, the motor 
function remains normal, although occasionally atony of the stomach 
may occur. In the 268 cases a slight atony existed in 57; a gastroptosis 
is not infrequently found, it being present in 41 of this series. 
Diagnosis.-This is made by the absence of all indications of organic 
disease, together with the general neurasthenic symptoms, associated with 
the digestive disturbances. It is further strengthened when the motor 
and secretory functions of the stomach are found normal. Greater 
difficulty, however, is manifested when these functions are not perfectly 
normal, but even then the symptoms present are so far out of proportion 
1 Verhand, des III Congresses f. Medicin, S. 253. 166 
DISEASES OF THE DIGESTIVE SYSTEM 
to the changes that these slight variations will not account for the 
condition found. The discomfort is not dependent upon the quantity 
and quality of food; indigestible food does not increase the distress. 
It is always necessary to exclude all organic conditions, but this is 
not always a simple matter. Boas advises the following plan in doubtful 
cases: A very easily digestible diet is given the patient, similar to that 
ordered during the third week of an ulcer treatment; while on this diet, 
the subjective symptoms are observed for a period of from three to four 
days, when other foods are gradually added, such as sauces, vegetables, 
desserts, and various fruits. The symptoms are now compared with 
those during the first period. In nervous conditions they do not increase 
in intensity on the fuller diet but will often lessen, while in organic 
disease they will increase. 
Nervous dyspepsia is distinguished from chronic gastritis in that 
the gastric disturbance is more or less directly dependent upon the 
quality and quantity of food ingested in the latter condition, while 
the gastric contents contain large amounts of mucus not observed in 
nervous dyspepsia. There may be an absence of free hydrochloric acid 
in both disorders, but an absence of enzymes does not usually occur 
in nervous dyspepsia. It is differentiated from ulcer by the absence 
of a localized, painful area in the epigastrium which, although it may 
be present for a few days at a time, is not constant; by the absence of 
hematemesis and occult blood in the stools and by the sudden dis- 
appearance of all discomfort. Often the diagnosis can only be made 
after trying the effect of an ulcer cure. 
In a certain number of cases of nervous dyspepsia the emaciation is 
so intense as to suggest carcinoma, especially if at the same time there 
is an absence of free hydrochloric acid. A correct diagnosis is arrived 
at by noting the age, the duration of the disorder, and determining the 
presence or absence of a motor insufficiency as well as of occult blood in 
the feces. The condition under discussion is further distinguished from 
gastric atony by the rapid changes in symptoms, and the non-dependence 
of discomfort on the quantity and quality of food ingested; atony and 
nervous dyspepsia are at times so combined that it is impossible to 
determine which is the primary disorder. 
Prognosis.-This is not always favorable, although, as a rule, it is not 
a fatal disease. It may become rather obstinate and resist all attempts 
at treatment; the milder forms usually yield readily to proper treatment, 
while the severer ones continue over a long period of time before entire 
relief is afforded or may show rapid loss of flesh and strength and finally 
end fatally. Relapses are not uncommon. 
Treatment.-Boas has made the statement that " in the larger propor- 
tion of cases of nervous dyspepsia drugs are not indicated. The patient 
should be taught that recovery cannot be brought about by the use of 
drugs, but only by a sensible mode of living and following the laws of 
hygiene." In all cases in which it is possible to determine the cause, 
this should be relieved, i. e., all intestinal disturbances should be corrected, 
anxieties and worries relieved, and sexual disorders treated. When no 
cause can be determined, the treatment should be directed toward the FUNCTIONAL DISEASES OF THE STOMACH 
167 
general neurasthenia. This is often best combated by change of scene 
and climate. The diet should not be too restricted, but strengthening- 
food, without any attempt at a too rigorous diet, should be prescribed. 
In those cases in which milk is well tolerated it may be given in large 
quantities; when it is not well borne, buttermilk, kefir, or koumyss may 
be substituted. The patient's appetite is humored, and he may be 
allowed to eat any food he can digest. Alcoholic stimulants are pro- 
hibited, or given only in very small quantities. In severe cases a well- 
conducted rest cure will produce the best results. In those cases in 
which the patient has lost much flesh and strength, the most beneficial 
results are obtained by these means with forced feeding and isolation. 
Hydrotherapy, massage, and electricity are useful. Rosenheim has recom- 
mended the gastric douche, while others practice lavage. Of the medi- 
cinal remedies used the milder preparations of iron, arsenic, bromides, 
and the preparations of valerian must be noted. 
Summary of 1592 Cases of Gastric Neuroses 
MONOSYMPTOMATIC GASTRIC NEUROSES 
Irritative Group 
Cases. 
Per cent. 
Males. 
Females. 
Superacidity or hyperchlorhydria . 
542 
34.00 
263 
279 
Supersecretion: Intermittent 
21 
1.50 
15 
6 
Continuous 
10 
0.65 
7 
3 
Digestive 
2 
0.10 
2 
0 
Bulimia 
24 
1.50 
5 
19 
Parorexia 
8 
0.50 
2 
6 
Gastralgokenosis 
7 
1.50 
7 
0 
Hyperesthesia 
31 
1.50 
4 
27 
Gastralgia 
24 
2.00 
7 
17 
Rumination or merycism 
24 
2.00 
20 
4 
Regurgitation 
32 
2.00 
26 
6 
Eructatio nervosa 
54 
4.00 
12 
42 
Vomitus nervosus 
49 
3.00 
15 
34 
Nausea nervosa 
40 
2.50 
10 
30 
Cardiospasm 
25 
1.50 
8 
17 
Pylorospasm 
4 
0.30 
1 
3 
Pneumatosis 
8 
0.50 
6 
2 
Peristaltic unrest 
1 
0.06 
1 
0 
906 
57.61 
411 (26%) 
495 (31%) 
Depressive Group 
Cases. 
Per cent. 
Males. 
Females 
Subacidity or hypochlorhydria 
. 80 
0.5 
34 
46 
Anacidity or achylia gastrica . 
. 112 
0.7 
55 
57 
Akoria 
5 
0.3 
3 
2 
Anorexia 
48 
3.0 
11 
37 
Sitophobia 
24 
1.5 
6 
18 
Incontinence of the pylorus 
2 
0.1 
1 
1 
Atony 
. 147 
9.25 
68 
79 
418 
26.15 
178 (11%) 
240 (15%) 
POLYSYMPTOMATIC GASTRIC NEUROSES 
Cases. 
Per cent. 
Males. 
Females. 
Nervous dyspepsia . 
. . . 268 
16.5 
154 (9.5%) 
114 (7%) CHAPTER V 
ORGANIC DISEASES OF THE STOMACH 
CHARLES F. MARTIN, M.D. 
GASTRIC AND DUODENAL ULCER 
Synonyms.-Simple ulcer of the stomach; round ulcer; peptic ulcer; 
chronic ulcer; perforating ulcer; ulcus ventriculi (Frank); Cruveilhier's 
disease (Cruveilhier was the first to give a good clinical and anatomical 
description of the condition). The first name is doubtless the best, for 
these ulcers are not always round, neither are they always chronic, nor 
do they always perforate. Erosions of the gastric mucosa are probably 
often early conditions of gastric ulcer, both as regards etiology and 
morbid anatomy, and the subsequent autodigestion affords the more 
typical appearance of the simple ulcer. 
Definition.-A more or less progressive destruction, beginning in the 
mucosa and sometimes extending to and even through the deeper 
layers of the stomach wall, of the nature of a degeneration or a necrosis. 
These ulcers occur practically only where the gastric juice flows, and 
are found, therefore, only at the extreme lower end of the oesophagus, 
in the stomach itself, and in the portion of the duodenum above the 
opening of the common bile duct. Such ulcers may be acute or chronic, 
with or without tendency to cicatrization and healing. They leave an 
open loss of substance, usually round or oval in shape, with edges which 
are, as a rule, clean cut in the acute and subacute cases, more irregular 
in the chronic. Acute exacerbations of chronic ulcers are commonly 
mistaken for acute ulcers, and the subsidence of the acute period is 
often mistaken for the cure. 
Statistical.-Statistics in regard to gastric ulcer are, on the whole, 
of very doubtful value. Those based upon clinical observation alone 
are unsatisfactory; because of the difficulties in diagnosis of obscure 
cases many other conditions are often erroneously included. Statistics, 
again, bearing upon pathological examinations are often insufficient, 
either from the frequency with which simple ulcers are overlooked, or 
because the healing has been so perfect that often, as Bramwell states, 
no scar at all is left behind. The unsatisfactory grouping of cases of 
simple round ulcer with those due to causes of an entirely different 
nature renders the statistics still more unreliable. Combined clinical 
statistics show 3036 cases diagnosed as ulcer among 339,575 patients, 
i. e., 0.894 per cent. Combined statistics of autopsies of various series 
show 2608 ulcers out of 59,450 autopsies, i. e., 4.4 per cent. As a cause 
of death, ulcer occurred in 410 out of 444,564 deaths. 
Geographical Distribution.-The regional differences are great, the 
most marked being, as Rutimeyer has shown, between North America 
on the one hand (0.12 to 1.28 per cent.) and Central Europe on the 
other, (0.54 to 3 per cent.) clinically. Their pathological variations are 
168 ORGANIC DISEASES OF THE STOMACH 
169 
even more marked (0.85 to 2.35 per cent, as against 1.30 to 11.0 per cent.). 
For the reasons cited it does not seem possible to obtain useful statistics 
on regional differences in distribution. 
Etiology and Pathogenesis.-The three main etiological factors in 
simple ulcer of the stomach are: (1) An injury to the gastric mucous 
membrane; (2) a circulatory disturbance; and (3) the acidity of the 
gastric juice. The combination of these three factors appears to permit 
of autodigestion. No single well-defined cause has been found. Much 
has been done to produce ulcers experimentally in the lower animals, 
but recent observations, particularly those of Kawamura, have shown 
that they possess a dubious value. It would appear that ulcers of the 
stomach abound in the greatest variety of conditions in rabbits and 
they have frequently been found in stomachs that were supposed to 
have been normal. Experiments on rabbits are unreliable, and those on 
dogs are open to a great deal of criticism, as it is impossible to determine 
what the real etiological factors were in the experiments. 
Age.-Gastric ulcer is most common between twenty and thirty years 
of age, though the age incidence differs according to the sex. The average 
for males is 36.7 years and for females 27.1 years of age. In infancy it 
is rare, no case occurring under ten years in 262 autopsies on cases of 
ulcer at the Berlin Pathological Institute. Cutler studied 29 cases, of 
which 6 were found immediately after birth, 8 under seven years of age, 
and 9 between the ages of eight and thirteen years. Rehn, on the other 
hand, collected 9 cases of simple ulcer in children, and Kundrat speaks 
of frequently having found minute pinhead-sized ulcers in children, 
which, however, were probably the result of hemorrhage and differed 
thus from ordinary round ulcer. Martha Wollstein, Holt, and others, 
have added cases, though many experienced pediatrists have never 
observed a case clinically. The symptoms seem less distinctive than 
in adults, and depend chiefly on evidences of blood in the vomitus 
or feces, for which many other causes than ulcer may be found, e. g., 
hemorrhages from the nose, throat, lungs, or from the mother's breast; 
or, again, from general constitutional diseases, such as scurvy, purpura, 
the malignant exanthemata, cirrhosis of the liver, etc. Perforation 
seems to be relatively more common in children than in adults. Henoch 
found ulcers occasionally in the newborn, and, according to Osler, they 
are sometimes found in the fetus. An example of the presence of ulcer 
at the other extreme of life is reported by Eleanor C. Jones in a man, 
aged eighty-four years, with a past history of gastric ulcer thirty years 
before, and in whom, at death, a fresh ulcer was found next to the scar 
of the old healed ulcer. 
Riegel's statistical table (compiled from clinical cases) is interesting: 
Age. 
Men 
Riegel's table. 
The writer's combined 
clinical statistics. 
Women. 
Total. 
0 to 10 years . 
1 
0.14 
per 
cent. 
10 to 20 years . 
... 8 
35 
43 
85 
12.00 
per 
cent. 
20 to 30 years . 
. . . 29 
62 
91 
259 
37.00 
per 
cent. 
30 to 40 years . 
... 35 
22 
57 
186 
26.50 
per 
cent. 
40 to 50 years 
. . . 36 
11 
47 
110 
14.00 
per 
cent. 
Over 50 years 
. . . 18 
4 
22 
63 
9.00 
per 
cent. 
Total 
. . . 126 
134 
260 
704 170 
DISEASES OF THE DIGESTIVE SYSTEM 
Sex.-Statistics on this point vary greatly and one should not attach 
too much importance to individual reports. Clinically, most statistics 
show a preponderance of women over men, in the proportion of 2 or 3 to 
1, but, pathologically, the numbers are about equal in both sexes. 
Occupation.-This bears some relation to ulcer only in so far as injury 
to the mucosa or the circulation may occur, and no walk of life appears 
to be exempt. According to some authorities, cooks are predisposed 
presumably because of their habit of swallowing foods which irritate 
the mucous membrane. In Payne's statistics only 3 out of 50 females 
were cooks. Workers in metals (Bouvert), glass and procelain factories 
(Bernitz), who are in the habit of swallowing dust particles, are thought 
by some to be more liable; so also tailors and shoemakers because of 
their position and occupation leading to abdominal pressure; but in all 
these there would seem to be some preliminary injury to the mucosa 
or the circulation. 
Dietetic Errors.-In themselves these are scarcely to be regarded as 
the cause'of true gastric ulcers except when they create trauma. Where 
a combination of circumstances may induce hyperacidity, disease of 
the mucosa, or other conditions, to assist formation of gastric ulcer, 
it may be that indigestible foods or dietetic indiscretions aid the develop- 
ment of the condition, or may be, at least, regarded as antecedents. 
Infections.-Letulle found gastric ulcer in a man suffering from dysen- 
tery and isolated bacteria from the stools, which, when injected in pure 
cultures into guinea-pigs, produced specific erosions and ulcerations. 
Erosions and ulcers, however, are frequently found in general infections, 
and although Martin believes that the pyloric site of ulcer favors the 
bacterial theory, the anatomical appearances of the ordinary round 
ulcer scarcely suggest a bacterial origin. Spirochaetae may predispose 
to gastric ulcer by producing vascular changes, but there is no relation 
between the specific luetic gastric ulcer and the one under consideration. 
Tuberculous ulcers, which seem to be more and more frequently found, 
are likewise not to be regarded in the category of the ordinary round 
ulcer. While it may be true that 20 per cent, of patients with ulcer 
die of tuberculosis, it is equally probable that the underlying conditions 
which favor the development of gastric ulcer likewise favor the develop- 
ment of the tubercle bacillus. Round ulcer is a pure necrosis and not a 
pure infection. 
Trauma.-As a cause of gastric ulcer this may be external or internal. 
Internal trauma, arising from hot foods, corrosives, foreign bodies, and 
mechanical and chemical irritants, may produce gastric ulcer or such 
early lesions as may later lead to ulcer. External injury, as from a 
blow or, perhaps, even from mere compression, may cause ulcer. 
Ritter produced experimental submucous hemorrhage in dogs after 
inflicting blows on the stomach, in one case causing even a separation 
of the mucous membrane, and it was his opinion that injuries predisposed 
to ulcers through the subsequent action of the gastric juice. He further 
describes an incident in which injury in the epigastric region was followed 
in eight days by hematemesis and other signs of gastric ulcer. Fertig 
describes an apparently undoubted case in which, as a result of a kick ORGANIC DISEASES OF THE STOMACH 
171 
in the abdomen, four gastric ulcers were found at autopsy. One may 
conclude, however, that such injuries sometimes provide the original 
lesion for the later formation of true ulcer. The same probably holds 
true of the theory of Rokitansky and Rindfleisch and Key, that ulcers 
arise from hemorrhage and subsequent erosion. 
This seems to be the view taken by Richardiere, whose traumatic 
ulcer cases are classed in two groups, the one, acute cases healing rapidly, 
the other, cases running a course similar to ordinary chronic ulcer. 
The difference in the result may depend on the condition of the gastric 
juice, especially as regards its acidity. Violent emesis as a mechanical 
factor in the causation of gastric ulcer is a doubtful cause and much 
more likely to be associated with some underlying condition, such as 
uremia. 
General Disease.-Chlorosis and anemia are thought by many to be 
predisposing factors, while, vice versa, chronic ulcer certainly often leads 
to anemia. Samuel and W. S. Fenwick hold that a definite relation 
exists between ulcer and anemia, and 72 per cent, of their cases showed 
symptoms of anemia before serious ulcer symptoms developed. Perhaps, 
as Cabot and Stengel suggest, the chlorosis is often due to hemorrhages, 
though in Fenwick's case the chlorosis occurred without these. There 
can be little doubt that ulcer occurs more commonly among those who 
are anemic than in persons in perfect health. 
Previous gastric trouble as an etiological factor is of doubtful impor- 
tance, except, of course, when hyperacidity and hypersecretion have 
existed. It is difficult, however, to draw the line between the symptoms 
of previous gastric disturbances and the early signs of ulcer, for a supposed 
preliminary gastritis may have been merely the indefinite symptoms 
induced by the already existing ulcer. C. H. Miller believes that inflam- 
matory swelling and rupture of lymphoid follicles may induce erosions 
which may probably develop later into true ulcers. Gastric ulcer is 
essentially a necrosis. It is doubtless due primarily to a circulatory 
disturbance, be it arterial, venous, or capillary, and when once a defect 
occurs it is prevented from healing by the action of the gastric juice. 
Excessive acidity makes the ulcer chronic. This tendency to chronicity 
with lack of healing power is the distinguishing characteristic of simple 
ulcer as opposed to a mere traumatic erosion. 
Relation of Circulatory Disturbance to Gastric Ulcer.-Various circu- 
latory disturbances may account for the early changes which produce 
lesions. 
Arteries.-Embolism.-Virchow, Orth, and recently Payr, insisted on 
the embolic nature of the disease. Payr's experiments have established 
the etiological relationship of ulcer with disturbance of the circulation. 
The fact that the arteries are not terminal implies that ulcer is not the 
necessary invariable result, and often, too, where ulcer exists, no emboli 
can be found. The same holds true with thrombosis. Arteriosclerosis 
comes under the same head (Floward), as, too, would ligature of the 
afferent vessels (Litthauer). 
Vascular Spasm.-Contractions of the muscularis mucosa, including 
the afferent vessels (Talma, Lichtenfeld, Bergmann, Rossie) have also 172 
DISEASES OF THE DIGESTIVE SYSTEM 
been associated with gastric ulcer. It is doubtful, however, if contraction 
of the muscularis mucosa would affect the arterial rather than the venous 
portal system. Arterial spasm, however, may be accountable for the 
acute perforating ulcer. 
Venous.-Hemorrhagic infarction and submucosal hemorrhages from 
external trauma (Ritter, Fertig, Kronlein), and internal, through 
chemicals and irritating substances, affect the surface of the projecting 
folds of the mucous membrane. Aschoff has insisted on the importance 
of this factor. Whatever the circulatory disturbance may happen to 
be-and any one of these may institute an early lesion-other factors 
must be superadded to produce the ordinary ulcer, for without them 
healing will occur. The mechanical factor is of great importance and 
helps to account for the production of some forms of circulatory dis- 
turbances. Aschoff has drawn attention to the early origin of ulcer on 
the top of folds of the mucous membrane, especially at the lesser curva- 
tures, where two large rugae exist, exposed to attrition, to contact with 
thermic, chemical and mechanical causes of injury, as well as to the 
effects of muscular spasm. There would seem to be certain points in 
the cavity of the stomach where contact with irritative substances is 
more constant and where food is retained for a longer period, thus keeping 
up the irritation. It is at these points, as Aschoff has shown, that ulcer 
is most frequent. 
Nervous influences originating in the central nervous system, in the 
coeliac ganglia, in the splanchnic, the vagus, and elsewhere, play a part 
which is only subordinate. It is possible that they produce the circu- 
latory disturbance which, later on, develops into an ulcer. The work 
of Eppinger and Hess, following the suggestions of Bergmann, is of 
interest. According to these writers the equilibrium between the vagus 
and sympathetic systems is sometimes disturbed, resulting in spasm 
of the muscularis mucosa, which helps to produce circulatory disturbance 
and ulcer. G. v. Bergmann has attempted to show that in cases of 
gastric ulcer there are already various stigmata to show this want of 
harmony, e. g., hypersecretion, spastic contractility of the muscles, 
spastic constipation, cold extremities, and other evidences of the so-called 
neuroses. 
The Relation of Hyperacidity and Hypersecretion to Gastric Ulcer.- 
Statistics vary regarding the frequency of hyperacidity in gastric ulcer. 
This may be due, in part, to faulty observations, but for the most part 
to a difference in interpretation of what hyperacidity and hypersecretion 
really mean. It would seem that in a large proportion of ulcer cases 
increased secretion of hydrochloric acid is found; in many others, however, 
repeated examinations have shown that the acidity is either normal or 
deficient. Einhorn, in America, found hyperacidity a common feature 
of gastric ulcer, as did also Robin in France, and Fenwick in England. 
Rutimeyer, however, in 162 cases (36 men, 126 women) found 42.5 per 
cent, with hyperacidity, and 57.4 per cent, with the acidity normal or 
diminished. Hyperacidity was relatively much more frequent in men. 
It is, however, thought that in gastric ulcer the symptoms of hyperacidity 
arise through the delay in neutralizing the acid contents discharged into 173 
ORGANIC DISEASES OF THE STOMACH 
the duodenum. This results in pylorospasm, which in its turn produces 
retention of secretion and the condition known as Reichmann's disease. 
Bickel has demonstrated that the proportional quantity of acid secreted 
in the gastric juice is, under all conditions, uniformly the same; hence 
the presence of excessive acidity means the presence of excessive secretion 
in general. 
In the present state of our knowledge the following views may be 
regarded as justifiable: 
1. Hypersecretion and hyperacidity are common in gastric ulcer, 
though not essential to the diagnosis. Gastric ulcer, however, occurs 
only where gastric juice flows. 
2. The amount of secretion and acidity vary at different stages and 
periods of the disease. Hyperacidity often appears at the time imme- 
diately preceding or following a hemorrhage; many exceptions to this 
occur. 
3. Hyperacidity occurs in the absence of gastric ulcer, but when 
persistent it should suggest the diagnosis of ulcer. 
4. Hyperacidity alone cannot produce gastric ulcer. 
5. The frequent association with chlorosis makes the combination 
an important factor in the etiology. 
6. Hyperacidity superadded to a lesion of the mucous membrane is 
an important etiological factor. 
7. Hyperacidity may induce gastric ulcer when through any cause a 
portion of the mucosa is injured. This may occur in two ways: through 
direct contact with the acid, and by its action on the exposed vessels, 
which are thereby contracted, and a local anemia and necrosis thus 
induced. 
8. That chronicity is directly induced by hyperacidity is responsible 
for the prolonged course of the disease, and prevents healing. It does 
not form ulcers often, but causes them to become chronic. 
9. The failure of many cases in which gastro-enterostomy has been 
performed is probably associated with hyperacidity and hypersecretion. 
Pathology.-Situation.-These ulcers exist wherever the gastric juice 
flows. The posterior surface of the stomach is the commonest site, and 
ulcers are found there in 42 per cent, of all cases, especially near the 
pylorus and along the lesser curvature. The situations are variously 
described. In statistics of over 2000 cases collected from various sources 
the following percentage occurred: 
On the lesser curvature 726 or 35.0 per cent. 
Posterior wall 585 or 28.0 per cent. 
Pylorus 291 or 14.0 per cent. 
Anterior wall 182 or 9.0 per cent. 
Cardia 134 or 6.5 per cent. 
Fundus 62 or 3.0 per cent. 
Greater curvature 75 or 3.6 per cent. 
Anterior and posterior walls together . . . 14 or 0.7 per cent. 
Total 2069 
Number.-These ulcers are usually single, but often multiple. Indeed, 
that they are commonly multiple is becoming more and more recognized. 174 
DISEASES OF THE DIGESTIVE SYSTEM 
There were 34 in one of Berthold's cases. Sometimes a perforated ulcer 
is found at operation and after healing another may perforate. In 
Brinton's 463 cases, 381 had one ulcer, 57 showed two ulcers, 16 had 
three, 3 had four, 2 had five ulcers, and 4 had more than five. When 
multiple, they mav all seem to be of the same duration, or some may be 
Fig. 2 
Two gastric ulcers: A. showing a shelving base and central perforation; B, more superficial 
in a state of healing, while others seem to be quite recent. Welch and 
others regard 20 per cent, of cases as multiple. In 13 out of 21 cases 
operated on and resulting fatally, Carless found more than one ulcer. 
Sometimes one ulcer is in the stomach and another in the duodenum. 
Shape.-The more acute ulcers are punched out in appearance, round 
or oval and sharp in outline, while the less acute ones are shelved or ORGANIC DISEASES OF THE STOMACH 
175 
terraced, the widest diameter and the greatest loss of substance being 
at the mucosa. The ulcers become gradually narrower as one approaches 
the serosa (funnel-like, Aschoff). This was seen to correspond to the 
distribution of the bloodvessels, and Orth had drawn attention to this 
fact. The still older lesions are often irregular in outline, spread out, and 
with the mucosa rolled inward and thickened at the edges. If extensive, 
they are serpiginous, especially where several have fused. Thickening 
and raising of the edges occur as the ulcer gets older. Often they are 
saucer-like, with bevelled edges, and rounded out or concave. 
Cicatrization may often be seen progressing in various portions of the 
walls. The muscle beneath is shrunken, the floor is smooth and grayish, 
brown or red, rarely ragged. It is generally covered with some necrotic 
tissue, and in old ulcers with indolent granulation tissue. Sometimes 
there is a hemorrhagic exudate. Adhesions externally and scarring 
within cause deformities in the organ (hour-glass stomach, etc.). 
Size.-The usual size varies from 2 cm. to 3 to 4 cm. in diameter; in 
many instances, however, they may be as small as 1 cm. or less, or, again, 
as large as 10 cm. in diameter, sometimes even forming a ring more or 
less completely surrounding the organ. Peabody records one measuring 
19 by 10 cm. 
Histology.-The lesion is essentially a necrosis. There is very little 
inflammation or sign of healing in acute round ulcers, and even in many 
older ones; hence the slow repair, resembling somewhat the ulcus per- 
forans pedis. There are, moreover, some signs of digestion. 
Healing and Cicatrization.-Undoubtedly many ulcers occur and heal 
without giving symptoms of any kind. Many are superficial erosions 
rather than ulcers and healing occurs with granulations from the sub- 
mucosa and scar formation. At all events, the frequent presence of 
scars and little fibroid areas suggests the possibility of ulcer as the cause 
of these. The healing process commences from the sides and floor of 
the ulcer. There is proliferation of the adjoining fibrous and glandular 
tissues, the edges become indurated, and the margins are more indefinite 
and irregular in outline, with signs of puckering and contraction. The 
gland structures are repaired to a limited extent only; the new tubules 
are small and atypical, not like the original epithelial structures, but 
with cylindrical cells often arranged around the lumen, with no opening 
toward the stomach cavity and no secretion from the cells. Sometimes 
in old ulcers the healing process leaves chronic inflammatory areas 
which tend to erosion and recurrent bleeding. The area of stomach 
around old ulcers is often infiltrated with small cells and fibroblasts to a 
great extent. Where muscle tissue is lost it is replaced by fibrous tissue. 
Scars vary in size, and, according to their size and situation and to the 
amount of contraction which follows the healing process, they may or 
may not cause perceptible deformities in the organ and corresponding 
functional disturbance. The deformities thus caused comprise hour- 
glass contraction, pyloric stenosis and gastrectasis, and other irregularities 
with or without obstruction. Perforation occurs when the ulcer pene- 
trates down to the serosa before adhesions have formed, and for this 
reason it naturally occurs most commonly on the anterior wall. 176 
DISEASES OF THE DIGESTIVE SYSTEM 
Symptoms.-Latency.-There may be no characteristic symptoms, 
and the first discovery of a gastric ulcer may be made unexpectedly at 
autopsy. Stoll found it latent in 27 per cent, of his autopsies; Lebert 
found that 15 per cent, of 110 cases were latent until severe symptoms 
arose. Then, again, the first evidence may be a sudden or perhaps fatal 
hemorrhage, or the peritonitis following a perforation. It may be latent, 
even if perforation has taken place, as in one instance in which an ulcer 
giving suspicious signs of perforation remained quiescent. The patient 
for some days after the event seemed to improve, and there was little 
or no tenderness in the abdomen. Several weeks later an abscess devel- 
oped in the pelvis, which was opened per vaginam and drained, and the 
autopsy revealed the origin to be in a fistulous opening from a perforated 
gastric ulcer. Sometimes nothing but backache occurs, as in the case of 
Beneke, in which for years this was the only symptom; a sudden peri- 
tonitis from perforation caused death and the autopsy showed old 
adhesions to the liver and a perforation between the adhesions into the 
abdominal cavity. Sometimes spinal disease is suspected, and a plaster 
jacket has been put on. 
Dyspepsia.-While the cardinal signs are pain after eating, epigastric 
tenderness, vomiting, and hematemesis, yet often, perhaps even as a 
rule, the symptoms are less definite and dyspepsia is the only evidence 
to be found, with perhaps a little vomiting or regurgitation. There 
may be a sense of fulness, weight, or distension with gaseous eructations. 
With these there may be pyrosis, occurring during the digestive period, 
or mere gnawing or burning or " heisshunger" (from hyperacidity). 
Orthoform has been used as a test, dulling the sensitive exposed areas 
of ulcers and having no effect on mere hyperesthetic mucous membranes. 
Its use, however, has justly been called into question, as its action is 
unreliable. The general condition of the patient, as a rule, remains 
good, although anemia, emaciation, and weakness, all due to local causes 
in the stomach, are common and sometimes marked. Nervousness, 
melancholia, headache, and dizziness are frequent; so, too, are amenor- 
rhoea and dysmenorrhoea. Fever is usually absent, unless complications 
arise (peritonitis, hemorrhage, etc.). Often there may be a rise of 1° 
without complications, perhaps associated with anemia. The appetite 
varies; it may be excessive, but the patient fears to eat because of pain. 
Thirst is common. Constipation is the rule because of sex, food, anemia, 
lack of exercise, and vomiting. The stools may show blood. 
The urine is lessened in quantity when vomiting occurs or when less 
nourishment is taken. It is usually less acid than normal, especially 
when gastric hyperacidity is present. Indeed, it is often alkaline, more 
particularly if gastrectasis be present, and then, if there is fermentation 
in the stomach, the urine will show an excess of ethereal sulphates and 
indican. Acetone and diacetic acid are sometimes present, and one 
may even find serious acidosis. Other alterations are unimportant. 
Sometimes there is albumin, and this is not uncommon after severe 
pain. Dreschfeld found albumoses occasionally present. 
Special Symptoms.-Pain.-This may exist in all degrees from a slight 
discomfort due to hyperacidity, to acute agonizing paroxysms. It may ORGANIC DISEASES OF THE STOMACH 
177 
be relieved or aggravated by food. Pain occurs in over 90 per cent, of 
all cases. Intermittency of the pain is one of its most characteristic 
features. It is frequently localized and nearly always referred to the 
same spot in the epigastrium below the xiphoid cartilage. Pressure of 
the hand or clothing usually aggravates it. It may or may not be altered 
by a change of posture. One may say, as a general rule, that the effects 
of posture give no clue to the site of the ulcer. 
Time of Appearance.-Pain occurs during the digestive period either 
at once after taking food, or at the height of digestion, two to four hours 
after; the hyperacidity increases it. 
Site.-The pain is usually in the epigastrium-high up-and may be 
to the right or left of the median line, though the tenderness is more to 
the right side as a rule. According to French writers, two points of 
pain exist: (1) Visceral pain corresponding to the injured area, occurring 
late in the disease and only with perigastritis; and (2) solar pain- 
epigastric and not characteristic of ulcer; it is equally common in other 
diseases. Not infrequently a tender point is found in the back, 2 to 3 
cm. to the left of the vertebral column, somewhere between the seventh 
to twelfth dorsal vertebrae. 
Effect of Food upon Pain.-It is distinctly aggravated by a large 
amount of solid food, but there are exceptions in which food sometimes 
gives relief, especially albuminous food, if there be hyperacidity. Some- 
times, too, there is no relation whatever between the food ingested and 
the onset of the pain. Rutimeyer found this to be the case in 14 per 
cent, of his 200 cases. The pain is often relieved by rectal alimenta- 
tion. 
The cause of the pain varies, it being apparently due sometimes to 
food, sometimes to the gastric movements or to involvement of the 
peritoneum. Scars do not usually cause pain unless there are adhesions. 
J. Mackenzie holds that it is a viscero-sensory reflex-a referred pain- 
and that the tenderness depends on muscular and cutaneous conditions 
rather than on the organic change in the stomach itself. 
Vomiting is perhaps less constant than the pain. Cantlie found 
vomiting in 79 out of 85 of his cases in Montreal. There may be merely 
nausea and flatulence without vomiting, or, again, the vomiting may 
appear only at intervals of a week or more. It has a very definite relation 
to pain, by which it is usually preceded. There is often no nausea, as 
one might naturally expect if the pain is the chief cause. It occurs 
sometimes immediately after taking food, but usually one, two, or three 
hours later, that is, during digestion and generally at its height. The 
pain is usually relieved by it. In some cases the vomiting may depend 
on infection from the mouth through the swallowing of bacteria. In 
more or less acute ulcer there are no signs of motor insufficiency, and 
the vomitus consists merely of the food taken; in the older ulcers, when 
perhaps pyloric obstruction has already occurred and the stomach is 
dilated, the usual vomitus of motor insufficiency and gastrectasis may 
be present. As hyperacidity is usually present, one finds, as a rule, 
that digestion is quick and the albumins are well divided, although at 
other times the food is quite undigested and the vomitus acid. 
VOL. HI-12 178 
DISEASES OF THE DIGESTIVE SYSTEM 
liematemesis.-Blood is frequently present in the vomitus, and 
occurred in more than 25 per cent, of all cases of gastric ulcer at the 
Royal Victoria Hospital. It is well to remember, in this connection, 
the many other causes of hematemesis that may exist, especially erosions 
of the mucosa. The source of the blood in gastric ulcer may be venous, 
arterial, or capillary. Savariaud found in 54 cases that the hemorrhage 
was venous in 4, from the splenic artery in 17, from the coronary artery 
in 6, from the pancreatico-duodenalis in 7, from the gastric arteries in 
10, while in 10 others the source was undetermined. Sometimes the 
bleeding is more latent, being not visible to the naked eye either in the 
vomitus or feces, although minuter methods of detection reveal its pres- 
ence. These "occult bleedings"have considerable importance in diagnosis. 
One cannot always tell the actual vascular sources from the amount 
of blood. The hemorrhage may be severe or slight. It may be fatal at 
once, even before ejection from the stomach, the "hemorrhagie foudroy- 
ante," when a large artery is eroded; or there may be repeated small 
hemorrhages. Hemorrhage is responsible for about 20 per cent, of all 
the deaths in ulcer. 
Symptoms and Signs of Hematemesis.-The hemorrhage comes on 
usually after meals, subsequent to some effort or strain, such as from 
vomiting or defecation. Usually when there is a serious hemorrhage, 
the patient vomits a large amount of bloody fluid, becomes pale, cold 
and clammy, complains of dizziness, is often semi-conscious or more 
or less collapsed. Headache and thirst follow. The pulse is rapid and 
small, and there is dyspnoea or sighing, and often complaint of a warm 
feeling in the epigastrium. If recovery occurs, the reaction is apt to 
come on with fever. The vomited blood may be bright or dark in color, 
bright if the vomiting be arterial, copious, and rapidly following upon 
the escape of the blood from the vessel, because the corpuscles are com- 
paratively unchanged. It is more usually dark red, sometimes brown, 
resembling coffee-grounds, the hemoglobin having been changed to 
methemoglobin by the hydrochloric acid, and few corpuscles are left 
unaltered. The vomitus, which may be copious, contains coagula, bits 
of food, is usually acid in reaction, and devoid of froth. There may be 
lesser repetitions of the hemorrhage, or after the one large one there 
may be spontaneous cessation. Hemorrhage may be divided into that 
from the acute and that from the chronic ulcer. 
In the acute ulcer there may be a spontaneous, abrupt, and alarming 
onset, without previous warning and history. Much blood is lost quickly, 
and the patient either soon dies or the hemorrhage ceases of itself, with 
only slight repetitions and with anemia; or there may be an abrupt 
onset, with short intermissions before one or more recurrences. In 
chronic ulcer, on the other hand, the hemorrhage varies much. There 
is a history of chronic indigestion with vomiting for some time previously, 
and of persistent anemia. 
Moynihan divided these cases into four groups: (1) The hemorrhages 
which are latent and insignificant. (2) Those which are intermittent, 
infrequent, and moderate in amount. There is no danger in these of a 
fatal issue. (3) Those which have become worse after the symptoms ORGANIC DISEASES OF THE STOMACH 
179 
have developed. The bleeding may be copious and repeated, and, 
therefore, perilous, perhaps even fatal. (4) Those cases in which the 
hemorrhage is sudden, overwhelming, and fatal. Sometimes the hemor- 
rhage is repeated in spite of care, and, according to Moynihan, is attribut- 
able to distension of the stomach and stretching of the ulcer. Some 
of the blood reaches the intestines, and during the next day or two 
the feces are black or brownish-black with a shiny surface. It does 
not, apparently, require a great deal of blood to produce a tarry stool, 
although Hosslin, quoted by Howard, states that 500 cc. are necessary. 
Sometimes the color is brighter, depending on the freshness of the blood, 
the amount, the rapidity of bleeding, and on its passing with the intestinal 
contents. The discoloration is due to the intimate mixing of the blood 
and chyme in the small intestines. Sometimes all the blood escapes per 
rectum, and there is no hematemesis; this occurs when the bleeding is 
more gradual or the ulcer near the duodenum. 
"Occult Bleeding."-Strauss first drew attention to this valuable sign, 
and, in 1902, Boas showed the diagnostic significance of the constant 
presence of occult blood in cancer of the stomach, and, following upon 
his observations, others have recorded their experiences, all of which 
tend to show that the examination of gastric contents, vomitus, or 
feces for evidences of hemorrhage and its underlying cause has con- 
siderable diagnostic value. It is a well-recognized fact that much blood 
may be present in the feces and yet go undetected, owing to alterations 
in its color and the nature of the diet administered. 
The examination for occult hemorrhages must, of course, be preceded 
by the exclusion of all other sources of blood, e. g., food containing blood, 
bleeding from the gums or nose, injuries to the gastric or oesophageal 
mucous membrane from passing a tube (in which cases, however, the 
bright-red blood is obvious to the naked eye), general or systemic diseases, 
and diseases of the digestive organs. Of the general systemic diseases, 
one considers especially hemophilia, purpura, scurvy, typhoid fever, 
arteriosclerosis, and tabes with gastric crises. There are two other 
classes of diseases of the alimentary tract in which this symptom may 
appear and give rise to some confusion in the diagnosis: (1) Malignant 
tumors of the gastro-intestinal tract and of the pancreas or liver with 
ulceration, and also hemorrhagic pancreatitis. These give marked and 
often constant reactions. (2) Stenosing gastritis, alcoholic gastritis, 
polypi, intestinal parasites, tuberculosis, syphilitic or simple catarrhal 
ulceration of the bowel-also hemorrhoids, fistula, and fissure. All 
of these give constant and marked reactions. The ingestion of much 
raw or ill-cooked beef (200 gm.), blood sausage, etc., will likewise give 
positive reactions. 
Extreme care in the preliminary dieting for these tests is unnecessary, 
for, as a matter of fact, there are but a few meats which yield positive 
reactions (e. g., the above-mentioned raw, minced beef and rich beef- 
steak and blood sausages), and the quantity must be over 200 grams. 
Well-boiled or roasted meat does not interfere with the tests. In sus- 
pected cases it is especially useful to examine the feces for the presence 
of blood after pain has occurred. 180 
DISEASES OF THE DIGESTIVE SYSTEM 
The Benzidin Test.-This is probably the most suitable of all the 
chemical tests. First used by the Adlers in 1904, benzidin, one of the 
diphenyl group, has been recognized as the most delicate test hitherto 
employed for the detection of occult blood, giving positive results in 
blood dilutions of 0.001 per cent. The quality of the benzidin is of 
importance for its delicacy of reaction. The test as modified by Schle- 
singer and Holst is as follows: A "knife-pointful" of benzidin is added 
to 2 cc. of glacial acetic acid in a clean test tube. A solution quickly 
ensues after shaking. In another test tube a tiny portion of feces (the 
size of a pea) is well mixed with 2 cc. of water, and heated to the boiling 
point. The reagent for use is made by mixing 10 to 15 drops of the 
benzidin solution with 2 or 3 cc. of a 3 per cent, solution of hydrogen 
peroxide. A few drops of the feces mixture are added to this, and in 
the presence of blood a green or blue color appears in one or two minutes. 
If much blood be present, the blue color predominates. 
Einhorn has simplified the test by preparing a benzidin paper, made 
by moistening filter paper with a saturated solution of benzidin and 
glacial acetic acid and drying it. (One must avoid contact with the 
fingers, as a drop of perspiration causes a similar reaction.) His method 
is as follows: A piece of benzidin paper is immersed in the solution to 
be examined, and a few drops of hydrogen peroxide are added. The 
paper is placed on a white porcelain dish and examined for the develop- 
ment of the blue color. This appears in positive reactions within one 
minute, or in great dilutions after a somewhat longer interval. Certain 
precautions must be observed in Einhorn's modification. Farina and 
boiled potato produce a reaction, so that in examination of the gastric 
contents the liquid parts alone must be used. Hydrochloric acid may 
likewise cause a reaction, but this is delayed beyond two minutes, so 
that one minute should be the maximal time limit for deciding upon a 
positive reaction. The paper method is recommended as a valuable 
preliminary test, which, if doubtful, must be confirmed by the aloin 
ether extract method. For examination of the stools, one takes a small 
piece of the feces, rubbing it up with 2 cc. of water, and immersing the 
benzidin paper. The hydrogen peroxide is then added and the color 
reaction observed. Certain limitations of this test must be noted: 
Some salts of iron, some organic fluids, e. g., saliva and sweat, certain 
chlorophyll-containing vegetables if unboiled, all may give a positive 
reaction. The patient must, therefore, be dieted to some extent, prefer- 
ably with lacto-farinaceous and egg foods. The action of the digestive 
juices will not prevent a reaction. 
The Value of Tests for Occult Blood.-After satisfactory exclusion of 
all extraneous sources of the blood, a positive result suggests a lesion 
of the mucosa in the alimentary canal, and three tests in succession must 
be made. If the mouth and the rectum be excluded as a cause, the source 
of the lesion is more limited still. When no evidence of inflammatory 
disease exists, e. g., enteritis, and where no general disease is found (e. g., 
cardiac or hepatic), a positive test for occult blood suggests ulceration- 
benign or malignant. Repeated positive tests occur more usually in 
cancer; the persistence of negative findings strong' suggests the absence ORGANIC DISEASES OF THE STOMACH 
181 
of any malignant disease of the alimentary canal. The prognosis of 
ulcer depends to some degree, too, on the results of occult blood tests, 
for the recurrent presence means inperfect healing and therapy is gov- 
erned accordingly. 
Signs.-But little is to be gained from physical examination of the 
stomach in acute ulcer. Tenderness is a common finding and yet the 
clinician who attaches too much importance to it alone is liable to be 
surprised and disappointed at an exploratory laparotomy. The tender 
point is often localized in the epigastrium, sometimes more diffuse. In 
pyloric ulcer it is apt to be in the right hypochondrium, though no rule 
obtains. No tumor is palpable in fresh ulcer. In older ulcers which 
have become callous or when scarring has occurred and causes pyloric 
obstruction or deformities in the stomach, the objective signs may be 
much more marked. Peristaltic movements, perhaps a dilated stomach, 
may be seen on inspection, while palpation may reveal a tumor of varying 
size, more or less movable, according to its situation and the presence 
of adhesions, usually at some part of the upper abdomen. The palpable 
mass present is either from the thickened ulcer itself, from muscular 
hypertrophy or adhesions, or may be due to fibromatosis (A. Thompson). 
Gastric Analysis.-This varies according to the type of the ulcer. 
In the acute forms the examination of gastric contents may show little 
that is abnormal. The hydrochloric acid may be normal in amount, the 
proteolytic digestion unimpaired, and the motor power good. At other 
times there may be hyperacidity with hypersecretion, or the reverse, 
and motor insufficiency may be evident. Blood is often present, and 
may be visible to the naked eye or found only by microscopic or chemical 
examination. In the more chronic forms the findings will depend on 
the site of the scarring ulcer. If pyloric stenosis is present, there is 
usually hypersecretion with retention of food, good digestion of proteins, 
and little or no change in the carbohydrates. Sarcinse are usually found 
in such cases, and also yeast cells in abundance. Blood, too, either 
evident or occult, is common. Lactic acid is present only where there 
is stagnation and hypochlorhydria. Hutimeyer found motor insufficiency 
of the first or second degree in 42 per cent, of his cases. 
X-ray Examination.-The use of the fluorescent screen and the sub- 
sequent skiagram forms a most useful adjunct to the diagnosis of ulcer. 
The routine method is best carried out by examination in the morning 
on an empty stomach, after purgation on the previous evening. The 
first examination is made after giving a "Barium sulphate porridge," 
first by the screen, and then a photograph is immediately taken. Six 
hours later a second examination is made for residue, and for noting 
the propulsion of food. A liquid bismuth solution is then given, and 
screen examinations made to watch the tone and contractions; palpation 
for mobility is also performed. A "bismuth pap" is next taken to fill 
the stomach to determine irregularities of outline, as also mobility and 
peristalsis, and a skiagram completes the examination. 
The employment of the z-rays in the detection of acute fresh ulcer 
has no foundation as yet, and the presence of a small metallic shadow 
has not been shown to be pathognomonic of such cases. In fresh cases 182 
DISEASES OF THE DIGESTIVE SYSTEM 
the x-rays may show signs of functional disturbances, i. e., spastic con- 
tractions which may or may not be associated with ulcers or perigastritis, 
or there may be evidences of altered motility, but these are not more 
than adjuncts. The coincidence of pressure points with the area of 
spastic contractions seen under the screen is equally dubious, but when 
perigastritis occurs from chronic ulcer the contraction may be marked, 
and the stomach may assume an hour-glass shape-temporarily or as a 
permanent condition. The persistent coincidence of painful point and 
irregularity of the viscus on the skiagram may confirm a suspicion already 
existing, as Bonniger has found. 
When chronic ulcer exists, the x-rays shed much light, and in various 
ways-normal peristaltic waves may be interfered with, the lumen may 
be encroached upon, mobility and motility may be altered, and the 
functions of the pylorus disturbed. Ulcers usually induce hypermotility 
with inhibition of pyloric closure, i. e., pyloric insufficiency with quicker 
emptying of the stomach; such is Rieder's view, although there is no 
doubt that many variations occur, owing to the size and other physical 
conditions of the ulcer. When duodenal ulcers occur, hypermotility 
is the rule (Baetjer and Friedenwald). It is, however, the more callous, 
crater-like ulcers, those which have penetrated into deeper structures, 
with perigastritis and deformities, that demonstrate the value of the 
skiagram for more accurate diagnosis. 
Ever since this discovery the frequency of these penetrating ulcers 
has been repeatedly shown, and means of diagnosis between chronic 
ulcers and cancer have been afforded that were previously beyond our 
reach. Briefly, one sees the following general conditions: (1) A metal 
shadow in one spot from the presence of the intraventricular crater-like 
ulcer with thickened walls. (2) An abnormal spot of metal shadow, 
lying in a niche or pocket, (extraventricular), apart from the general 
picture, connected to it by a channel like a diverticulum lying toward 
the lesser curvature, or quite separated. This shadow remains long 
after the rest of the metal has passed on into the duodenum and 
lower, a bubble of gas lies over it, and palpation for mobility makes no 
appreciable impression on the metal. This picture is due to the crater- 
like pocket formed by the penetration of the thickened ulcer, and its 
extraventricular extension, nearly always from the lesser curvature. 
Further, the incisure or transverse contracture may be seen, indenting 
the greater curvature. A residue after six hours, delayed opening of 
pylorus, and rapid settling of the metal to the lowest level come from 
atony. Sometimes deformity exists from the scarring, a perigastritis, 
or a true hour-glass stomach. The x-rays in simple perigastritis show 
no isolated niche of metal and no air bubble. 
With hour-glass stomach the x-rays show saccules of varying size and 
number, usually two only, connected by a channel, which in length, 
size, and contour, varies according to the lesion. The pyloric sac in these 
ulcer deformities is usually larger than the ulcer, and shows signs of 
food retention because of pyloric spasm. The upper or cardiac sac, on 
the other hand, is more distended in cancer, for the lower empties more 
quickly because the pylorus is usually insufficient, through fibrosis. ORGANIC DISEASES OF THE STOMACH 
183 
These views of course contradict the findings of older observers by use 
of the tube. The metal shadow shows the retraction on the greater 
curvature which is drawn up toward the lesser, so that the canal between 
the two sacs is always found at the lesser curvature. This is in contra- 
distinction to the hour-glass contraction of cancer, which shows a median 
channel and a "minus" in the metal shadow, instead of a "plus" as in 
ulcer. In other words, in ulcer there is a plus shadow because of the 
defect, while in cancer the tumor does away with the metal shadow at 
the point of the growth. In ulcer, too, the outline of the connecting 
channel is smooth by comparison, its transition into the lesser sac being 
more sudden. 
Diagnosis.-A careful consideration of all the signs and symptoms is 
essential, and the anamnesis is above all things important; no one symp- 
tom or test is pathognomonic, but pain, tenderness, vomiting, the 
presence of blood whether manifest or occult, continuous hypersecretion 
and pylorospasm are the more important signs, and are characterized 
by their periodicity and intermittency. In the more acute cases with 
hemorrhage, it is not usually possible to differentiate absolutely between 
simple round ulcer, hemorrhagic erosions, and the oozings from the 
mucosa which have no demonstrable anatomical lesion. 
Pain and tenderness as signs of gastric ulcer are unreliable signs in 
themselves, and disappointments often come from the laparotomy 
performed on the basis of these signs alone. The gastric analysis, too, 
is never pathognomonic, indeed it usually leaves one as uncertain as 
before, even if showing hypersecretion. Some authorities regard the 
presence of much gas with hyperacidity as strongly suggestive of ulcer. 
Evidence of blood intimately mixed with the contents is likewise an 
adjunct to a positive diagnosis. The arrays furnish no aid in the diagnosis 
of acute ulcers. The seat of the ulcer is not readily determined, unless 
at the cardia when pain occurs with deglutition, or sometimes at the 
pylorus or in the duodenum, when with other signs the pain occurs 
several hours after the ingestion of food. Many exceptions, however, 
could be recorded. 
Einhorn has invented a duodenal bucket, and Bassler a somewhat simi- 
lar "string" test, the object in each case being to detect the presence of 
an ulcer and possibly its location by means of the blood stain, or brown- 
black discoloration on the string, from contact with the eroded surface 
of the ulcer. The bucket or shoe button, or B. B. shot with string (No. 
8 braided silk) attached and of known length, is swallowed on the evening 
and is removed in the early morning and examined for any stain on the 
string. The situation of the stain on the string, measured according 
to its distance from the incisor teeth, determines the site of the lesion. 
In the more chronic cases diagnosis depends especially on the anam- 
nesis and physical signs, and much assistance is often gained through 
the use of the fluorescent screen and the skiagram. The history of pain, 
more or less intermittent, localized, and accompanied by tenderness, 
the recurrence of vomiting, sometimes with blood, the absence of marked 
and progressive emaciation, the frequent hypersecretion, all point to 
ulcer. Sometimes with these signs the scarred ulcer is palpable as a tumor. 184 
DISEASES OF THE DIGESTIVE SYSTEM 
Differential Diagnosis.-One must differentiate between ulcer and 
many other conditions, among which may be mentioned gastralgia, 
hyperesthesia, hysteria and simple hypersecretion, pylorospasm, gastritis, 
cancer, cholecystitis and cholelithiasis, renal calculus, pancreatitis, 
aneurism of the abdominal aorta, and even spinal disease and tabes 
with gastric crises. In most of these conditions the careful consideration 
of the anamnesis with the physical findings make clear the underlying 
disease. In some, however, the differentiation is not so easy. 
Hypersecretion.-Simple hypersecretion (gastrosuccorrhoea). In this 
condition, which in its pure state is a functional disorder of secretion, 
there is absence of the positive signs of ulcer (vomiting, tenderness, 
hemorrhage). The pain is digestive in time, the analysis shows HC1 in 
excess, and proper treatment directed againt the secretory trouble is 
effectual. When the correct therapy fails, an ulcer, or other irritation, 
should be suspected as the cause of the trouble. 
Gastralgia.-In this there is paroxysmal pain, not directly excited by 
food, nor related to or regularly affected by its ingestion. Pressure 
often relieves the pain; there are no tender points. If there be vomiting 
(and usually this is inconstant and irregular in onset), it does not nec- 
essarily give relief to the pain. Digestion itself is normal, and milk or 
other bland diets are of little use in the treatment. Aerophagia and 
eructations of gas are common. Neurasthenic symptoms and mucous 
colitis are often superadded. Epigastric pulsation is common. Hema- 
temesis is absent, as also occult blood. Gastralgia often accompanies 
uremic symptoms, but there are other signs present, and the urine will 
probably be characteristic. 
Gastritis.-A cause is present; the pain is more diffuse, less severe, 
and not increased much on pressure. The tongue is foul and coated. 
The vomitus contains much mucus, often organic acids, and there is 
usually diminution in the amount of free hydrochloric acid. If blood 
be present it is rarely large in quantity. Certain cases of gastritis with 
hemorrhage are at times indistinguishable from ulcer. 
Cancer.-Debility and emaciation often precede the other signs; the 
pain is more constant and more independent of food, is often nocturnal, 
though it may at times be quite absent, and there may be simply a 
discomfort. The breath is foul and there is anorexia, as a rule; vomiting, 
which is common, gives less relief than in ulcer. The vomitus is rather 
that of motor insufficiency, and shows little or no hydrochloric acid, but 
usually some lactic acid, and other evidences of fermentation in the 
odor and in the presence of ill-digested food and the Boas-Oppler bacilli. 
Any hematemesis that occurs is more of the character of coffee-ground 
vomitus. Occult bleedings are more constantly found than in ulcer. 
The case is somewhat different where ulcer exists as a pyloric tumor with 
dilatation of the stomach, or where a cancerous growth has been engrafted 
upon a previous ulcer. Cancer limited to the pylorus is rare; the 
onset is obstructive, with vomiting, cramps, and emaciation, in a more 
elderly person; the course is progressive, and dietetic treatment affords 
no relief. If first seen when dilatation is really pronounced, the diagnosis 
must be made chiefly from the history and by examination of the gastric ORGANIC DISEASES OF THE STOMACH 
185 
contents and stools. Free hydrochloric acid is absent in 90 per cent, of 
these cases and lactic acid is evident. With ulcer there is usually hyper- 
ch lorhydria, or a normal amount of hydrochloric acid. The history of 
ulcer causing dilatation is of years' duration, because the condition is 
one of gradual development. The appetite improves with lavage, as 
also does the general condition. Where there is a cancer engrafted upon 
an old ulcer, there is increase in the pain, especially if there be some 
emaciation and weakness; the hydrochloric acid is gradually lessened; 
and the tumor increasing in size assumes a more nodular character. 
The skiagram is of great assistance. 
Gallstones.-The differential diagnosis is often extremely difficult, 
and in a number of cases quite impossible for the time being. This is 
especially the case when the ulcer lies at the pylorus or is in the duodenum. 
There may be persistent pain, as in ulcer, especially after the taking 
of food, and with it vomiting; the vomiting may give relief; there may 
be tender points, and upon careful treatment even the symptoms may 
for the time disappear, and all this without jaundice, bile in the urine, 
or other signs of gallstones. As a rule, however, there is sudden, colicky 
pain at any time, of great severity and subsiding suddenly, tenderness 
in the right hypochondrium, slight fever, and perhaps sweating. Retching 
and vomiting occur with the pain and give no relief, pain continuing 
long after the stomach is empty. There are intervals of health and normal 
digestion. The co-existing gastralgia may be paroxysmal, and there 
is often hyperacidity. Not infrequently the sclerotics are subicteroid, 
and a trace of bile may be found in the urine. 
Complications and Sequelae.-The most important are: perforative 
peritonitis, perigastritis (suppurative and adhesive), subphrenic abscess, 
fistula between the stomach and adjacent organs, abscess of the liver, 
chronic hepatitis, acute and chronic pancreatitis, constriction of the 
bile-duct with jaundice, cardiac stenosis, pyloric stenosis, deformities 
of the stomach with dilatation or hour-glass stomach, cancer of the 
stomach, general emphysema, parotitis (sometimes with perforation and 
sometimes after hemorrhage), tetany, hemorrhage, anemia, etc. 
Perigastritis.-As a result of chronic ulcer, peritoneal reaction occurs 
in the vicinity, and may be infectious in origin. The resulting inflam- 
mation may be suppurative or merely adhesive. Adhesions occur to 
neighboring organs or to the parietal peritoneum, and symptoms are 
thus produced which may give a clue to the diagnosis of the complicating 
condition. Surgical experience indicates that these are extremely 
common. The adhesions form most commonly about the lesser curva- 
ture, in the mid-region in front and behind, where the parts, too, are 
most at rest; also at the extreme ends of the organ, cardia and pylorus, 
described by the French writers as precardiac and prepyloric perigas- 
tritis. They are firm, well organized, and thick, and extend well beyond 
the limits of the ulcer and in extreme conditions even to the pelvis. With 
pyloric ulcers the gall-bladder and liver may be firmly bound to the 
stomach and gastrectasis thus commonly ensues. Sometimes an hour- 
glass stomach is formed often with penetrating ulcers. The .r-rays have 
shed much light on these cases. The ulcer very frequently penetrates 186 
DISEASES OE THE DIGESTIVE SYSTEM 
deep into the adherent parts, forming tracts with expansion at the end, 
in which the bismuth shade is constant for days following the meal. 
The Symptoms.-The location and degree of adhesions, as well as the 
type of inflammation, determine the course and special symptoms. The 
special features are pain, tenderness, and chronicity, without either cure 
or markedly progressive failure of health. Gallstones, angio-cholecystitis 
or cancer, may simulate the condition or a secondary pyloric stenosis, or 
the perigastritis may be a mere accompaniment of a neighboring disease. 
Signs of ulcer have usually been present for a long time previously, and 
to these are added exacerbations of the gastralgic pains often radiating 
to the back or upward, only to some extent relieved by rest, and 
increased on forcible straightening of the trunk. Ingestion of food or 
fasting has no lasting effect on the symptoms. Examination reveals 
perhaps nothing but tenderness, or there may be increased resistance 
and even a definite mass, which is subcostal, perhaps superficial. 
The differential points are briefly: A previous ulcer or one still 
unhealed, with a history of long standing and yet an absence of cachexia 
and metastases; perhaps gastrectasis; persistent pains more or less 
influenced by posture and sudden exertion; localized tenderness; occa- 
sional jaundice without involvement of the liver; periodical febrile 
attacks of short duration. Gastric analysis gives no distinctive results. 
The x-rays are of great value here, revealing frequently a perforating 
ulcer with fixation of the viscus from perigastric inflammation. 
Perforation.-This is one of the most serious complications of gastric 
ulcer, and occurs in a varying percentage of cases (1 per cent., Leube to 
18 per cent., English). Clinically, in 1336 cases there were 45 perfora- 
tions, i. e., 3.4 per cent. In 1615 autopsy cases there were 336 per- 
forations, i. e., 22 per cent. General peritonitis occurs chiefly when the 
perforation takes place rapidly before adhesions form. The extent 
depends upon the time from onset, for the transverse colon and the 
mesocolon act as temporary barriers for a few hours before extension 
occurs into the lower half of the peritoneal cavity (Berg). Perforation 
of a gastric ulcer sets up a general peritonitis more commonly than does 
a duodenal ulcer, perhaps because the duodenal contents are more 
sterile, or because there are more chances of adhesions. The same rule 
applies to pyloric ulcers as compared with ulcers elsewhere in the stomach. 
Course of Perforated Ulcer.-Sometimes, though rarely, an acute per- 
forative general peritonitis may heal spontaneously. This is extremely 
rare in the acute cases. Some subacute and chronic cases recover, 
although usually with conditions which lead to more or less chronic 
invalidism. Extension may occur in almost any direction. Perforation 
into the liver or pancreas may occur with abscess or chronic inflammation 
in either organ. There may be obstructive jaundice with pressure on 
or stricture of the ducts and a catarrhal cholangitis. Subphrenic abscess 
may occur, and was due to ulcer in 20 per cent, of 179 cases (Maydl). 
The portal vein is sometimes invaded, and pylephlebitis follows. The 
gall-bladder may be involved and stones may fall into the stomach 
through the fistulous opening. Sometimes the spleen is involved, and 
we may find a perisplenitis. If the perforation penetrates the intestines, ORGANIC DISEASES OF THE STOMACH 
187 
there may be a severe diarrhoea and bloody or purulent feces or fecal 
vomiting. A gastro-colic fistula may form; Murchison found 10 cases 
of this in 33 perforations due to ulcer. 
Rarely perforation occurs into the abdominal wall with an external 
fistula. In the more chronic cases sometimes the perforation occurs at 
a place far distant from the original ulcer, by dissecting and pointing, 
as in one instance in which a pelvic abscess formed and was drained 
through the vagina some weeks after the perforation of the ulcer. 
The Symptoms and Signs of Perforation.-The early signs are the 
most characteristic, hence the importance of seeing cases early, but 
there are no pathognomonic symptoms previous to perforation. The 
onset is usually sudden; indeed, the sudden pain or other distress may 
be the only sign of the ulcer, though a careful anamnesis is of the greatest 
importance in the diagnosis. English found no history of stomach trouble 
for some time before perforation in 11 of 50 perforation cases. The 
patient need not be overcome and incapacitated at once; sometimes he 
is able to walk into the hospital with such a perforation. In one case 
under Seymour Taylor's charge there was a single bloody stool as the 
only sign of perforation, without pain or abdominal signs of any kind, 
and a fatal result ensued with no other local development. It commonly 
follows some strain, such as vomiting, trauma, or a hearty meal. 
Pain is the earliest symptom, is not only sudden but of great severity, 
usually referred to the epigastrium and spreading soon to the right and 
left, but not leaving its original site. Dyspnoea soon follows, and deep 
breathing causes pain about the diaphragm, so that these cases are 
sometimes mistaken for acute pleurisy. Vomiting is not so infrequent 
as was formerly thought, a small opening does not allow escape of so 
much contents-though with the gradually developing peritonitis, the 
cessation of a previously existing vomiting is very suggestive of perfora- 
tion. Collapse and prostration supervene. In some cases remarkably 
little prostration is observed, a fact which is apt to mislead, especially 
as the general signs may greatly improve after a few hours before graver 
symptoms develop. The degree of collapse depends in large measure 
on the amount and extent of the extravasation. The face is anxious, 
often pinched, and there is apt to be great restlessness. The pulse is 
usually accelerated, though sometimes it is normal, and the temperature 
may be but little altered immediately after perforation has occurred. 
Usually there is slight fever. 
The abdomen may be flat and tense, sometimes it is distended; the 
muscles are rigid, often in the upper zone only, and there is diminished 
mobility, two signs of greatest significance. Tenderness is chiefly about 
the epigastrium and hypochondrium. Eighteen out of a series of 49 
cases were diagnosed as appendicitis. Percussion may or may not give 
dulness here, and the liver dulness need not be obliterated, although 
this depends in great measure on the escape of gas into the surrounding 
parts. The sign of obliteration of the liver dulness is unreliable. Even 
when absence of liver dulness exists as far back as the midaxillary line, 
it may imply no abnormality. Nor, again, is it true that well-marked 
stomach tympany in the left hypochondrium excludes the possibility 188 
DISEASES OE THE DIGESTIVE SYSTEM 
of perforation. A valvular perforative opening may exist allowing 
distension. On auscultation, a friction rub may be heard over the 
diaphragm, and sometimes the gurgling of fluid through the perforation. 
Pseudo-perforation is not uncommon, i. e., the signs and symptoms of 
perforation without other anatomical lesion than mere ulcer, as in a 
case recorded by Manges, in which a woman, aged twenty-seven years, 
after previous signs of ulcer (hematemesis, etc.), suddenly had pain and 
tenderness in the epigastrium, with a temperature of 102°, pulse 120 to 
140, and marked rigidity. Operation was performed, but no perforation 
and no peritonitis were found, simply the uncomplicated gastric ulcer. 
Leukocytosis varies in this as it does in the perforation following typhoid 
fever. We are told that attention should be paid to the base of the 
thorax on the left side, where one often obtains restricted movement, 
localized pain, and tenderness, with dulness in the lower axillary region 
and other signs of fluid (Osler). Fluid may collect beneath the diaphragm 
about the' anterior and external surface of the spleen, or in the lesser 
peritoneum, and later on the usual signs of general peritonitis may 
develop. 
Cancer Developing upon Ulcer.-Cruveilhier first suggested this possi- 
bility in 1835, although he believed a cancerous diathesis essential to 
its development, and Rokitansky, in 1839, added further observations 
on its probable concurrence. The importance of ulcer as a possible 
cause of cancer has since then been repeatedly suggested and perhaps 
much .exaggerated (Wilson and MacCarty, 71 per cent.), for patholo- 
gists incline rather to the opinion that where the two conditions co-exist, 
the ulcer is a secondary degeneration of the cancer and not vice versa. 
Such is Aschoff's view. 
Any dogmatic statement on the origin of cancer from ulcer seems 
impossible in the present state of our knowledge, and other methods of 
deciding this dubious point must be looked for. Clinical histories seem 
to point to the possibility in some instances and a definite anamnesis 
applicable to such a transition exists. It must be admitted, however, that 
a history of gastric trouble prior to cancer does not mean a pre-existent 
ulcer, and that, on the other hand, many cancers may grow slowly over 
a period of years before declaring themselves, and thus perhaps the 
so-called transition period was one in which cancer alone was present 
from the start, though without showing clinical or pathological evidence. 
Paterson has pointed out the infrequency of duodenal cancer in spite of 
the ever increasing records of ulcer in that location, and that ulcers left 
alone after short circuiting rarely show cancerous change. Friedenwald's 
statistics likewise show but a small proportion of cancers arising from 
gastric ulcer (7 per cent.). 
The Symptoms and Diagnosis of Cancer Forming on a Previous Ulcer.- 
The transition period between the signs of the original ulcer and the onset 
of the cancer varies greatly. There are some undoubted cases on record, 
and the duration of symptoms in these has varied; it is sometimes short, 
or, in others, years have elapsed since the ulcer first formed. Malignant 
development is suspected when loss of weight persists with a cachexia 
greater than a mere ulcer would justify. In such cases, too, there is ORGANIC DISEASES OF THE STOMACH 
189 
more constant pain, although perhaps even less intense, and its character 
alters to a more dull, sickening ache. Tenderness is more diffuse. There 
is more nausea and vomiting; at all events, the vomiting is more regular, 
and even if a longer time intervenes between the attacks, it is more 
copious and rancid, and readily excited by liquid food. Blood appears 
more frequently in the vomitus, and in small amounts; and occult blood 
is more constant in the feces. The appetite usually becomes less, the 
patient is more languid, nervous, and weak, and is markedly anemic. 
The gastric analysis is not always characteristic of cancer and then 
only late in the disease, and often hyperacidity is present to the end. 
Mechanical and medical treatment are without avail, and if, with proper 
ulcer treatment, there is increase of the symptoms, especially emaciation, 
pain, vomiting, anemia, and weakness, cancer may be suspected. 
Parotitis.-This is not common. S. Paget and Hone mentioned several 
cases in 1897, and English reported 5 instances among 50 cases with 
bilateral parotitis. Sometimes suppuration occurs. The condition 
probably arises in the same manner as in other diseases of the abdominal 
and pelvic viscera. Rolleston and others, while dubious as to its causa- 
tion, do not regard the complication as arising from infection of Stenson's 
duct. 
Tetany.-This, while commonly associated with old scarred ulcers 
with dilatation, sometimes occurs without any such complication. 
Moynihan had 5 cases. There are mild and severe grades, the former 
with mere cramps and paresthesias at times, the more severe forms 
often resulting fatally. Albu reported 31 deaths out of 40 cases. Any 
source of irritation may induce an attack, and not infrequently the 
mere lavage of the stomach which so often relieves the symptoms may 
at other times precipitate an attack. The tetany is supposed to arise 
from some auto-intoxication due to absorption of decomposed gastric 
contents. 
Pyloric Stenosis with Dilatation.-(See article on Gastrectasis and 
Motor Insufficiency.) Dilatation is fairly common and is associated 
either with pyloric stenosis from a scarred ulcer or perigastric adhesions 
as direct causes, or with contraction or spasm of the pylorus and mechani- 
cal irritation as indirect causes. 
Cardiac Stenosis.-This may occur from cicatrized ulcers at the cardiac 
end of the stomach as also diverticula at various portions from similar 
causes, or through traction of perigastric adhesions. 
Hour-glass Contraction of the Stomach.-Sanduhrmagen, I'Estomac 
Biloculaire.-This condition is much commoner than was supposed 
formerly, largely owing to the findings in surgery and by the rr-rays. 
It consists of a contraction anywhere between the cardia and the pylorus 
dividing the stomach into two or more portions; sometimes it is trilocular. 
Moynihan has described a case with four sacs. 
Etiology.-The condition is rarely a congenital one. Moynihan denies 
any such origin and deals with individual instances, which he claims as 
being inaccurately described as congenital, regarding it as almost always 
dependent on some organic disease from one of three causes-ulcer, 
perigastric adhesions, or carcinoma. Nevertheless, in one of the speci- 190 
DISEASES OF THE DIGESTIVE SYSTEM 
mens in the McGill Museum removed from an infant, the condition is 
so marked, as to leave no other conclusion than that it was, at all events 
in that instance, congenital. Meckel has the same view of its possible 
origin. The direct and most common cause is an old ulcer with cicatrix 
or adhesions of the stomach wall or other parts, or both, or the formation 
of independent bands of fibrous tissue. Among 48 cases reported by 
Robson and Moynihan in 1906, 41 were due to ulcer. Other cases are 
not infrequently associated with cancer of the stomach, while tuberculous 
peritonitis may cause bands of fibrous tissue to form about the stomach 
and produce identical results. 
Fig. 3 
Hour-glass contraction of the stomach: A, cardiac portion; B, pyloric portion. 
The symptoms are at times quite indefinite, and at other times appear 
to be quite characteristic. They apparently depend on the original 
cause at first, but later the effect may be diagnosed, provided one exercises 
sufficient care and patience. As has been pointed out by others, the 
main symptoms are pain after meals, vomiting of stomach contents 
and sometimes also of blood, emaciation, and the presence of a tumor, 
due to cicatrization of old ulcers, with an absence of secondary nodes 
and of ascites. The condition is naturally associated with symptoms 
for many years, and the patients suffer much. For a time the symptoms 
seem to simulate stenosis of the pylorus, the presence of pathognomonic 
features depending largely on the site of the contraction. This, as a 
rule, lies four inches from the pylorus, and therefore simulates pyloric 
obstruction with dilatation, all the more so as hyperacidity usually 
co-exists and the secondary cavity is small. Moynihan gives the following 
sets of symptoms, the result of the experience of various authors: First, 
in lavage of the stomach, all the fluid fails to return, some, which is in 
the secondary pouch, being apparently lost (Woelfer's first sign); second, 
after lavage has apparently thoroughly cleaned the stomach, more ORGANIC DISEASES OF THE STOMACH 
191 
contents reappear, probably foul and evil-smelling, the washings thus 
being again dirty (Woelfer's second sign), or the same may be found on 
withdrawing the tube after washing the stomach clean and then passing 
it again; third, the sign of paradoxical dilatation (Jaworski); this consists 
in the succussion splash on palpation after apparent removal of all the 
gastric contents, a sign which is of course present because only the 
cardiac sac is emptied; fourth, after percussing out the stomach and 
then distending it, a change in the position of the distension tumor is 
found at times. First the proximal pouch is distended and then the 
distal, and the notch is often visible between the two tumors when both 
parts are dilated (von Eiselsberg); bubbling and sizzling are distinguished 
at a point distinct from the pylorus on dilatation (von Eiselsberg), and 
patients are sometimes themselves conscious of this and of food passing 
from one pouch to the other. This may be detected by the stethoscope. 
The z-rays form by far the most satisfactory means of diagnosis. 
Fig. 4 
Duodenal ulcer. 
Duodenal Ulcer.-Many ulcers diagnosed as duodenal prove to be 
pyloric and vice versa. Duodenal ulcers are very common, and surgeons 
have proved that their frequency approaches that of gastric ulcer. 
They are commonest in the third decade, though no age is exempt, 
and perhaps oftener in males. Tull found equal numbers in males and 
females in the Montreal statistics. As to the site, 90 per cent, or more 192 
DISEASES OF THE DIGESTIVE SYSTEM 
occur in the first portion, while they are least common in the lower 
portions. Practically all those in the first portion extend to within 
three-quarters of an inch of the pyloric sphincter, and the deepest portion 
is usually just below the pylorus, where the acid chyme most affects 
the intestinal mucous membrane. In 6 out of 10 cases in MacCallum's 
series the ulcer was on the posterior wall; in the other 4 it was situated 
anteriorly. 
Number.-Collin found one ulcer alone in 80 per cent., two ulcers in 
11 per cent., three to four ulcers in 4 per cent. When multiple they are 
usually crowded together in the first portion. Moynihan, in 1902, drew 
attention to the co-existence of gastric and duodenal ulcers. 
Symptoms.-While, as in gastric ulcer, many cases run a latent course 
(91 out of 151 of Perry and Shaw's cases), yet, as a rule, pain is the 
prominent symptom, and is present in 80 per cent, of all cases. In 
some cases the pain resembles severe biliary colic, for which, indeed, 
it is often mistaken, especially if, as commonly happens, jaundice is 
also present. Long intermissions with recurrent pain extending over 
months or years are not uncommon. Radiation of the pain is by no 
means the rule. It is usually local only, although at times it radiates 
to the breast, shoulder, or back. While usually related to the ingestion 
of food, in that it comes on from one to four hours after, it is not neces- 
sarily so. It is at times relieved by food, drink, lavage, or alkalis. The 
pain may be associated with local peritonitis, spasm, the action of acids, 
or, again, with gaseous distension. Tenderness, if present, is perhaps 
more frequently to the right of the median line, although quite often 
only in the epigastrium. It is at times diffused and not localized. It 
is rarely posterior. 
Vomiting is less common than pain, being present in less than 20 per 
cent, of the cases. It is irregular, delayed, often acid, and the amount 
varies according to the amount of obstruction and of hypersecretion. 
Acidity is usually increased, and hyperchlorhydria has been frequently 
found. The appetite remains good and constipation is the rule. Hem- 
orrhage from the stomach or bowels is common. Oppenheimer found 
melena in 50 per cent. The diagnosis is made more commonly from the 
association of the local tenderness and the melena, or even from the 
tarry stools in the absence of pain than from any other signs. Some- 
times hematemesis and melena occur together, and there may be so 
much hemorrhage as to produce a fatal result. It is severe in at least 
one-third of the cases. The hemorrhage of duodenal ulcers is more 
difficult to check and usually of longer duration than that of gastric 
ulcer. In the 23 pure duodenal ulcers recorded by Moynihan, 4 had 
both hematemesis and melena, 3 had hematemesis alone, and 4 had 
only melena. 
Loss of weight is common, and is probably often due to insufficient 
nourishment being taken, from fear of pain after ingestion of food. 
The clinical types of duodenal ulcer may be divided into: (1) Those 
indistinguishable from gastric ulcer in symptoms and signs. (2) Those 
with hemorrhages from the stomach or bowel, or both, and with no other 
symptoms. (3) Those with symptoms resembling biliary colic, especially ORGANIC DISEASES OF THE STOMACH 
193 
the pain, tenderness, and intermittent jaundice. (4) The perforative 
cases, which simulate gall-bladder perforation and appendicitis. 
Complications.-These are numerous, and the most notable are: 
Perforation, periduodenitis, implication of the gall-bladder and bile- 
ducts or of the pancreas, cicatricial stenosis of the duodenum and ampulla 
of Vater, with obstruction of the outflow of bile and pancreatic juice, 
compression of the portal vein, and cancer. Perforation occurs frequently, 
(43 per cent., Chvostek). Of 131 collected cases with perforation, 91 per 
cent, were in the first part, 6 per cent, in the second part, and 3 per cent, 
in the third portion; 80 per cent, were in males. Nearly all perforations 
are anterior (in 20 per cent, there are no preceding symptoms of ulcer). 
Diagnosis.-Wrong diagnoses are frequently made, and many cases 
with perforation have been mistaken for appendicitis (19 out of 51, 
Moynihan). The mortality of perforation cases, while 80 per cent, in 
Brunner's time, is now much less, and modern methods of diagnosis 
and clean surgery have done much to improve statistics of cure. Early 
operation is most important and delay beyond twenty-four hours adds 
greatly to the risk. 
Course and Prognosis of Gastric Ulcer.-The fact that so many 
gastric ulcers are latent, and the difficulty attending the diagnosis of 
simple cases has made it impossible to determine with accuracy the 
average duration. Many cases, if not the majority, are undoubtedly 
acute in onset, and while some heal rapidly within a few weeks or less, 
others are of many years' duration. In MacCallum's and Tull's cases, 
some had a history of ten or more years, with intermissions, while some 
duodenal cases gave symptoms for twenty years. It is difficult to say, 
however, how much of the history was attributable to ulcer, and in how 
many cases multiple ulcers occurring at long intervals may have given 
rise to the prolonged symptoms. 
The mortality from all kinds of ulcers is variously given as 8 to 10 
per cent. (Riegel). Russel, in England, has investigated the after- 
histories of cases of hemorrhage, and finds the direct mortality 2.1 per 
cent.; 4.3 per cent, died of intercurrent diseases; 42.6 per cent, recovered 
(27.7 per cent, had only one attack, and 14.9 per cent, recovered after 
one or more relapses); 6.4 per cent, were indefinite as to the prognosis 
and 44.7 per cent, still had gastric symptoms of varying intensity. 
Leube claims 50 to 75 per cent, of cures after four to five weeks of medical 
treatment, and holds that when cases are thereafter refractory, no 
medical treatment is of any avad, and surgical interference is justifiable. 
Lenhartz's results would seem to give even a more favorable outlook, 
and modern surgery, with its excellent cures through timely gastro- 
enterostomy, has entirely altered the former unfavorable statistics. 
Relapses are frequent, and may occur after several years. Einhorn's 
view's are most encouraging as regards the prognosis of gastric ulcer. 
He draws attention to the fact that at postmortems one sees twice as 
many scars as fresh ulcers. Older ulcers are in some respects more 
favorable. Sometimes a new ulcer forms alongside of an old and chronic 
one, and again sometimes cancer forms on the ulcer and quite alters the 
complexion of the case and the outlook. 194 
DISEASES OF THE DIGESTIVE SYSTEM 
How can we determine if an ulcer is healed or not? This is fraught 
with difficulties. In general, one may say that if the patients are free 
from digestive complaints, if pain is absent, especially after solid food, 
if epigastric tenderness has disappeared, and if no occult blood is found 
in the feces after repeated tests, the conclusion is reasonable that healing 
has occurred. This idea is strengthened by the additional evidence of 
normal weight and strength. Postmortem, however, one sometimes 
finds open ulcers which have given no symptoms for several years, 
showing that in spite of latency of all symptoms, healing may not be 
complete, or recurrence may have taken place. 
Treatment.-Prophylaxis.-The etiology of gastric ulcer being still 
obscure, it is not easy to suggest along what lines the occurrence of 
ulcer may be prevented. We may say, maintain good health and a 
normal nervous system, and protect the stomach against irritation. 
Early diagnosis is of paramount importance, not only to prevent 
complications later on, but to effect a cure. The acute and the chronic 
ulcers require different treatment, according to their physical conditions. 
For the cases of so-called acute gastric ulcer, the strictest discipline 
is essential to a cure, and no neglect in hygiene, diet, or medicine is 
permissible. Failures in medical treatment come from indifference or 
incomplete discipline. The essentials of treatment are: (1) Protection 
of the mucous membrane. (2) To counteract hypersecretion. (3) To 
counteract causes of hypersecretion (irritation). (4) If operation is 
performed, continue the same care. Rest in bed is essential once the 
diagnosis has been established and the treatment commenced. By 
resting from at least four to six weeks in this way, hemorrhage and 
perforation may be prevented, and less of caloric units are required in 
the diet. After this the transition from rest in bed to walking should 
be very gradual, and when once able to go about the patient should be 
made to rest after every meal. These precautions should be observed 
for some months or even longer; sometimes even this does not suffice. 
Diet.-There is no general rule of feeding applicable to all ulcer cases. 
Each patient must be considered individually; some may require more, 
others less food; when the motor power is good and the stomach not 
readily contracted through spasms, a more generous diet may be recom- 
mended. If, on the other hand, the stomach is irritable and food causes 
pain and distress, it is well to give such patients as little food as possible 
and proceed very carefully in the transition to a more liberal diet. 
In the so-called abstinence cure, during the first few days one depends 
exclusively upon rectal alimentation. This gives complete rest to the 
stomach, and may if necessary be kept up for several days, provided 
some nutrition be maintained per rectum. Saline enemata alone may 
suffice, but starvation is good, and often well borne. 
Saline injections are specially commendable because less gastric 
secretion is produced than when nutrient enemata are employed. One 
may, however, if preferred, give nutrient enemata, the patient receiving 
every six hours six ounces of broth with an egg and salt, and if desirable 
a little whisky may be added. These enemata should be given by means 
of the funnel and tube, slowly and by gravitation, and the bowels should ORGANIC DISEASES OF THE STOMACH 
195 
be gently irrigated before every second or third enema. Ewald recom- 
mends an enema made up of two or three eggs beaten up with one-half 
ounce of cold water, this mixture being added slowly to another made 
up of a few starch granules boiled in one-half cup of 20 per cent, grape 
sugar, to which two ounces of claret are added when lukewarm, the 
total being eight ounces. This should be introduced slowly high up, 
and should, if there be a previous cleansing saline injection, cause no 
irritation. This may be used twice or three times daily for from three 
to eight days. Water enemata may be used at intervals between the 
nutrient enemata if there is thirst, a dry tongue, or a bad breath. 
Mouth Feeding.-The early administration of food by the mouth is 
apt to cause distension, increase the hyperacidity, induce vomiting, and 
thus directly or indirectly prevent the healing of the ulcer. When food 
is administered by the mouth it is well to commence with milk and lime- 
water, albumin-water, or strained oatmeal gruel, at first in small quan- 
tities, a few ounces every two hours, and combine this as required with 
nutrient enemata. Whey is recommended by some. Milk may be 
given warm and diluted with one-eighth of lime-water or sodium bicar- 
bonate. If curds form, one may add a little meal or flour to the milk, 
or peptonize it. To many butter is tasteful in the early stages of treat- 
ment. Fiitterer strongly recommends the early use of beef juice. After 
several days of this diet one may add rice or sage soups, broths in small 
quantities, and raw or soft-boiled eggs, and at the end of two weeks 
finely divided albuminous foods, such as minced meat, white fish, chicken, 
partridge, and tender beef, and mashed potatoes. One cannot lay too 
great stress upon the necessity of care in the transition stages from the 
liquid to the semisolid diet. After six weeks other meats may be given, 
and from that time on the greatest care should be taken for several 
months, even after an apparent cure has been obtained, and all coarse, 
irritating, and spicy, rich foods should be avoided. Examination of the 
feces for occult blood is an excellent guide for change in diet. 
Medicinal Treatment.-Perhaps the most universally employed drug 
in gastric ulcer is bismuth, which may be given as the subnitrate, or 
preferably the subgallate, in doses of from 20 to 30 grains (gm. 1.3 to 2) 
or more several times daily. It is perhaps best suspended in gruel or 
barley-water. It may be given alone or combined with sodium bicar- 
bonate or calcined magnesia, which ease the pain and burning and count- 
eract the hyperacidity. Bismuth, however, constipates, and may in 
this way be a source of trouble. The constipation may be relieved by 
Carlsbad salts, given in doses of one dram in hot water in the early 
morning; or it may be better at first to give merely enemata of soapsuds 
or glycerin. Fleiner's bismuth cure consists of daily lavage and sub- 
sequent administration through the tube of six ounces of water with 
2| to 5 drams of subnitrate of bismuth. The patient lies down for half 
an hour and then takes breakfast, this procedure being carried on for 
two weeks. It is very doubtful if the results and requirements justify 
a method of treatment so troublesome to the patient. 
Silver nitrate is also highly recommended as an astringent and antacid. 
It may be given in pill form, | to | grain (gm. 0.016 to 0.03) per dose, 196 
DISEASES OF THE DIGESTIVE SYSTEM 
or in solution with a few grains of sodium bicarbonate. Some prefer 
giving it through the stomach tube. Boas uses silver nitrate in a solution 
of 1 to 500, and gives it in gradually'increasing strength up to 1 to 300, 
adding peppermint to prevent nausea. 
Lavage is carried out when the stomach is intractable; and for ambu- 
latory cases some sodium bicarbonate may be added to the water. 
Treatment of Symptoms.-For the pain, if severe, morphine may be 
necessary; a wet compress over the epigastrium is often soothing; ortho- 
form may be used with some benefit. For the vomiting, ice, bismuth, 
nitrate of silver, cocaine, and opium are recommended. For the anemia, 
albuminate of iron may be given, as Ewald suggests, by adding 1 dram 
(4 cc.) of a 2 per cent, solution of iron sesquichloride to 2 ounces of 
albumin water; or Bland's pills with a laxative may be used. For the 
hematein esis, absolute rest and quiet, ice to suck, and small doses of 
adrenalin chloride, 10 to 20 drops of the 1 to 1000 solution three or four 
times a day, may be effective. Lucas Championniere seems to have 
shown that lavage is good because the stomach is not in repose during 
hemorrhage, and washing out gives it the necessary rest. Ewald used 
ice-water for the lavage, and others recommend gelatin water. It is 
thought by some that high enemata of hot water, acting reflexly, may 
check the hemorrhage and combat the shock. It is well, perhaps, both 
for the restlessness and for the quieting of the circulation, to use morphine 
hypodermically. For the severe recurrent hemorrhages surgical inter- 
vention may be necessary, and is often most successful. 
Lenbes Method.-The patient is placed in bed for ten days, the epi- 
gastrium washed with alcohol and sublimate solution, then boracic 
ointment is applied on a cloth, and over this a hot flaxseed poultice, 20 
by 10 cm., every fifteen minutes, for ten hours during the day; at night 
a wet compress is applied. This treatment is carried on for ten days. 
Then a simple cold compress is applied at night during the next three 
weeks, while in the day an abdominal flannel binder is worn. During 
convalescence the patient rests for two hours after meals, not even doing 
sewing, etc. The only contra-indications for poultices are menstruation 
and recent hemorrhage (within three months). When recent hemorrhage 
has occurred, or when the stools show traces of blood, an ice-bag may 
be applied instead of the cold compresses. One pint of Carlsbad water 
is drunk slowly each morning for one month, and alkaline waters are 
taken during the day. Few drugs are used, unless bismuth or sodium 
bicarbonate. The constipation is treated by enemata of tepid water, 
by Carlsbad salts, or other salines. 
Lenhartzs Method.-Bismuth subnitrate, 30 grains (gm. 2) is given 
daily with careful limitation of fluids. Morphine is unnecessary. Some- 
times silver nitrate is useful, and iron later on. Occasional glycerin 
enemata may be given after the first week. In the diet fresh eggs are 
the main article, given in increasing quantities each day, chiefly raw and 
beaten up. One to three eggs are given on the first day, and one added 
on each subsequent day, until eight are taken daily, and this number 
maintained. They may be given iced in teaspoonfuls, and later soft 
boiled. Sugar is added to the eggs on the third or fourth day, in gradually ORGANIC DISEASES OF THE STOMACH 
197 
increasing amount (30 to 50 gm.). Iced milk must be given in extremely 
small amounts, only increased with the greatest care to obviate unneces- 
sary distension, which Lenhartz regards as the most serious of all 
ordinary events which may obviate the healing process. Eggs alone 
being insufficient, finely divided meat, preferably raw, or scraped beef, 
is given from the sixth day onward (at first 35 to 70 gm.). On the 
seventh day, soft-boiled rice is given, and on the eighth day, toast, 
softened rusks, or cereals, and 20 to 40 gm. of butter, and finely divided 
raw ham on the tenth. Strong broths are harmful on account of their 
extractives and spices, which tend to increase hyperacidity. 
The treatment is begun at once, in order to bind the hydrochloric 
acid and prevent its evil effects on the recent thrombus. Absolute rest 
is maintained by this means better than by the abstinence cure, for 
even with an empty stomach some peristalsis takes place and is only 
likely to be increased by an excess of hydrochloric acid. 
Senator adopts a middle course and argues that one should not distress 
the stomach by an excessive amount or weight of food, that a soothing 
diet is useful to prevent recurrence of the hemorrhage, that a diet which 
will counteract the hyperacidity is useful, and that the food administered 
should be easily digested and nutritious. To this end he believes that 
glutin, fat, and sugar fulfil all these requirements. For this purpose he 
recommends lerin, or its modification glutin, or one may use gelatin 
because of its hemostatic effect. Fat is useful because of its counteraction 
on the acids, and its soothing effects on the surface of the ulcer. He 
allows fresh butter and cream in small amounts, often, e. g., 30 gm. of 
butter and 250 cc. of cream in twenty-four hours. If the butter is not 
well borne, it may be given iced in lumps to suck or swTallow\ Cream is 
given iced and beaten up. These quantities may be gradually increased 
if no hemorrhage occurs, and one may add milk, beaten up eggs, and 
meat, as recommended by Lenhartz. Gelatin should be stopped after 
a while because of its constipating effect, and in its place one may use 
jellies. Instead of butter, good oil may be given, either iced or as an 
emulsion (almond emulsion or almond milk). 
Rosenheim likewise approves of gelatin, using it in 5 to 8 per cent, 
solution in citric acid, and avoids meat, preferring a lacto-vegetable 
diet. 
Chronic ulcers which have failed to respond satisfactorily to medical 
treatment are in some cases benefited by surgical interference; others, 
again, do not admit of operation because of associated gastric and other 
abdominal conditions which render the operation unsuccessful and 
merely aggravate the already existing misery. 
Einhorn has recently devised a method of feeding directly into the 
duodenum by means of a tube especially constructed for this purpose, and 
claims some success in suitable cases-with persistent bleeding and 
tendency to stasis. The method does not seem to have received general 
approval, though in theory much might be said in its favor. 
Surgical Considerations.-Many statistics have been compiled with a 
view to demonstrate the superiority of medical over surgical methods 
of treatment, and vice versa. Such proofs, however, scarcely carry 198 
DISEASES OF THE DIGESTIVE SYSTEM 
much weight when diagnoses are often uncertain, when conditions and 
symptoms vary within the widest of limits, and when the individual 
circumstances make it always imperative to consider each case by itself 
and for itself, rather than to place it under any very general category. 
Many cases certainly fail under medical treatment, and just what 
particular circumstances interfere with the healing of so many simple 
ulcers, even when seen in early stages, are as yet unknown. Certainly 
statistics now in use are for the most part unreliable and more or less 
useless. 
Surgical interference shows an ever-diminishing mortality in each 
succeeding year since operations on the stomach have become common. 
While in earlier years operations were frequently repeated because of 
incomplete results, the number of these likewise attains an ever-dimin- 
ishing proportion in accord with the more judicious selection of cases 
and better methods of operation. Repetition of operation was necessi- 
tated either from recurrence of old ulcers, from formation of new ones 
near the site of operation, persistence of old symptoms, the development 
of vicious circles, or hernia, but the proportion of these has rapidly 
lessened. 
The following figures present the case as it now stands with modern 
surgery: Up to April, 1905, among 153 gastro-enterostomies, etc., 
(two only requiring second operation), there were 2 deaths (1.5 per 
cent.). Later, among 206 gastro-enterostomies, etc., including hemor- 
rhagic cases and hour-glass stomach, there were 9 deaths (4.3 per cent.). 
In May, 1906, among 251 gastro-enterostomies, etc., there were 9 deaths 
(3.5 per cent.). Mayo Robson, among 210 gastro-enterostomies, etc., 
had 8 deaths (3.8 per cent.). Comparing these figures with those of 
earlier years, the improvement is striking, and comparing them with 
the mortality by medical treatment alone, the benefit attributable to 
surgery is enormous. Graham1 reports from the Mayo Clinic that of 
438 cases of duodenal ulcer which had been followed, 70 per cent, were 
cured, 27 per cent were improved, and 3 per cent unimproved. The 
results are slightly better when there is an obstruction present. This 
was even more marked in the gastric ulcers which caused obstruction. 
Of the patients with ulcer operated on during a period of six years, 
76 per cent, were males and 24 per cent, females. In the males 70 
per cent, of all ulcers were duodenal or involved the duodenum, and 
in the females 60 per cent. 
Of 162 cases of gastric ulcer, 59 per cent, were cured, 22 per cent, 
were much improved, 13 per cent, showed some improvement, and 7 
per cent, were unimproved. 
Surgical Methods and Indications.-Surgical Treatment of Perforation.- 
Howard states that 8 cases have been recorded as recovering after 
generalized peritonitis without operation, and Carless' statistics, which 
seem optimistic, give 4 per cent, recovering under similar conditions. 
The early surgical treatment as a result of early diagnosis and perfected 
technique has given brilliant results, and the following statistics afford 
1 Boston Med. and Surg. Jour., 1914, clxx, p. 221. ORGANIC DISEASES OF THE STOMACH 
199 
ample evidence of the success of more modern methods: Mikulicz, 1885 
to 1893, had 35 cases with 34 deaths, i. e., 1 recovery, and from 1894 
to 1896, 68 cases with 36 deaths, i. e., 32 recoveries. Tinker, in 1900, 
recorded 232 cases, with 113 recoveries, and Robson, in 1900, recorded 
429 cases, with 279 recoveries (65 per cent.). J. Bell, of Montreal, in 
1903, had 10 cases, with no deaths. The proportion of recoveries has a 
direct relation to the early time of operation after rupture; the sooner 
operation is done, the greater proportion of recoveries. 
The multiplicity of ulcers is of the greatest importance, and is to be 
considered in all operations for perforation, and in not a few cases a 
second operation has been necessary for this reason, when the first had 
healed. Hence the recommendation of some surgeons to perform a 
gastro-enterostomy in all cases after closing the perforation, in this way 
obviating possible extension of other ulcers. 
Hour-glass Contraction.-The treatment of hour-glass contraction is 
essentially operative, the object being first to drain both sacs and allow 
of healing, which, however, involves a double operation. Many methods 
are recommended. (1) Gastroplasty, which affords better communica- 
tion between the two sacs, is a suitable operation for the simpler cases 
with little infiltration. It is done with or without gastro-enterostomy, 
according to the requirements. (2) Gastro-gastrostomy, in which the 
two sacs are brought together and directly joined, is often commendable 
in patients whose hour-glass contraction is extreme, and where the 
opening between the sacs is very small. (3) Partial gastrectomy, 
which removes the total area of disease and unites the divided healthy 
ends of the stomach, is the ideal operation, because it corrects the deform- 
ity as well as eliminates all the old or any recent disease. (4) Gastro- 
enterostomy alone is of little use. To be beneficial it should be double, 
and this makes a serious operation and affords some danger of a double 
vicious circle. The necessity for anastomosis is largely determined by 
the situation of the ulcer, its extent, and its liability to induce stenosis, 
adhesions, and deformities. 
CANCER OF THE STOMACH 
Definition.-A malignant epithelial neoplasm of the stomach. 
Incidence.-About one-half of all cancers arise in the stomach, and 
statistics of hospital admissions show 0.47 per cent, of gastric cancers. 
Autopsy statistics show 4 per cent.; Reiche's Hamburg statistics (1872 
to 1895) show that 50.2 per cent, of all cancers are gastric, and that 
cancer of the intestinal tract, as a whole, forms 75 to 85 per cent, of all 
cancers. 
Regional.-Deaths per 1000 population from cancer in general vary 
within rather wide limits: Amsterdam, 12; Berlin, 22.4; Geneva, 53; St. 
Petersburg, 15; New York, 19.3; and London, 28.7. Climatic conditions 
seem to have but little influence except that in tropical countries gastric 
cancer is more uncommon, e. g., in Egypt (Griesinger). Regional differ- 
ences where they exist are probably associated more with the manner 
of living and the diet than with the climate. 200 
DISEASES OF THE DIGESTIVE SYSTEM 
Etiology.-Race.-Gastric cancer is much less common in negroes. 
In 1880 the death rate in the United States from all cancers was: white, 
25.9; negroes, 12.6. 
Age.-The following results appear from 7000 cases gathered from 
combined statistics. 
Ages. 
Per cent. 
10 to 20 years 
0.08 
20 to 30 years 
1.5 
30 to 40 years 
8.4 
40 to 50 years 
18.0 
50 to GO years 
28.0 
60 to 70 years 
28.0 
70 to 80 years 
14.0 
Over 80 years 
2.0 
Congenital cases have been described (Williamson and Widerhofer), 
and Cullingworth performed an autopsy on a child, aged five weeks, in 
which gastric cancer was found. Osler and McCrae found 10 cases in 
the literature under ten years of age, and 13 cases between ten and 
twenty years. Probably more than 2 per cent, of all gastric cancers 
occur under thirty years of age; 80 per cent, or more between the ages 
of forty and seventy. With better methods of examination more and 
more cases are found among youths, which alters the ratio somewhat 
and brings the average down to earlier years. 
Sex.-Of 20,000 cases collected from my combined statistics, 58 per 
cent, were in men. Welch gives the relation as five males to four females. 
Heredity.-Opinions vary widely and statistics are very incomplete. 
In 1075 cases Snow found heredity in 167, i. e., 15.5 per cent.; Schule 
gives 6.5 per cent, as hereditary; Lebert 7 per cent., and Roth 50 per 
cent. Of 2700 cases of gastric cancers, 12 per cent, showed an hereditary 
history. In the Royal Victoria Hospital, 24 per cent, gave a probable 
hereditary history, which was undoubted in 18 per cent. Cancer as a 
family affection perhaps occurs in 10 per cent, in all cases. At the same 
time, gastric cancer being in any case a frequent disease, there can be 
little that is reliable in such findings. Just how frequently the offspring 
of cancerous patients have subsequently developed the disease we do 
not know, and histories refer to relationships which are often too remote 
and indefinite to permit of accurate conclusions. Warthin has recently 
drawn attention to the marked incidence of cancer in certain families. 
Previous Gastric Disease.-Long-continued irritation as a cause of 
cancer of the stomach is extremely dubious, and " badly used" stomachs 
seem to suffer no more than do those well treated. On the contrary, 
the development of cancer is often almost sudden when the digestion 
had previously been unimpaired. 
Chronic Ulcer and Cancer.-Wide variations in the statistics are noted, 
because of many views and imperfect observations as to the diagnosis 
of ulcer. Cruveilhier discussed the relation of cancer and ulcer in 1839, 
and Rokitansky soon after recognized its possible implantation in ulcer. 
Dittrich, in 1848, recorded 160 cases of cancer, of which 6 were of this 
etiology. Fiitterer concluded that cancer frequently formed at the ORGANIC DISEASES OF THE STOMACH 
201 
edge of ulcers, especially where the part was most exposed to irritation, 
and in the pyloric region this development occurs in the lower margin. 
But if the position of the organ alters from dilatation or adhesions, 
other parts of the edges may be involved. Cancer develops in ulcer 
most frequently in the pylorus. (Fuller discussion of the subject will 
be found in the article on gastric ulcer.) 
Alcohol.-Fifty-six per cent, of the Royal Victoria Hospital cases 
were habitues, and of these 20 per cent, were hard drinkers, and 30 per 
cent, drank moderately but constantly. 
Trauma.-In 62 cases of cancer of the intestinal tract, Boas found 9 
with a clear history of antecedent trauma, and only 1 in gastric carcinoma. 
According to some, and especially Fiirbringer, trauma has a definite 
effect in aiding the development of latent cancers and increasing the 
rapidity of their progress. Kuttner and Lindner, after careful inquiry, 
found no history of injury in 66 consecutive cases. 
Auto-inoculation.-Transplantation of cancer from a primary growth 
on the tongue into the stomach has been recorded by Klebs, Cornil, 
and others, but such instances must be very rare. The possibility of 
auto-inoculation from one cancerous tissue to another has been frequently 
noted, and surgeons have found it in the line of incision or of puncture 
in abdominal cancers infected from the original neoplasm. 
Pathology.-Cancer of the stomach is a malignant epithelial over- 
growth extending from the secreting cells of the mucosa to the other 
coats of the organ, and thence usually to the neighboring tissues, glands, 
and organs, or to distant parts by continuity, contiguity, and metastases 
through lymphatic and blood channels. It is nearly always primary in 
this organ. 
Secondary cancer of the stomach is rare. Statistics show the propor- 
tion to be about 1.1 per cent. (i. e., 5 cases out of 440), up to as high as 
6 to 7 per cent. (Hale White). It arises either from contiguity or by 
metastases from distant viscera. Involvement by contiguity from the 
pancreas, liver, oesophagus, etc., is, of course, common and even trans- 
plantation from the tongue has been recorded, with the development of 
a secondary epithelioma of the stomach as a direct result of swallowing 
detached particles of the tumor. 
Site of Growth.-The pylorus (27.2 per cent.) and the lesser curvature 
(26 per cent.) are the most frequent sites. The frequency of the latter 
site accounts for the absence of obstructive signs in many cases of 
apparent pyloric cancer in which the arrays show the patency of the 
pylorus. Mikulicz and Kausch, in 1900, mentioned the probability that 
40 per cent, of cases of cancer of the stomach began in the lesser curva- 
ture, their observations depending on laparotomies and thus representing 
earlier types than are seen by the pathologist. As regards other sites 
of origin, two series may be quoted: 
Pylorus and lesser 
Anterior or 
Greater 
curvature. 
Cardia. 
Diffuse. 
posterior wall. 
curvature. 
Per cent. Per cent. 
Per cent. 
Per cent. 
Per cent. 
Lebert and Hahn. 51 
29 
15 
0.08 
0.04 
Orth . 
. . . 80 
10 
10 202 
DISEASES OF THE DIGESTIVE SYSTEM 
Multiple Cancers.-Occasionally several tumors are found in the same 
stomach, e. g., Maurizio saw one case with cancer at both the pylorus 
and at the cardiac end, and Gierke reported a case with four cancers in 
one stomach. 
Relation of Cancer to the Changes in the Mucosa.-The general mucosa 
elsewhere suffers coincidently with the progress of the cancer. Usually 
the superficial cells are fairly preserved or more goblet cells appear. 
The peptic glands become mucous glands, the border cells disappear 
more than the chief ones, and all are more or less surrounded by new 
small round cells. The mucous membranes may be completely absent 
in some places, due to the development of a general atrophic gastritis 
with small-celled infiltration, cysts, etc. The observation of Fenwick 
is noteworthy, viz., that with cancers of organs other than the stomach 
there may be absence of normal acid gastric juice. Friedenwald and 
Rosenthal found a similar result in 9 out of 29 patients. 
Fig. 5 
Scirrhus carcinoma of pyloric end of stomach. 
The cancer may be circumscribed or diffuse, i. e., a fungating mass with 
a villous surface, or one that is more smooth and flat, and showing 
central dimples or areas of degeneration and ulceration, or else diffuse, 
extending mainly in the submucosa, which thus becomes thickened, 
giving to the whole wall a greater rigidity and firmness. The mucous 
membrane itself is usually roughened and in parts degenerated, while the 
organ is either large and dilated (if pyloric stenosis has occurred), or 
shrunken and the cavity much smaller than normal. In some of these 
diffuse cancers it may be impossible to distinguish the condition from 
a mere cirrhosis (interstitial gastritis) even by microscopic examination. ORGANIC DISEASES OF THE STOMACH 
203 
Two main types occur: The scirrhus and the medullary, although 
transition forms and mixed types are usually present in nearly all gastric 
cancers. They are, as a rule, hard tumors, due to the preponderance of 
fibrous tissue (where epithelium and stroma preserve the alveolar arrange- 
ment the name carcinoma simplex is used). The wall is thickened, the 
extension is often diffuse rather than circumscribed, and there is a 
tendency to scar formation in some places, while in others superficial 
ulceration is seen. Scirrhus cancers are slow growing, spread gradually 
into the surrounding tissues, especially the muscle. It is in this form 
that differentiation is sometimes difficult between cancer and simple 
chronic indurated ulcer or cirrhosis ventriculi. Scirrhus neoplasms 
are commonest at the pylorus, so that stenosis occurs, owing to the 
increasing size of the tumor or to shrinkage and rigidity at the 
orifice. 
The medullary form is soft, very cellular, and thus on section shows 
more "juice." The progress is more rapid, degeneration and hemorrhage 
more common, and metastases are more readily formed. The glands 
especially are subject to invasion. 
Papillary outgrowths of a special adeno-carcinomatous form are not 
uncommon. They form soft, fungating excrescences, oftenest at the 
pylorus, where they are sharply delimited at the duodenal end. Ulcera- 
tion, necrosis, hemorrhage, and even perforation are apt to occur with 
this special variety. 
The colloid changes may supervene in any form of gastric cancer. 
Diffuse thickening occurs from the presence of yellowish-brown, jelly- 
like, translucent fluid, which is seen occupying large or small spaces in 
the neoplasm. It is essentially a degenerative process of the cells and 
tends to invade the omentum, but not, as a rule, the intestines. 
Myxomatous degeneration may occur in the fibrous stroma of any 
cancerous tumor. 
Squamous-celled cancer commonly occurs about the cardia as the result 
of an epithelioma commencing in the oesophagus. It is rarely elsewhere 
in the stomach, except when secondary nodules form there either by 
transplantation from squamous-celled tissues (tongue, oesophagus), or 
by metastases from the oesophagus. 
Extension and Dissemination.-The disease may be confined to the 
stomach, and may induce ulceration, degenerative changes, hemorrhages, 
etc. Extension within the stomach occurs chiefly by the lymphatics 
which run in the fibrous intersections between the muscle bundles. Here 
the course is vertical toward the serosa, which may also be involved. 
Cuneo has shown that the gastric lymphatics run toward the glands 
along the lesser and greater curvatures, more especially toward the 
pyloric end and in the adjoining portions of the great omentum, and 
thence through the coeliac glands on their way to the thoracic duct, 
thence to the supraclavicular region, as well as to the subclavian vein 
and the general circulation. In pyloric cancer the lesser curvature is 
rapidly invaded, and the lymphatics and glands become involved as 
far as the point where the coronary artery joins the stomach; here the 
lymphatics pass from the lesser curvature. The lymph nodes of the 204 
DISEASES OF THE DIGESTIVE SYSTEM 
greater curvature do not usually go farther to the left than a point near 
the median line. The fundus is almost devoid of lymphatics. 
The disease commonly spreads in the subserosa and if degeneration 
occurs here, ulceration, and even perforation may follow with a con- 
secutive peritonitis, general or local with adhesions, and perigastritis. 
Perforation is, however, an uncommon event (4.46 per cent.). In this 
way abnormal communications may form between the stomach and 
other viscera and tissues, e. g., large intestine (gastrocolic fistula), small 
intestines, the anterior wall, pleura, pericardium, with admission of 
air and infected material into these cavities, the lungs and bronchi, 
with formation of abscesses, gangrene, etc. 
Sometimes there is partial healing; scars form, hithough the process 
does not cease, and in other parts the neoplasm shows progressive 
degeneration. Ulceration occurs in a very large number of cases, prob- 
ably in more than 80 per cent., and hemorrhages are common, the amount 
depending on the size of the eroded vessel or the degree of capillary 
oozing. Suppuration occurred in 4 of 40 cases observed by Boas. 
Extension outside of the stomach occurs through continuity of structure, 
contiguity by means of adhesions, or by direct implanatation, chiefly, 
however, by the lymphatics and sometimes by the blood stream, especially 
the portal vein. 
Metastases arise either from the blood stream or lymphatics. They 
may appear before any suspicion is aroused of the gastric origin of the 
neoplasm, as in Tilling's case in which a secondary node on the humerus 
was the first evidence of the gastric cancer. Often, too, the growths in 
the liver or peritoneum mask the original site. Metastases travelling 
by the blood stream most commonly enter the portal vein and liver. 
They also commonly extend to the peritoneum and omentum, the pan- 
creas, spleen, kidneys, pelvis, bones, and lungs (especially the left). No 
organ is immune. The lymphatics bring metastases to the neighboring 
glands (85 per cent., according to Cuneo), chiefly those at the diaphragm, 
the perigastric and retroperitoneal glands, the extension occurring in 
the glands of the thorax and supraclavicular region as well as in the 
thoracic duct. Out of 556 cases the cervical glands were involved in 
only 21 (4 per cent.). Statistics show that in 2156 cases, metastases 
formed according to the following proportions in various parts of the 
body: glands, 44.1 per cent.; liver, 33.2 per cent.; peritoneum and intestine, 
27.6 per cent.; pleura and lung, 7.3 per cent.; and pancreas, 7.6 per cent. 
In the Tubingen statistics (1891 to 1905) the distant glands were involved 
only in 7 out of 91 cases; in only 3 were the supraclavicular glands 
involved, and in the others the bronchial and mediastinal glands. Cancer 
of the cardia often extends to the oesophagus; that of the pylorus, on 
the other hand, rarely involves the duodenum. 
The abdominal wall is at times invaded, chiefly through lymphatics 
of the obliterated umbilical cord, and great diagnostic importance 
attaches to the discovery of small secondary nodules in the subcutaneous 
abdominal tissue, especially about the umbilicus. Peritoneal cancer is 
common, and there may be ascites from various causes. The ascitic 
fluid may be serous, hemorrhagic, or chylous. ORGANIC DISEASES OF THE STOMACH 
205 
Secondary gastric cancer sometimes results from a primary growth 
in the stomach, e. g., a cancer of the cardia may follow upon a pyloric 
growth, or, again, a pyloric stenosis may occur from compression by 
periportal cancerous glands, which become involved from a primary 
cancer of the cardiac orifice. 
The general morbid anatomy reveals, as in any other cancer, marasmus, 
with brown atrophy of the heart and fatty degeneration of its muscle, 
brown atrophy of the liver, fatty kidneys, and not uncommonly degenera- 
tions in the spinal cord and peripheral nerves. Multiple thrombi asso- 
ciated with the marasmus, or arising directly from the neoplasm are 
sometimes found in the bloodvessels. General anasarca, anemia, and 
cachexia are added. 
Symptoms.-These vary according to the stage of the disease, the 
situation, the extent and pathological character of the growth, and upon 
its direction of progression. 
Latency.-The onset may be quite unnoticed either by patient or 
physician and the disease may be an accidental discovery at autopsy. 
Patients with gastric cancer may enjoy apparent health for months, 
with undisturbed appetite and digestion, and with maintenance of 
strength and nutrition even when extensive metastases are present, 
as described by Cheney and others. Cases occurring elsewhere than at 
the orifices are especially apt to be latent, although in cancers of the 
cardia when no obstruction has yet occurred, and no tumor can be felt, 
the course may be unobserved. Sometimes these cases simulate perni- 
cious anemia. The examination for occult blood in the stools has aided 
in the diagnosis of cancers of the digestive tract. 
Onset.-Symptoms usually begin with inexplicable "dyspepsia," 
which does not respond to treatment. Following upon this are pain, 
loss of weight, and weakness, later vomiting, perhaps of blood, and the 
cachexia progresses to a fatal issue. The onset and persistence of dys- 
pepsia in a man over forty years of age, who has previously enjoyed 
good health, is a suspicious circumstance. Sometimes the onset is 
apparently sudden, in the midst of health, or after some acute illness, 
or perhaps after a trauma. In one class of cases the onset is often 
characteristic, viz., where cancer follows ulcer or is engrafted upon it. 
In many of these the diagnosis is obscure through the presence of 
hyperacidity, especially as the HC1 may be in excess to the end, and 
with it hypersecretion and early motor insufficiency; perhaps all the more 
so because spasm develops at the pylorus with the hyperchlorhydria. 
The deficiency of HO in these cases appears late, and lactic acid 
is correspondingly small in amount and only found late. Pain and 
hemorrhages are early signs in these cases and usually marked features. 
Early Digestive Symptoms.-Flatulence is frequent, at first odorless. 
Later on with degeneration or ulceration of the neoplasm, the expelled 
gas has a fetid or foul odor from gangrene, suppuration, or the presence 
of organic acids. A sensation of fulness occurs even after very little 
food. Anorexia is common and early, and is'apt to be progressive, 
although in many cases unimpaired until late in the disease. The 
appetite often shows caprice and an especial dislike for meat may develop. 206 
DISEASES OF THE DIGESTIVE SYSTEM 
The taste is altered and often perverted. Smokers commonly lose all 
desire for tobacco. Bulimia and dysphagia are rare. Thirst is definitely 
related to the degree of stenosis and to the motor insufficiency. The 
tongue is usually thickly coated, although at times clean for months; 
much depends on the condition of the teeth, gums and pharynx. 
Vomiting.-This is very frequent, and occurs in 80 to 90 per cent, of 
all cases. It usually takes place late in the course of the malady, and 
is especially common in pyloric cancer, owing, of course, to the stagnation 
and dilatation. In Warren Lyman's statistics from the Royal Victoria 
Hospital, it was noted in 68.2 per cent. Sometimes it is early (in 7 out 
of 83 of our patients it was the first symptom, and in 34 it was very 
early). Acute fatal cases with rapid emaciation and repeated uncon- 
trollable vomiting have been described. As dilatation becomes more 
pronounced the vomiting may be at longer intervals and then more 
copious, the vdmitus being largely unaltered and mixed with mucus, 
blood pigment, detritus, etc., and having a foul or fetid odor from organic 
acids. Often three layers form in the vomitus when retention of food 
has existed, the uppermost frothy, the middle layer consisting of turbid 
fluid and partly digested foodstuff, while at the bottom there is a granular 
material with food in various stages of digestion and other matter foreign 
to normal digestion. When an ulcerating obstructive growth at the 
pylorus breaks down to create a new passage, the vomiting may cease 
for weeks and the motor insufficiency be temporarily relieved. Vomiting 
is much less frequent when the fundus or anterior wall is the original 
seat of the cancer. In 26 of our 83 cases, vomiting was either absent 
until death or until discharge from the hospital. When the cardia is 
affected alone, vomiting will be more of the nature of a regurgitation 
and with much mucus. It is, as a rule, preceded by nausea, salivation 
and digestive discomfort. As a rule, vomiting causes some relief to the 
general discomfort, but not much to the pain. 
Hematemesis.-This is a common symptom, but occurs as an obvious 
sign in less than half of all gastric cancers. Chemical tests for occult 
blood, however, show hemorrhage to be much more frequent. It is 
important to distinguish between true coffee-ground vomiting and 
altered foodstuffs which have a similar appearance. This can be deter- 
mined often only by chemical tests, by the microscope or the spectro- 
scope. 
The bleeding may occur from erosion of a large vessel, and be copious 
and even fatal, although this is rare (1 per cent., Welch); death may 
occur from hemorrhage without emesis. More usually there are small 
repeated hemorrhages, either from the degenerated tumor, or from 
superficial erosion of the mucosa. The blood oozes slowly, remains a 
long time in the stomach, and for this reason it is altered to hematin, 
giving to the contents the coffee-ground appearance. Tiny specks of 
very dark clotted blood, which frequently appear in the vomitus with 
cancer of the lesser curvature, are of diagnostic importance, coming from 
folds of the mucous membrane or in depressions of the neoplasm. This 
is often a very early sign of cancer, especially if associated with the 
Oppler-Boas bacillus. The blood, though sometimes pure, is usually ORGANIC DISEASES OF THE STOMACH 
207 
mixed with food. Occult bleedings are a very important finding, and 
form one of the most constant signs in the disease. 
Pus is less commonly vomited, and if copious may be seen by the 
naked eye, or detected by its fetid odor. If in small amount, it may only 
be revealed by the microscope. It arises through degeneration and 
ulceration of the neoplasm, and its presence is important for diagnosis. 
Pain.-This is usually preceded for a time by a mere sense of pressure 
and discomfort, especially after meals. It was the first symptom in 
25 out of 83 cases in the Royal Victoria Hospital (31 per cent.), and was 
present in the gastric region in 75 per cent. In from 75 to 90 per cent, 
it occurs at some time during the progress of the disease. In Osler and 
McCrae's series 13 per cent, ran a painless course. In the Royal Victoria 
Hospital, 22 per cent, had no gastric pain (Lyman). The time of its 
appearance varies, sometimes only every few days or weeks, sometimes 
only at night, etc., while at other times it is constant. The degree of 
intensity, as a rule, is not excessive. There is painful distress or a dull 
ache, usually fairly well localized to the gastric area. Sometimes it 
radiates to the back and to the sacrum. If the cancer be at the cardiac 
end, the pain may be at the lowTer end of the sternum. In pyloric stenosis 
peristaltic, cramp-like pains occur, and there is a sense of unrest. 
A relation between the presence of a tumor and the site of the pain 
does not necessarily exist. In some of our cases with diffuse infiltration 
of the stomach no pain existed, and pain was absent in at least one of 
each typical variety of regional disease. Cardiac cancer was especially 
free from pain. A relation to food may or may not exist. 
The Bowels.-These are rarely regular and are usually constipated at 
first. F. Miiller says that diarrhoea occurs in 35 per cent, of all gastric 
cancers and at times the two conditions alternate. Occult blood is 
present in the stools in probably over 90 per cent, of cases. 
The Urine.-The quantity is usually diminished and the urine is con- 
centrated according to the degree of gastrectasis and pyloric stenosis. 
The chlorides vary within wide limits, and phosphates are increased. 
Nitrogen is increased because of the great albumin destruction that 
occurs in gastric cancer (vide Salomon's test.) Albumin is frequently 
present although usually in small amount. Albumoses (peptonuria) 
have been found from time to time in gastric carcinoma. A certain 
diagnostic significance attaches to their presence. Aldor examined 56 
unselected cases, and found albuminuria in every patient with fever 
and in 5 others in whom cancer of the stomach was present, and in one 
with cancer of the omentum. It is merely a confirmative test. Indican 
and ethereal sulphates are sometimes in excess and acetone and diacetic 
acid are sometimes present, and of no diagnostic import. Volatile fatty 
acids are in excess sometimes when cancer occurs with stasis and dimin- 
ished HC1, but Sigel doubts the diagnostic value of this finding. The 
variations of these acids is too great to be relied upon (Rosenfeld). 
The presence of sugar in the urine implies the probable involvement of 
the pancreas or brain and perhaps of the liver. 
Nutrition.-Emaciation is the rule; it is usually progressive, and is 
often the first symptom to arouse suspicion. The skin becomes lax, 208 
DISEASES OF THE DIGESTIVE SYSTEM 
dry, and wrinkled, the color earthy, sallow, and sometimes jaundiced. 
Cachexia supervenes, especially with motor insufficiency. There is 
nothing pathognomonic about the cachexia, and it has no diagnostic 
value in itself. Two exceptions are worthy of mention: (1) Sometimes 
patients run an advanced course with well-maintained nutrition. (2) 
Remissions occur, patients regaining some or much of their lost weight 
for a time, especially under careful lavage and diet, with encouragement. 
In cancer of the lesser curvature there is usually but little emaciation 
early in the disease. Loss of strength usually accompanies emaciation. 
Anemia.-This is due to the toxemia, hemorrhage, and malnutrition, 
but the blood examination is of little value in the diagnosis. Usually 
there is moderate leukocytosis. The red cells are normal or much 
diminished, sometimes there is marked poikilocytosis, and the picture 
may resemble that of pernicious anemia. The hemagiobin is diminished. 
The average red count is usually about 2,000,000 per cmm.; the average 
hemoglobin is about 50 per cent. The absence of digestive leukocytosis 
has no practical diagnostic value. 
Fever.-This occurs in about one-half or three-quarters of all cases, 
and at varying and irregular intervals. Sometimes there is an initial 
fever or irregular temperature during the course, and not uncommonly 
sudden elevations to 105° or 106° with rigors and as sudden a termination. 
At other times the type resembles that seen in malaria with chills and 
sweats. These irregularities in temperature are probably toxic, arising 
from absorption, if not due to complications, e. g., peritonitis, pleurisy, 
etc., which should be looked for. Terminal pneumonia or pulmonary 
metastases often cause fever during the latter days of the disease. 
Adenitis.-The neck may show enlarged supraclavicular lymph glands, 
especially on the left side. They become swollen, palpable, perhaps 
visible above the clavicle. The diagnostic value of this is doubtful and 
it may occur in any visceral cancer. Again, it is usually a late sign, 
not an early one. Sometimes, however, it is early enough to be of use, 
and therefore should be looked for. 
The Abdominal Examination.-Inspection.-This is of great import- 
ance. Osler has drawn special attention to examination of the abdomen 
for unevenness of the furrows below the ribs, for fulness in the epi- 
gastrium, nodules in the skin and about the navel, peristalsis and anti- 
peristalsis, and, lastly, for a wide area of aortic pulsation. It is w'ell to 
inspect the recumbent patient from behind the head of the bed. The 
tumor is often easily seen as if descends with deep respiration, and 
ascends with expiration, especially when the stomach is empty. With 
a full stomach a tumor may be pushed upward beneath the ribs or liver 
and be invisible. Respiration often has a marked effect on the position 
of the tumor, especially if it be localized to the pylorus, circumscribed 
and solid, and with adhesions to the liver. It may be accepted as a 
general rule that absence of respiratory mobility implies non-adherence 
to the liver. Cancers of the curvatures move readily, and may show 
fixation on expiration. This aids in the differentiation both of cancer 
of the stomach from that of other organs, and of cancer of the pylorus 
from that of the lesser curvature. Often tumors which descend with ORGANIC DISEASES OF THE STOMACH 
209 
inspiration may be held in that position during expiration. The changes 
of position depend on the size, the state, and the extent of the tumor. 
A large, wide tumor, adherent to the liver and yet extending below it, 
may be partly fixed even when the liver returns with expiration. 
Insufflation and inflation have some influence on the situation of a 
neoplasm in the stomach. Inflation should be carried out with care. 
The writer saw a severe laceration of the mucosa under such conditions 
in a European clinic, where the autopsy revealed four or five linear 
tears from end to end of the organ. Pyloric tumors descend to the 
right, and those of the lesser curvature move backward and disappear 
because the larger curvature turns forward. By inflation, too, the 
position and size of the stomach are easily detected, and ptosis becomes 
more obvious, especially in cancer of the lesser curvature. 
Palpation.-The examination should be made in various positions, and, 
if necessary in a hot bath, or under ether, in order to determine the size, 
shape, and situation, mobility, character, etc., of the growth. In the 
absence of a palpable tumor, the diagnosis often remains dubious. Some- 
times a tumor is not accessible to palpation even when large, especially 
if (1) it is high up in the cardia, (2) if it is in the lesser curvature and 
fixed to that vicinity, or under the left lobe of the liver, or (3) if it is in 
the posterior wall of the stomach. Tenderness is common, in variable 
sites, and there are often tender points behind near the vertebrae. It 
is often possible to feel a hardness and the nodular character of a neo- 
plasm and the knobs of cancerous masses with central depressions of 
degeneration (Farre's tubercles). 
Pyloric tumors are the easiest of all to palpate, especially in women 
with lax abdomens and descended stomachs. Not infrequently one 
may feel the gurgling of gas through the pylorus. These tumors are 
sometimes quite movable, especially if non-adherent elsewhere and if 
confined to the pylorus. Sometimes they may be moved to almost 
any position in the abdomen, as in one instance in which the tumor 
could at will be pushed beneath the right costal margin, to the right 
iliac region, or across the epigastrium to the left of the median line, and 
even below the umbilicus. 
Gastric Rigidity.-Boas has drawn attention to this symptom, although 
Creveilhier noted it more than half a century ago. The rigidity may exist 
merely as slight contractions of short duration confined more or less to the 
fundus, or as more marked tonic spasms of the muscle over a larger area, 
causing prominences of the fundus, and creating a sensation of pain to the 
patient, or, again, there may be still more decided contractions, which 
are both visible and palpable and are of longer duration. Gastric rigidity 
implies pyloric obstruction, and it is best observed with a full stomach. 
Percussion.-Dulness or dull tympany may exist over a large tumor. 
There is increased tympany with gastrectasis. Inflation aids mensuration. 
Auscultation.-Auscultation and auscultatory percussion are of doubtful 
value, although perhaps future developments may demonstrate their 
usefulness. The sign of the deglutition sounds, viz., delay in their 
occurrence and transmission to the ear, is of doubtful value, and cer- 
tainly not pathognomonic. It is possible to hear, too, the gurgling of 
vol. in-14 210 
DISEASES OF THE DIGESTIVE SYSTEM 
gas through the pylorus. Friction from a localized peritonitis is some- 
times audible. 
The Functional Signs and Analysis of the Stomach Contents.-There 
is no one pathognomonic sign of cancer. The diagnosis is made from 
the symptom and sign complex. The signs vary greatly according to 
the site, size, and extent, shape, character, etc., of the neoplasm. Macro- 
scopically the stomach contents show stagnation, fermentation, and poor 
protein digestion. Tumor fragments are rarely seen. Blood is common 
and sometimes there is pus. In typical cases three changes occur: (1) 
Motor power is impaired, (2) HC1 is diminished or absent, (3) lactic 
acid is present. 
The motor power is nearly always diminished early in all forms of 
gastric cancer and is a most important element in the diagnosis. It is 
not necessarily associated with dilatation, for a small rigid, cancerous 
stomach may equally well show motor insufficiency. It rapidly becomes 
more severe, especially with marked stenosis and insufficient hypertrophy 
of the muscularis. In cancer of the cardia it is less frequent than in 
cancer elsewhere. In cancer of the lesser curvature, motor insufficiency 
is slight at first until extension and infiltration have occurred, involving 
the pylorus, but not necessarily causing stenosis so much as preventing 
peristalsis and inducing a rigidity of the wall with insufficient pylorus. 
In cancer of the body of the stomach, more than 50 per cent, of cases 
show motor insufficiency because of the infiltration of the walls and 
their weakness through toxemia and cachexia. Where the wall is much 
infiltrated or where pyloric stenosis is marked, food may be retained for 
days or even weeks and the increase is usually progressive. 
Secretory Power.-There is usually a gradual and progressive diminu- 
tion of the free HC1 until it is absent, and the ferments also disappear 
in part or entirely. This occurs in perhaps 80 to 90 per cent, of cases. 
One examination of the contents is never enough to form conclusions; 
it is the persistent diminution or absence of IIO which is significant. 
Variability in the amount of HO secreted in gastric carcinoma is prob- 
ably much greater than is commonly recognized, and the total acidity 
varies within still wider limits. Combined HO is often absent. It is 
possible that much HO is secreted but is quickly taken up by products 
resulting from the cancer. Emerson found that in ulcerating cancers 
certain basic substances were produced by autolytic processes, which 
combined with HO. He believes these to be ''hexone bases, the result 
of the digestion of the protein by a ferment furnished by the tumor 
itself." With cancerous dilatation we may get free HO in an empty 
stomach, but not after meals. The important feature is the early dis- 
appearance of HO with normal total acidity; later in the disease the 
total amount also falls off. 
Ziegler, Sailer, and others have reported cases of hyperacidity with 
cancer of the stomach occurring early in the disease. The writer has 
observed repeatedly such cases in which the early hyperacidity lasted 
for more than a year before cancer was at all evident. In one of these 
cases the autopsy showed no sign of previous ulcer, but a carcinoma en 
plaque. In cancer of the fundus we get absence of HC1 much earlier, ORGANIC DISEASES OF THE STOMACH 
211 
because the process is more diffuse, and therefore it affects the secreting 
glands more. In all cases one must distinguish between hyperchlorhydria 
and mere hyperacidity which is often due to organic acids as well. Hydro- 
chloric acid may be present throughout the whole course of the disease, 
especially with localized tumors or where ulcer previously existed. 
Absence of HC1 is but one sign, and is of partial importance only; 
for it occurs, too, in gastric neuroses, catarrh, atrophy, etc., and in 
fevers, constitutional disturbances, cardiac disease, etc. 
Organic Acids: Lactic, Butyric, Acetic.-The presence of lactic acid 
depends mainly on diminished motor power and lessened HC1, and 
therefore lessened digestion of albuminous foods, i. e., lessened ferment 
activity because of atrophy of the glands. It may be introduced pre- 
formed into the stomach by the food, e. g., bread, milk, fish, meat, etc., 
and for this reason Boas recommends a test meal of oatmeal and water. 
He gives this meal after having previously washed out the stomach, and 
removes it in the usual time. 
Lactic acid is formed in the stomach, however, only under abnormal 
conditions, and is the commonest organic acid found in cancer. Its 
origin may be from acid producing microorganisms, e. g., the Boas- 
Oppler bacillus, or from some special ferment associated with the cancer- 
ous tumor. Lactic acid is not pathognomonic of cancer, and may be 
present in many other conditions, though rarely in so marked a quantity 
as in cancer. Its early appearance in cancer of the stomach, together 
with a diminution of the total acidity, even before any signs of stenosis, 
is very important. Its absence is no proof that cancer is not present. 
Usually it is not an early sign, because it depends in part on atrophy of 
the glands and motor insufficiency. Still, these do sometimes atrophy 
early, as Hammerschlag and others have shown. The mucous membrane 
is sometimes destroyed even when a tumor is quite localized, and, vice 
versa, with extensive cancerous disease the mucous membrane is some- 
times preserved. Hence the variations in time of the appearance of the 
lactic acid. Its constancy is very suggestive, for the persistent presence 
of lactic acid is rare in gastric diseases other than cancer. 
Ferments.-Hammerschlag, in 1884, examined 280 patients with 
gastric disease, and found the peptonizing power (according to his 
method) below 15 per cent, in only 32 cases, of which 26 were cancer. 
In these there was no albuminous digestion in 23, and in the other 3 
it was below 15 per cent. Oppier found that HC1 secretion and ferment 
activity ran parallel, indicating that diminution of the pepsin cannot 
be regarded as an early sign of cancer. It is, moreover, not always present 
in cancer, and, vice versa, is present sometimes in benign stenosis with 
gastrectasis and in neuroses. The presence or absence of secondary 
atrophy of the glands is alone the decisive feature in the production 
of ferments. Early diminution of ferment production, even when HC1 
secretion is preserved, has been repeatedly observed. 
Occult bleedings from the stomach or bowel should be carefully looked 
for as being one of the early and most important signs of gastric cancer. 
The benzidin test should be used. The importance of this sign in the 
diagnosis depends, however, on their persistent presence and on their 212 
DISEASES OF THE DIGESTIVE SYSTEM 
association with gastric subacidity. If occult bleedings occur in the 
stools, when HC1 is present in the gastric contents, the diagnostic value 
is less, as ulcer could also produce similar results. If occult blood is not 
found in the feces, and there is gastric subacidity and good motor power, 
it argues against the presence of cancer. 
Microscopic Examination of the Stomach Contents.-This is more or 
less valuable according to the period of the disease. Blood cells and 
pigment are commonly found. Pus cells vary in amount, and at least 
a few leukocytes can almost always be seen. The presence of blood or 
pus, or both, in the early morning lavage is of great significance. Bits 
of mucous membrane and of cancer tissue are not commonly found. A 
few cases are recorded, but being a late sign, this has but little value. 
The lavage water frequently has little shreds of torn mucous membrane, 
because the mucous membrane in cancer is friable. Examination of 
these shows widening of the submucous tissue at expense of the true 
gland layer, i. e., glandular atrophy. It is often hard to be sure of this, 
however, because it depends upon which part of the mucosa accidentally 
comes away in the washings. Often more catarrh is evident, and this 
is not specific for cancer. Sahli, however, laid great stress on this, 
believing that a thorough lavage at night, and again of the empty stomach 
in the morning, would reveal in the last washing torn portions of the 
tumor. A true piece of tumor is the only single pathogenomonic sign of 
cancer of the stomach. But this means ulceration, and therefore is a 
late stage. Lubarsch regards early diagnosis by this means as impossible. 
Malkow found bits of tumor in the feces. 
Boas-Oppler Bacilli.-These have been frequently found in the stomach 
contents in gastric cancer. They have been cultivated by Schlesinger 
and Kaufmann in pure culture on sugar agar, on beef peptone agar with 
the addition of cancer juice, and on grape sugar agar, although best 
of all are media to which blood is added. Hence they are frequent in 
coffee-ground contents. The average length of the bacillus is 6 to 8m, 
although it varies between 3 and 10m; sometimes it occurs in long spirals 
and continuous threads, Im broad. It is non-motile, Gram positive, 
stains a deep blue-red color with aqueous methylene blue, is falcultative 
aerobic, and has no spores. It coagulates milk. 
Schlesinger and Kaufmann demonstrated the formation of lactic acid 
from various forms of sugars by these bacilli, therefore they may be 
regarded as one of the excitors of lactic acid formation in the stomach, 
but only one; there are others, and therefore they are not specific for 
lactic acid formation. They have been found in 22 out of 70 cases of 
gastric disease; of these 22, 19 were cancers and 3 presented other con- 
ditions. Their absence does not prove the non-existence of cancer. 
Heichelheim emphasizes the findings in gastric contents of clots of blood 
with these bacilli, in the absence of HC1, as almost pathognomonic of 
cancer. 
Ziegler has recently called attention to the microscopic evidence of 
stasis as important in the early diagnosis of cancer, especially the finding 
of the Boas-Oppler bacilli amid mucus which may plug the introduced 
tube, also food remains and numerous leukocyte^. These early signs he ORGANIC DISEASES OF THE STOMACH 
213 
attributes to cancerous invasion of the lesser curvature, hence the rigidity, 
the lessened peristalsis, and slight stasis. 
Sarcinoe are uncommon unless free HC1 is present; therefore, as a 
rule they are only present when the cancer has formed on an old ulcer. 
The presence of sarcinee is no proof that cancer is not present, although 
if they are in abundance the diagnostic value is of some importance as 
suggesting a benign rather than a malignant condition. 
A few years ago Cohnheim recorded six cases of cancer with trichomonas 
and megastoma entericum. He attaches diagnostic importance to their 
presence in early stages before the lactic acid forms. They cannot 
live where lactic acid exists, and are hence more likely to be found in 
cancer of the cardia and lesser curvature, for in these cases often the 
lactic acid develops late. Others partially confirm these findings. 
Amcebce and flagellata are found in cases of cancer of the stomach in 
which no stasis exists, but in which an alkaline reaction obtains on the 
gastric surface, i. e., non-pyloric cases. Cohnheim thinks them an early 
sign, and that they are found before the ulcerating tumor has become 
gangrenous. Later they disappear. 
Yeast cells sometimes occur. Meat fibres are found because of delayed 
and lessened protein digestion. Starchy foods may be abundant, but 
are found to be more digested than the meats. Fats are likewise present. 
Diagnosis.-Inasmuch as extirpation at the commencement of the 
disease is essential to a cure, the earliest possible diagnosis is necessary 
for rational treatment, and one must endeavor to determine not only the 
location of the disease, but the extent of its development, the presence or 
absence of complications, and the possibilities of satisfactory treatment. 
When possible, a diagnosis should be established before a tumor is 
detected, although from recent surgical statistics even this is not essential 
for a radical cure. Many tumors, even though palpable, are sufficiently 
localized for removal, and even when fairly large, a successful resection 
of the stomach has been accomplished. Then, too, many tumors feel 
larger than they really are, and vice versa. As regards palpation, it does 
not follow that because a tumor is not yet palpable that the disease is 
in an early stage. Huge cancers with adhesions and metastases may 
have already formed and be entirely covered and inaccessible to palpation, 
and, vice versa, an advanced condition may remain localized for a long 
time and grow slowly long after the diagnosis is made. 
The main evidence in the early cases lies in the findings of functional 
disorder. There is no single pathognomonic sign of cancer of the stomach, 
and one must consider the whole symptom-complex, using for his purposes 
not only the history, but a careful examination of the symptoms, signs, 
the physical examination, the chemical and microscopic examination 
of gastric contents and stools, and such investigations require often 
prolonged, patient, and thorough observations. In spite of all there 
are numerous cases in which it is quite impossible to make a diagnosis. 
One general rule holds in most cases, viz., the absence of all gastric symp- 
toms and signs is important evidence against cancer. Penzoldt has well 
said that in individuals over forty years of age with gastric trouble, one 
should not rest until one has satisfactorily decided for or against cancer. 214 
DISEASES OF THE DIGESTIVE SYSTEM 
Klemperer advocates as a therapeutic test that elderly patients in doubt- 
ful early states should be placed on a rest cure with a protective diet 
for several weeks. If with this method improvement does not supervene, 
cancer may be strongly suspected. 
General Signs.-When no tumor is evident one must rely on the age, 
family, and personal history, the history of the illness, especially its 
onset in the midst of good health, the anorexia, especially for meats, the 
hematemesis, weakness and emaciation in spite of apparently sufficient 
food, the motor insufficiency, and the results of chemical analysis and 
other investigations of the vomitus and contents from test meals, and 
upon the presence of persistent occult blood in the feces. In the stomach 
contents the cardinal features are evidences of motor insufficiency, the 
persistent diminution of HC1, the presence of lactic acid and of blood. 
Tumor.-The possibility of palpating a growth depends much on the 
topographical conditions of the stomach and of the tumor, e. g., cancers 
with adhesions, with extension upward of the growth, etc., may not be 
accessible to palpation. Where tumor is evident, one is called upon to 
decide (1) whether or not it be gastric, and (2) if gastric, whether it be 
of a cancerous nature or otherwise. 
Certain general tests have been recommended as aids in the early 
diagnosis of gastric cancer before a tumor is palpable, although none 
of these have justified the claims originally made for them. The tryp- 
tophan reaction is based on the effect of chlorine or bromine to produce 
a red-violet color on the proteinochrom which forms as a result of the 
great albumin destruction. The test is expensive, lengthy and not 
constant, having failed in 13 out of 15 cases (Sigel), and having been 
found positive in other conditions, e. g., ulcer. Bassler's and Kuttner's 
opinion was similar to that of Sigel. Oppenheim's test with acetic acid 
is equally inconstant. 
Salomon believed an earlier diagnosis possible by testing the lavage 
water for nitrogen and albumin, his test being based on the idea that 
in gastric cancer owing to the great destruction of tissue, an albuminous 
serum is poured into the stomach. The stomach is first carefully washed 
on the evening before testing, after a preliminary non-albuminous fluid 
diet for twenty-four hours. On the next morning the stomach is washed 
thoroughly with normal saline solution (400 cc.), the same fluid being 
repeatedly used and then tested by Esbach's and Kjeldahl's tests. More 
than 20 mg. of nitrogen to 100 cc. or 0.5 gm. albumin suggests the 
presence of cancer. In negative cases there should be little or no turbidity 
with Esbach's reagent, and the nitrogen by Kjeldahl's method is not 
greater than 15 mg. Minkowski is not in accord with these views. 
Gerster, however, regards this test as useful in cancer of the lesser 
curvature without stenosis, unless the cancer has formed on an old 
ulcer, in which case the little IIC1 present would digest the albumin 
present. Reicher, Siegel, Tabora, and Zirkelbach confirm the test as 
being at all events of some value, especially as indicating an ulceration 
of the gastro-intestinal tract, although not necessarily differentiating 
malignant from benign conditions. Furthermore, it may assist in 
diagnosing cancer from chronic gastritis unless the cancer be of an early ORGANIC DISEASES OF THE STOMACH 
215 
diffusely infiltrating character. E. H. Goodman concludes that the 
test is not pathognomonic. He has modified the method, estimating 
the phosphates in the washings instead of the N and albumin, thus 
simplifying the test. Normal individuals show less than 10 mg. per 
100 cc. In cancer the percentage usually exceeds 10 mg. 
Gluzinski's test for the relative diminution of HC1 has been mentioned. 
0. Reissner's contention that the diagnosis of gastric cancer is aided 
by the determination of the chlorides in the stomach contents, is worthy 
of mention. In gastric carcinoma the chlorides are apparently much 
increased, despite the fact that HC1 is itself deficient, the alkaline cancer 
juices evidently themselves containing the chloride excess. The method 
of Lutke-Martius is employed, and while in other gastric diseases 100 
cc. of gastric contents have a corresponding chloride value of 24 to 40 
cc. of silver solution, in carcinoma 50 to 70 cc. of silver solution 
are required. 
Serum Test.-Abderhalden's early pregnancy test, as modified and 
carried out by Doctors Bruere and Hardisty at the Royal Victoria 
Hospital, may be considered useful for certain cases of carcinoma, 
where the physical signs reveal any evidence of the disease. The cancer 
must be of such a size as to have caused a generalized blood reaction, 
i. e., with antibodies or ferments in the blood. Pregnancy should be 
excluded. About 15 cc. of the patient's blood is drawn while fasting. 
No syringe should be used, but the needle placed in the vein should 
permit of the blood flowing into a sterilized tube under careful aseptic 
precautions. The blood is placed in the thermostat for five or six hours 
until the serum is well separated and the hemoglobin is removed by care- 
ful centrifugalization. Three hydrometer tubes are taken and sterilized. 
Into one 20 cc. of chloroform water (1 to 200) is added. A suitable 
parchment thimble (4 dialyses) is inserted, so that its surface comes 
in contact with the fluid. Into this thimble is placed 1 grm. of antigen, 
and 2 cc. of serum. If cancer be present a decided reaction should occur 
at the end of twenty-four hours. The other two hydrometer tubes 
are used as controls, placing into one of them 2 cc. of saline, instead of 
serum, and into the other 2 cc. saline with 2 cc. of serum (i. e., without 
the antigen). All three tubes are carefully plugged and placed in the 
thermostat for twenty-four hours. The diffusates are each tested with 
ninhydrin for protein bodies. A positive reaction is indicated by the 
presence of a violet-blue color, which must be very decisive in order to 
call the reaction positive. 
X-rays.-The method adopted at the Royal Victoria Hospital (A. 
H. Pirie) is as follows: A barium sulphate meal is given on an empty 
stomach. A cup of tea or coffee may be taken at 7 a.m., and the examina- 
tion should be made before any food is taken. The stomach should 
then be found to be empty. In severe pyloric stenosis the stomach may 
be found nearly full, and this can be recognized before giving the barium 
meal by the horizontal line of the fluid in the stomach with the air 
chamber above it. The barium meal consists of a pint of thick butter- 
milk, to which 2 to 6 ounces of pure barium sulphate have been added. 
One ounce per 50 pounds of body weight should be allowed. The chemical 216 
DISEASES OF THE DIGESTIVE SYSTEM 
taste and grit of the barium sulphate can be got rid of by repeatedly 
washing it with hot water, and allowing the mixture to settle, then pouring 
off the clear water. This should be done on three successive days. The 
upper layer of the sediment should then be used. A patient with cancer 
of the stomach will frequently refuse to drink even half a pint of fluid. 
Carcinoma at the cardiac end is usually made evident- by stenosis at 
the oesophageal opening, and delay is observed in the entry of the barium 
into the stomach. This is best observed by screen examination. 
/n the lesser and greater curvatures carcinoma is recognized by a filling 
defect, with complete want of peristalsis in the affected part. The filling 
defect has a ragged appearance with indentations resembling the imprints 
of a child's finger-tips pressed into a mass of clay. 
Cancer of the pylorus may cause unusual patency of the pylorus, with 
rapid evacuation of the stomach contents, or delay due to stenosis. 
When stenosis is well marked there are extra waves of peristalsis followed 
by periods of rest, during which no peristalsis goes on. Reverse peri- 
stalsis may be seen in stenosis of the pylorus. 
If food is present in the stomach and the barium meal is superadded 
the junction of the two meals gives the appearance of a filling defect. 
The presence of this filling defect should be confirmed by two plates 
made at an interval of half an hour, and in both plates the essentials 
of the defect should be the same. Fluoroscopy and rontgenography 
should both be used for the diagnosis. Stasis in the stomach is simulated 
when the patient takes a meal before the barium meal has left the 
stomach. Thus if a barium breakfast is taken at 9 A.M., and lunch at 
12 a.m., the barium of the breakfast mixes with the lunch, and may not 
leave the stomach for another five hours, so that at 4 p.m. barium will 
be present in the stomach. To avoid this possible mistake no food 
should be given after the barium meal until the stomach is empty, or 
until the fact of stenosis has been established. 
Differential Diagnosis.-Two main types of condition may be con- 
sidered: (A) Gastric cancer without evidence of tumor. (R) Gastric 
cancer with tumor. 
A. Where no tumor can be detected, two classes of cases exist: (1) Those 
with little or no motor insufficiency. (2) Those with definite gastrec- 
tasis. (Cancer at the cardiac orifice, which will be dealt with separ- 
ately.) 
1. Where no motor insufficiency exists, the cases are easier to 
diagnose if lactic acid is found, for it is rare in the other gastric diseases 
that have no atony. The main diseases in this group are: 
(a) Ulcer without tumor or stenosis. 
(&) Neuroses. 
(c) Chronic Gastritis.--The history of a cause (alcohol), the gradual 
onset and slower progress, with remission and exacerbations, are impor- 
tant features. The secretions are disturbed later in the disease, and the 
features are more local than constitutional. Hydrochloric acid is less 
constantly absent and is often diminished. Motor insufficiency is later, 
progresses less rapidly, and there is less gastrectasis; there is also less 
stagnation and occult bleedings are less persistent, if at all present. ORGANIC DISEASES OF THE STOMACH 
217 
(d) Atrophy of the mucous membrane (including pernicious anemia, 
primary atrophy of the gastric follicles, terminal stage of advanced 
chronic gastritis, cancer of distant organs, Addison's disease, etc.). 
2. Cases with gastrectasis are harder to differentiate, because the 
lactic acid is so often present in gastric diseases with atony (other 
than cancer), and therefore its presence has less significance. 
The main diseases to be differentiated are: Scarred ulcer of the pylorus 
without palpable tumor (which may lie beneath the liver or be too small 
for palpation). The history of previous ulcer, the longer duration of 
the malady, the presence of HC1 (perhaps even in excess), the absence 
of lactic acid, the eructations of gas containing H2S, and the findings of 
sarcime, all suggest the benign condition; and the absence of cachexia 
aids in excluding carcinoma. Hypertrophic stenosis of the pylorus 
(Boas' stenosing gastritis) if acquired, is usually due to ulcer and gives 
signs similar to the above. Sometimes a carcinoma developing on an old 
ulcer must be differentiated, and the diagnosis is not always easy; indeed, 
often it is quite impossible. As a rule, there is a history of old ulcer 
and the symptoms change in character, becoming more persistent and 
resistant to treatment. There is, however, greater wasting, anemia and 
pain. Bleeding and perforations are not uncommon. HC1 is present, 
often in excess, and there may be hypersecretion (continuous or alimen- 
tary). Gluzinski's tests are perhaps useful in these cases; at all events, 
if positive, they indicate the presence of cancer, and if negative, they 
do not prove its absence. Cancer developing on an ulcer shows a tumor 
more easily because of the usual perigastritis and pyloric spasm. 
B. When Tumor Exists.-Two questions arise: (1) Is the growth 
gastric or extragastric ? (2) If gastric, is it benign or malignant? The 
z-rays usually afford a satisfatory answer to the first question. One 
must use careful palpation,' if necessary with the patient in a wTarm bath 
or under ether, unless, indeed, an exploratory laparotomy be undertaken. 
Minkowski suggested inflation of the stomach, and at the same time 
distension of the colon with water for differential diagnosis of gastric 
and perigastric tumors, though since the introduction of skiagrams this 
method occupies a subordinate place. Inflation or distension of the colon 
with water would displace gastric tumors upward, as also those of the 
spleen. Tumors of the kidney disappear behind an inflated colon. 
Tumors of the liver would vary according to size and position, while 
those of the omentum would be displaced downward. 
Growths Located Outside the Stomach.-The tumors simulating gastric 
growths, but existing in reality outside the stomach, are mainly: 
1. Perigastritis, with an exudate and perhaps adhesions about the 
pylorus, or the lesser curvature, may induce chronic pain with dyspepsia 
and even dilatation, simulating cancer. The main features against 
cancer are the long duration without sufficient corresponding emaciation 
and cachexia, the different chemical signs on analysis and the skiagraphic 
differences. (See "Complications of Gastric Ulcer.") 
2. Cancer of the Duodenum.-1This condition is rather rare. Schle- 
singer found only 7 primary cases in 25,000 histories. Rolleston could 
collect only 41 cases in the literature; of these, 8 were in the first portion, 218 
DISEASES OF THE DIGESTIVE SYSTEM 
5 in the first and second parts, 24 in the second portion, and 4 in the 
third portion of the duodenum; 10 were in females and 31 in males. 
Here the difficulties are great indeed; it may be impossible to diagnose 
the true condition. One may have diminution or absence of HC1. Lactic 
acid, on the other hand, may be present, as, indeed, may most of the 
other signs of gastric cancer. 
3. Omental or general peritoneal tumors often cause difficulty in the 
differential diagnosis, especially if accompanied by ascites. These 
neoplasms are less mobile with respiration, and chemical tests on gastric 
analysis usually give negative results. The rectum should always be 
examined in doubtful cases of the kind. 
4. Peritoneal tuberculosis with ascites may simulate gastric cancer 
with secondary peritoneal involvement. However, it occurs usually in 
younger subjects, runs a more protracted course, with exacerbations 
and remissions, and is accompanied by more persistent irregular fever. 
No occult bleedings occur. Dock has drawn attention to the value of 
cytological diagnosis of the fluid with its characteristic cells, in which 
mitoses are very common. 
5. Tumors of the transverse colon usually give evidence of some degree 
of intestinal obstruction; the stools may be bloody and examination of 
the stomach itself is negative. 
6. Tumors of the gall-bladder are situated in their appropriate place, 
are somewhat movable, and may by pressure upon the surrounding 
ducts cause early jaundice. At times, however, the differential diagnosis 
is extremely difficult. Adhesions in the neighborhood may cause pyloric 
stenosis and certain signs of gastric cancer. The absence of respiratory 
mobility may suggest a gastric cancer rather than one of the gall-bladder; 
but a test meal again is negative. 
7. Cancer of the liver is usually secondary, and the tumor is less easily 
fixed with expiration than are tumors of the stomach. A satisfactory 
means of differentiating is, where possible, to place the hand above the 
tumor. Then, if the liver can be felt still higher, the tumor is probably 
gastric; at all events, it is not hepatic. The same is true if, with inflation 
of the stomach, the tumor alters its position. When the cancer of the 
liver is primary, the liver becomes large rapidly; jaundice is early and 
pronounced. The gastric signs are slight or absent, and there is no 
hematemesis or gastrectasis, Moreover, the usual signs after a test 
meal are not found. 
8. The pancreas, either normal or pathological. When normal, it is 
deeply situated in the median line, fixed and immovable with respiration, 
and disappearing upon inflation of the stomach. When it is diseased, 
and especially when it is the seat of a cancerous growth, one may find 
clayey, fatty stools, even without jaundice. Jaundice may, however, be 
present from pressure of the growth upon the common duct. The portal 
vein may be pressed upon, and the resulting obstruction may give rise 
to ascites. There may be glycosuria, and, as a rule, the course is a rapid 
one. Armstrong recently reported a case in which a large pancreatic 
cyst simulated cancer of the stomach, even to the analysis of the gastric 
contents. The stools, however, had not been observed. ORGANIC DISEASES OF THE STOMACH 
219 
9. Other conditions which may simulate a gastric tumor are gumma 
of the left lobe of the liver, aneurism of the abdominal aorta, swollen 
glands about this artery, a movable kidney, and enlarged spleen, the 
last simulating a cancer of the fundus. 
Tumors within the Stomach.-Gastric tumors arise either from carcinoma 
or sarcoma, cicatrized ulcer of the stomach or duodenum, with or without 
a perigastritis, thickened or spastic pylorus, fibroma, lipoma, or foreign 
bodies (hair ball, etc.). The differential diagnosis depends upon the 
history, the symptom-complex, and the physical examination: 
1. In scarred pyloric ulcers, stenosis and gastrectasis occur with the 
results common to all cases of pyloric obstruction, but the history of 
previous ulcer, the long duration, the presence of a smoother and more 
movable tumor, the character of the vomitus with proteins well digested, 
and chemical findings typical of benign stenosis, usually render the 
diagnosis clear. There are, moreover, no metastases. 
2. A hypertrophic stenosis of the pylorus is usually acquired, but occurs, 
however, oftenest in early infancy. The cases late in life usually have 
diagnostic features common to scarred pyloric ulcers with obstruction, 
with which, too, they have usually a causal connection. Simple hyper- 
trophy is undoubtedly rare. Sometimes it occurs with mere hyper- 
secretion. One relies on the history and duration, the chemical analyses, 
and absence of general signs of cancer. Occasionally it may be impossible 
to differentiate the two conditions. 
3. Spasm of the pylorus may possibly induce gastrectasis, and if so 
will manifest few if any of the signs of malignant disease. The condition 
will be of long duration, with exacerbations and remissions, and will 
present no chemical signs in the gastric contents of malignant disease 
nor occult bleedings in the stools. 
4. Fibromata and lipomata can only be inferred and not definitely 
diagnosed in the present state of our knowledge. 
Regional Diagnosis of Tumors within the Stomach.-Certain differential 
features are useful to determine the exact site of the neoplasm in the 
stomach. 
Cancer of the lesser curvature usually presents achylia from the begin- 
ning. There is less motor insufficiency until cancerous infiltration 
occurs. Peristalsis is absent, but one may get tonic contraction of 
muscle (gastric rigidity). When the neoplasm extends to the pylorus, 
we get pyloric rigidity with insufficiency, i. e., a paradoxical condition 
of motor insufficiency with pyloric insufficiency, which may be tested 
by inflation. It is usually a late sign. Cancer of the lesser curvature 
is palpable only if ptosis exists or if the tumor has attained a considerable 
size. The weight is often maintained for a long time, because there is 
less motor insufficiency. Salomon's test has special value in cancer of 
the lesser curvature without pyloric stenosis, although it is useless if 
the cancer has developed on an old ulcer, because small amounts of HC1 
will digest the albumin. Estimation of the ferments aids regional 
diagnosis sometimes. The fact that the fundus yields pepsin and rennin, 
while the pylorus gives merely pepsin, affords an opportunity by ferment 
estimates of locating the probable site. If rennin is preserved while 220 
DISEASES OF THE DIGESTIVE SYSTEM 
the pepsin is relatively diminished, it implies involvement of the pylorus, 
while if both are lessened it signifies a tumor of the fundus. 
Cancer of the Cardiac End.-Statistics of the Middlesex Hospital (1854 
to 1904) recorded 227 cases of cancer of the stomach, of which 19 had 
their origin at the cardia; 13 were in males and 6 in females. Certainly 
the condition is uncommon, and many cases supposedly originating in 
the cardia have probably commenced in the oesophagus. Fagge's views 
expressed in his reports from Guy's Hospital on the frequency of gastric 
cancer suggests that "almost all cases that have been set down as 
examples of cancer affecting the cardia have really been instances of 
cancer of the end of the oesophagus extending into the adjacent parts 
of the stomach .... Indeed, on a priori grounds we should expect 
that a part at which the digestive tube is opening out into a large cavity 
should have little or no tendency to be affected with the disease in com- 
parison with the narrow passage above it." The type of cancer origin- 
ating at the cardia is usually adenocarcinoma. Sometimes a cardiac 
cancer with stenosis is accompanied by separate cancer of the pylorus, 
and sometimes, too, cancer of the cardia is accompanied by a secondary 
stenosis of the pylorus from pressure of metastatic periportal glands. 
Symptoms of Cancer at the Cardia.-Being usually inaccessible to 
palpation they remain latent for a long time. An interesting example 
under personal observation occurred in a man, aged forty-eight years, 
whose death occurred within four weeks of the onset of the symptoms. 
His earliest symptoms were those of abdominal distension, swelling of 
the left leg, and some weakness. Careful inquiry elicited the fact that 
while for three weeks he had felt general abdominal pain with some 
anorexia, there had been no other subjective evidence of gastric disease. 
At the end of three weeks there was enormous distension from ascites, 
and he died two days later, sudden abdominal pain appearing; the 
autopsy revealed a primary cancer of the cardia, with secondary involve- 
ment of the peritoneum. 
Apart from the general signs of malignant disease, there is dysphagia 
and distress immediately after meals with regurgitation of food and 
mucus. Pain comes on at once after food, and is usually greater in this 
form than in cancer of the pylorus, and often there is tenderness on 
percussion or pressure over the xiphoid cartilage. As obstruction develops 
at the lower end of the oesophagus, there is at first some difficulty in 
the ingestion of solids, and their deglutition is assisted by liquids. 
Oppression and discomfort usually supervene. Later on, even soft foods 
are swallowed with difficulty, and finally only liquids can be taken 
into the stomach. When the obstruction is greatest, all food is ejected 
with retching. Vomiting is less frequent than mere regurgitation. The 
passage of a tube meets with an obstruction near the cardiac orifice. 
The withdrawal of blood on the end of the tube is of great diagnostic 
value. Motor insufficiency is usually slight and lactic acid fermentation 
need not exist. The delay of the deglutition sounds is not a reliable sign. 
Course and Duration.-Dyspepsia, loss of flesh, pain, and vomiting, in 
the order mentioned, mark the progressive course of the malady. As 
a rule, the disease has few or no remissions, and the progress to a ORGANIC DISEASES OF THE STOMACH 
221 
fatal ending is uninterrupted. Sometimes temporary improvement, 
both subjective and objective, occurs with marked gain in weight, color, 
appetite, and even strength. These ephemeral remissions often render the 
differential diagnosis from chronic gastritis most difficult. Sometimes 
there is an acute rapid course with vomiting, and a fatal termination in 
a few weeks, with carcinosis. Schweppe, in 1890, collected 22 cases from 
the literature, and since then numerous others have been observed. 
The duration varies according to the nature of the neoplasm, its site 
and extent. Non-obstructive scirrhus cancers are the slowest to develop, 
while medullary cancers and those causing stenosis of the orifices proceed 
more rapidly. Some authorities regard the cases which occur in youth 
as being especially rapid, but statistics do not all bear out this view. 
The average duration in cancer of the stomach is about one year, although 
some patients live longer than three or even five years. Death occurs 
either from marasmus, metastases, or complications (hemorrhage, per- 
foration, peritonitis, sepsis, pneumonia, etc.). 
Prognosis.--This is always extremely grave, and few cases are cured. 
The medical treatment is purely symptomatic, and permanent relief 
is only to be had from complete resection of the malignant tissue. This 
is unfortunately suitable in but a limited number, although with 
improved methods of early diagnosis and better surgical technique, 
the hope of cures shows a satisfactory advance in the last five years 
out of all proportion to the gains in all previous years. 
Treatment.-Medical.-This varies chiefly according to the situation 
of the growth and the functional signs. While the radical treatment 
is essentially surgical, there is much to be said for the medical treatment, 
which may be of great benefit, even though it cannot in any sense cure 
the condition. It is especially called for in inoperable cases, or when 
for some reason operation is refused, and finally in those cases in which 
a palliative gastro-enterostomy has been performed and the physician 
is called to aid in alleviating the distressing symptoms which inevitably 
occur even under such conditions. The cases may be divided into (1) 
those with obstruction at the cardia, (2) those with pyloric stensois, 
and (3) those in which no orifice is involved, but the body of the stomach 
is the main site of the neoplasm. The treatment is dietetic, mechanical, 
and medicinal. 
In cancer of the cardia, especially with the development of obstruction, 
soft or liquid diet is essential, and solids should be avoided. Small 
amounts with frequent feedings are better than large meals, and will 
better prevent regurgitation, pain, and distension of the oesophagus. 
Mechanical treatment plays but little part, and the use of a sound for 
therapeutic purposes is of questionable value. There is great danger of 
increasing the distress by injuring the parts, although if a tube of proper 
size and consistence be carefully employed it sometimes gives freer 
passage to food for a time and relieves symptoms. 
In pyloric stenosis with gastrectasis the diet should not be too restricted. 
As a rule, liquid foods which are easily assimilated are best borne. But 
one should be largely guided by general principles, consulting the pre- 
ferences of the individual. The meals should be small, frequent, and 222 
DISEASES OF THE DIGESTIVE SYSTEM 
non-irritating. Hydrochloric acid being usually deficient, meats and 
albuminous foods should be restricted. When administered they should 
be finely divided, and free from cartilage and other ingredients difficult 
of digestion. White meats are preferable, chicken, game, and pigeon, 
also veal and beef in small amounts, and fish. It is well after the use 
of proteins to give small quantities of dilute HC1 (unless HC1 be present 
in the gastric secretion). Fleiner recommended the use of sauces con- 
taining HC1, e. g., beef juice with warm water, to which ten drops of 
dilute HC1 is added. This is theoretically of little value, as it cannot 
duly replace the deficiency, yet experience teaches that it often aids 
digestion. The same may be said of the use of pepsin and pancreatin, 
which, despite the observations of Chase and others, give a sense of 
comfort to the patient after the food has been taken. Instead of HC1, 
Eichorst uses phosphoric acid after meals, and if pain be present, he 
recommends the addition of small doses of codeine. 
It is a delusion to believe that the liberal use of albuminous foods 
prevents decomposition of the albumin of the body. The more a 
cancerous patient gets, the more he destroys. 
The finer vegetables, preferably mashed, may be used in relatively 
large amounts, avoiding those with shells, skins, fibres, etc., as also 
those which induce much fermentation. Stale bread may be allowed, 
as also gruels, vegetable soups, and thin, farinaceous preparations like 
rice, macaroni, barley, tapioca, sago, and oatmeal. Stewed fruits are 
also well taken. Milk with coffee, cocoa, cereals, etc., may be employed, 
as also buttermilk and koumyss. Infant foods are often taken with 
relish and should be tried. Butter is the best borne of all the fats. 
As beverages any of the ordinary drinks may be given, but in limited 
amount because of the motor insufficiency, and also light wines, brandy, 
and whisky in small amounts and diluted. Thirst is often troublesome 
and if not relieved by the moderate use of fluids, saline enemata may 
be used, one-half to one pint being injected night and morning. 
The Mechanical Treatment.-Lavage with plain water, as a rule, 
alleviates the distressing local symptoms, and may help to increase 
the appetite and stimulate the secretions. The washing should be 
thorough at each occasion and unless gastrectasis be extreme, one 
lavage daily will suffice, before the last small evening meal or in the 
early morning. Cohnheim introduces two or three ounces of warm oil 
through the tube after the completion of the lavage, thereby giving 
still greater relief to the local distress. 
In cancer of the body of the stomach, where motor insufficiency is but 
little evident, the main treatment is dietetic, the food being administered 
as described in pyloric stenosis. In these cases mechanical treatment is 
less indicated. 
Medicinal Treatment.-No medicine is of any great value. Orexin 
in doses of 5 grains (gm. 0.3) may help the appetite, as also may an 
infusion of condurango bark. Alkaline mineral waters before meals 
sometimes stimulate the secretions, while HC1 after meals helps protein 
digestion. For the vomiting, especially of blood, rest to the stomach is 
essential. Nutrient enemata may be given, and then careful feeding ORGANIC DISEASES OF THE STOMACH 
223 
by mouth may be begun with small quantities of fluid. For the ordinary 
vomiting, lavage is the best form of treatment. 
Diarrhoea should be treated by a proper diet when possible, and by 
the use of lavage to remove irritating substances, which are the probable 
cause of the condition. For the constipation, aloes, rhubarb, and cascara 
are the most effective remedies. Enemata should be given when the 
condition is aggravated, but these should not be continued for too long 
a time. Authorities differ as to the use of saline purgatives, and doubtless 
in individual cases their use will have different effects. 
For the pain wet compresses upon the stomach, lavage, and the use 
of spirit of chloroform may be of value, and it is only in the extreme 
cases that morphine should be employed. 
X-rays.-X-rays and radium have been used with varying success, but 
with no results sufficiently brilliant to warrant favorable statements. 
When, however, extirpation of a cancerous tumor has been attempted, 
the use of radium is undoubtedly of value in preventing the rapid 
recurrence of the neoplasm, if not in entirely healing the disease. 
The use of thymus extract hypodermically has been suggested, based 
on the researches of Gwyer, Rohdenberg and others, and a certain 
measure of palliation has resulted. No records, however, have shown 
that a cure may be obtained by using any of the internal secretions. 
Surgical Treatment.-Statistics of surgical treatment are still to be 
regarded with reserve. Alexis Thompson has emphasized the frequency 
of non-malignant fibromatosis simulating cancer, thus exposing many 
of the difficulties of diagnosis and inaccuracy of reports on surgical 
"cure" of cancer. 
Two measures must be considered: 1. Exploratory operation for 
diagnosis, and not merely to confirm the diagnosis. When a tumor is 
present and the gastric analysis gives every indication of cancer, it is 
but idle curiosity to explore, unless it is known beforehand that some 
chance of giving relief exists. The object of exploration is to make the 
diagnosis wThen great suspicion and doubt exists as to the possibility of 
cancer. If in such cases a reasonable suspicion exists, the earlier discovery 
which an operation thus permits, gives to the patient the better chance 
of radical surgical cure, and as such, exploration is not only justifiable 
but advisable in the extreme. Delay under these conditions, to await 
further evidence, implies unnecessary waste of time. At other times 
it may seem uncertain (even when a tumor is palpable) whether extirpa- 
tion is advisable and possible, and under these circumstances exploration 
is justifiable. 
2. Operation for treatment, either curative or palliative. The cases 
which promise successful results are as follows: (1) Those in which 
the neoplasm is well localized and movable. One should be guided 
chiefly by the character and extent of adhesions, those which are not 
extensive and uninfiltrated being most satisfactory to deal with. Hence, 
Ewald's contention that one must explore before deciding on further 
operative interference. (2) In the stomach itself the course of the lymph- 
atics has an important bearing on the prognosis and treatment. The 
studies of Cunea have shown that the lymphatics along the lesser curva- 224 
DISEASES OF THE DIGESTIVE SYSTEM 
ture run for the most part from the pylorus toward the cardia, while 
those along the greater curvature and fundus lead toward the pylorus. 
Thus in operations for gastric cancer, the extent of removal depends 
largely on the site of the growth. Pyloric cancers do not tend to spread 
to the fundus and greater curvature, and these parts, therefore, do not 
need to be included in the resection. On the other hand, the lesser 
curvature should be removed, at all events as far as the gastric artery 
(Mikulicz's point), and along the greater curvature as far as Hartmann's 
point, which delimits the lymphatic extension along that line (Hartmann- 
Mikulicz line of section). Toward the duodenal end, the resection 
should be made one inch clear of the pylorus, this being the extreme 
limit of secondary involvement in nearly all cases. Even in cancers of 
long duration the neighboring glands are sometimes left free. 
Special Considerations.-Infiltrating adhesions are a contra-indication 
and a dangerous complication in operations. It has been estimated that 
73 per cent, of such cases die, and the remaining 27 per cent, recover 
because the adhesions were slight, and probably noil-infiltrating. 
The Size of the Tumor.-The fact that a tumor is externally palpable 
is no longer regarded as a contra-indication to surgical treatment. In 
fact, the size of the tumor is less important than is the presence of 
adhesions. Many large tumors may be capable of successful removal 
because they are free from adhesions and metastases, while many primary 
tumors which have remained very small may have involved neighboring 
glands and organs. Metastases in the liver, for example, may be large 
and numerous even when the primary local gastric neoplasm is small, 
movable, and non-adherent. 
Complications form another important contra-indication, e. g., arterio- 
sclerosis, fatty heart, and tuberculosis. 
Statistics from the various surgical clinics are published from time to 
time, showing the average duration of life after operations of various 
kinds. These, of course, have no value as regards the selection of opera- 
tion. To know, for example, that after a gastro-enterostomy, 33 per 
cent, died is of little value. Such an operation is merely palliative and 
the cancerous growth proceeds. Immediate results depend largely on 
the technique and the condition of the patient at the time of operation, 
both of which factors determine the success of operation and the ultimate 
duration of life. The only operations which are curative are those which 
remove the entire diseased parts. 
Methods.-Gastrectomy was first successfully performed by Billroth in 
1881, when a partial operation w'as done, while complete removal of 
the stomach was first attempted by Connor, of Cincinnati, in 1883, 
who, although unsuccessful, paved the way for the later good results of 
Schlatter, of Zurich, in 1897, who performed a complete gastrectomy with 
recovery. The oesophagus and jejunum were united and the duodenal 
opening closed. Since then gastric operations have become matters of 
everyday experience, and the European clinics especially give large 
series of cases with statisical results (Kroenlein, Mikulicz, Kocher, 
Czerny, Robson, and Moynihan). 
Partial gastrectomies result in improved motor power; secretion is ORGANIC DISEASES OE THE STOMACH 
225 
not altered, as a rule, although sometimes HC1 returns and lactic acid 
disappears when stagnation ceases. Modern surgery advocates partial 
gastrectomy as the best of all operations, as yielding less mortality, and 
because it results in better health, comfort, and appetite, and in general 
well-being, with the best chances of complete recovery. Mayo quoted 
MacDonald as having found 43 undoubted cures from operation. Kocher, 
in May, 1907, reported 95 cases, of which 13 were well, and 4 others, 
although cured of cancer, had died later on from other diseases, i. e., a 
total of 17 (19.3 per cent.) cured. Le Riche has recently tabulated cases, 
of which 89 cancers with gastrectomies were cured for a period varying 
from five to sixteen years. Of these, 1 had survived sixteen years, 34 
from five to ten years, and 5 at least ten years. These cases include 
all kinds of cancers anatomically, mostly from the pyloric region, but 
one had been at the cardia. In a total of 1366 collected gastrectomies 
for gastric cancer, the mortality was 25 per cent. Peterson and Colmers 
recorded 30 cases with 20 per cent, of cures (Lisbon Congress), adding 
that all these patients were then in good condition, performing ordinary 
daily work with no gastric complaints, with an easy digestion, and that 
even the distaste for fats and meats had disappeared. The secretions, 
however, were feeble. In all there was deficient HC1; some still have 
lactic acid, but the motor power was excellent. Undoubtedly, such 
statistics are more than favorable, and in view of general experience, 
extremely optimistic. Much probably depends on the virulence of the 
cancerous growth and the susceptibility of the individual. 
Remote Results.-Evidently the mechanical, physiological, and 
chemical functions of the stomach can be taken up by the parts left 
behind. Sometimes the oesophagus or small bow'el dilates to form a kind 
of reservoir. Digestion is carried on well by the intestinal juices and 
pancreatic and hepatic secretions, and absorption takes place in an 
apparently satisfactory manner, and thus perfect health is maintained. 
Hayem has observed " hypopepsia" after years in patients in whom 
cures have resulted following operations for gastric cancer. 
Palliative surgical treatment is employed in some inoperable cases when 
the strength of the patients permits surgical interference if the indications 
therefore justify the undertaking. Cure is not aimed at, but merely a 
relief of certain symptoms and fulfilment of certain requirements for 
improvement of local and general conditions. The indications for gastro- 
enterostomy are, briefly, pyloric stenosis from a cancer which cannot 
be removed, either because of its extent or owing to the involvement 
of too many neighboring glands, hour-glass or other deformity involving 
stagnation of food and its complications, hemorrhage which is persistent, 
and uncontrollable vomiting, whether from retention or from general 
causes. It is further indicated in some cases as a temporary measure 
prior to the more serious operation of gastrectomy, when patients are 
too weak to undergo the latter operation immediately. 
In any doubtful cases with adhesions to the neighboring organs or 
pressure of inflammatory tissues about the pylorus, a gastro-enterostomy 
may not only relieve, but cure. In a patient whose condition was 
recently reported by my colleague Garrow, a large indurated and 
vol. in-15 226 
DISEASES OF THE DIGESTIVE SYSTEM 
nodular mass was found at operation involving the pylorus. It had 
been tucked up underneath the liver, and thus was not palpable; a 
second mass extended along the lesser curvature, while the glands in 
the lesser omentum were enlarged, although not indurated, as was the 
mass in the pyloric region. The condition was regarded as undoubtedly 
of a cancerous nature, and a palliative gastro-enterostomy was per- 
formed. One year later the patient was seen again in excellent health, 
suggesting the probability of some lesion other than a malignant one. 
Operation should be delayed when there is little gastric disturbance and 
when there is great weakness. Cases with small stomachs and infiltrating 
cancers should be let alone. 
The beneficial results of gastro-enterostomy are often marked. 
Patients may gain in weight, the appetite may increase, vomiting and 
pain diminish, and general improvement follow for some months. Com- 
parative comfort may thus be attained. In other cases, however, results 
are discouraging and the patients decline rapidly; the rapidity of growth 
in the neoplasm is marked, even closing the artificial opening. 
Gastrostomy is indicated where food cannot be properly taken into 
the stomach, either through cancer of the oesophagus or of the cardiac 
end of the stomach. The operation should be done early to obviate the 
great weakness resulting from defective nutrition, and thus the ordinary 
dangers from a comparatively simple operation may be avoided. 
ACUTE GASTRITIS 
Definition.-An acute inflammation of the gastric mucosa with varying 
degrees of local and constitutional disturbance. 
Classification.-Various types exist dependent upon the different 
etiological factors. Clinically there are three main types: (1) Acute 
simple gastritis (primary and secondary). (2) Phlegmonous gastritis. 
(3) Toxic gastritis (mild and severe). Anatomically one may add two 
other forms: (4) Mycotic gastritis. (5) Diphtheritic gastritis. 
Acute Simple Gastritis.-Definition.-This is an acute catarrhal 
inflammation of the gastric mucosa, frequently accompanied by excessive 
secretion of mucus, desquamation of epithelium, and a resulting dis- 
turbance of digestion. 
The condition is more often wrongly than correctly diagnosed, and 
in numerous instances a functional disturbance with slight temporary 
atony, or a neurosis, is misnamed gastritis. The term gastritis should 
be restricted to those patients in whom definite evidence of gastric 
inflammation exists, and should not be applied to temporary disturbance 
of function resulting from slight indiscretions in.diet. Certainly one 
often cannot decide clinically whether or not a true inflammation exists, 
for there are very few pathognomonic symptoms and signs of a mild 
simple gastritis. The autopsy room reveals often enough an acute 
inflammation of the gastric mucosa without a previous history of gastric 
symptoms, and, vice versa, where much disturbance of digestion may have 
occurred and when even much mucus has been secreted, the inflamma- 
tory lesion may be very slight indeed. ORGANIC DISEASES OF THE STOMACH 
227 
Etiology.-The condition is either primary or secondary. 
Primary Acute Simple Gastritis.-Predisposing and direct causes 
exist. The former are numerous: faulty hygiene, the hot summer 
season, malnutrition, anemia and other circulatory disorders, constitu- 
tional and metabolic disturbances, and infectious diseases. Previous 
chronic gastritis predisposes to acute attacks. Individual susceptibility 
is an important factor, and perhaps heredity plays a part. Age, too, 
has much to do with susceptibility, infants being peculiarly liable. 
The direct causes are mechanical and dietetic, thermal, chemical 
(toxic), or parasitic (vegetable or animal). 
1. Mechanical causes are mainly associated with errors in diet, e. g., 
irritating food or drink, too bulky or coarse food, or excess after pro- 
longed fasting. Food when taken in too large an amount may remain 
undigested, and induce fermentation or putrefaction, so, too, the shells of 
some vegetables, the stones and rinds of fruit, foreign bodies, hair, etc. 
2. Thermal Causes -Food and drink if at extremes of temperature 
may induce gastric catarrh, so also the external application of heat and 
cold; and extensive burns on the body. Whether or not "cold" is a 
cause in itself is doubtful. 
3. Chemical causes are perhaps the most frequent. Alcohol is the 
commonest factor and leads to the disease in its most typical form. Those 
unaccustomed to alcohol are the most liable, and the inflammation arises 
either from irritation from the amount taken, or in the case of some wines 
because of the acid produced by acetic fermentation. In children unripe 
fruit is a common cause. Any chemically strange substance if toxic, 
in strong enough concentration and of sufficiently irritating character, 
will induce a gastritis, e. g., alcohol, acids, alkalis, salts of the heavy 
metals, calcium chloride, and certain drugs, e. g., salicylates, the bromides, 
iodides, arsenic, mercury, phosphorus, copaiba, etc. 
Decomposed pus, as in gangrene of the lung when the irritating sputum 
is swallowed, and, indeed, any decomposed albumin may directly or 
indirectly induce the disease. Foods if tainted or decomposed ("crapulous 
gastritis") bring about an inflammation directly through the action of 
fermentative or putrefactive agents; so also does stale beer. Toxalbumins 
form another group of agents. They are secreted in the stomach from 
a variety of sources, e. g., in Asiatic cholera. Such agents may be 
denominated as autotoxic causes, and are present in numerous diseases, 
(uremia, diabetes, gout, cholemia, and also in burns). 
4. Parasitic Causes.-Vegetable Parasites {Bacteria}.-The invasion 
of bacteria is one of the most common causes of acute gastritis-hence 
its frequent presence in the various acute infections of all kinds. The 
colon bacillus is one of the most frequently found organisms, and in 
cases where it occurs in the course of acute infections is often regarded 
as the cause of the secondary gastritis. In all such instances the origin 
of the gastritis may be largely chemical, and due to the products of the 
bacteria. An epidemic form of gastritis has received attention from 
various writers who regard this ill-understood condition as originating 
in some form of microbic infection. This " gastritis infectiosa" is regarded 
by some as a special disease. 228 
DISEASES OF THE DIGESTIVE SYSTEM 
Animal parasites are commonly associated with a true gastritis, 
although it is by no means a necessary feature of parasitic invasion of 
the stomach. The ascarides, the tsenia, and even the oxyurides may 
induce an accompanying simple catarrh of the gastric mucosa, as may 
also the diptera, flies, and larvae of various kinds. 
Secondary acute gastritis develops in the course of many infectious 
diseases, and may indeed be the main initial symptom to arouse suspicion 
of a grave infection. This is especially the case with children. In various 
pulmonary diseases when degenerated or decomposed tissues and 
exudates are introduced incidentally into the stomach an acute catarrh 
results. Ellis records a hemorrhagic gastritis due to a swallowed laryngeal 
pseudomembrane, which also obstructed the pylorus. As an accompani- 
ment of various intestinal diseases, acute renal and cardiac disease, etc., 
acute gastritis is not uncommon. 
Pathology.-The size and shape of the stomach are not usually altered. 
There is a more or less diffuse redness and swelling of the mucosa, with 
congestion or patchy hemorrhages and an excessive quantity of mucus. 
The pyloric region is most frequently involved. 
Microscopically, muciparous, cylindrical epithelium covers the free 
surface of the mucous membrane as well as the relatively deep stomach 
cells. The glandular epithelium itself shows granular degeneration, 
with more or less fatty change and atrophy, and the lumen contains 
debris, for the cells themselves have desquamated. Hyperemia occurs 
either diffusely or in patches, and there are more or less minute hemor- 
rhages. Leukocytes have escaped from the surrounding dilated capill- 
aries, and a certain amount of small-celled infiltration is evident in the 
interstitial tissue. The solitary lymph follicles may be swollen, and 
sometimes burst on to the surface, leaving minute ulcers. The resulting 
changes affect the secretion of mucus and gastric juice, and alter the 
general functions. Hence disturbances of the sensory, secretory, absorp- 
tive, and motor gastric functions occur. 
Symptoms.-These depend much upon the cause. Usually within a 
few hours, or at most a couple of days after action of the causative 
agent, there is gastric discomfort, fulness and sense of pressure or pain, 
with pyrosis, nausea, and vomiting. Often an initial rigor or chilliness 
ushers in the disease. The patient complains of a curious taste, some- 
times bitter; there is also salivation. Thirst is a prominent feature. 
Nausea usually precedes the vomiting and occurs with food or at the 
mere thought of it; vomiting itself occurs early and gives relief. The 
vomitus contains undigested food, mucus, bile, and sometimes streaks 
of blood. It is bitter in taste, and, as a rule, of a foul odor. Cardialgia, 
pyrosis, and waterbrash add to the distress. The teeth are set on edge 
and the burning acid fluid irritates the pharynx and oesophagus. There 
is hiccough, and eructations of gas, either bitter or tasteless, are common. 
Pain is almost always present, slight or severe, and sudden or gradual 
and progressive. With all these subjective sensations are numerous 
nervous phenomena, headache, dizziness, and depression of spirits. 
Signs.-The patient shows more or less prostration, and, if the condition 
be at all severe, the face is pale, the extremities are cold, and he breaks ORGANIC DISEASES OF THE STOMACH 
229 
out in a cold and clammy perspiration. The pulse is at first increased, 
later lessened in rapidity. Fever, if present, appears early, and is usually 
slight, although sometimes, when there is an initial chill, it may be 
high and accompanied by herpes; often, indeed, there is no fever through- 
out, but when, on the other hand, fever persists for days, one should 
examine carefully for some other factor to which gastritis may be merely 
secondary. In the so-called epidemic or infectious gastritis, the fever 
remains high for days, sometimes even for several weeks. The condition 
differs otherwise but little from ordinary simple gastritis, although an 
enteritis is a much more frequent complication and the general symptoms 
are more severe. 
The tongue is coated, usually dry, and indented where the edges come 
in contact with the teeth. The breath is foul and salivation is marked. 
Herpes labialis is often present. The epigastrium shows distension 
and tenderness. The vomitus contains HC1 with lactic and fatty acids, 
and mucus, and there is motor insufficiency of a mild degree. The test 
meal likewise shows evidence of stagnation and perhaps subacidity, 
while mucus is excessive. After a test breakfast the bread is almost 
unchanged, much mucus is present, and HC1 is absent or much 
diminished. There is usually constipation or later on diarrhoea, and 
involvement of the intestines is an important and often troublesome 
complication. Jaundice may be present if the common duct is 
obstructed by a plug of mucus. The urine is scanty, high colored, 
has a high specific gravity, and shows abundance of urates. 
Diagnosis.-The etiology is an important factor, while the acute onset 
and the reaction to treatment suffice to make the condition clear. The 
absence of a known and plausible cause should suggest caution in a 
diagnosis which may subsequently require modification. The differential 
diagnosis deals mainly with gastric neuroses, neuralgia, and hyperacidity, 
hysteria and ulcer. Further, biliary colic, catarrhal jaundice, appen- 
dicitis, incarcerated hernia, ileus, and the onset of some infectious disease, 
especially typhoid fever, scarlet fever, smallpox, and pneumonia have to 
be considered. The gastric crises of tabes dorsalis, the onset of menin- 
gitis in children, and lastly pregnancy should not be forgotten in 
considering the differential diagnosis, for awkward mistakes are thereby 
avoided. The appropriate adjustment of the history and symptoms to 
the physical findings will usually in time make the diagnosis simple. 
Exclusion of the important causes of a secondary gastritis is the essential 
point. 
Prognosis.-This depends on whether the condition be primary or 
secondary, and the gravity of the associated underlying cause. As a 
rule, primary acute simple gastritis quickly responds to appropriate 
treatment. The more frequent the attacks, however, the greater the 
liability to recurrence. The course and duration depend very largely on 
the cause and severity. The symptoms may last merely for twenty- 
four hours, or in severe cases for several weeks. Sometimes vomiting 
relieves at once, but such cases are in most instances merely acute 
dyspepsia, i. e., acute disturbances of function. When the intestines 
are involved the disease is aggravated and its duration lengthened. 230 
DISEASES OF THE DIGESTIVE SYSTEM 
Fatal cases are those in which the gastritis is secondary to some other 
disease, usually some severe infection or intoxication. 
Treatment.-Prophylaxis.-In children the cause is more frequently 
dietetic than in the adult, and in them proper feeding is an important 
prophylactic measure. The overloading of children's stomachs with 
unsuitable food is a frequent cause of gastritis. 
The Direct Treatment.-Two considerations are of special importance: 
(1) To remove the cause. (2) To protect the stomach and lessen the 
inflammation. 
1. Nature often provides for the removal of the cause by inducing 
vomiting, and subsequently anorexia; or else emesis may be produced 
by some simple measures. The remnants often irritate and keep up the 
symptoms, and are liable to add intestinal disturbances, so that fre- 
quently it is well to wash out the stomach; this is especially useful with 
children because thorough and rapid in its effects. When vomiting is 
not rapidly induced one may use emetics with care, apomorphine hypo- 
dermically, or a mixture of tartar emetic, gr. | (gm. 0.016), and pulv. 
ipecac, gr. 5 (gm. 0.3), every quarter of an hour until it acts. The 
latter drug is especially useful for children in the form of vin. ipecac, in 
3] doses. Other medicines are rarely required. 
2. For twenty-four hours the stomach should be given as complete 
a rest as possible. A little ice relieves the thirst and a suitable mouth- 
wash should be in frequent use. Whatever else is given should be in 
small quantities and only in fluid form, for example, a little weak, unsweet- 
ened tea, perhaps with brandy; effervescent water or soda lemonade; 
peppermint tea; later milk and lime-water (or soda-water) may be 
taken, other food being begun only when the desire for food returns. 
Pancreatized milk is also useful. Broths, gruel, and a little stale bread 
may be added. Solid food is given later on if no diarrhoea be present, 
the transition period being devoted to light puddings, rice, etc., then 
lean fish, and later on stewed chicken and fillet. Light vegetables 
should be allowed only after some days of convalescence when the stools 
are quite normal, for relapses are common and easily induced by too 
early a return to a mixed diet. Rectal feeding is rarely needed, but is 
advisable for those of advanced years. 
Medicinal.-The early administration of muriatic acid is beneficial, 
sometimes, as Riegel advises, in 8 to 10 drop doses of the dilute acid 
in a wineglass of water, taken in sips before meals, or else, as Eich- 
horst prefers, given after food. Narcotics are not usually required, 
and may do harm by stopping peristalsis and thus prolonging the 
symptoms. 
Mechanical Measures.-A Priessnitz compress and an early warm 
bath are sometimes of use. 
Special Symptoms.-For the constipation, drastic purgatives are to 
be condemned; however, small doses of calomel and soda are useful, 
especially for infants, or castor oil and laudanum. "Fluid magnesia" 
is preferable in mild cases because less drastic. For the diarrhoea, lime- 
water in doses of a few ounces every two hours, or bismuth and chalk 
in powder form may be given. For the nausea and to rest the stomach, ORGANIC DISEASES OF THE STOMACH 
231 
cocaine in doses of gr. | (gm. 0.016), or creosote in 1 drop doses may 
benefit. Vomiting is best treated with rest, and the administration of 
dilute hydrocyanic acid in doses of 5 minims with bismuth, soda, and 
spirit of chloroform, although, as a rule, a sufficiently prolonged abstinence 
will in itself suffice. 
Phlegmonous Gastritis.-Synonyms.-Interstitial purulent gastritis; 
inflammation of the submucosa (Rokitansky); gastritis submucosa 
(Dittrich, Klebs, and others); phlegmon ventriculi; linitis plastica et 
suppurativa (Brinton); linite phlegmoneuse. 
Definition.-This is an acute suppurative inflammation of the gastric 
submucosa, sometimes primary, but usually secondary as a metastatic 
or other infection. It may be diffuse or circumscribed. In 1904, Robson 
and Moynihan collected 85 cases. Since then others have been described, 
and more than 100 cases are now on record. 
Etiology.-The condition is rare, especially in its primary forms, and 
but few cases are on record. The primary cases are doubtless all microbic 
in origin, although alcohol is often regarded as a predisposing factor. 
Such were the cases described by Welch, and E. Janeway and Kinnicutt. 
Marasmus, faulty diet and ptomaines, corrosive poisons, e. g., oil of 
turpentine (Kelynack), oxalic acid and trauma of various kinds (Hopkins), 
all play a part. A fair proportion of cases follow gastro-enterostomy 
and other operations of the stomach. The commoner causes are some 
general infection, e. g., scarlet fever, smallpox, typhoid, etc., an ulcerating 
cancer or infected ulcer, or some defect in the mucosa admitting virulent 
bacteria. In a number of the cases hemorrhagic erosions suggested the 
site of invasion, or the infection may occur through the mucous mem- 
brane, even without the presence of a defect (Konstantinovitch). More 
rarely pus swallowed from a suppurative stomatitis has caused the dis- 
ease. Streptococci have been the commonest microorganisms present, 
and the colon bacillus frequently coexists. Many other common bacteria 
have been found and sometimes yeast. But, as Cecil and others have 
pointed out, the bacteriological examination is not always satisfactory, 
for coccus forms may die off early, leaving the field to other organisms 
not directly associated with the true cause. 
Age.-The youngest patient afflicted was ten years of age (Hun), the 
eldest eighty-five. The diffuse lesions nearly all occurred between twenty 
and sixty years. 
Sex.-The proportion is about four males to one female. 
Pathology.-Of the 96 cases collected, 76 were probably of the diffuse 
variety and 12 were definitely circumscribed. The remaining cases 
recovered or did not come to autopsy. The disease commences in the 
submucosa, and unless a local ulceration (benign or malignant) exists, 
or some generalized infection, it is not always easy to determine the 
origin. Cases originating in chronic ulcer and in cancer are not uncom- 
mon. The submucosa, especially at the pylorus, is thickened, infiltrated 
with pus or sero-pus, sometimes almost jelly-like or cedematous in 
appearance. The underlying muscle is involved to a greater or less 
extent; indeed, it may be entirely destroyed. Sometimes merely a 
channel or cavity remains, containing little or no pus whatsoever. The 232 
DISEASES OF THE DIGESTIVE SYSTEM 
mucosa is usually more or less affected and signs of infiltration are seen 
between the glandular loops. 
The mucosa itself is also thickened, hyperemic, and ecchymotic in 
patches. The epithelium is here and there degenerated, and erosions 
and ulcers are frequent. Sometimes the sinuses leading from the sub- 
mucosa are so numerous as to give to the lining membrane a coarse or 
fine sieve-like appearance, as in a case described by Polak. The result 
may be that more or less of the mucosa itself is lifted away from the 
underlying submucous layer. The peritoneal surface shows at times 
marked swelling of the lymphatics. Perigastritis always accompanies 
the malady and adhesions occur in various ways and situations about 
the viscus. Purulent peritonitis is not an infrequent termination, or 
infiltration and dissection may occur along the submucosa of the 
duodenum or up into the oesophagus (Chvostek). In some instances 
the diaphragm has been invaded, resulting in a purulent pleurisy 
or pericarditis. Thrombi are often found in the neighboring veins 
and the causative microorganism is not infrequently detected in the 
vessels. 
Splenic tumor, acute nephritis, necrosis of the colon, mediastinitis, 
cholecystitis, etc., may result from the primary gastric affection, or as a 
part of a general septic state. The circumscribed phlegmonous gastritis 
forms an abscess of varying size in the submucosa, or there may be 
numerous smaller collections. Perforation may occur into the stomach 
cavity, externally into the peritoneum or into neighboring viscera. 
Symptoms.- The Diffuse Variety.-The onset is nearly always sudden, 
although with no characteristic symptoms. A rigor may usher in the 
affection, followed by a rise of temperature to 104° or 105° F. There is 
general malaise, and severe prostration appears very early. Very soon 
the gastric symptoms become marked. Not infrequently two stages 
are evident, at first the signs of gastritis and later those of peritoneal 
inflammation. Some cases, however, show no gastric symptoms what- 
ever, and the condition is found only after death. 
Nausea and vomiting appear early, are of long duration and rarely, 
absent. Toward the end the vomiting usually diminishes; it may be 
feculent and foul in odor. The vomitus rarely contains macroscopic 
pus (as in the cases described by Glax, Deininger, and others), unless 
the mucosa be perforated, although leukocytes are usually seen on micro- 
scopic examination of the gastric contents. Progressively increasing 
pain in the epigastrium is a prominent feature and rarely absent. Soon 
the pain extends over the whole gastric area, resembling that of local 
or general peritonitis. Tenderness is usually present, and if a large 
abscess exists fluctuation may be detected. Meteorism is often marked. 
The fever is irregular, usually persistent, and has a wide range; in Testi's 
case, however, there was no elevation of temperature. Repeated rigors 
are sometimes present. The pulse is rapid, small, and often irregular 
in volume and rhythm. There may be diarrhoea or constipation, and 
thirst is often marked. Collapse, wThich has been imminent from the 
onset, becomes progressive; delirium and coma usually usher in the final 
stage, with or without the signs of general peritonitis. The course is pro- ORGANIC DISEASES OF THE STOMACH 
233 
gressively downward and the duration is rarely longer than two weeks. 
The diffuse cases are more rapid than those which are circumscribed. 
The circumscribed variety presents a similar type of symptoms, although 
at first less severe. Sometimes pain is quite absent. A distinct tumor 
is often felt. The abscess may burst into the peritoneal cavity and cause 
death, or rupture may occur through the mucosa into the stomach. 
Some of these cases recover as pathological specimens testify. 
Diagnosis.-This has rarely been made. The signs are those of acute 
peritonitis (local or general). Leube has pointed out that the vomiting of 
pus need not be pathognomonic, and may arise from a purulent gastritis 
alone. The probable diagnosis is suggested when in the course of a 
pyemia or other severe general infection, the symptoms arise as above 
described, although this form of metastatic infection is comparatively 
rare. The circumscribed form is perhaps more readily diagnosed, espe- 
cially when a tumor, which has already been felt, disappears after the 
vomiting of pus; though this may arise from an abscess arising outside 
of the stomach and perforating into the viscus. Leukocytosis is probably 
present in most of the cases (Lengeman). In the differential diagnosis 
one must consider chiefly perigastritis following ulcer, peritonitis, acute 
pancreatitis, cholecystitis, abscess of the liver, and corrosive poisoning. 
Prognosis.-About 95 per cent, of the recorded cases have been fatal. 
Death usually occurs within one week, and many end fatally in two or 
three days. The more subacute and chronic cases later on develop 
peritonitis or metastases. 
Treatment.-This is symptomatic, unless a localized abscess is diag- 
nosed, in which case operation offers some hope of success. Mikulicz 
had a patient thus cured (Lengeman). Bovee recently described an 
undoubted phlegmonous gastritis cured by gastrostomy and drainage. 
Severe Toxic Gastritis.-Various irritant and corrosive poisons when 
brought into contact with the gastric mucosa induce an intense inflam- 
mation which is merely an aggravated form of the acute simple gastritis, 
the intensity depending on the character of the poison, its nature, con- 
centration, quantity, and length of time present in the stomach, as well 
as upon the volitional or accidental ingestion of the irritant. These cases 
are not necessarily severe, and all stages occur from simple hyperemia 
to ulceration, gangrene, and perforation. Practically all the known 
poisons may directly or indirectly induce a severe gastritis. 
The exogenous poisons are especially irritant in their action, i. e., con- 
centrated acids, alkalis and alkaline salts (sodium and potassium salts, 
potassium and sodium hydrates, ammonia compounds, etc.), metalloids 
(chlorine, bromine, and iodine preparations, phosphorus, sulphur, arsenic, 
and antimony), metallic salts (lead, silver, zinc, copper, mercury, etc.), 
certain of the methane derivatives in large doses (alcohol, petroleum, 
croton oil, etc.), bodies from the aromatic groups in certain dosages 
(benzol and its derivatives), ethereal oils, turpentines, balsams; also 
some of the alkaloids and glucosides, etc. 
The endogenous group includes poisons which are supposed to result 
from retention in the body of injurious substances which are under 
normal conditions eliminated by various channels, e. g., in uremia and 234 
DISEASES OF THE DIGESTIVE SYSTEM 
cholemia, and also poisons resulting directly from metabolic disturbances 
of a profound nature (diabetes, carcinoma, etc.). Further, there are 
the bacterial products from all forms of infections, almost any of which 
may directly or indirectly act as irritants to the gastric mucosa. 
The action of the different poisons varies not only according to their 
nature, but likewise according to the method of ingestion and the position 
of the victim while taking the irritant. The site of the lesion varies. 
Sometimes but a small portion is affected; sometimes merely the cardia 
is involved; or, again, only the greater curvature. Most change naturally 
occurs where the poison was longest in contact with the wall, which 
event occurs in most instances at the fundus, pylorus, and posterior wall. 
As repair takes place, scars form, and according to the extent of the 
original lesion mere cicatrices exist, or else more or less deformity devel- 
ops. As a result one may find pyloric stenosis, hour-glass contractions, 
sacculations, etc. Often very extensive lesions heal remarkably well. 
The mucous membrane is not impaired. The secretory changes are 
marked; hydrochloric acid diminishes or is completely absent. 
As a rule, the alkalis are more penetrating than acids; perforation 
is extremely common, and where the serious effects are not fatal one 
usually finds more or less deformity of the oesophagus as the result of 
cicatricial contractions. Often the oesophagus alone is severely affected, 
for the acid becomes diluted in its journey to the stomach. 
Symptoms.-In a typical case the sudden severe onset of pain and 
vomiting is the most prominent feature. The pain is usually felt all the 
way from the oral cavity to the stomach. There are burning pains in 
the mouth and gullet, and behind the sternum. Nausea, retching, and 
vomiting follow almost immediately. The vomiting is frequent, painful, 
and brings no relief of the symptoms. In the vomitus blood-stained 
material, perhaps food remnants, mucus, shreds of mucous membrane 
and the poison itself are found. Great thirst is a prominent symptom, and 
the dysphagia intensifies the suffering. Diarrhoea appears later, and 
the stools may show evidences of mucus and blood, usually because of 
an accompanying enteritis. Signs of collapse rapidly supervene. The 
facies is anxious and pale, or cyanbsed, and the lips and mouth show 
evidences of the corroding poison. Petechise often appear in the skin, 
and jaundice is not infrequently present from toxic or obstructive causes. 
The pulse is rapid, small, and often irregular in volume and rhythm. 
The respirations are shallow, quickened, and thoracic in type, because 
the diaphragmatic movements are limited through the pain. The 
temperature may rise slightly above the normal. The condition of the 
sensorium varies according to the exciting cause. In many instances 
there is great excitement, convulsions intervene, and, later on, coma. 
The condition of the urine depends on the kind of poison ingested. 
The abdomen in the acute stages shows nothing beyond tenderness 
and distension, unless perforation and peritonitis have occurred with 
their usual signs. Death occurs usually from exhaustion, convulsions, 
suffocation, or from general intoxication. Should recovery take place, 
complete restoration of the tissues may occur in those cases where no 
marked corrosion of the gastric mucosa has been present, but this is only ORGANIC DISEASES OF THE STOMACH 
235 
with the milder forms of irritant poisoning. In other cases the results 
are less favorable. Chronic indigestion supervenes from atrophy of the 
glands, or persisting gastritis with vomiting, progressive weakness, and 
emaciation. Sometimes ulcerations persist, or their healing results in the 
formation of stenoses and deformities. 
Diagnosis.-This is based on the history, the nature of the symptoms, 
the oral and pharyngeal evidences of corrosion, etc., the odor of the 
breath in certain cases, the chemical analysis of the vomitus or of the 
washings from the stomach, and the analysis of the urine. 
Prognosis.-This depends upon the special cause, the kind of poison, 
its amount in relation to its toxicity and irritant properties, the early 
emesis, and the possibility of early removal. Collapse and peritonitis 
are serious symptoms. 
Treatment.-Rational therapeutics depend upon a recognition of the 
special toxic agent, for which the proper antidote can be given. In 
addition to this, one should attempt to get rid of the poison, if early 
recognized, by rapidly acting emetics, e. g., apomorphine. Lavage should 
be used when it is improbable that extensive corrosion is present, and 
soothing remedies for the gastric mucosa may then be administered. 
For corrosive acids one may give mucilaginous and oily drinks or weak 
alkalis. For corrosive alkalis, vinegar and water, or citric acid are 
useful. Counterirritants externally may aid in giving relief, while 
medicinally one should use demulcents, opiates, bismuth, etc. Rectal 
feeding will be necessary for some days. Collapse must be checked, or 
treated by appropriate remedies. 
Mycotic Gastritis.-Many of the commoner parasites are found in the 
stomach under normal or abnormal conditions, both bacteria and mould 
fungi, as well as yeasts, and while in many instances they are the direct 
cause of changes in the gastric functions or anatomical conditions, at 
other times their presence seems to be rather accidental and unimportant. 
Inflammation of the gastric mucous membrane as a result of bacterial 
invasion through the blood or lymph streams is common enough, and 
gastritis due to streptococci, typhoid bacilli, pneumococci, and other 
infectious agents is well recognized. Whether or not bacteria which 
are ingested with the food can induce a true gastritis seems still open to 
question. It would appear that the acid gastric juice retards the growth 
and development of bacteria, although moulds seem to resist the acid 
better than do the schizomycetes, which latter grow better when sub- 
acidity is present. The acidity, the stagnation, and the quality of food 
ingested are the factors which determine the growth or retardation of 
development of the various fungi in the stomach. 
As a general rule, moulds and yeasts do but little harm in the stomach 
and have an anatomical rather than a clinical interest and importance. 
Kundrat found favus in the stomach associated with a favus universalis, 
which was distributed throughout the body, and Rudnew found the 
penicillium glaucum in a woman who died of Asiatic cholera. Klebs 
and Fraenkel associated a gastritis with favus, yeast, and oidium albicans; 
certainly the last-named fungus has often been seen in cases of gastritis, 
and yet in spite of its frequency during childhood in the pharynx and 236 
DISEASES OF THE DIGESTIVE SYSTEM 
oesophagus, it is rare in the stomach. Epstein drew attention to the 
fact that a healthy mucosa was not a suitable medium for the growth of 
this parasite in the pharynx, and perhaps the same applies to its growth 
in the stomach. This may account for the frequently abrupt termination 
of the affection at the cardia, despite the fact that large numbers of the 
fungi reach the interior of the stomach. Reisz described the stomach 
of a girl aged eighteen years which was covered with patches of fungus 
growth, the underlying epithelium was partially degenerated, and the 
mucosa infiltrated with small round cells. 
Von Wahl and von Recklinghausen recorded cases in which fungi of 
the leptothrix group penetrated the gland ducts and were anatomically 
associated with necrotic areas. In one case many pustules existed in the 
glandular layer and submucosa of the pylorus, in the other the fundus 
was chiefly involved. 
Symptoms.-The relation of the presence of moulds to the symptoms 
is dubious. Talma was of the opinion that the carbohydrate fermenta- 
tion, caused by the presence of microorganisms, was the antecedent of 
many cases of hyperacidity, but although moulds may coexist with 
hyperacidity and gastralgia, it is not certain whether their presence is 
a cause or an effect of the condition found. Einhorn has admirably 
described a few cases, and was among the first to recognize the condition 
clinically. The lavage water from the empty stomach demonstrated the 
presence of blackish-gray or brownish-green flakes indicating the existence 
of moulds which microscopically showed spores and mycelia. The species 
could not be determined even though carefully examined. These flakes 
varied in number from 4 to 50 or more, were 2 to 5 mm. in size, and 
often intimately mixed with mucus, which fact together with their pres- 
ence in the empty stomach argues that their presence is not merely an 
accidental admixture. Probably the moulds adhered closely to the 
mucous membrane and perhaps proliferated in it. At all events they 
can evidently thrive in the stomach and retain their power of growth, 
regardless of the gastric juice. 
Two types of cases occur, one with signs of hyperchlorhydria (occa- 
sionally with hypersecretion and vomiting), the other with gastralgia, 
the gastric secretion being normal or reduced. The relation of the fungi 
to the symptoms is either etiological or a cause of increased severity. 
Lavage improves the symptoms. 
Treatment.-Systematic lavage rapidly removes the fungi permanently 
from the stomach. Einhorn advised the further use of weak solutions of 
silver nitrate in the lavage water. 
Diphtheritic Gastritis (Gastritis Membranacea).-This condition, 
which has much more anatomical than clinical significance, may be 
defined as a pseudomembranous inflammation of the gastric mucosa, 
usually a sequel to a similar condition of the nasopharynx, but sometimes 
primary (Delafield) and associated with varying bacterial agents, and at 
other times apparently due chiefly to chemical causes. . 
True diphtheria of the stomach, due to the Klebs-Loeffler bacillus, is a 
rare condition and nearly always secondary to a similar bacterial invasion 
of the contiguous parts, oesophagus, throat, or upper respiratory passages. ORGANIC DISEASES OF THE STOMACH 
237 
Leary observed only two instances out of 136 fatal diphtheria cases 
examined at the Boston City Hospital. While, as a rule, diphtheritic 
gastritis is secondary to some other diphtherial infection, it may com- 
plicate various other infectious diseases, e. g., typhoid fever (Thorel), 
pneumonia (Foulerton), pyemia, the exanthemata, etc. Isolated 
instances of the malady were described by Sir William Jenner, Wilson 
Fox, Wilks, and others. Children seem to be most commonly affected. 
Pathology.-The stomach is not usually altered in size or shape. The 
chief feature is the presence of the pseudomembrane. This may be 
diffuse and cover the entire surface of the stomach as in the case described 
by Talfourd Jones, but more often there are streaks or patches of mem- 
brane-of varying size, thickness, and number, irregularly arranged. 
The mucosa is discolored, usually darker than normal, reddish or grayish 
red in appearance, and thickened. The rugae are usually well-marked, 
and covered with the more or less firmly adherent membrane. Micro- 
scopically the picture resembles that seen in ordinary pseudomembranous 
lesions of any mucous membrane. As in pseudomembranous inflamma- 
tions elsewhere, so here the bacteriological findings vary widely. Strepto- 
cocci and Klebs-Loeffler bacilli are those most commonly isolated. 
Symptoms.-There are no characteristic symptoms, and the mere 
vomiting of a pseudomembrane does not necessarily imply that the 
disease has affected the stomach itself-unless, indeed, a cast of the 
whole stomach be vomited up, as was recorded by Thomson in one 
instance. Such membranes are readily swallowed and sometimes are so 
extensive as to cause pyloric obstruction. Seitz, however, has recorded 
a diagnosis of pseudomembranous gastritis during life and confirmed at 
autopsy. Some of the membrane has been vomited concurrently with 
the presence of other evidences of gastric disturbance. 
CHRONIC GASTRITIS 
Definition.-A protracted inflammation of the gastric mucous mem- 
brane with motor or secretory changes in gastric digestion. It may be 
primary or secondary. 
Incidence.-In its primary pure form the condition is clinically quite 
uncommon-at all events much more rare than is ordinarily supposed- 
being frequently confused with a purely functional disease in which 
similar signs and symptoms exist without any pathological changes. 
For this reason, and in view of the unsatisfactory means of diagnosis, 
the time-honored term "chronic dyspepsia" should not be despised. It 
may be that after some time even functional disturbances lead to patho- 
logical changes in the gastric mucous membrane, a true superficial 
inflammation, as in the cases referred to by Cohnheim, in which the 
gastritis resulted in his opinion from motor insufficiency, and was 
induced by irritation of the stagnant chyme. 
As a primary affection, chronic gastritis is not often found in the 
autopsy room, the cause of death usually being some general or local 
condition to which the gastritis is secondary (cardiac or hepatic disease, 238 
DISEASES OF THE DIGESTIVE SYSTEM 
nephritis, tuberculosis, pernicious anemia, etc.). Thus, in the Royal 
Victoria Hospital, among 1300 autopsies, there were 108 with chronic 
gastritis, and of these, 92 were definitely secondary to other causes, 
while the remaining 10 were more or less mild in type and associated 
with other diseases not necessarily the cause of the condition. Statistics, 
however, with reference to the incidence of chronic gastritis are notor- 
iously unreliable. Clinically, the signs and symptoms are often most 
ill-defined as evidence of true inflammation of the stomach, and much 
has been called gastritis which undoubtedly would more truly come under 
the category of neurosis of the stomach, or under the old name of chronic 
dyspepsia, a purely functional disorder often due to atony. Vice 
versa, many cases of chronic gastritis as seen at autopsy (secondary to 
other diseases) were utterly devoid of evidence of that malady during 
life. 
Pathologically, statistics are almost equally unreliable, through the 
infrequency with which primary gastritis comes to the pathologist's 
notice, and because of the numerous errors in pathological observations. 
Marked contractions of the gastric wall are mistaken for chronic thick- 
ening, and passive congestion for true gastritis, where a microscopic 
examination would have revealed no sign of disease. 
Classification.-Classifications have been based upon the nature of 
secretions, and the gastritis acida, gastritis anacida, gastritis mucosa, 
etc., have been described. The mere analysis of the secretions, however, 
affords practically little clue to the underlying conditions, and cannot 
determine differentiation from certain neuroses. In many instances a 
hyperacid secretion is found in the early stages of chronic gastritis to 
be followed later by a diminution of the hydrochloric acid. Sometimes, 
however, hyperacidity may appear late, while not infrequently it persists 
throughout the whole course. When one realizes how widely the secre- 
tions may vary from day to day; how on one day an excessive acidity 
may be followed by a marked hypochlorhydria on the next; how inter- 
mittent is the pathological secretion of mucus, one can scarcely feel safe 
in relying upon a classification of chronic gastritis based on such clinical 
signs. As well might one classify the various forms of pneumonia 
according to the account and character of the sputum. 
The term mucous gastritis, for example, is used to designate the simple 
chronic gastritis, or gastric catarrh, in spite of the fact that mucus may 
be abundant in any of the different pathological varieties of this malady. 
Again, in hyperacid gastritis much or little mucus may be present, 
and the underlying condition may be proliferative and degenerative in 
nature. Proliferative gastritis, as a rule, induces diminution in the 
secretion of HC1, although, in many instances, there is hyperacidity. 
In cases of chronic gastritis with atrophy of the glands (anadenia, 
achylia gastrica), the symptoms and signs are apt to be most constant; 
in certain instances of this variety there is a rapid course with signs of 
chronic gastritis and progressively downward tendency. Examination 
of the gastric contents after a test meal shows little or no digestion and 
the secretions appear absent. Here, however, as in the other forms of 
chronic gastritis, great variations occur in the symptoms at times, and, ORGANIC DISEASES OF THE STOMACH 
239 
moreover, there are all grades of transition to the other varieties of the 
disease. Again, whether owing to treatment or to the natural course of 
the malady, a hyperacid gastritis may change to the anacid type, and, 
vice versa; if enough gland elements remain, the condition of achylia 
gastrica may alter to one with normal or even hyperacid secretion. 
Apparently the state of the motor power has greater significance in 
the production of clinical signs and symptoms than has the secretory 
function; often indeed the marked evidences of the malady are synchron- 
ous with the signs of motor insufficiency. Certainly many cases in which 
autopsy has shown marked disease of the gastric mucosa have given 
few symptoms during life so long as the motor power was unimpaired. 
It would seem well, therefore, to avoid any clinical classification into 
subdivisions, and to recognize the fact that the manifestations being 
varied, one may recognize the malady from the complexity of signs, 
symptoms, etiological factors, and be content with the general diagnosis 
in all such cases of "chronic gastritis." 
Etiology.-Primary chronic gastritis is mainly caused by irritants 
acting over a prolonged period and in a strength not so great as to corrode 
the mucosa. Oft-recurring acute gastritis is followed by the chronic 
form. Alcohol is the commonest irritant, and the most important cause, 
especially if taken undiluted, e. g., brandy, gin, or wines of all kinds when 
taken to excess-their action being either as direct irritants or perhaps 
in part due to the production of acids in the stomach. So also diluted 
alcohol may act in the same way by inducing acetic fermentation. 
An analysis of cases in the Royal Victoria Hospital has called our 
attention to the fact that alcohol in excess is by no means a necessary 
cause. In 10 autopsies performed on men dead of acute alcoholism, 7 
showed no definite chronic gastritis whatever, while in the others the 
signs were marked in only one. Of the autopsies upon 40 other patients, 
in whom a marked alcoholic history was obtained, but in whom death 
was due to other causes, there were 20 cases with chronic gastritis, and 
the remainder showed no definite signs of true inflammation; 10 showed 
mere congestion, 10 showed swelling and congestion, 9 showed a granular 
mucosa, and only 5 showed definite thickening; 4 others had mammilla- 
tions, and in the remaining 2 true polypi existed. Macroscopic erosions 
existed in only 1 of these 40 cases. It is interesting to note that 21 of 
these 40 patients gave no history of gastric symptoms, while 16 had pain 
and vomiting. 
Other causes of irritation acting directly or indirectly are spices, strong 
tea or coffee, certain irritant drugs and drastic purgatives, as also tobacco, 
especially if chewed, and dietetic errors, Improper quality of food (if 
coarse, too rich, too spicy, fatty, or otherwise irritating), excessive 
quantity as regards bulk, especially of rich foods, improper mastication 
of food and also irregularity at meals are all of great importance, and 
more so in proportion as the individual's habits are sedentary. 
Secondary gastritis may be due to local or general conditions. The 
chief local conditions are as follows: Gastric diseases of any chronic 
nature, affections of the portal system, especially obstruction, and 
also the presence of parasites (bothriocephalus, etc.). The main general 240 
DISEASES OF THE DIGESTIVE SYSTEM 
conditions are numerous, e. g., cardiac and arterial disease, pernicious 
anemia, leukemia, gout, diabetes, etc., and general infections (typhoid 
fever, pneumonia, tuberculosis, sepsis, etc.). 
Pathology.-Pathologically two main types of chronic gastritis exist, 
the one chronic productive, the other atrophic. In the productive type, 
part or all of the stomach wall is thickened, while in the atrophic variety 
it is thinned in one or all of its coats. The stomach is usually larger 
than normal, except in the cirrhotic forms where there is shrinkage of 
the organ. At autopsy, mucus is usually thick, or a more or less grayish 
or slaty color, and sometimes reddened with blood pigment. It is either 
translucent or opaque, and sometimes appears semipurulent. 
The mucous membrane varies according to the type of gastritis present, 
but both types may be found in different portions of the same stomach. 
In the productive variety the mucosa is swollen and thickened, and of 
a dark red or grayish-red color, especially in the neighborhood of the 
pylorus. The color varies. In the older cases there is more pigment, 
which appears beneath the mucosa as a black or dark gray discrete 
discoloration. Not infrequently one sees small, follicular ulcers or 
hemorrhagic erosions, apparently due to inflammatory hyperplasia of 
the lymph follicles, with subsequent degeneration. The affection of 
the mucosa is either general or local. In diffuse inflammation there is 
dense thickening from interglandular inflammation as well as from pro- 
ductive inflammation of the gland structures. The thickened wrinkled 
mucosa with its flat mammillated appearance may be polypoid in appear- 
ance ("gastritis polyposa") or more coarsely granular (gastritis granu- 
losa). The submucosa and muscularis may also be affected, the muscle 
itself thickened, and the interstitial tissue increased. One may even 
see the serosa involved. 
Microscopically, the mucous membrane shows small-celled infiltration, 
degenerated epithelium, hemorrhages, cystic dilatation of the gland 
tubules, and here and there some true erosions. The round-celled 
infiltration occurs early, is usually chiefly superficial and beneath the 
uppermost layers of epithelium, as also to some extent between the 
glands. Small round-celled infiltration may persist for a long period 
of time without developing into fibrosis. The degeneration of epithelium 
affects mainly the secreting cells, while the mucous cells appear to resist 
the inflammation longest. Often the epithelium is so distorted that it 
is impossible to distinguish chief fFom parietal cells, and many assume 
a cylindrical or a cuboidal shape. Cystic dilatation of the tubules is 
common (retention cysts). This so-called "gastritis cystica" is some- 
times very pronounced. Capillaries and lymphatics are usually dilated 
and there are hemorrhages, old and new. 
Atrophic Type.-The second type of chronic gastritis, with atrophy 
of the mucous membrane, sometimes called anadenia ventriculi, is said 
to be preceded usually by gastritis proliferans. The mucous membrane 
is devoid of properly developed glands. The surface is pale, thin, 
and smooth and in the advanced cases consists more of granulation 
tissue or well-developed fibrous tissue. The muscularis takes part 
in the process and is usually atrophic. Sometimes, however, there is PLATE VIII 
FIG. 1 
Chronic Productive Gastritis. 
FIG. 2 
Chronic Productive Gastritis. PLATE IX 
FIG. 1 
Chronic Productive Gastritis. 
FIG. 2 
Chronic Atrophic Gastritis. ORGANIC DISEASES OF THE STOMACH 
241 
muscular hypertrophy with atrophy of the mucosa, and one may see 
pigmentary changes, the so-called atrophic pigment induration of the 
stomach. 
Microscopically, the mucosa resembles more and more that of the 
small intestine. There are evidences of round-celled infiltration. The 
atrophy of gland structures varies; often the secreting glands are alone 
involved, while the mucoid cells are unaffected; but the changes in this 
respect vary in different cases, as well as in different portions of the 
stomach in each individual instance. Illustrative types of these cases 
are often found in pernicious anemia. Some advanced cases are difficult 
to distinguish from a diffuse scirrhus, the gland structures being so 
atrophied that only a flat fibroid-looking surface remains whose base 
enclosed the remains of gland structures. 
Cirrhosis of the stomach is only another variety of the atrophic in the 
sense that gland structures disappear. Here the organ is smaller than 
normal, contracted, and thickened usually in all its coats from excessive 
growth of the products of chronic inflammation. 
Symptoms.-The disease both in its primary and secondary forms, 
may be latent throughout, or gradual and insidious in onset. To a 
certain extent the symptoms and signs depend upon the condition of 
the secretions and motor power (sthenic and asthenic, hypertrophic, 
sclerosing or atrophic), although certain general features apply to most 
of the cases. 
Early symptoms are usually those of a so-called dyspepsia; slight 
dietetic errors cause discomfort in the epigastrium, with a sense of fulness, 
pressure, or weight, and perhaps even slight pain. Unless hyperacidity 
exists there is usually anorexia, especially for meats, or the appetite is 
fickle, with yearning for spices, acids, or liquids. A disagreeable taste 
in the mouth is present, and flatulence commonly intervenes, often 
being a marked symptom. Eructations of gas frequently relieve the 
distress. The tongue may be furred and is often sore at the edges and 
tip. Nausea and vomiting occur either at the height of digestion or 
sometimes in the early morning-perhaps induced by the swallowing 
of pharyngeal mucus during the sleep. Thirst is usually present, although 
less common than in acute cases. Lassitude, neurasthenia, and dizziness 
during the digestive period are the rule. Later in the disease, when 
the condition is more pronounced the symptoms are aggravated. Nausea 
is more persistent, waterbrash and cardialgia are more common, and 
vomiting comes on with greater frequency and the vomitus contains 
undigested food with fermentation products. Fluids may be well borne, 
but solids aggravate the symptoms. The intestines are likewise affected, 
and constipation alternates with diarrhoea. The nutrition varies. 
Emaciation may be rapid when the intestinal functions are simultaneously 
impaired. The urine shows urates and calcium oxalate is often present 
in excess. Not infrequently the ethereal sulphates are increased. 
Physical examination of the abdomen gives little information, as the 
only constant sign is tenderness-more or less diffuse and perhaps more 
often found to the right of the epigastrium than elsewhere. The stomach 
may or may not be distended. 
vol. ni-16 242 
DISEASES OF THE DIGESTIVE SYSTEM 
Gastric Contents.-Usually the food removed is abnormally large in 
amount, appears undigested, coarse, and mixed with mucus. The most 
constant abnormality is the excessive amount of mucus, although it 
may originate in some portion of the tract above the stomach, e. g., 
pharynx or oesophagus, and need not be an evidence of disturbed gastric 
function. Mucus from the stomach occurs more commonly in shreds 
or flakes, not in isolated lumps, is mixed with the food and is often found 
in most abundance after the test meal has been removed and the remain- 
ing contents gained by thorough lavage. It usually contains leukocytes 
in more or less abundance. The presence of abundant gastric mucus 
enclosing many leukocytes is positive evidence of gastric catarrh. 
The secretion of acid varies. Best and Cohnheim showed that in 
gastritis we first have subacidity through deficient secretory function 
and the neutralizing effect of alkaline mucus. The gastric juice is thus 
too weak to exercise its inhibitory acid action, so that the stomach empties 
itself too quickly and as a result we again get hyperacidity with its 
characteristic symptoms. They produced hyperacidity in dogs by 
artificially emptying the stomach more quickly, e. g., by a fistula, thus 
doing away with the acid which regulates the movements. Hyperacidity 
is uncommon and when present usually indicates an early condition of 
the gastritis, or an associated neurosis (gastritis acida). Diminution 
of hydrochloric acid is more common and may be progressive up to the 
period of total achylia (achylia gastrica, atrophic gastritis). From time 
to time, however, during the course the amount of acid shows great 
variation. McCaskey, in an analysis of 600 cases of so-called chronic 
gastritis, found no hydrochloric acid in 20 per cent., subacidity in 26 
per cent, normal acidity in 34 per cent., and hyperacidity in 20 per cent. 
The pepsin keeps pace with the hydrochloric acid, and the rennet ferment 
likewise diminishes with the progress of the disease. Bouveret regards 
a quantitative estimation of the rennet ferment as a valuable aid in 
prognosis as indicating possibilities of repair. 
Achylia not infrequently occurs in the late stages of chronic gastritis. 
From the pathological standpoint achylia does not imply anadenia. 
Faber, especially, draws attention to the fact that in gastritis there may 
be achylia even although secreting cells are unimpaired, and concludes 
that the accompanying gastritis has merely disturbed their function 
but not their anatomical structure. In order to prove that the achylia 
is not merely temporary, several test meals should be given. The 
enzymes are absent as well as the hydrochloric acid; mucus may be 
abundant. 
The motor power varies. As a rule it is not greatly impaired, although 
if insufficiency be present there is much more fermentation and the 
general gastric symptoms are much more pronounced. In most cases 
of typical chronic gastritis there is some atony, more readily induced 
by persistent dietetic errors. The gastric functions are readily taken 
on by the intestines when normal motor power exists. Gastrectasis is 
uncommon. 
Some authors (Cohnheim and others) described valuable aid from 
examination of bits of mucous membrane which sometimes come away ORGANIC DISEASES OF THE STOMACH 
243 
with the lavage water, but Lubarsch's studies have revealed many sources 
of error in this means of diagnosis. The alterations they present are 
often but semblances of inflammatory change; and vice versa, even if 
the cells and glands be actually altered structually, it does not necessarily 
mean that they have been functionally inactive. Bassler has directed 
attention to the value of free gastric cells in the fasting stomach as 
evidence of the atrophic variety. Saline installations are used (250 cc. 
of water with sodium chloride 21 grs., sodium sulphate, sodium carbonate 
and sodium phosphate aa 1 grain). The fluid is drunk, the stomach 
agitated by palpation and exercise, and after five minutes the fluid is 
siphoned off and allowed to stand. The sediment is then examined and 
the cells are differentiated by eosin (for acid cells), and hematoxylin (for 
peptic cells). In atrophic gastritis the acid cells are in abundance and 
stain readily, with stippled protoplasm and eosinophile granules with 
well defined nucleus. 
Course and Prognosis.-It is usually of long duration, and the general 
health suffers either periodically or progressively, but alternation of 
good and depressed health is the rule. The mental condition suffers, 
neuroses appear and often great physical depression as a result of the 
hypochondriasis and neurasthenia. The exacerbations usually depend 
on indiscretions, and recurrences are very common, especially in alco- 
holics. The mild cases are readily cured, but in the more severe ones 
the probability of cure depends on the condition of the muscular wall, 
the state of the mucosa, and the kind and degree of inflammation present. 
With atony of the stomach, and especially gastrectasis, and with achylia 
gastrica, the condition is much more difficult to treat successfully. 
When the intestines are healthy, the chances of cure are naturally aug- 
mented. The prognosis should be based less upon the general condition 
than upon the outlook for securing a sufficient supply of nourishing food 
and the maintenance of secretory and motor functions. In every case 
the individual affected has himself most to do with the cure by observing 
due regard to the requirements of treatment, which, after all, are readily 
followed and are usually of benefit in cases not too far advanced. 
Diagnosis.-The condition whether primary or secondary is very 
often latent, and repeated observations may be necessary; the etiology, 
the symptoms and signs as above described render the diagnosis certain, 
but by exclusion rather than by any other means. The main features 
in the diagnosis are: (1) The etiological factors. (2) Persistent indiges- 
tion, with nausea and frequent vomiting of much mucus, gastric pain, 
and tenderness. (3) The relation of the symptoms to the ingestion of 
food. (4) The variations in the course, with its exacerbations and 
remissions. (5) The moderate loss of strength and weight as compared 
to the lowered nutrition in more serious conditions. (6) The com- 
paratively slight alterations of the motor power. (7) The presence in 
the gastric secretions of much mucus and variable quantities of acid 
from complete achylia to hyperacidity. (8) The finding in the stomach 
contents of many leukocytes either in the mucus or in bits of mucous 
membrane. (9) The beneficial effect of proper treatment. 
In the differential diagnosis one must distinguish between primary and 244 
DISEASES OF THE DIGESTIVE SYSTEM 
secondary forms; the primary affection is much more uncommon than 
the secondary, hence the importance of detecting the original cause. 
Chronic Gastritis and Gastric Neuroses.-The differentiation is often 
impossible. The distinctive features are as follows: In chronic gastritis, 
(1) An obvious cause. (2) Poor nutrition. (3) The symptoms are 
digestive in time and cause-much mucus is vomited. (4) Gastric 
analysis. (5) Duration with exacerbations and remissions. 
In cancer there is no apparent cause, the disease is progressive with 
wasting, gastric pain, and hematemesis. The gastric analysis differs. 
There is occult blood in the stools, and tumor'may ultimately appear. 
Treatment has less marked benefit. Atrophy of the gastric follicles, 
achylia gastrica, is an occasional sequel of chronic gastritis, as also an 
accompaniment of gastric cancer, pernicious anemia, etc. It may, 
however, occur as a neurosis. Thus, Ewald, Einhorn, and others have 
found that for years there may be complete absence of hydrochloric 
acid in the gastric secretions in individuals who are either quite well or 
merely neurotic. These patients show no dyspeptic signs in spite of 
the secretory deficiency, and, moreover, show a mucosa which is perfectly 
normal according to observations made upon bits of mucosa removed 
in washings. In many instances even after years of achylia the secretions 
may return to the normal. The presence of much mucus and many 
leukocytes in the gastric contents in cases of achylia would seem to favor 
the diagnosis of gastritis, implying, as it does, a probable catarrh. 
Treatment.-A detailed diagnosis is essential to the proper treatment 
of chronic gastritis. Secondary gastritis must be treated according to 
the cause, which will involve the therapeutics of the lungs, heart, liver, 
or general constitution. In the primary cases, on the other hand, the 
treatment embraces prophylaxis, palliative, and curative measures. 
The curative measures are mechanical, dietetic, and medicinal. One 
must consider the cause of the disease as well as the condition of the 
secretory and motor functions. 
Prophylaxis.-This is of importance, and one should, therefore, remove 
any external conditions which tend to bring on or aggravate the malady. 
Excesses of all kinds must be guarded against; bad habits cured; the 
patient should be taught to eat slowly, to chew his food well, and carefully 
to select his diet both as regards quantity and quality. Faulty teeth, 
an important factor in the etiology of gastritis, should be repaired. 
The mechanical treatment consists mainly in lavage, and is to be used 
only when atony and fermentation exist. It is well to clean the stomach 
before any food enters, to remove any mucus which covers up the super- 
ficial epithelium, and prevents proper action of the digestive juices. 
Lavage may be carried out daily or every second day, in the early 
morning, or, in severe cases, six hours after dinner (which is usually 
taken at midday), and the evening meal should be as light as possible. 
Lukewarm water usually suffices, but if much mucus is present, sodium 
chloride may be added, or, if there be much fermentation, boracic acid. 
The lavage water must return clear before the treatment is completed. 
When, for one reason or another, lavage is impossible, one may employ 
"natural lavage" by means of frequent administration of mineral waters, ORGANIC DISEASES OF THE STOMACH 
245 
especially the saline waters with carbonic acid, which are often beneficial 
in relieving the stomach of its mucus and inducing a combination of the 
organic acids. The alkaline sulphates (Carlsbad) are useful for this 
purpose as well as for relieving constipation. When there is irritation 
in the stomach with diarrhoea, they are best taken hot. Whenever atony 
exists only small quantities of fluid should be taken at one time. 
Daily cold baths or shower baths, with subsequent friction of the 
skin, are of great benefit. When pain or great discomfort is present, a 
wet compress may be placed upon the epigastric area and covered with 
gutta-percha tissue. A suitable abdominal binder of thin wool is often 
soothing to patients who go about, and is a protection to the sensitive 
abdomen. Electricity is of doubtful value, but the proper regulation 
of rest and exercise (which latter should always be moderate) is of the 
greatest importance. 
A change of scene, climate, and general surroundings is one of the 
most efficacious forms of treatment, both for its stimulating effect on 
the constitution generally, and more particularly as an aid in dispelling 
the accompanying neurasthenia. A sojourn at some of the numerous 
watering places is often of the greatest benefit, not so much on account 
of the waters taken (although they have their definite use), but on account 
of the diet and general regime under which patients are placed, and 
under conditions which are not usually followed at home. When this 
is impossible, suitable exercise and properly regulated diversion are 
commendable, especially if accompanied by the regular use of mineral 
waters selected according to the condition of the secretions. 
Dietetic treatment is of prime importance, although often hard to 
regulate because of the individual preference. The food must be non- 
irritating and easily digested, calling for little effort on the part of the 
gastric juice or muscular action of the organ. When only the scantiest 
diet is tolerated, milk, preferably diluted with lime-water, may be 
given at regular intervals, and this, while the patient is at rest, may 
suffice. Later on a mixed diet, selected with reference to the needs of 
each case, is advisable. The motor power is the best guide and when 
this of the stomach is normal, one may administer albumins, starches, 
and fats. When, again, the secretory power of the stomach is defective, 
a mixed diet is very easily given, so long as the motor power remains 
unimpaired. In all cases, however, albuminous food should be finely 
divided. Carbohydrates should form the bulk of the food in those cases 
in which the hydrochloric acid is deficient, using preferably those in 
which there is least residue after digestion is complete. 
Fats are imperative when malnutrition exists, and for these cases 
butter and cream form the most easily digested varieties. It is thus 
essential, when possible, to give a mixed diet, non-irritating, finely 
divided, and containing as much nutriment as possible within the smallest 
compass. In severe cases, in addition to the milk, one may give gruel, 
milk soups, light puddings, rice arrowroot, toast, and then eggs. In 
some cases minced meats may be added; but it is not wise to add spices 
or any rich sauce. The craving which many patients with a chronic 
gastritis have for spicy things, under the impression that they will 246 
DISEASES OF THE DIGESTIVE SYSTEM 
stimulate the functions of secretion, should not be encouraged. Of the 
lighter meats, calves' brains, sweetbreads, chicken, fish, minced beef, 
are best. Alcohol is to be avoided unless in the form of very light wine. 
The quantity of water taken with the meals should be restricted, unless 
there be hyperacidity, in which case it is well to dilute the food moder- 
ately. Effervescing alkaline waters may be tried with benefit. 
The determination of the proper number of meals per day is based 
upon the condition of the motor power. If this be good, three meals a 
day may suffice, but if there be atony, four or five meals, each small in 
quantity, are better. Weak coffee, tea, and cocoa may be given except 
in hyperacidity. As the patient improves, such vegetables as spinach, 
carrots, maize, potatoes (mashed), and macaroni may be added in 
small quantities and gradually. Bread should be stale and not hot. 
When constipation is marked, it may be well to give stewed fruits. 
Medicinal.-Inasmuch as hydrochloric acid is deficient in many cases, 
one may add a few drops after each meal with benefit. Thirty drops 
of dilute hydrochloric acid in a glass of water, to be sipped at intervals 
for an hour after each meal, may be prescribed. On the scientific basis, 
there is little to be gained from the use of pepsin, although practically 
one frequently does find that its employment seems to afford considerable 
aid to digestion. Pancreatin in doses of fifteen grains is perhaps better, 
and should be administered with soda, although rationally this should 
not be prescribed unless there is some evidence of atrophy of the gastric 
follicles. Papain is also recommended by many. After all, these arti- 
ficially prepared ferments are realized to be of little use when one considers 
that the intestines carry on the defective actions of the stomach. 
It seems of prime importance, however, to give some stomachic before 
each meal, and for this purpose one may try either dilute nitromuriatic 
acid, in doses of THx to xv (1 cc.), nux vomica, quassia, gentian, or 
condurango. In many cases the greatest relief from the pain incident 
to chronic gastritis is a pill consisting of silver nitrate, gr. | (gm. 0.01); 
opium, gr. | (gm. 0.016), and extract of hyoscyamus, gr. | (gm. 0.03). 
When fermentation is an annoyance the diet should be carefully 
looked into; one may sometimes add thymol, carbolic acid, or creosote 
to the other modes of treatment. Germain See has recently recommended 
the use of strontium bromide, gr. 30 to 60 (gm. 2 to 4), especially when 
hyperacidity co-exists with the fermentation. For a distinct pyrosis, 
bismuth subnitrate and sodium bicarbonate, of each 10 grains (gm. 0.6), 
combined with 3 to 5 grains (gm. 0.2 to 0.3) of calcined magnesia, will 
usually afford relief. Small doses of atropine may be added with benefit 
if the secretion of mucus is excessive. For persistent vomiting, lavage 
is the most rapid means of giving relief. When this is impracticable, 
a careful adjustment of the diet, with perhaps the administration of 
one or other of the usual drugs for that purpose, may be of benefit. 
Constipation is one of the greatest annoyances. It is well that the 
patient should develop great regularity in his habits, going daily to 
stool at regular hours, whether there be any desire or not. As soon 
as possible vegetables containing much cellulose should be added to 
his food, also stewed fruits, especially a combination of figs and prunes; ORGANIC DISEASES OF THE STOMACH 
247 
or in the early morning he should drink cold water or eat a fresh orange; 
and only in aggravated cases should we resort to either purgatives or 
enemata. When purgation is necessary, it is a difficult matter to deter- 
mine what drugs should be employed; only the mildest forms of purgatives 
should be given, and of these aloes and cascara are probably the most 
beneficial. The use of Carlsbad salts in the morning is another efficacious 
means of treatment for aggravated constipation. 
MOTOR INSUFFICIENCY 
Synonym.-Gastrectasis. 
Definition.-Gastrectasis is an acute or chronic enlargement of the 
stomach cavity associated with a relative or absolute diminution of 
motor power. The condition may be mild (mere atony) or severe 
(retention) and all transitions may occur. It is a clinical sign rather 
than a disease per se. In the severe variety there is permanent stag- 
nation, i. e., retention. It is a functional disturbance of motor power 
rather than mere enlargement of the organ. Of the functions of the 
stomach the motor is by far the most important, and modern methods 
of investigation confirm this view more and more. 
The size and motor power of the stomach are not necessarily correlated. 
It is an organ whose size is subject to very wide variations in health, 
and clinical experience and z-rays prove the fact that mere increase in 
its dimensions does not imply a pathological state of the gastric functions. 
The stomach may occupy almost twice its normal area in the abdomen, 
and yet the subsequent examination with the stomach tube reveals 
no disturbance of its motor function. This is mere megalogastria, a 
matter of size and not of function. 
Various forms of motor insufficiency exist: (1) Mere atony of mild 
degree (the commonest form of dyspepsia). (2) Severe atony (idiopathic 
dilatation), in which food is retained for a long time. (3) Relative motor 
insufficiency (obstructive), in which some hindrance at the pylorus, either 
intragastric (often hypertonic) or extragastric, causes the dilatation. 
These forms have in common one clinical sign, stagnation of food-other 
signs and symptoms depend on the severity and associated conditions. 
Probably the commonest form of gastric indigestion is that due to 
deficient muscular power-the so-called atonic dyspepsia-a condition 
of " slight motor insufficiency." 
Atony without obstruction is not always easy to explain. Here again 
confusion seems to exist in the terminology. The motor power depends 
on rhythmical contractions of the antrum and action of the pyloric 
sphincter. The fundus plays a subordinate part, though recently an 
effort has been made to reestablish its importance. Idiopathic dilatation 
seems to be quite easily induced. Cannon has shown that intragastric 
pressure has a marked influence on motility and that some mechanical 
stretching of the viscus is an efficient stimulus to muscular contraction. 
No smooth muscle can contract, however, until it has tone, i. e., it must 
be shortened and resilient, ready for contraction when the stimulus 
comes. Without tonicity we get no rhythmical movements. 248 
DISEASES OF THE DIGESTIVE SYSTEM 
The nervous system plays an important part. The normal motor power 
depends upon the harmonious working of the two sets of nervous 
systems, vagal and sympathetic. The reflexes governing the motor 
power come through the stomach, the duodenum and jejunum, as, 
also, through psychic causes, and all sorts of reflexes may arise from 
the whole sensory periphery (e. g., appetite, exercise, etc.). Tone for 
example is absent in general weakness of the body, as well as that of 
the nervous system, and without tone we get hypomotility. The pro- 
pulsion of food is governed partly by the amount and character of the 
gastric secretion. Normally the passage of food is controlled by the 
duodenal mucous membrane, in other words, only as much food is 
passed through as can be utilized by the alkaline juices; if no acid exists 
we may get hypermotility because there is no acid to be utilized, i. e., 
hypoacidity induces hypermotility, and vice versa, hyperacidity and 
hypersecretion may induce stagnation either from atony or from pyloric 
spasm, the latter induced by the irritation. 
Cannon has shown that the rhythmic movements of the antrum are 
regulated by the action of HO and it is the acid which keeps the cardia 
closed. The secretory values depend so much on motility that our 
methods of estimating increased HC1 seem nowadays rather inaccurate. 
The normal gastric juice with atony may give hyperacidity to our tests, 
while if hypertonus exists a diminished HC1 may be apparent. It 
certainly seems in view of the importance of motility in its relation 
to secretion, that our older classifications of hyperacidity and hyper- 
secretion need some modification. 
Certain mechanical factors influence motility. (1) The amount of 
food in the stomach and (2) its consistence. The more food in the 
stomach, the quicker is this motility due to the distension (within limits), 
which acts as a stimulus to contraction. The fundus contractions are 
greater, the peristalsis of the pylorus is more energetic, and the intervals 
between the contractions are shorter. 
All grades of motor insufficiency occur from mere atony to extreme 
gastrectasis, although whether these may be etiologically linked together 
is uncertain. Two conditions must exist to establish a rational use of 
the term gastrectasis-there must be enlargement of the organ and 
impairment of its motor power. The impairment may be merely relative, 
that is, the muscular activity may be greater than is normal, as when 
a pyloric stenosis hinders the rapid outflow. This terminology applies, 
however, only to the chronic forms, for the acute variety of dilatation is 
essentially a different condition and to be considered separately. 
Acute Dilatation of the Stomach.-This is probably more common 
than is generally supposed, and certainly as a terminal feature in pneu- 
monia and cardiac disease, as well as a complication in surgical conditions, 
it is by no means rare. German students have been described by Riedel 
as commonly affected after beer-drinking bouts, and it has followed 
other errors and indiscretions in the diet. Brinton referred to the condi- 
tion fifty years ago, although Fagge first gave prominence to its clinical 
features. He recorded two fatal cases in patients eighteen and thirty 
years of age, in whom the stomach filled up rapidly with fluid. His ORGANIC DISEASES OF THE STOMACH 
249 
description holds good today as one of the most complete pictures of 
the condition. Campbell Thompson, in 1902, collected 44 cases, and 
Neck, in 1906, recorded 60 instances. The most recent reviews of the 
subject are by Conner,1 who analyzed 102 cases of the disease (1907), 
and Laffer, who collected 217 cases in all. 
Etiology.-Various degrees of dilatation occur involving the stomach 
alone, the stomach with the duodenum, the stomach with the duodenum 
and jejunum, or the stomach with even a larger area of small intestine. 
This indicates that the causes must be varied and the pathogenesis 
different in various instances. There are predisposing and exciting 
causes, although it is not easy to dissociate these in all cases, all the 
more so as the etiology is apparently not only varied but often not to be 
determined at all. 
1. Debilitating Conditions.-(a) General, e. g., anemia, rickets, toxic 
states, certain infections, especially pneumonia, typhoid fever, and miliary 
tuberculosis, also cardiac disease (Goodhart). These may be the result 
of various influences which alter the muscular tone of the stomach wall, 
either indirectly by affecting nervous control, or more directly by toxic 
action on the muscle. There may be perhaps a neuroparesis, with spasm 
of the pylorus and stenosis, although, as Conner and others have sug- 
gested, the theory is unstable in view of the constant presence of bile 
in the vomitus in such cases. Nevertheless, the very sudden onset in 
many of these patients suggests some special circumstance which the 
toxic state or nerve lesion has favored. The condition is common in 
children with rachitic manifestations. In one case of pneumonia under 
personal observation the dilatation came on without warning, in a 
patient who had shown no signs of any gastric distress or abdominal 
distension half an hour before the extreme dilatation and agonizing 
symptoms had reached their full development. Lavage was at once 
performed with immediate relief and disappearance of the enormous 
distension tumor. Six hours later the symptoms recurred quite suddenly 
with similar results, the patient having rested quietly without signs of 
distress or distension in the interval, (b) Local: Previous gastric 
disease may predispose to the condition, usually through fermentation, 
giving rise to what has been termed the "gaseous form" of acute dilata- 
tion. This is often combined with the etiological types. Excessive 
secretion has been regarded by some as the primary cause, although 
there is little to support the view. 
2. Trauma.-Various forms of trauma are associated with acute 
dilatation: Head injuries (Erdmann, 1868, Thomson, etc.), with supposed 
lesions of motor nerves. Spinal injuries, with or without cord symptoms; 
in one instance (Edmunds) the dilatation appeared five weeks after a 
paraplegia. Blows on the abdomen (Wallace and Box). 
3. Postoperative or Postnarcotic.-These cases, which are numerous, 
are remarkable in that few have been recorded in which operations on 
the stomach itself preceded the dilatation. Abdominal operations of 
various kinds (gall-bladder, uterus, ovary, kidney, appendix, etc.), as 
1 Amer. Jour. Med. Sc., 1907, cxxxiii, 345. 250 
DISEASES OF THE DIGESTIVE SYSTEM 
also operations on the extremities for a great variety of conditions have 
been followed by acute gastric dilatation. The interval between anes- 
thesia and the advent of gastric symptoms varied. In most cases the 
dilatation followed closely upon recovery from the effects of the operation 
and anesthetic; in others, days or weeks intervened. James Bell's 
statistics from the Royal Victoria Hospital are of interest in this connec- 
tion. There were 12 instances which followed various abdominal opera- 
tions; some accompanied general peritonitis; in a few, definite gastro- 
mesenteric ileus was present, while in others no cause whatever was 
found. Several of the milder cases recovered completely. 
The evidence tends to show that in many instances there is a paretic 
condition of the gastric muscle, associated with some toxic condition of 
unknown origin. Bloodgood has given an analysis of cases observed 
by him after operation and in association with varying causes, one of 
the principal being the obstruction which occurs at the junction of the 
duodenum and jejunum (gastromesenteric ileus). In these cases the 
enormous distension of the stomach and duodenum is characteristic, 
and is to be differentiated from high occlusion of the small intestine. 
Doubtless with acute dilatation there may be additional dilatation of the 
duodenum with or without constriction at the mesentery, and in other 
cases, again, much of the small intestine may be concomitantly dilated. 
The diagnosis of the exact site of the obstruction (if this exist) has an 
important bearing on the selection of the treatment. 
4. Traction on the duodenum or pressure upon it from various condi- 
tions, especially a low situation of the small intestines in the pelvis, is 
no doubt a common cause. Here the tightened mesentery may incar- 
cerate the duodenum as it lies on the vertebral column and produce the 
condition (Kundrat). Albrecht, however, regarded this as a result, 
and not as the cause of the dilatation. He believed that through dilata- 
tion of the stomach the small intestine was held low in the pelvis, and 
thus pulled upon the mesentery and indirectly compressed the duodenum. 
This "arteriomesenteric incarceration" thus aggravated the already 
existing gastrectasis. Whatever be the cause, certainly a large number 
of cases show at autopsy this constriction of the duodenum, and Baumler's 
beautiful anatomical proof is especially worthy of mention. In his classi- 
cal case there was a very localized constriction near the lower end of the 
duodenum where it was crossed by the mesentery, and in the mucosa 
there was a well-defined circular necrosis corresponding to the external 
compression. 
Albrecht had already demonstrated the fact that at this point the 
duodenum, even under normal conditions, is more flattened than round, 
because of the pressure of the overlying mesentery with its superior 
mesenteric artery, and, as Conner points out, this may be readily demon- 
strated in the cadaver, as also the increase in the constriction, by gentle 
downward traction on the mesentery with the finger inserted in the 
duodenum at this point. The three things considered essential to this 
are "the dorsal decubitus, an intestine nearly or quite empty of gas and 
feces, and a mesentery of suitable length-long enough to permit the 
intestines to slip into the pelvis and yet not so long that they may be ORGANIC DISEASES OF THE STOMACH 
251 
supported by the pelvic floor." Perhaps it may be for this reason that 
lobar pneumonia is sometimes complicated by acute dilatation, owing 
to the weight of the lungs and violent coughing (Lehmann). 
5. Deformities of the spine have been frequently observed in patients 
developing acute dilatation, and in many cases the orthopedic surgeons 
have been the first to observe the condition. Doubtless in these cases 
dietetic errors leading to fermentation and distension were often the 
exciting cause, while the restricted cavity of the trunk accounted in 
part for the onset of symptoms. In other cases perhaps the vagus has 
been indirectly acted upon and the control of peristalsis interfered with. 
6. Pressure of a kidney which had been surgically fixed was the cause 
in one instance (Oppenheim). 
7. Dietetic Errors.-Possibly too much or unsuitable food may directly 
induce acute dilatation by fermentative processes and distension; such 
are the repeatedly quoted cases in which one meal or one indiscretion 
preceded the symptoms. Sometimes the combination of great fatigue 
followed by dietetic indiscretions has seemed to be the direct cause, 
and sometimes the compression of a plaster jacket, together with errors 
in feeding, may have accounted for the onset. 
8. Spasm of the cardia and pylorus combined was believed by Kelling 
to initiate the symptoms, although the frequent absence of these condi- 
tions scarcely bears out this view. Perhaps the association of hyper- 
secretion with acute dilatation, to which special attention has been 
drawn by Heile, belongs to this category. 
9. The pancreas is thought by some to have some relation to acute 
dilatation, and Bardenheuer mentions one instance following traumatic 
pancreatitis which was cured by gastro-enterostomy. Hoffmann, too, 
describes a case in which chronic pancreatitis and multiple necroses 
were intimately associated with acute dilatation. 
Pathology.-The stomach is usually of enormous size, often extending 
down into the pelvis, and may be bent in an irregular U-shape, with the 
largest half at the fundus. The color is bluish, purple red, or pale; the 
wall is often thin. Definite pyloric obstruction is rare. The duodenum 
is dilated partially or throughout in half the cases. Sometimes the 
dilatation definitely stops near the lower end of the duodenum where 
the mesentery crosses, and may compress it against the vertebral column. 
At other times the dilatation extends throughout the whole of the small 
intestines. 
Symptoms.-Mild and severe cases are found, the mild ones being 
slow of cure, with emaciation, weakness, and prolonged convalescence. 
The symptoms are usually acute and without previous signs of gastric 
disease, closely resembling those of intestinal obstruction, for which, 
indeed, they are frequently mistaken. There is acute abdominal distress 
with distension of the area to the right of the midline and beyond it. 
There is pain in the epigastric or umbilical region, or perhaps in the left 
hypochondrium, with dyspnoea, increase in the pulse and respiration 
rates, but no fever. Vomiting, which is almost invariably present, 
appears early, as a rule, and is persistent. The vomitus is a dark brown 
fluid, very abundant, often amounting to many quarts, containing bile 252 
DISEASES OF THE DIGESTIVE SYSTEM 
and sometimes traces of blood. The odor is usually foul but not fecal. 
Analysis shows that HC1 is a very variable quantity and that lactic 
acid is sometimes present. Hydrogen sulphide has been noted in several 
instances. Lavage, if carried out, empties the stomach of liters of such 
contents, the removal of which gives immediate relief. Constipation 
is the rule; the urine is diminished and of high specific gravity, because 
concentrated, and there is marked thirst which is not easily satisfied. 
Objective Signs.-Inspection • often shows the outlines of a distended 
stomach, which disappear partially after vomiting, and totally after 
lavage. There is no visible peristalsis in the majority of cases. Palpation 
shows tenderness and sometimes the firm, tense cushion of the dilated 
stomach, and but little else, unless increased resistance in the left hypo- 
chondrium. Sometimes tenderness is absent, although this is not usually 
the case. A succussion splash is almost invariably obtained. Percussion 
shows diminution of the tympanitic gastric area and its replacement by 
dulness, especially in the left side of the abdomen and below the navel, 
reaching up as high as the right costal margin. This is an important 
diagnostic sign. In fatal cases there is collapse with the hippocratic 
facies; in case of recovery the stomach returns to its normal size in a 
few days or weeks. 
Diagnosis.-The condition is usually mistaken for some acute abdomi- 
nal disease, especially perforative peritonitis or intestinal obstruction, 
and operation is frequently undertaken unnecessarily. The diagnosis 
requires a careful anamnesis. Of 60 recorded cases, only 13 were rightly 
diagnosed. The diagnostic features are the onset, with pain, collapse, 
and absence of fever, abdominal distension and localized left-sided dul- 
ness, with uncontrollable vomiting of large quantities of fluid containing 
bile, and having no fecal odor. The relief of symptoms and signs after 
lavage and postural treatment (knee and elbow position) are important 
confirmatory signs. The differential features of high intestinal occlusion 
are mentioned by Bloodgood as follows: "Initial pain, accompanied 
perhaps by peritoneal shock, which may later somewhat disappear, 
and vomiting without marked distension." In acute dilatation the 
initial pain is often absent, there is epigastric distress and gradual and 
progressive collapse. Epigastric distress is early and relieved by 
lavage in acute dilatation, but is much later in high intestinal ob- 
struction. 
Prognosis.-The outlook is bad if the diagnosis be not made early 
and suitable treatment adopted; 47 out of 64 cases published died. In 
Conner's series of 102 cases, 74 died, although, as he remarks, many 
unreported cases recover where either the condition was mild or unrecog- 
nized. In 75 per cent, of Conner's cases the duration was less than five 
days, and in a few instances the patients died within three hours from 
the onset of the symptoms. If the complication does not end fatally, 
some impairment of motor power usually persists. The symptoms may 
disappear at once after treatment, or days and weeks may elapse before 
complete recovery. 
Treatment.-Early lavage is essential, with the head low and the 
pelvis high; one is otherwise very apt not to reach the fluid at all. It ORGANIC DISEASES OF THE STOMACH 
253 
is of great importance to thoroughly wash out the organ, at first often, 
later on less frequently. No food should be given by the mouth until 
recovery has sufficiently advanced, and one should use water enemata 
or subcutaneous saline infusions instead. Stimulants should be given 
as required. Operation is of no benefit unless after lavage there is no 
improvement, in which case some severe intestinal obstruction may be 
suspected. In these cases the probable incarceration of the duodenum 
requires special treatment. Schnitzler first pointed out the benefits 
to be gained by turning the patients over from the dorsal position, and 
Baumler recommended the knee and elbow posture as having been 
successful in two of his cases. 
When such measures fail, operation may be tried, although hitherto 
the results of gastro-enterostomy have been far from encouraging. 
Bloodgood's study of the condition has led him to believe that it is well 
to regard these cases as probably instances of gastroduodenal dilatation, 
and if lavage fails the duodenum should be carefully explored. If the 
dilatation be purely gastric, then gastrostomy or gastrojejunostomy 
should be performed, whereas if the duodenum too is involved, jeju- 
nostomy or duodenojejunostomy is preferable. Borchardt, quoted by 
Conner, states that when other methods of treatment have failed, it is 
doubtful if operation will meet with any greater success. 
Chronic Dilatation.-Varieties.-There are two forms: (1) Idiopathic, 
or absolute, otherwise called primary or atonic; simple gastrectasis; 
myasthenia gastrica; and (2) symptomatic, or relative, otherwise called 
secondary or obstructive-the result of stenosis of the pylorus-usually 
hypertonic and mechanical. There is either benign or malignant obstruc- 
tion and rarely the duodenum is the seat of the stenosis. Allbutt suggests 
the term extension as including especially the cases of idiopathic dilata- 
tion. A differentiation of the main forms is not always possible, either 
clinically or at autopsy, for cases with pyloric spasm, which has been 
the supposed cause of the atony, will often show no visible lesion. The 
idiopathic form is milder and rarely with retention; the secondary nearly 
always shows retention. The very existence of a true idiopathic condi- 
tion is still a matter of doubt to some. 
The diagnosis of idiopathic dilatation can only be made by prolonged 
observation to exclude stenosis. The proof of its existence lies mainly 
with clinical medical experience and surgical findings at operation. It 
has certainly fallen to the lot of every medical man of any experience 
to successfully treat individuals with a marked idiopathic gastrectasis. 
Gastric analysis shows retention of food, with all the evidence of gastrec- 
tasis, and the absence of further developments should suffice to prove 
the existence of a dilatation due to causes other than stenosis. Surgeons, 
too, find such a condition not uncommon, and operate for gastrectasis 
when careful search fails to reveal any signs of obstruction at the pylorus. 
Mikulicz evidently thought them not infrequent. 
Idiopathic Dilatation.-The walls lose their resiliency and the viscus 
expands, becoming gradually more unable to handle the ingested food, 
especially when in large quantities. From various causes atony and 
temporary distension are produced. If the cause acts often enough, 254 
DISEASES OF THE DIGESTIVE SYSTEM 
long enough, and severely enough, the elasticity diminishes, the tonus 
is wanting, and food is retained, and dilatation is the result. 
Etiology.-It occurs most commonly in adults of middle age, although 
it is not infrequent among rachitic children (Ladd). Two classes of 
causes exist, local and general. It may be taken for granted that in 
many cases, simple atony, the result of manifold local and general 
conditions, is one of the most common predisposing antecedents of 
idiopathic dilatation. Local conditions are trauma, improper clothing, 
laparotomy, repeated pregnancies, chronic gastric disease of any kind, 
especially if with fermentation (Cohnheim's so-called vinegar and gas 
factory) and excessive improper food, whether in quantity or quality. 
Kaufmann describes two classes of patients: (1) In the one there is 
variable secretion (high or low), with atony; the symptoms are really 
due to the atony, and are cured by lessening it. (2) In the second 
there is variable secretion without atony. Such cases come under the 
category of neuroses, e. g., hyperesthesia of the gastric mucous membrane, 
and resemble similar conditions in other organs (e. g., cardiac neuroses, 
nervous diarrhoea without excessive mucus, dyspnoea without lung 
trouble, etc.); i. e., gastric neuroses so-called. Such patients need no 
local therapy for the stomach but rather general treatment. In such 
cases the secretions remain abnormally high or low, and yet the symptoms 
disappear because depending on a general neurosis, which when cured 
is accompanied by an alleviation of the local symptoms. Certainly in 
gastrectasis the HC1 secretory changes alone are mere accidents in the 
symptomatology and must not be given too prominent a place. Usually 
when the motor power is repaired any symptoms supposedly due to 
hypersecretion or hyposecretion will disappear. 
Gastroptosis frequently accompanies gastrectasis. It is quite con- 
ceivable and it very often happens that when gastroptosis exists in 
excessive eaters the persistent overloading of the stomach will cause 
more and more descent of the organ, with the result of finally causing a 
kink at the duodenum-as may occur in the cases which show the cres- 
centic horizontal variety of gastroptosis. A progressive stenosis with 
increasing motor insufficiency may occur. Steele and Francine found 
on examination of 70 patients with gastroptosis that dilatation existed 
in all. The degree, however, must be very slight when one considers 
how extremely common it is to find gastroptosis when absolutely no 
signs or symptoms of indigestion exist. This fact alone should indicate 
that except under certain other predisposing conditions, gastroptosis 
does not generally cause gastrectasis, even though it frequently precedes 
and more often follows it. 
General Causes.-A hereditary weak stomach is recognized as a factor 
of some importance, and predisposition to chronic dyspepsia certainly 
exists as a family weakness. Chronic constipation is regarded by Ewald 
as a source of gastrectasis. The persistent inactivity of the intestines 
or their paresis leads to diminished gastric peristalsis and atony. So 
also may any intestinal disease. General causes assist the local conditions 
and thus aid directly and indirectly in inducing dilatation, for local 
causes act more forcibly in stomachs rendered susceptible through ORGANIC DISEASES OF THE STOMACH 
255 
prolonged illness or general myasthenia, be it organic or neurotic. The 
cause may be toxic or muscular, e. g., in sepsis, typhoid fever, tuberculosis, 
and pernicious anemia (whether it be that toxins weaken the wall or 
the muscle be altered through the anemia and malnutrition. The same 
holds in chlorosis and in repeated hemorrhages). Toxic causes act either 
generally, e. g., tobacco, or both generally and locally, as in the case of 
alcohol. A busy life with no rest after meals and hasty eating is often 
an antecedent cause. Thus it is with musicians of sedentary habits, 
neurotics, and hypochondriacs. Venereal excesses are regarded by some 
as a factor in the etiology. Anything which induces general weakness 
may be regarded as a predisposing general cause. 
Relative, Symptomatic, or Obstructive Gastrectasis (From Stenosis).- 
The causes of stenosis are numerous; spasm with gastric ulcer, erosions 
and scars (never from neuroses) (Cohnheim); foreign bodies: e. g., resin 
balls from swallowing shellac spirit for ten years, hair balls, cherry stones 
(Cramer), gallstones and beans and peas (Fleiner), (such bodies may 
remain for three months); hypertrophic pyloric stenosis; polypi; tumors 
(Cramer); scarred ulcers; cancer of the pylorus and of the lesser curvature 
extending to the pylorus. Tumors outside the stomach (e. g., of the liver 
or gall-bladder, pancreatic tumors pressing on the duodenum, floating 
spleen with pressure on the duodenum, movable kidney, dermoids, 
enlarged glands, etc.) may be a cause. Perigastritis: inflammation 
outside of the stomach and associated with neighboring organs, 
e. g., liver, gall-bladder, pancreas; cicatricial puckering associated with 
cholelithiasis, perigastritis, etc.; epigastric hernia; appendicitis with or 
without adhesions; omental adhesions from appendicitis, especially if 
to the linea alba; torsion, flexure, and kinking of the duodenum at the 
duodenojejunal fold in enteroptosis; trauma, producing inflammations 
near the pylorus, hematoma of the wall, or spasm of the pylorus. 
Pathology.-The dilatation varies in degree and character. The 
one anatomical feature is the altered size of the organ, although that is 
not always increased even with marked motor insufficiency; sometimes 
it is monstrous and may. seem to fill the entire abdominal cavity. In 
Strauss' case of stenosis from an old ulcer the stomach held five and a 
half liters. Much larger dilatations are mentioned. Jadow's case in 
which the capacity was 45 liters is worthy of mention, if true. 
The gastrectasis may be partial and is sometimes diverticular. Dila- 
tation begins in the lowest portions and those most overtasked, the 
fundus, pylorus, and greater curvature. Later it becomes general. 
The other abdominal viscera are in extreme cases compressed and pushed 
in various directions. The spleen and liver may lie abnormally high 
while the small intestines are pushed downward. The thickness of the 
stomach wall varies. In one case with chronic inflammation (Lebert) 
it was 14 mm. thick. It is especially in the obstructive cases that this 
increase occurs, although even in idiopathic cases it may be abnormally 
thick. As a rule, when no stenosis exists the gastric wall is thin and 
atrophic. The mucous membrane may be thickened, hypertrophic, 
or irregular and hard, a condition usually existing when chronic gastritis 
is also present. Sometimes the mucosa is thinned and atrophic, and not 256 
DISEASES OF THE DIGESTIVE SYSTEM 
at all infrequently atrophy and hypertrophy alternate in the same 
mucous membrane. The muscle is changed, its appearance depending 
on the cause and pathological condition. With pyloric stenosis, especially 
if benign, there is muscular hypertrophy (compensatory), while in idio- 
pathic cases the atrophied muscle is but a feature of the general myas- 
thenia. Fatty and colloid changes are often seen in microscopic prepara- 
tions. The interstitial tissue is often infiltrated in the chronic cases 
with increased fibrous tissue and small round cells, while in the acute 
cases there may be small round cells, extravasated blood cells, and sepa- 
ration of muscle and fibrous tissue cells. 
Symptoms.-These vary according to the degree. In mild cases there 
may be but a few digestive disturbances, mental torpor, thirst, anorexia, 
constipation, and diminished urine, with little evidence of any serious 
condition. This, too, occurs in the early stages of the more serious types. 
Advanced cases from whatever cause show certain general symptoms in 
common. The general appearance of the patient shows emaciation, 
but a fair color is preserved. The skin is naturally dry because of 
retention of fluids in the stomach, and the extremities are often cold. 
Dyspeptic symptoms develop early. The appetite is usually diminished 
(unless hyperacidity exists from some benign stenosis), the breath is 
sour, and flatulence and pyrosis are present. Thirst is an important and 
often a distressing symptom. Water not being normally absorbed in the 
stomach, the degree of thirst corresponds to the amount of retention 
and the degree of motor insufficiency, of which it is therefore a good 
criterion. Constipation is marked, because no water is passed into the 
intestines, and there is atony of the bowel. Dry, hard scybala are often 
passed with colicky pains; piles and fissures form. The degree of con- 
stipation is also a good criterion as to the degree of motor insufficiency. 
Diarrhoea is rare, and sometimes alternates with constipation; mucous 
colitis may co-exist. Emaciation occurs in proportion to the degree of 
dilatation, and is worse if the intestines are deranged. 
Pain is less marked in idiopathic than in obstructive cases. In obstruc- 
tive cases, especially if from ulcer or spasm, or cancer, it is often intense. 
Sometimes, even in cancerous dilatation, there is no pain. Vomiting is 
not so constant in idiopathic as in obstructive cases. In the latter it is 
the rule because the food cannot pass, and the stomach empties itself 
by emesis. A feature of the vomiting is its periodical occurrence and 
explosive type after every few meals. The amount has no relation to the 
previous meal, and the vomitus consists of food from days or weeks 
before. It is thus copious, and may amount to several quarts. Later 
there may be little or no vomiting because the walls are weakened, a 
condition which is of course serious. The general appearance of the 
individual foodstuffs depends on the character of the gastric secretions. 
The color is usually of a dark gray brown. There are three layers, froth 
on top, fluid in the middle, while the sediment below contains yeast, 
sarcinae, mucus, and food (new and old). Mucus, if abundant, indicates 
a probable gastritis. Microscopically, one sees bacteria, fatty acid 
crystals, epithelial cells, sometimes blood cells and pigment. There is 
an odor of fermentation and organic acids may be abundant. The finding ORGANIC DISEASES OF THE STOMACH 
257 
of lactic acid is important only when in the fasting contents or after a 
test meal; moreover, Strauss maintains that lactic acid from ferment 
action does not appear in the stomach if 0.12 per cent. HC1 (total) is 
present. Vomiting gives temporary relief even although it only partly 
empties the stomach. HC1 may be in excess, deficient, or normal. 
The Urine.-Corresponding to the amount of retention, so is the 
diminution in the renal secretion. It forms a good basis for measurement 
of the gastrectasis and is also a guide to prognosis and treatment. Small 
amounts indicate a more serious form, and suggest the use of water 
enemata at regular intervals. Increase in the urine indicates improve- 
ment. The urine when diminished is concentrated and has a high specific 
gravity. The chlorides are lessened and the phosphates increased. If 
much hyperacidity is present the urine may be alkaline. Albumin and 
also acetone and diacetic acid are sometimes present. 
Cardiovascular symptoms are common: Palpitation, anginoid attacks, 
dyspnoea, and throbbing sensations. The pulse is often weak and irregular 
and the blood shows secondary anemia. Old heart lesions and many 
chronic febrile conditions exhibit gastrectasis in their terminal stages. 
The temperature is lowered and the patients feel chilly from slight 
causes. More rarely there are febrile attacks from a concomitant gastritis 
or toxic causes. 
The nervous symptoms are varied. Languor, apathy, depression of 
spirits, and melancholia are common features. Headache and dizziness 
are frequent. Mild psychoses, insomnia, deafness, etc., are common 
manifestations, and when coming on at a regular time are regarded by 
patients as the cause rather than the effect of the malady. These are 
probably the result of dryness of the tissues, inanition, and toxemia. 
Tetany is worthy of special notice. Mentioned by Morgagni, it was 
first described by Newman in 1861, and later by Steinheim, while 
Kussmaul gave it prominence as a classical feature of dilatation in his 
description of gastrectasis and its treatment by the stomach pump in 
1869. This condition, although common to various diseases of the gastro- 
intestinal tract, is chiefly associated with pyloric obstruction in which 
dilatation, hypertrophy of the stomach wall, with hyperacidity and 
hypersecretion are present. It is thus more commonly associated with 
benign stenosis, and is rare in obstruction from malignant disease or 
from external pressure. It is probably induced by the absorption of 
some poison which is not neutralized in the stomach. The attacks appear 
after severe and persistent vomiting, and after lavage, and are associated 
less with the act of vomiting than with the presence of putrid contents 
in an overfilled stomach. The stomach should be emptied some hours 
before lavage is practised to avoid the onset and recurrence of the attacks. 
The duration may be from a few minutes, to hours, days, or weeks. 
When prolonged it ends usually fatally. Mild grades are common and 
probably often overlooked. Muscular twitchings, prickling sensations, 
etc., in gastrectasis are doubtless warnings to urge surgical intervention. 
Cramer's view was that any gastrectasis not vastly improved in four weeks 
under lavage, dieting, and massage should be subjected to operation. 
Various theories exist as to the causation of tetany. Kussmaul 
vol. in-17 258 
DISEASES OF THE DIGESTIVE SYSTEM 
regarded it as due to dehydration of the tissues-nerves and muscles- 
on the analogy of the occurrence of cramps in Asiatic cholera, an analogy 
which, however, is scarcely justifiable, inasmuch as the same cramps 
occur in the so-called cholera sicca in which dehydration of tissues takes 
no part. Later on Kussmaul himself disclaimed the theory, although 
Fleiner, Albu, and others still maintained it. Germain See held the 
theory of its causation by reflex action from stimulation of the sensory 
nerves of the stomach, e. g., after lavage, vomiting, etc., and its frequency 
in sucklings, its occurrence with intestinal parasites and disappearance 
after their removal, suggest this possibility. Gerhardt regarded the 
complication as the result of a poison, basing his views on the nervous 
symptoms, some of which resembled those of alkaloidal poisonings. 
Bouveret and Devic originated the theory of auto-intoxication from the 
prolonged action of abnormal processes of digestion, and this theory 
holds its preeminence up to the present. In proof thereof they isolated 
a substance soluble in alcohol, resembling Brieger's peptotoxin, which 
when injected into animals caused general convulsions. Opponents of 
these experiments held that the convulsions were not of the nature of 
tetany, that alcohol alone could induce similar attacks, and that untreated 
gastric contents are incapable of inducing such symptoms. Dickson 
tried the injection of gastric contents in various ways to produce tetany 
but without success. 
Indican has often been found in the urine of patients suffering from 
gastrectasis with tetany. Acetone has been found in the stomach, but 
not in enough quantity to do harm, because oxidized. 
The prognosis in tetany is always grave, and the average mortality 
has been given as 70 to 80 per cent. There were 31 deaths in 40 cases 
(Albu). Death usually follows only after the tetany has been well 
developed, from failure in treatment. Patients who pass successfully 
some attacks of tetany, are liable to recurrence of attacks. 
Treatment of Tetany.-Medical treatment may be tried for a short 
time, but surgical interference should not be delayed too long when 
lavage and medicines fail. Careful washing of the stomach should be 
beneficial. Greenfield suggested after careful lavage with some mild 
antiseptic a final washing with a solution of sodium phosphate and 
then the introduction of about ten ounces of boiled milk containing 
sodium phosphate in the proportion of one dram to a half-pint, diluted 
with hot water. The one efficacious method is the surgical one which 
provides proper drainage by performance of a gastro-enterostomy. 
Physical Signs of Gastrectasis.-These vary greatly, especially 
according to the cause and extent of the condition, for cases of primary 
or spastic dilatation show no tumor. 
Inspection.-This is very important. The prominence of the stomach 
may be visible, although in mild cases there is usually nothing abnormal 
seen. The stomach is seen better if stenosis exists, because it is then 
less flabby and more hypertonic. The abdomen is usually flabby, the 
stomach much enlarged, and the outline of the greater curvature may 
perhaps be visible down as far as the pubis. Unless ptosis is also present 
the lesser curvature remains high in the epigastrium. Inflation may aid ORGANIC DISEASES OF THE STOMACH 
259 
in locating the organ. Visible peristalsis is rare without obstruction. 
With pyloric stenosis it is either spontaneous or induced by flicking the 
abdomen with a wet towel or the finger. A tumor-like prominence 
appears in the left hypochrondrium, which swells, falls, and re-appears 
to the right. Antiperistalsis sometimes exists. 
Palpation should be done systematically, carefully and gently with 
the flat hand first, then following the respirations, examining with the 
patients in various positions, and even in doubtful cases with the aid of 
an anesthetic. In idiopathic dilatation one gets merely a sense of the 
air cushion present, and this more definitely tense with obstruction, 
while sometimes one can feel gas passing the pylorus. Boas lays stress 
on the importance of palpating for contraction of the stomach, both 
stiffening and rigidity (so-called Magensteifung) and peristalsis. The 
percussion splash has a certain value. The presence of a succussion 
splash is only of value if used when the stomach would be empty under 
normal conditions, i. e., seven hours after a meal. The splashing which 
neurasthenics can voluntarily induce by contraction of the abdominal 
muscles is of course not to be confused with the above, for it may be 
performed without gastrectasis and even when very little fluid is present. 
Percussion determines the size of the organ, or at all events its outlines. 
There is a deep tympany over the stomach, the extent depending upon 
its size and situation. Dehio's percussion tests after drinking water 
may be mentioned. Dulness may be found below when the patient is in 
the upright posture, if much fluid is present. Sometimes the dulness is 
more to the left, and changes with position and after emptying the 
stomach. This is merely a slight aid to diagnosis and only to be used 
with insufflation tests as well. Absence of liver dulness may exist and 
depends on the position of the hepatic flexure and is not in itself a reliable 
sign of any pathological state. Percussion affords us no information as 
to function. Auscultatory percussion has not as yet given the satisfaction 
hoped for it; Broadbent recommends it, Allbutt does not. Certainly 
control tests do not prove it infallible for outlining the borders of hollow 
viscera. Too much depends on the nearness of the scratching or per- 
cussing finger and on many other factors which alter the note. 
Examination with the a-rays after the administration of bismuth 
subnitrate may enable one to see the outlines and the less active fundus; 
one may also see the pylorus open intermittently and the impaction of 
masses in imperfect solution prolonging the closure of the pylorus. 
The salol and potassium iodide tests are unreliable. The desmoid 
test is also of doubtful value, depending much on the quality of the 
material used. 
Stomach Contents.-The essential feature is the abnormally large 
quantity of food returned after a test meal. This alone is a proof of 
motor insufficiency and is pathognomonic. Chemical examinations give 
varying results according to the primary cause of the dilatation. In the 
milder forms, depending on idiopathic conditions, HC1 is usually dim- 
inished or normal, and rarely increased. In the obstructive forms it is 
excessive or normal, rarely diminished unless late on, and then chiefly 
in cancerous and atrophic conditions. Bile may or may not be present. 260 
DISEASES OF THE DIGESTIVE SYSTEM 
Varying evidences of fermentation exist (lactic acid, yeast, gas, etc.), 
according to the conditions present. Thus, while lactic acid is commonest 
in malignant disease, gaseous fermentation with hydrogen sulphide is 
usually an indication of benign stenosis. The production of gases is 
not prevented by the presence of HC1, nor is albuminous putrefaction; 
in fact, the latter is usually only present when HC1 is there. The motor 
insufficiency, not the secretions, is the cause of the gas fermentation. 
The state of the secretions determines the degree of digestion of foodstuffs 
after test meals. Microscopically the findings differ according to the 
cause of the dilatation, i. e., whether benign, malignant, etc. 
Benign pyloric stenosis gives special features to the clinical picture of 
gastrectasis. The earliest physical signs arouse suspicion when the past 
history yields some cause for a stenosis. Distress appears soon after 
dietetic errors and the symptoms increase slowly but progressively. 
The two predominant subjective features are pain and vomiting. The 
two predominant physical signs are visible peristalsis and evidence of a 
tumor. Gastric analysis usually shows increased hydrochloric acid 
secretion, and microscopically there are yeast cells and sarcinse. 
The pain soon follows upon the early feelings of mere distress. It 
comes on chiefly after food, and while periodic or intermittent, it recurs 
with ever increasing frequency and often with progressive intensity from 
week to week, and sometimes is almost continuous. Later, as retention 
of food occurs, the pain may be nocturnal, associated perhaps with hyper- 
acid secretion, fermentation, or dependent on the special nature of the 
obstruction at or about the pylorus. Often the pain is definitely asso- 
ciated with the increased peristalsis, and is therefore sometimes of a 
cramp-like nature, especially if hypertrophy of the gastric muscle has 
occurred. The vomitus, which in the course of the malady follows closely 
upon the onset of the pain, may consist chiefly of solids. Vomiting occurs 
often with increasing frequency up to the time when hypertonus gives 
way to atony, and then the emesis recurs at longer intervals and is less 
explosive in character. 
Physical Signs.-The early stages may reveal nothing but a prominent 
epigastrium or a slight fulness, but visible peristalsis soon appears and 
should be carefully looked for. Often much patient watching is required 
before the peristalsis apppears. Inspection, further, often reveals the 
pyloric tumor, sometimes as movable, shifting with respiration or by 
alterations in the position of the internal viscera. Palpation reveals 
increased resistance over the pyloric area, and a cushion-like sensation 
over the viscus itself. In thin, flabby persons the tumor may be palpable 
quite early. Movability is a characteristic feature of non-adherent pyloric 
tumors resulting from scarred ulcers. They may often be shifted to 
widely different areas of the abdomen, are usually not very sensitive, 
and do not seem to be very nodular. Bouveret described a sign which 
he calls intermittent gastric tension. In the recumbent posture the 
left side of the epigastrium is more prominent than the right, and on 
gentle palpation is balloon-like to the feel; during palpation, however, 
the swelling disappears, re-appearing very soon, off and on, and especially 
after the ingestion of food. PLATE X 
Congenital Stenosis of the Pylorus. 
a, pylorus; b, hypertrophied muscularis. ORGANIC DISEASES OF THE STOMACH 
261 
Diagnosis.-The various considerations may be tabulated thus: (1) 
As to the presence of gastrectasis. (2) If present, as to its nature, i. e., 
idiopathic or obstructive. (3) If obstructive, as to the nature, i. e., 
benign or malignant stenosis. (4) If probably benign, as to its special 
form, viz., spasm, foreign body, hypertrophic stenosis, intragastric 
tumor, extragastric tumor, inflammation, etc. 
Gastrectasis must be distinguished from several conditions. From 
dilated colon: One must make repeated examinations at various hours 
and empty the stomach by siphonage. It is often hard to tell without 
such tests, and it may be well to inflate the colon from the rectum. The 
history and symptoms will assist in the decision. Absence of splenic 
dulness in itself is of little importance in the diagnosis, being merely an 
aid. One must exclude emphysema, pneumothorax, and diaphragmatic 
hernia. Moreover, one must look for a cause, movable or diseased kidney, 
umbilical hernia, tumor, etc. If necessary, an anesthetic should be used. 
From Gastroptosis: In simple dilatation, the lesser curvature is in its 
normal position, while if there be gastroptosis, the site will be lower 
than normal, and the position of the stomach may be vertical, horizontal, 
or otherwise. In simple gastroptosis there is no sign of motor insufficiency 
after a test meal. The fluoroscope and skiagraphic picture aid the 
diagnosis. From Nervous Dyspepsia (without Motor Insufficiency}: 
The symptoms are out of all proportion to the organic changes, and there 
are various stigmata of a neurosis. From Chronic Gastritis: The stomach 
is of normal size and the motor power normal or nearly so (unless dila- 
tation co-exists, as it usually does later on). There is a history of the 
cause, and much mucus is vomited. From Hypersecretion: After com- 
plete lavage of the stomach on the previous evening there is abundant 
gastric juice found in the early morning (more than 40 cc. should be 
present to make a diagnosis of hypersecretion). From Gastric Crises: 
These present one feature resembling gastrectasis, viz., the marked and 
copious vomiting, not, however, of retained food, but of concentrated 
gastric juice and mucus. Gastric digestion is usually normal in the 
intervals between the attacks. Other conditions, e. g., ovarian tumors, 
dilated gall-bladder, sacculated peritoneal exudates, and pancreatic 
cysts should offer no difficulty. Sometimes a spindle-shaped dilatation 
of the oesophagus may occasion doubt because of the periodical vomiting 
of food from previous days. This may be hard to differentiate. The 
stomach, however, is not enlarged, the introduced tube causes immediate 
vomiting of alkaline material, while if the tube be pushed farther it 
reaches the stomach and withdraws acid contents. 
The Differentiation Between Idiopathic (Atonic} Gastrectasis and 
Obstructive (Hypertonic} Gastrectasis (from Pyloric Stenosis}: Advanced 
cases are usually readily diagnosed but in early stages, and even in some 
that are of long standing, the diagnosis may be impossible for a long 
time. As a rule, one must take the whole history, symptom-complex, 
and signs into consideration. The following table indicates in a general 
way the essential features: 262 
DISEASES OF THE DIGESTIVE SYSTEM 
Idiopathic dilatation. 
Dilatation from pyloric stenosis. 
History. 
None, except of dietetic ex- 
cesses. 
Previous ulcer, hemorrhage, 
gallstones, carcinoma, etc. 
Course. 
Slow. 
Rapid. 
Emaciation. 
Slow. 
Rapid. 
Pain. 
Little or none. 
Marked. 
Vomiting. 
Infrequent and copious, 
liquid and incomplete. 
Less painful. 
Frequent, copious, thick, and 
mixed with much solids, 
and complete. Accom- 
panied by pain. 
Dilatation. 
Moderate as a rule. 
Extreme. 
Visible peristalsis. 
Absent. 
Present, and often very 
marked or easily induced. 
Tumor. 
Absent. 
Often present. 
Lavage. 
Quick inflow, slower egress. 
Perhaps slow ingress, but 
rapid exit. Expression is 
easier and often explosive. 
Therapeutic tests. 
Improvement marked with 
lavage, etc. 
No improvement, but pro- 
gressive decline in spite of 
lavage. 
Varieties of Pyloric Stenosis.-Pylorospasm.-This occurs at the 
height of digestion, as a rule, and may be constant or periodical, resulting 
in temporary closure of the pylorus with retention of food. There may 
be severe pains, vomiting, and signs of motor insufficiency, such as 
thirst, diminished urine, constipation, and enlarged gastric area. The 
vomitus is hyperacid, and there is often hypersecretion. The vomiting 
relieves the discomfort until the cycle recurs. Analysis shows stasis, 
increase of HC1, sarcinse, yeast, fatty acid crystals, and signs of marked 
fermentation. The pyloric area is tender and may show tonic con- 
tractions, while palpation of the fundus may reveal the characteristic 
rigidity (Magensteifung). The prognosis is more favorable, although 
recurrences are frequent. 
Cicatricial stenosis of the pylorus (the type is the scarred ulcer, although 
caustics, etc., may induce it). The history is of importance, especially 
the record of previous hematemesis or of recurrent attacks of vomiting 
and pain ("indigestion"). The signs of progressive stenosis, as seen on 
physical examination, gastric analysis, and examination of the stools for 
occult bleedings, are likewise important. 
Duodenal stenosis may be indistinguishable, unless the obstruction be 
infra-ampullary, in which case there will be a constant back flow of bile 
into the stomach. Stenosis of the duodenum usually occurs from cancer, 
pressure of benign tumors, scarred ulcer, localized peritonitis, gall-stones, 
malformations, etc. 
Perigastric adhesions with pyloric stenosis (cholelithiasis, inflammation, 
etc.). Here, too, the history is of great importance, also the physical 
signs, the presence of jaundice previously, and the existence of traces 
of bile in the urine. । 
Stenosis from external pressure occurs from enlarged glands, dermoids, 
new-growths, and inflammatory exudates, also from kinking or constric- 
tion through fibrous bands, etc., as also from traction as occurs in acute 
dilatation where the duodenum is constricted through traction of an 
arteriomesenteric fold. ORGANIC DISEASES OF THE STOMACH 
263 
Impaction of food or foreign bodies in the pylorus may be the cause of 
benign tumors within the pylorus, e. g., polypi. 
Hypertrophic stenosis, the so-called stenosing gastritis. The condition 
is probably a rare one, arising from different causes and presenting as its 
two main features at first a chronic gastritis and later the signs of motor 
insufficiency with stenosis. There are no cicatrices and no tumors, but a 
diffuse thickening of muscle or fibrous tissue may be present, a localized 
benign stenosis. Quite a number of isolated cases are on record (Boas, 
Habershon, Tassia, Tilger, etc.). The condition has been found most 
commonly in middle age, runs a slow course over years, with exacerba- 
tions and remission of symptoms (chiefly those of gastritis followed by 
stenosis). There is anorexia and emaciation. The gastric analyses vary. 
It is not easy to distinguish from a scarred ulcer which may have been 
latent for years, but the diagnostic features are those found in the 
general picture with its protracted duration. In recent descriptions by 
Russell and by Maylard, cases' of adult stenosis of congenital origin 
are described with symptoms of varying intensity, and these writers 
conclude, whether or not on sufficient proof, that such cases are very 
common indeed. It seems, however, not always easy to prove the 
existence of a stenosis during operation, and the mere improvement 
after gastro-enterostomy should not of itself convince one that a pyloric 
stenosis had been present-still less that it was congenital. 
Stenosis from Malignant Disease of the Stomach-The following table 
will outline the essential differences from benign conditions causing 
stenosis: 
Benign. 
Malignant. 
History. 
Ulcer, toxic gastritis, caus- 
tics, etc. 
Previous normal digestion, 
perhaps. 
Age. 
Any age. 
Usually after forty years of 
age; not infrequently earlier, 
however. 
Course. 
Rapid, but with less marked 
decline in health. 
Rapid and progressive devel- 
opment of weakness, etc. 
Tumor. 
Smooth, often more mov- 
able. 
Nodular, hard, fixed. 
Secretions and con- 
HC1 normal or excessive; no 
HC1 less or absent; lactic and 
tents. 
lactic or butyric acid; H2S 
present sometimes; few or 
no Boas-Oppler bacilli; 
sarcinae long present. 
butyric acids often present; 
H2S uncommon; Boas- 
Oppler bacilli common; 
sarcinae uncommon, and 
soon disappear. 
Therapeutic 
Sometimes nutrient enemata 
benefit. 
Nutrient enemata useless. 
Metastases. 
None. 
Usually sooner or later. 
Course of Gastrectasis.-The cause determines not only the duration 
but also the essential features and symptoms. Idiopathic cases are 
slow in development, and their course depends on the persistence of the 
exciting cause and the possibility of its removal. Patients who have 
long been the victims of the disease in an advanced stage will be difficult 
to relieve. With early and suitable treatment the condition is often held 
in check and development will extend over years. Thus the idiopathic 
cases and those due to pylorospasm, being more amenable to therapy, 
will run a mild course and last a shorter time than those associated 264 
DISEASES OE THE DIGESTIVE SYSTEM 
with stenosis. Pyloric obstruction causes a more or less rapid develop- 
ment of symptoms, rapid where the obstruction develops quickly, as 
in carcinoma, subacute perigastritis, etc., more slowly with gradual 
cicatrization of an ulcer at the pylorus. Where benign stenosis exists, 
its special nature, its degree, extent, and curability, the condition of 
the muscular wall of the stomach, and the early diagnosis determine the 
probable duration. If not relieved by appropriate treatment these 
patients get rapidly worse and fail from inanition; surgical intervention 
(gastro-enterostomy), on the other hand, may alter the whole course of 
the malady, and quickly bring about recovery even after advanced 
disease exists and after years of suffering. 
The stenosis of luetic origin may improve under specific treatment, 
or else the newly formed scars which result from the effect of specific 
treatment upon the healing process may also increase the stenosis. 
Cancerous stenoses, of course, run a progressively downward and usually 
a rapid course unless removal of the neoplasm is carried out. Under 
rare conditions, they improve markedly for a time, either because the 
pylorus is reopened through breaking down of the obstructing cancerous 
mass, or because of the effects of general treatment. 
The occurrence of gastritis and intestinal disease lengthens the duration 
of the malady and adds to the difficulties of cure. Relapses are very 
common in the idiopathic cases, and are usually dependent on indiscre- 
tions of diet or excesses in daily routine. Persistence in the exacting 
treatment is by no means easy, and the tendency to relax in care makes 
it difficult for patients to lead a model life of the kind required for per- 
manent cure. 
Prognosis.-In the early stages of gastrectasis one should carefully 
guard against a too definite assurance as to the cause and probable out- 
come. The two features which govern the prognosis are the cause and 
the possibility of its removal. Cures are possible in idiopathic cases 
that are even advanced, provided the wall of the stomach is not per- 
manently damaged and the general condition of the patient capable 
of improvement. Gastroptosis renders these cases much more difficult 
of cure. Early cases are of course always amenable to cure if the proper 
treatment be employed and conscientiously carried out. The normal 
amount of urine, the lessened degree of thirst, the good condition of the 
musculature, and possibility of obtaining suitable diet are all favorable 
features. The onset of tetany is a serious complication and one of grave 
omen. Relapses are common and due recognition of their frequency is 
important in dealing with questions of prognosis. In obstructive cases 
the cure is always possible, except in malignant disease, for the possibility 
of surgical intervention, when a new opening may be made to short- 
circuit the passage, renders a benign stenosis of no importance in itself. 
Prophylaxis.-Proper hygiene, diet, and mode of life are essential 
to the prevention of pure gastrectasis from atony of the stomach, as is 
also moderation in the use of food and drink. Special care in debilitated 
states, as regards diet, exercise, and habits, must also be carefully 
remembered, and one should avoid the previously mentioned causes of 
idiopathic dilatation. ORGANIC DISEASES OF THE STOMACH 
265 
Treatment.-A detailed diagnosis as to the nature of the gastrectasis 
is essential to rational treatment, which should be based on (a) the etiology 
as regards food, drink, and habits, and (6) the social state, history, family 
history, previous diseases, and conditions of the viscera. In all patients 
with motor insufficiency certain general rules apply, no matter what 
the cause or underlying condition may be. The stomach must be as 
far as possible emptied within the normal time, and stagnation and 
retention of food avoided. Food must be administered of a kind which, 
as regards quantity and quality, will not excessively burden the stomach. 
The motor power being weak, one must aid its activity by avoiding 
unnecessary effort on the part of the gastric muscle, while fermentation 
must be avoided or reduced to a minimum. Where pyloric stenosis 
exists surgical intervention must be carefully considered. In the benign 
cases it is often curative. 
Diet-The main objects are as follows: (a) To supply sufficient 
nutriment in an easily assimilable form, (6) to avoid over-burdening 
the weakened stomach with bulky foods, (c) to avoid fermentation and- 
retention of foods, (d) to give foods of such kinds and in such a way as 
to assist their early propulsion into the intestines where the chief digestive 
function is carried on, and (e) to supply enough fluid to the body to fulfil 
the requirements of tissue thirst. These results are best obtained by 
giving frequent small meals, six small meals daily rather than three of 
ordinary amount. Food must be given either in soupy form, or as dry, 
solid food in a finely divided form. It must be taken slowly and well 
masticated; for this reason the teeth must be kept in good condition. 
The patients must rest before and after food, preferably in a recumbent 
position, on the right side. Occasionally lavage assists materially. This 
principle depends on the evidence given some years ago by von Mering, 
that water is not absorbed in the stomach, so that its propulsion into 
the intestine is necessary for its usefulness to the tissues. 
In any case much fluid should be avoided, no matter how great may 
be its nutritive value, for gastrectasis has been well called dyspepsia of 
fluids. Whatever of fluids be taken they should be sipped slowly. Milk, 
being one of the most perfect foods, is also one of the most suitable in 
gastrectasis. It is well to add some cereal to it, e. g., barley, rice, oatmeal, 
etc., or one of the numerous concentrated albuminous foods. One may 
add cream or make a custard. Milk is often distasteful to patients who 
suffer from retention of food, and for this reason any ordinary flavoring 
extract may be added to aid in its administration. The addition of lime 
water or brandy may be desired and may effect the same purpose. 
Bouillon with eggs makes an excellent form of concentrated nourishment, 
and is usually readily assimilated; so also are meat juices and meat 
jellies. The dry foods and those more solid should be prepared in a 
finely divided form, especially the meats and vegetables. 
Whatever meats are used should be chopped up and well masticated. 
Scraped raw beef, tender roast beef or fillet, thinly sliced smoked ham, 
oysters, and sweetbreads are often well borne, as also chicken, pigeon, 
tender mutton, and white fish of various kinds. Vegetables must be 
mashed or in puree form. Only the less coarse varieties and those with 266 
DISEASES OF THE DIGESTIVE SYSTEM 
least cellulose should be employed. Purees of potatoes, peas, spinach, 
asparagus-tops, or cauliflower can usually be taken with ease. Bread 
may be given, preferably white stale bread, or toasted, or one may use 
rusks and unsweetened biscuits. Fats, notably milk fat, are good, espec- 
ially with the addition of HC1. Alcohol is of value only when weakness 
is great and small quantities of stimulant are necessary. It should 
be remembered that although absorption occurs in the stomach, the 
alcohol at the same time induces an increased secretion of water into 
the stomach. Malt extract in small amounts may aid the appetite. 
To some extent the diet must depend on the results of gastric analysis. 
With subacidity, cereals are preferred rather than albumins, and whatever 
meats are used should be finely divided before eating. White meats 
are preferable, and dry white fish is usually well borne. Vegetables, 
even though better taken than proteins, must be finely divided and 
given in limited amount. In these cases the use of drinking water to 
which a little diluted HC1 has been added is often beneficial; it should 
be sipped slowly after food. With hyperacidity one should select mainly 
albuminous foods, meat, milk, eggs, and fats in moderate amount, of 
which butter is the most easily borne. Starches should be carefully 
restricted, although rusks and dry toast are suitable. Sweets should 
either be much limited or altogether avoided. Fluids are more tolerated 
than in subacidity, especially the still alkaline waters. Saline enemata 
are often most useful to relieve the tissue thirst in idiopathic dilatation. 
Of mechanical measures the most important is thorough lavage of 
the stomach. This is indispensable in the medical treatment of motor 
insufficiency if that condition be at all marked. In the mild cases it 
may not be required, although it often affords great relief. It is not 
merely a form of symptomatic treatment, but is even curative in the 
early cases. As a rule, however, early mild cases merely require strict 
attention to diet and daily regimen to effect a cure. One must judge 
according to the individual case how much lavage is necessary. In the 
moderately severe cases the stomach is never empty during the course 
of the day, food being retained until the subsequent meal, but the stomach 
empties itself during the night. In such cases a careful lavage given 
before the evening meal does good by removing the fermenting products 
of the day's feeding, and a small appropriate meal taken thereafter on 
an empty and cleaned stomach has a good opportunity for absorption 
with the patient at rest for the succeeding ten hours. 
In the very severe cases when food remains in the stomach over night, 
and has not been propelled into the intestine by early morning, lavage 
is still more imperative, and in the most extreme forms it may be well 
to wash the stomach twice daily, in the early morning as well as in the 
evening. The essential is that the lavage be thorough, and that the 
return flow of water be finally quite clear. It may be necessary to wash 
out the stomach with the patient in various positions, standing and 
lying down. Much time and patience may be needed, and often an hour 
of lavage is required before the water returns perfectly clear. Lavage 
should not be left indiscriminately to the patient, but the physician 
does well in most cases to perform it in person or by a trained assistant. ORGANIC DISEASES OF THE STOMACH 
267 
Lukewarm water suffices for the purpose, although when much fermenta- 
tion is present, salicylic acid solution (1 to 1000) may be used. How 
long should one keep up lavage? This must depend on the persistence 
of motor insufficiency. It should be done daily until we are sure the 
digestion is not delayed overnight. The lavage should be discontinued 
gradually, daily treatment giving place to one washing on alternate 
days, the condition of the contents deciding the subsequent frequency. 
Other mechanical measures are of less importance, although often of 
benefit. Massage is beneficial in a general way, but should be used 
systematically, and under proper skilled direction. In extreme cases 
of gastrectasis it is not well to employ vigorous massage to the abdomen, 
for it is not supposed to benefit the muscle of the stomach directly, but 
assists more by increasing the general muscle tone, by improving the 
circulation, and aiding the nervous system. It also assists in obviating 
the chronic and often most persistent constipation. It should not be 
done until at least one and a half hours after any meal. When much 
fermentation exists, or where there are organic causes for the dilatation, 
it is well to avoid the upper abdomen and confine the treatment to the 
lower zone and to the general musculature elsewhere. 
Hydrotherapy is of the greatest benefit; in fact, apart from lavage, 
there is no mechanical treatment so beneficial in gastrectasis. Warm 
shower douches gradually made colder, with the use either of the strong 
hose stream playing up and down the back, the use of the Scotch douche, 
the employment of salt rubs, or of douche massage give eminently 
satisfactory results. When hydropathic apparatus is not available, 
much benefit is gained from daily cold baths, followed by dry friction 
with a rough towel. The use of compresses over the stomach at night 
covered with oiled silk and a binder often gives great relief. 
Bandages of a supporting nature, or proper-fitting corsets for women 
which support from the pelvis, are useful; such corsets are constricted 
about the hips, but are loose about the epigastrium and lower part of 
the thorax, thus affording room for breathing, and not allowing the 
stomach to be without support from below. These are especially useful 
when gastroptosis exists. 
Electricity has merely a general value in the same way as has massage. 
Its direct local action is very dubious. Experiments on dogs have showm 
that faradism does not directly affect the gastric muscle, but causes 
contraction merely of the external abdominal muscles. Apart from this 
general effect, electricity, even if applied as intragastric faradism, is 
but another form of suggestive therapeutics. The same applies with 
even more truth to the use, or rather the abuse, of static electricity and 
high-frequency currents. 
Drugs form the least satisfactory of all methods in the treatment of 
gastrectasis. No drug that is known can effectually contract the dilated 
organ or act with continuous benefit upon the gastric muscle. Strychnine 
is much used for this purpose, although but little evidence exists to prove 
that its value is other than as a general tonic. The drug therapy is 
purely a symptomatic one. When hypersecretion exists, relief is often 
obtained from atropine in small doses (gr. at night, or if need be 268 
DISEASES OF THE DIGESTIVE SYSTEM 
in the morning as well. Alkalis have perhaps an indirect value in neutral- 
izing an excess of acid, although, of course, they have no effect in dimin- 
ishing the secretion. For subacidity the use of well-diluted HC1 sipped 
in a tumbler slowly every few minutes after food seems to aid digestion, 
or at all events to give added comfort. The use of bitter vegetable 
tonics is much lauded. In moderately severe cases the writer has had 
beneficial results from the use of olive oil, in dessertspoonful doses after 
food, as was recommended by Cohnheim. This author, however, 
preferred its adiministration through the tube in doses of 200 to 500 cc. 
Antifermentatives can only be of use in the milder cases, but with marked 
prolonged retention their use can have but little effect. Probably 
salicylic acid is one of the most satisfactory. 
Constipation requires varying treatment according to its degree of 
severity. In mild cases no drugs are required, and proper feeding, 
massage, exercise and perhaps occasional water enemata will suffice. 
It is often useful to administer Rochelle or Sprudel salts in small doses 
in the early morning, after which the patient takes moderate exercise 
for a short time previous to breakfast. In any case drastic purgatives 
do harm, and only mildly acting drugs are to be recommended. Should 
these fail in the more severe forms of dilatation, reliance must be placed 
on enemata every other day. Daily evacuations are not necessary to 
health, and patients should be advised accordingly. 
Vomiting should be controlled by proper diet and by lavage. When 
these are ineffectual, nutrient enemata should be administered, and in 
persistent cases it will be necessary to call for surgical intervention. 
For the thirst the proper use of saline rectal injections will aid, and the 
mouth should be frequently rinsed with some pleasant wash. 
Surgical.-The indications for operative interference include three 
types of cases: (1) Acute cases when medical treatment has failed or 
is known to be useless, e. g., with twisting of the duodenum. (2) Pyloric 
stenosis, whether for removal of adhesions, fibrous bands, tumors 
obstructing the orifice, external compression from any cause, or when 
relief is impossible unless one is enabled to create a new passage for the 
food. (3) Idiopathic dilatation without marked gastroptosis or general 
enteroptosis, when medical treatment has been unsuccessfully tried, 
and where, in consequence, the patient is losing in weight and strength 
from insufficient nutriment, or again, when the symptoms even though 
not grave, are sufficiently irksome to interfere with daily routine. 
Two objects are to be attained: (1) To remove the cause; (2) to remove 
the results. The methods are: (1) Resection of the pylorus, pylorectomy. 
(2) Heineke's pyloroplasty. (3) Gastro-enterostomy. (4) Bircher's 
gastroplication, which reefs up the anterior wall and diminishes the 
size of the stomach. This latter was advocated by Keen, Weir, and 
Brandt. Eight of Bircher's ten cases did well. Gastro-enterostomy in 
uncomplicated cases has given excellent results. Enteroptosis is dis- 
tinctly a contra-indication to surgical interference-and even mere 
gastroptosis, if at all marked, is not likely to permit of successful operation 
in cases of gastrectasis, even although the gastrohepatic omentum be 
shortened to aid in removing this complication. ORGANIC DISEASES OF THE STOMACH 
269 
"CONGENITAL" HYPERTROPHIC STENOSIS OF THE PYLORUS 
Synonyms.-Congenital pylorospasm; hyperemesis lactentium (M. 
Schmidt), infantile hypertrophic stenosis of pylorus. 
Pathology.-Two distinct conditions seem to exist: 
1. Pylorospasm.-This, without true hypertrophy, is described by 
Pfaundler in systolic and semisystolic stomachs, a pseudohypertrophy. 
The condition is often seen at operation and autopsy, for fixation of the 
muscle occurs during certain phases of digestion. Heubner and Freund 
share this view. These cases must be regarded in the light of mild 
types, of short, perhaps intermittent course, and not requiring surgical 
intervention because there is no permanent anatomical disturbance. 
2. True Hypertrophy.-The pyloric ring is increased in size and thick- 
ness, owing to hypertrophy of the muscular fibres, chiefly the circular 
ones, although it is difficult to measure to what degree the longitudinal 
muscle shares in the increase. The swelling is sharply delineated at its 
duodenal end, but diminishes gradually toward the fundus. The mucous 
membrane is folded up and the submucosa is little, if at all, altered. 
The lumen is small. The stomach is dilated, and in cases of long standing 
often shows a diffuse hyperplasia of its muscle. The duodenum is empty. 
It is quite conceivable that all transitions may occur between mere 
spasm and true hypertrophy. 
Pathogenesis.-The recent work of Cunningham, Stiles, and others 
has thrown much light on the anatomical condition. Normally, the 
stomach may be considered as an organ in which the pylorus is a distinct 
and separate portion, with a function both to expel and to retain food. 
The cylindrical canal, which is about 2 to 3 cm. long, is contracted at 
birth, and its lumen is obliterated by the folds of mucous membrane. 
The ring projects normally into the duodenum in a way similar to that 
in which the cervix protrudes into the vagina. The muscular fibres of 
the pylorus are so arranged that the circular ones, which surround the 
whole length of the canal, are to some degree antagonized by the longi- 
tudinal bundles, which as Cunningham shows are derived from the body 
of the stomach, and spread about, in gradually increasing numbers 
over the pylorus, and dipping even into the submucosa, aiding in relaxa- 
tion of the sphincter. Between the circular fibres of the pylorus and 
those of the duodenum there is a dividing band of connective tissue. 
In the cadaver the pyloric canal is usually tightly closed, so also probably 
during life except during digestion, when it opens irregularly and inter- 
mittently. When pyloric stenosis exists, the whole canal is probably 
involved, and the changes are primary, while any lesions in the stomach 
elsewhere are secondary. 
Other conditions of a mild nature, such as recover readily on medical 
treatment, may be regarded as due, in most instances, to obstruction 
of the pyloric lumen from swollen membrane or an inspissated mucous 
plug, a condition, too, that one might readily conceive to be associated 
with spasm. Such a case was described by Scholten, in which a true 
thickened membrane was observed at operation and at postmortem. 270 
DISEASES OF THE DIGESTIVE SYSTEM 
Doubtless the earlier observers had the correct view in regarding 
the condition as developmental hyperplasia of the pyloric muscle, a 
congenital redundancy, or prenatal overgrowth (Nicholl, Cautley, 
Ibrahim). The fact that the pylorus first appears in fetal life at the 
third month shows that enough time exists before birth for excessive 
growth, while the degree .often found excludes the possibility of postnatal 
development. Sometimes when pyloric stenosis occurs as a congenital 
condition, other parts of the body show abnormalities, e. g., there may 
be congenital atresia of the anus, and perhaps, as Stiles suggests, we 
have an analogous condition in incontinence of urine with overdistension 
of the bladder, overcoming finally the sphincter vesicse. Other analogous 
conditions are pathological dilatation and hypertrophy of the rectum. 
Torkel, in 1905, cites an instance in which, on anatomical grounds, a 
proof exists of a congenital origin, aberrant embryonic tissue (Brunner's 
glands) being found amid the fully developed structures. 
A nervous theory was advanced by Thomson and Still, according to 
which the condition was associated with disturbed coordination of the 
relaxing and contracting fibres of the pylorus, with increased irritability, 
and this latter whether originating during intra-uterine or extra-uterine 
life leads to spasm, and this spasm leads to hypertrophy-a hypertrophy 
from overwork. However, no proof exists of incoordination or of nervous 
derangement in fetal life. Nor are we sure that spasm causes the hyper- 
trophy of the pylorus. If this were the case, the same spasms might be 
expected then from other conditions of irritability, e. g., hyperacidity and 
faulty feeding, but such facts have not been shown to occur. Freund, 
however, regarded hyperchlorhydria as an important factor. 
Symptoms.-The condition is more frequent than was supposed until 
recently. The infant, frequently the first-born and, as a coincidence, 
more often of the male sex, is healthy at birth; symptoms usually begin 
to show from the third to the sixth week, and very rarely as late as the 
fourth month. Very few cases are on record in which the symptoms 
began immediately after birth-a point of great importance in the 
diagnosis. Cases may go on to adult life and Bassler has described 
authentic instances. Digestive troubles of an intermittent type usher 
in the symptoms. The breast or the bottle is taken reluctantly no matter 
how careful the feeding, and the child is easily satisfied. When vomiting 
begins early, however, the appetite is often maintained in a striking way. 
Vomiting is the chief early sign, is explosive, and often copious according 
to the degree of retention. At first it seems unimportant, although no 
adequate cause is found; then its persistance rather than its frequency 
attracts the attention. Gastric analysis gives variable results. 
Signs.-Constipation is the rule, requiring the use of enemata, or 
more rarely diarrhoea occurs with green, watery stools, containing mucus, 
and perhaps tarry from the presence of blood. The urine is diminished. 
Wasting is sometimes rapid, and there may be marked weakness, the 
result of the starvation, the condition resembling and often being mis- 
taken for marasmus. The child is often in severe pain, with violent 
cramps and epigastric resistance, and cries out or whines; at other times 
it is quiet and dull. ORGANIC DISEASES OF THE STOMACH 
271 
Dilatation.-Sometimes the stomach region bulges if the organ be 
full, and the dilated viscus may be seen extending to the navel. Dilata- 
tion is often marked; in one of HenscheH's cases the stomach held 400 
cc. Heubner found the majority of cases with undistended stomach, 
which he attributed to the constant vomiting. Dilatation is perhaps 
more common with bottle-fed infants. Visible peristalsis is most marked 
in long-standing cases, although Sarvonat and Audry described it in a 
child aged two weeks. Probably when mere pyloric spasm exists, without 
true hypertrophy, there is much less peristalsis,. It is an important 
sign when present, although not always found, and often only at long 
intervals especially after food. The tumor may be palpable, is sometimes 
lower than, and sometimes beneath the enlarged liver, as a hard cylin- 
drical or spherical lump, the size of a filbert, which may even be felt to 
contract and to change in hardness during peristalsis. 
The Diagnosis of "Congenital" Hypertrophic Stenosis (not Pyloro- 
spasm).-The symptom complex gives the clue. (1) The time of onset 
and the age; symptoms develop in early infancy, but not immediately 
after birth. (2) The vomiting, which is persistent and forcible, occurs 
always after meals, but also regardless of feeding in healthy children. 
(The vomitus does not contain bile.) (3) The absence of milky stools. 
(4) The visible peristalsis. (5) The tumor, which is palpable as a finger- 
like mass, and movable downward. It is not always to be felt, as it 
sometimes lies under the liver, in which case one must diagnose by 
exclusion and by a careful experimenting with food. (6) The dilated 
stomach. (7) The crying from hunger and pain. (8) The emaciation. 
Congenital hypertrophic stenosis is to be distinguished from (1) 
simple regurgitation in which the above symptom-complex is absent. 
(2) Stenosis of the duodenum; kinking from shortened ligaments, adhe- 
sions, etc. (3) Tumors near the duodenum, such as enlarged glands 
narrowing the lumen by pressure from without. (4) Congenital atresia 
of the pylorus, which is a rare condition due to developmental error and 
rapidly fatal. It is therefore incompatible with life, unless relieved by 
operation. Vomiting occurs immediately after birth, even if food is 
withheld, or in other cases as soon as this is given. (5) Malformations 
and atresia of the small intestines. There is bile in the vomitus and the 
duration is short, at most a week. Sometimes an atresia occurs at the 
pylorus or in the duodenum, and is incomplete at first, so that the 
failure of health is more gradual, and the stomach may be hypertrophied 
in consequence. (6) Gastritis. (7) Simple vomiting and constipation 
from faulty feeding. (8) Habit vomiting. (9) Pylorospasm due to 
faulty feeding. Here the signs and symptoms are similar, but milder, 
as a rule; there is less visible peristalsis and the contracted nodule is 
usually smaller than the tumor of true stenosis. The condition, too, is 
more amenable to treatment. 
Prognosis.-This depends to a large extent upon one's ideas as to 
what is meant by the term pyloric stenosis. Wherever the symptoms 
are due to pylorospasm or to obstruction from a swollen mucosa and 
plugs or mucus, the patients recover on a careful diet and rational 
therapy. Both mild and severe cases occur, the latter often producing 272 
DISEASES OF THE DIGESTIVE SYSTEM 
extensive gastrectasis. True hypertrophic stenoses are much more 
serious, and in the grave cases the result depends upon surgical treatment 
being undertaken early. To wait too long is a grave error, and yet experi- 
ence shows in many instances that proper variation of the food often 
produces excellent results and rapid cures. Koplik's cases bear out the 
importance of suitable diet. When dilatation and marasmus exist, the 
prognosis is more serious (Cautley). The milder cases have less hyper- 
trophy and obstruction, and may get well with lavage and diet, or else 
may pass into a mild chronic state with gastritis and ultimately die from 
marasmus. Other cases may terminate later in life with dilatation and 
hypertrophic stenosis, and perhaps originate some of the instances seen 
in adults. That congenital stenosis of the pylorus in adult life is common, 
as held by some surgeons, is scarcely yet proved. 
Treatment.-In the early stages the diagnosis is usually doubtful, 
and the patient should be subjected to medical treatment under careful 
observation, to determine whether one is dealing with stenosis from mere 
spasm, temporary obstruction, or with a true hypertrophic condition. 
Dietetic.-Careful feeding with non-irritating food and rest after 
feeding is the main thing. If the child is being nursed, the breast feedings 
should be regulated; if artificially fed, a wet-nurse may be employed, or 
the simplest kind of food, as whey, albumin water, peptonized milk, and 
raw meat juice, in small amounts, may be used. Fats should be very 
limited in quantity, these being the last to leave the stomach, and for 
that reason a milk with a low fat percentage should be selected. Heubner 
recommends feeding every three hours, as much as they care to take, 
letting them vomit, and applies poultices three times daily for two 
hours, changing every half hour. Batten suggested nasal feeding, but 
this is of doubtful value. The infant should be weighed from time to 
time to estimate the value of the feeding. 
Mechanical.-Lavage is of great benefit, relieving the vomiting and 
distress, keeping up the appetite and helping nutrition indirectly, but 
lavage does not cure the condition and may easily deceive the clinician 
as to its true nature. Saline injections per rectum may be useful. 
Medicinal.-Various remedies are suggested, the main objects being 
sedative: of a drop of tincture of opium with a few drops of tincture 
of valerian (Heubner); or gr. of cocaine, or, better still, atropine in 
small doses will relieve spasm by its action on the muscle tone. Alkalis 
by neutalizing the excess of HC1 help to relax the spasm. They should 
be given after feeding. Koplik adds citrate of soda to the food. 
General Medical Directions.-One must watch the weight, but need 
not expect a gain at once. If after a few days there is marked loss of 
flesh, weakness, tetany, or convulsions, operation is indicated. If there 
are persistent vomiting, progressive emaciation, visible peristalsis, and 
absence of feces in the stools, the indications for operative treatment 
are obvious. . 
Operative Measures.-Just so soon as it is wise to operate this should 
be done without delay. The difficulty is to know clearly the surgical 
indications when a true stenosis is not so obvious. Divulsion if possible 
is preferable, either by means of Einhorn's rubber bag or Sippy's method. ORGANIC DISEASES OF THE STOMACH 
273 
The operative methods employed are-divulsion, gastro-enterostomy, 
pyloroplasty, and pylorectomy, the choice being a matter of surgical 
opinion, and as yet the statistics are unreliable. 
CIRRHOSIS OF THE STOMACH 
Definition.-This may be defined as a non-malignant, slowly develop- 
ing, and progressive affection of the stomach, characterized by diffuse 
or circumscribed increase in the connective tissue, involving chiefly the 
submucosa, and to a less extent the other layers, and sometimes 
extending to the connective tissue in the parts bordering upon the 
stomach. The definition excludes all cases of scirrhus cancer. 
Nomenclature.-Although the condition has been recognized for more 
than two centuries, there have been so many views as to its underlying 
cause and its real nature that the synonyms for the disease are very 
numerous; e. g., chronic interstitial gastritis; sclerosis of the stomach; 
fibroid induration; stenosing gastritis (Boas); fusocellular sarcoma 
(Lyonnet); plastic linitis (Brinton). This last term seems to have been 
that generally adopted, and certainly the French writers have done much 
to perpetuate its use. The nomenclature is probably also confused 
through an apparently unnecessary mingling of various conditions, each 
of which has a different cause. The names mostly describe the nature, 
situation, and extent of the lesion, the anatomical change being the same. 
Historical.-We are indebted to Andral (1835) for the first accurate 
description of the condition and its differentiation from cancer, though 
descriptions occur as far back as the seventeenth century. Rokitansky, 
in 1859, maintained that submucous hypertrophies of the stomach belong 
in reality to the group of fibroid cancers. Brinton, however, two or 
three years later, gave to the condition the most used names "cirrhosis 
of the stomach/' and "plastic linitis," thus assuring to it a clinical and 
anatomical distinctiveness. He classified it, not in the category of 
gastritis, because he held that the mucous membrane was never affected 
at the onset, and, indeed, was often quite intact; neither was it a hyper- 
trophy, for often in the midst of new tissue much atrophy exists, but 
rather he regarded it as a cirrhotic inflammation, and not a pure sclerosis, 
which latter term applies merely to the last stages of the disease. Brinton 
recognized both its resemblances to and its dissimilarity from cancer, 
and admitted the difficulty of satisfactory classification owing to the 
insufficiency of data. 
Among the most important papers which have appeared in connection 
with the subject was that of Hanot and Gombault, in 1882, a contribu- 
tion of special value in view of the careful microscopic examination made 
in almost serial sections of the diseased tissue. The lesions were most 
marked at the pylorus and lesser curvature, and there was much invasion 
of the neighboring tissues, thus creating a callous retroperitonitis; but 
nowhere could they find either macroscopic or microscopic evidences of 
a malignant origin. Such, too, was the experience of Tourlet, who 
discussed the whole subject some ten years later, and who concluded 
vol. in-18 274 
DISEASES OF THE DIGESTIVE SYSTEM 
from his own observations and from analyses of others that the disease 
was not cancerous. Nevertheless, to Bret and Paviot cirrhosis of the 
stomach is merely a cancer with cells which are metatypical in the 
stomach, and the real nature of which is only seen in those rare instances 
where one finds in the generalized process the typical gastric epithelial 
cells which came originally from the stomach lesion. Garret, a pupil 
of Bard, seemed to regard the condition as of the nature of a fusicellular 
sarcoma. Still more recently Jonnesco and Grossman insist on the 
benign character of the lesions (1908). 
Pathogenesis.-Diverse as the views are of the nature of this condition, 
and uncertain as is still its origin, many of the theories advocated may 
be readily refuted by an analysis of the reported cases. That it is not 
essentially an advanced stage of chronic gastritis, for instance, is demon- 
strated by the comparative infrequency of typical inflammatory lesions 
of the mucosa, which in so many cases appears quite unaffected. The 
same holds true of the theory of Fenwick, for primary atrophy is by 
no means a constant or even frequent lesion. Arteriosclerosis and senile 
changes do not again explain many cases occurring in young subjects, 
devoid of the manifestations of senile disease. Nor, again, is tuberculosis 
anything but a rare accompaniment and obviously a mere coincident. 
The occasional presence of ulcer, as described by Formad, Hoche, and 
others, does not certainly explain the origin of those advanced cases 
of linitis in which, in spite of the extensive disease of the submucosa, the 
overlying mucous membrane was intact, and showed not the slightest 
evidence of either recent or healed ulceration. Alexis Thompson de- 
scribed in 1913, a series of cases with fibromatosis of the gastric wall, 
non-malignant and not necessarily originating from ulcers. It is, however, 
more difficult to decide whether the theory of its cancerous origin is or 
is not applicable to all cases. There is no doubt that clinically the features 
are, as a rule, not usually identified with cancer of the stomach, e. g., 
the long duration, the slow cachexia, the long remissions, the character 
of the emesis, etc.; furthermore, the presence of the oblong tumor, 
cylindrical, regular, unyielding, with an abscess of secondary invasion 
or metastases, all point to a condition of chronic inflammation rather 
than that of carcinoma. 
Conclusions from the observations hitherto made would lead one to 
believe that plastic linitis is an interstitial overgrowth, chiefly in the 
submucosa, with or without muscular hypertrophy, in some cases 
primary from an unknown cause, in others secondary, perhaps to ulcer 
or to cancer, or to a cancerous degeneration of an ulcer; and at times 
perhaps associated etiologically with other irritating conditions such 
as might anywhere in the body favor the overgrowth of connective 
tissue. 
Sex seems to have no influence in its causation. Trauma, through 
compression of the epigastrium from occupation, is mentioned by Hare, 
Schacher, and also by Snellen as a possible factor. There is no proof 
that alcohol induces the linitis, nor does the frequent association of this 
poison with chronic gastritis bring it into any nearer relation to the 
other malady. Moreover, in many of the cases described there is an ORGANIC DISEASES OF THE STOMACH 
275 
assured absence of an alcoholic history. Syphilis has been mentioned 
as a possible cause, although where this is present one may be said to 
be dealing with a specific disease by itself and not with plastic linitis. 
Pathology.-The lesions which are essentially sclerotic and hyper- 
trophic vary in their location, in the extent and multiplicity of their 
various foci, and in the degree of invasion of other structures. The 
typical lesion usually described is that found in the diffuse variety. 
The stomach itself is either of normal size or contracted. It may be 
freely movable, fixed in the epigastrium, or pulled up underneath the 
liver by firm adhesions to the gastrohepatic omentum. While at times 
it is universally surrounded by adhesions, these are usually most firm 
at the splenic end. They may be so firm and extensive as to cause 
intimate attachment to any of the neighboring organs and tissues, to 
which the same process may likewise extend. The capacity of the 
stomach is usually diminished in these diffuse cases, and it may not 
contain more than 150 cc. Dilatation occurs, as a rule, only when the 
pylorus is involved. Externally the organ has a grayish appearance, 
with a curious opacity due to the overlying peritoneum. It is oval, 
irregularly ovoid, or cylindrical in shape, resembling in size and form a 
thickened transverse colon. Its consistency is firm, in parts almost 
cartilaginous, but with the elasticity and resiliency of a large artery. 
When removed from the body and placed upon the table its shape is 
retained because of the thick, firm walls. The cut surface is unevenly 
thick, and may be in some places twenty times greater than normal; 
although in most instances the average thickness has been 2 to 2.5 cm. 
Usually the greatest thickness occurs at the pylorus, the hypertrophy 
gradually diminishing as one gets farther away from the outlet of the 
stomach. More rarely the cardia is chiefly involved, or it may happen 
that several portions are separately diseased, the intervening tissues 
remaining comparatively normal. Everywhere the cut surface has a 
fibrous, pearly grayish appearance and the individual layers of the 
stomach are readily recognized. 
The mucosa is often normal in appearance and structure, or slightly 
thickened and firmer than normal, and in some cases can be lifted 
off from the submucosa. The thickness is diffuse or patchy, and in a 
few instances areas of atrophy are also seen, with pale or reddish color 
or pigmentation. It may be smooth or rough, the surface being some- 
times thickly granular with excrescences. Sometimes a few polypi are 
seen, and there may be erosions, ascribed by Fillet to vascular obliteration 
due to fibrous constriction. The submucosa presents the greatest hyper- 
trophy and thickness. Its tissue is dense and firm, its color grayish- 
white, and the fibrous strands running through and from it in all direc- 
tions traverse the underlying muscle tissue so as to form a network about 
the individual bundles (hence the name "linitis"). 
The muscularis is likewise thickened from true hypertrophy of the 
muscle, as well as an increase in the connective tissue among its bundles. 
The fibrous tissue may finally invade even the subserous cellular tissue, 
so frequently, indeed, that Brinton regarded this layer as the site of 
origin. The peritoneum may or may not be involved; in the case of 276 
DISEASES OF THE DIGESTIVE SYSTEM 
Hanot and Gombault so great was the involvement of peritoneum as 
to render it worthy of a special title-retroperitonite calleuse. There 
was chronic inflammation, with thickening, induration, retraction of 
the stomach, and fixation of the organ. Amid the adhesions which involve 
the gastrohepatic omentum, the great omentum, and the gastrosplenic 
ligament, obliteration of the common duct and the portal vein has 
occurred, and even an obstructive biliary cirrhosis. The visceral cap- 
sules may be thickened (liver and spleen) and these organs themselves 
sclerosed or atrophied. Even the intestines are sometimes thickened 
(more especially the transverse colon), and their caliber diminished 
even to complete obstruction. Simultaneous involvement of the cecum 
has been mentioned. 
The lymphatics of the mesentery are frequently seen 'to be dilated, 
sometimes so markedly as to suggest that the lymphatic obliteration 
was the primary cause of the condition (Bouveret, Tourlet). The glands 
are almost invariably small, although their cut surface may show an 
interstitial increase similar to that seen in the submucosa. 
Histology.-The mucosa shows either a normal condition or the 
minute lesions of a chronic productive or atrophic gastritis. The glandu- 
lar structures may be displaced and the development of fibrous tissue 
may cause constrictions and cystic dilatations of the tubules, or else 
may have caused the gland structures to entirely disappear. In a case 
mentioned by Osler the mucosa was smooth without any trace of gland- 
ular elements-a distinct sclerosis of the mucous membrane itself with 
atrophy. The lymphoid nodes are sometimes proliferated. The sub- 
mucosa, which is much thickened by strands of fibrous tissue densely 
arranged, and forming a network, may be at times most abundantly 
gathered around the bloodvessels. And the muscularis, which is normal 
in some places, is in others like an irregular checker-board traversed by 
intersecting lines of fibrous tissue. The subserous layer exists in various 
stages of progressive inflammation, and the peritoneum itself may 
show increased connective tissue, and more or less destruction of the 
endothelial cells. 
The circumscribed form, of which the commonest and most typical 
lesion is the " hypertrophic stenosis of the pylorus," shows anatomical 
lesions of a similar nature, although, as a rule, there is dilatation of the 
organ rather than contraction, and the muscle tissue itself gradually 
degenerates. Habershon's fibroid disease of the pylorus and Boas' 
hypertrophic stenosing gastritis are the synonyms. The delimitation 
toward the stomach itself is usually gradual, while toward the duodenum 
it is much more sharply defined. The cases of congenital hypertrophic 
stenosis of the pylorus may sometimes belong to this category, although 
their origin is more of the nature of a developmental morbidity than of 
an inflammation. Of the other sites of localization the cardia has already 
been mentioned, and Formad's case, in which the greatest thickening 
was at that orifice, is worthy of special mention. An ulcer existed in 
the posterior wall near the cardia, the floor of which was formed by 
splenic tissue and the peritoneal coat of the transverse colon. The 
stomach was contracted and held less than 150 c~. ORGANIC DISEASES OF THE STOMACH 
277 
Symptoms.-The onset is insidious, and the early development slow, 
gradual, and by no means easily determined. The early symptoms 
correspond in most particulars to those of chronic gastritis, and there 
are vague symptoms of indigestion, with a fickle appetite and usually 
anorexia, a sense of heaviness after meals, and later vomiting of mucus 
or of partially digested foodstuffs. In the early stage pain is moderate 
or entirely absent, and rarely so severe as to suggest ulceration. For 
one or more years these milder symptoms, which are usually slowly 
progressive, or else with occasional long periods of remission, are gradually 
superseded by signs that indicate a more serious disease. The pains, 
which at first were insignificant, become more constant, of a dragging 
nature, sometimes spontaneous, sometimes only excited by food. They 
may extend from the epigastrium to the back, and are usually increased 
by pressure. Nausea, eructations of gas, and vomiting of liquid gastric 
contents accompany the pain, which is usually relieved by free emesis. 
The vomiting, which is always digestive in time, appears sometimes at 
once after meals, as though from an involvement of the oesophagus, 
and Roux has drawn special attention to the diagnostic importance of 
this symptom as suggesting gastric intolerance because of the rigid 
contracted cavity. When the chief lesion is at the cardia, regurgitation 
of food or mucus would be a common sign, but in the commoner diffuse 
cases the vomiting appears one to two hours after meals. It is most 
continuous in the severe cases, and if stenosis of the pylorus be present 
there will be signs of retention. In about 20 per cent, of the cases slight 
hematemesis is noted, but there is never much bleeding because there 
is rarely ulceration. For the same reason obvious melena is uncommon. 
The increasing limited capacity of the stomach for food is an important 
symptom. The intestines are not commonly involved, but sometimes 
the bowels are irregular and there may be a mucous enteritis. The general 
appearance of the patients may vary; while, as a rule, some pallor is 
conspicuous, the patient has lost flesh, and has become somewhat 
cachectic, yet at other times, both the nutrition and the color are well 
preserved, a circumstance to which Trousseau has drawn special attention. 
In the gastric contents, the HC1 is variable, often absent, and lactic 
acid is commonly present. 
Examination of the abdomen in uncomplicated cases may show some 
retraction of the epigastrium, or a mass, more or less localized, may be 
seen prominently beneath the abdominal wall or moving with respiration. 
Peristalsis may be visible. Palpation demonstrates, usually, a diffuse 
resistance in the epigastrium, not always marked, especially if the con- 
tracted stomach be drawn up and fixed beneath the liver. At other times 
a hard oblong transverse tumor may be felt in the epigastrium, and 
extending to the left false ribs, or again only in the neighborhood of 
the pylorus. The mobility of the tumor varies according to its site and 
the nature and extent of any adhesion present. It has been mistaken for 
a movable spleen and for the transverse colon. Trousseau has drawn 
attention to the sensation of grating conveyed to the palpating hand 
on deep respiration. As time progresses, the condition may extend 
beyond the stomach to the peritoneum and the surrounding viscera. 278 
DISEASES OF THE DIGESTIVE SYSTEM 
Ascites may develop, make palpation difficult, and conceal the real 
underlying cause; or the symptoms may change to those of intestinal 
obstruction, in which to the conditions of cachexia and anasarca may be 
added persistent and uncontrollable vomiting until death follows from 
asthenia. Jaundice is rare in these cases, and apparently due only to 
constriction of the common bile duct from adhesions. When the cardiac 
orifice is mainly involved, so that constriction occurs, the process is 
more rapid and the fatal termination induced through starvation and 
inanition. Rapid emaciation, dysphagia, regurgitation of mucus and 
food are the characteristic features. When typical hypertrophic stenosis 
of the pylorus is present the signs are those of a benign stenosis. To the 
primary digestive symptoms are added the slow development of the 
affection, the marked emesis, with is digestive, infrequent, and small in 
amount at first, and later less often but more abundant; later come the 
signs of marked motor insufficiency with constipation, great thirst, and 
hunger, diminution in the quantity of urine, localized pain, visible 
peristalsis, perhaps a visible tumor, rapid emaciation, and death from 
inanition. 
Course.-Chronicity is the characteristic feature, and although 
Bouveret's case lasted apparently only twenty months from the onset, 
this is much shorter than the average duration. Tourlet's patient 
suffered seven to eight years before operation, and the average is perhaps 
ten to fifteen years. No general rule can be made, for the duration 
depends on the variety of the lesion. Circumscribed cases not obstructing 
an orifice will naturally last much longer than those which are localized 
at the pylorus, or still shorter time if at the cardia. The diffuse cases 
will be of still shorter duration than those confined to the pylorus, and 
where peritonitis, ascites, and adhesions supervene, the course is rapidly 
and progressively downward. 
Diagnosis.-This has rarely been made during life. When, even at 
autopsy, it is so difficult to make an anatomical diagnosis, one can 
scarcely expect that the clinical diagnosis would be easy. While the 
uncomplicated cases are difficult to determine, still more do the cases 
with complications lack ready means of diagnosis. The chief features 
are the long duration, the slow cachexia, the limited capacity of the 
stomach, and its intolerance of much food at any one time, the absence 
of hematemesis or melena, the presence of an oblong cylindrical tumor 
in the epigastrium in patients in whom the history and physical signs 
present neither the local evidence of carcinoma, metastases, or any 
signs of generalization. Plastic linitis has frequently been mistaken for 
cancer of the stomach, for portal cirrhosis, for obstructive biliary cirrhosis 
and simple chronic or tuberculous peritonitis. When pyloric stenosis 
is present one considers the possible presence of an old gastric ulcer 
and consequent perigastritis, and for the elucidation one trusts to the 
past history. Syphilis rarely presents similar symptoms; as a rule, the 
lesion presents mere strands of fibrous tissue, and gummata are uncom- 
mon. Much interest attaches to Einhorn's case, as reported by Brissaud, 
in which a large tumor, the size of a pigeon's egg, disappeared in a few 
weeks under antiluetic treatment. Deguy, in 1896, described his case ORGANIC DISEASES OF THE STOMACH 
279 
in which, for the first time, a diagnosis was made during life, and sub- 
sequently confirmed at autopsy. McCrae reported a similar experience 
from Osler's clinic. 
Treatment.-The rational treatment is essentially surgical. Medically 
there are but two considerations: in the early stage to treat the condition 
as in chronic gastritis, and later, when stenosis exists, to employ pallia- 
tive treatment until the more radical cure is attempted by surgical 
measures. Gastro-enterostomy as a mere palliative operation has been 
found successful, but where possible, a removal of the diseased tissue, 
in view of the possible cancerous nature of the affection, is the one 
thoroughly scientific treatment worthy of consideration-for the localized 
condition, pylorectomy, and for the diffuse lesion, total resection. 
Mauclaire and also Terrier have recorded cases in which an apparent 
cure followed exploratory laparotomy, and Roux records an interesting 
case in which the patient was well three and one-half years after operation 
(anterior gastro-enterostomy). Total resection was performed by Gayet 
and Patel (1904) for a linitis of definite malignant origin, this being 
probably the first operation of its kind for this condition. 
HEMATEMESIS 
Synonyms.-Gastrohemorrhagia; vomitus cruentus. 
Definition.-Hematemesis is a vomiting of blood-regardless of its 
origin-and it must not be confounded with "gastrorrhagia," for the 
blood vomited in hematemesis may come from other sources than the 
stomach itself. It is merely a symptom, to be referred not only to the 
stomach itself, but also possibly to conditions in structures contiguous 
to that organ. It is much more common than is usually recognized, 
probably because spectroscopic, microscopic, or chemical aids are not 
usually employed to reveal the presence of blood when not in macro- 
scopic quantity. Certain minute hemorrhages more often go unrecog- 
nized than is usually believed, and in this way the early manifestations 
of disease remain undetected. 
There may be no anatomical lesions (diapedesis), as in Lancereaux's 
supposed neuropathic hemorrhage occurring in gouty, nervous, or 
rheumatic individuals; or the lesion may be so minute as to escape 
detection even although the hemorrhage be very copious. Such con- 
ditions often arise from a general oozing from various portions of the 
mucous membrane, and in some cases the blood streams forth from a 
wide surface of the mucosa. More often the lesion is obvious (rhexis), 
and gross anatomical disturbance, such as ulcer, cancer, or phlegmon, 
explains its origin. 
Etiology.-The bleeding may be (1) gastric, or (2) extragastric. 
1. Gastric Bleeding.-Gastric bleeding may be from local or general 
causes. Local causes may be direct or indirect. 
Direct Local Causes.-Among these are: Ulcers simple, round, tuber- 
culous, typhoidal, diphtheritic, septic, etc.; varices, and miliary aneur- 
isms, perhaps associated with arteriosclerosis; gastritis, simple, acute, 
chronic, phlegmonous, or toxic; cancer and trauma. The trauma may 280 
DISEASES OF THE DIGESTIVE SYSTEM 
be direct or indirect, and the causes physical and chemical. Physical 
causes, e. g., foreign bodies; the strain of vomiting; injury from the 
stomach tube; stretching from distension by CO2. Chemical causes, as 
poisons, purgatives, emetics with degeneration of the mucous membrane, 
fatty, hyaline, or amyloid; and postoperative hematemesis, as yet ill- 
understood. 
Indirect Local Causes.-Portal obstruction in cirrhosis of the liver, 
syphilis of the liver, atrophy, pressure on the portal vein, portal throm- 
bosis (of these cases 80 per cent, are oesophageal in origin). Thoracic 
disease with circulatory obstruction, emphysema, chronic pleurisy, 
fibroid lung, and organic heart disease. Splenic enlargement, as in 
splenic anemia, etc. 
General Causes.-In these hemorrhage occurs from various mucous 
membranes as well as from the gastric. The conditions are many: sepsis 
(with or without signs of local lesion); the exanthemata (hemorrhagic 
forms) and other fevers such as typhoid; hematemesis neonatorum 
perhaps belongs to this group; autotoxic states, uremia, cholemia, etc.; 
blood dyscrasias and diseases, hemophilia, purpura, scurvy, pernicious 
anemia, leukemia, etc., possibly degeneration of vessels and capillaries, 
or emboli with hemorrhagic infarctions or infected thrombi; neuropathies, 
epilepsy, tabes, general paresis, hysteria, and meningitis, in all of which 
the hemorrhages may be vasomotor in origin; vicarious menstruation 
and burns. Debove and Coutois-Suffit attribute these unexplained 
hemorrhages without discernible lesions to abdominal congestion due to 
depressor nerves acting on arterial tension, as has been declared possible 
by Ludwig and Cyon. 
2. Extragastric Bleeding.-Apart from the hemorrhages which arise 
in the oesophagus from varices, etc., the blood may come from abscesses 
contiguous to the stomach bursting into that organ; or ulcers and fistulse 
may open up a suppurating tract into the stomach and cause hematemesis. 
Vertebral caries or aneurism of the abdominal aorta or coeliac axis may 
perforate the stomach and cause hematemesis. 
Age and Sex.-The age at which hematemesis occurs is usually from 
fifteen to forty; it is rare in infants. It is probably more common in 
women. 
Pathology.-The originating cause will in large part determine the 
nature of the general changes, e. g., cachexia in cancer, cloudy swelling 
in sepsis, etc. The mucous membrane of the gastro-intestinal tract 
is usually pale, and about the seat of the hemorrhage there will be the 
remains of blood more or less tarry. The clot formed varies in appearance. 
If there be little blood and gradual oozing one gets a chocolate or coffee- 
ground appearance perhaps, with black specks like powder sprinkled 
through the contents, or a diffuse bloody, or darkly stained fluid. At 
the seat of the hemorrhage one may find eroded vessels, and sometimes 
an imperfect clot formation. The opening is often very difficult or 
impossible to find or only evident after injection from the main vascular 
arrangement. 
Symptoms.-These depend chiefly on the amount of blood poured out 
and the rapidity with which it flows. Sometimes gastric hemorrhage is ORGANIC DISEASES OE THE STOMACH 
281 
latent, especially when the amount is small, and the blood must then 
be detected in the vomitus or feces (occult). At other times the blood 
is not vomited even when very copious, and the patient may even die 
with no other signs than those of internal hemorrhage. In true hema- 
temesis the blood, however, is vomited and may be large (up to two 
liters) or small in quantity. When small in amount it is usually mixed 
with mucus and food and appears either as minute specks or as streaks 
mixed with the other gastric contents. Its color depends upon its amount 
and the time in the stomach. The blood of minute hemorrhages is most 
easily transformed in color. When fresh, the color is bright and the 
blood cells are unchanged. When for some time in the stomach, the 
blood is dark and the oxyhemoglobin is changed to hematin, resembling 
coffee-grounds. Experiment has shown that if 50 cc. of blood reach 
the stomach and remain in it for five minutes, the red cells become 
altered and the color already much darker than normal. Microscopically 
one sees cells more or less broken down and blood pigment. Sometimes, 
again, there is much dark-red clot with an acid reaction. 
The patient may have a sense of warmth in the epigastrium and along 
the oesophagus; sometimes an abnormal pulsation with fulness is felt 
in the abdomen. Pain is frequently felt in the epigastrium for some 
time before hemorrhage, and may cease when this occurs. If quickly 
vomited, the blood may come not only through the mouth, but from the 
nose, and may get into the air passages and cause coughing. As a rule, 
hematemesis is accompanied by great anxiety and fear of death. The 
general signs of hemorrhage are present-pallor, faintness, dizziness, 
ringing in the ears, specks before the eyes, dimness of vision, cramps in 
the thighs and calves and perhaps clonic spasms, oedematous swellings 
over the smaller bones and eyelids, drowsiness, insomnia at night; the 
pulse is often dicrotic, anemic systolic murmurs are heard over the 
heart, and a venous hum over the large vessels. The blood picture is 
that of a secondary anemia. Fever is present, especially if the intestines 
have contained much blood, because absorption occurs; on this account 
the temperature is not infrequently reduced by purgative treatment. 
Recovery is sometimes rapid, at other times very slow, because bleeding 
from the vessels may be often repeated and small in quantity. 
Diagnosis.-When hematemesis has occurred one must consider the 
following questions: (1) Does the vomitus really contain blood? (2) 
If so, is it from the digestive tract? (3) Is it gastric in origin, and if so, 
does it come from near the cardiac end, from the duodenum, or from the 
stomach proper? (4) What is the etiological and anatomical lesion? 
(5) What vessel is affected? (6) Is it amenable to medical treatment, 
or, if not, is it accessible to operation? 
Hematemesis is so often latent or unrecognized that one must make 
careful observations both as regards the previous gastric history and 
the present state of the abdomen and gastric contents or vomitus. Not 
infrequently there is a fulminating gastrorrhagia, in which no blood is 
vomited and the diagnosis is made from the general sensations and 
symptoms of hemorrhage and the previous history of gastric disease. 
Even when very copious it may not be evacuated and the patient may 282 
DISEASES OF THE DIGESTIVE SYSTEM 
die with merely the signs of internal hemorrhage, or vomiting may be 
delayed for some time, or the blood may appear only in the stools. 
1. Is Blood Really Present in the Vomitus?- It not infrequently 
happens, both with patients and physicians, that a faulty diagnosis is 
made because the food previously taken may resemble blood, e. g., red 
wine, cherries, cranberries, red cabbage, red turnips, red sausages, coffee, 
and cinnamon. Pseudohematemesis may be associated with various 
preparations of iron or bismuth; the bismuth crystals, moreover, under 
the microscope, resemble to some extent those of hematin. In doubtful 
cases one should always examine microscopically for blood cells or blood 
pigment, and where doubt still exists, test with the spectroscope or by 
chemical means, to prove the presence of occult hemorrhages. 
2. Is the Blood from the Digestive Tract?-The blood may not be from 
the digestive tract at all, but from hemoptysis, epistaxis, or from a rup- 
tured aneurism. To differentiate from hemoptysis one must remember 
that in hematemesis the blood is dark-red in color, usually resembling 
venous blood; that it contains no air, has usually an acid reaction 
from contact with the gastric juice; that it is mixed with food; that it 
is vomited, not coughed; and it does not contain tubercle bacilli, for 
tuberculous ulcers of the stomach are extremely rare; and lastly, local 
findings in the lungs are absent, while those in the stomach are often 
obvious; or there may be signs of a heart lesion, the possible cause of 
hemorrhagic infarction of the lungs. Epistaxis may give rise to error 
through swallowing of the blood and subsequent vomiting. For this 
reason it is always well to examine the nasal cavity carefully and to 
look for polypi and other source of nasal hemorrhage. 
3. Having excluded other sources, one must decide whether the hemor- 
rhage he gastric, duodenal, or oesophageal. 
(Esophageal Varices.-There is nothing distinctive about the hemor- 
rhages from the oesophagus. (Esophageal varices are most commonly 
associated w7ith early cirrhosis of the liver, and one should therefore 
examine carefully for it. The evolution of the condition may help the 
diagnosis. In two-thirds of such oesophageal hemorrhages the patient 
improves, but recurrence takes place after intervals of days, months, 
or years. Sometimes they are fulminating in character. (Esophageal 
cancer may also simulate gastric ulcer, but has other evidences of malig- 
nant disease. (Esophageal ulcer causes pain after swallowing, increased 
secretion and regurgitation of mucus and food, and progressive signs 
of stricture. 
Duodenal hemorrhage from ulcer is sometimes accompanied by hema- 
temesis. Men are more commonly afflicted. As a rule, the stools show 
the first evidence of this condition. The pain is usually situated more 
to the right; it occurs later after meals than does that of ordinary gastric 
ulcer (two to four hours) or, at all events, is increased at that time; the 
digestive signs of pain, etc., coming on several hours after meals and the 
presence of HC1 help to establish the diagnosis. 
4. The nature of the causative lesion is often most difficult to determine, 
and is sometimes impossible. Neuropathic hematemesis is a problematical 
condition which is perhaps receiving less recognition each year; it is ORGANIC DISEASES OF THE STOMACH 
283 
presumably more common in nervous people, in females than in males; 
comes on after emotion with prodromata of heat, weight, or pain in the 
epigastrium and sometimes vertigo. It co-exists or alternates with 
hemorrhages from other organs which are presumed to have a similar 
cause. It is not usually fatal, and seems to have no effect upon the system 
in general. As a rule, patients thus afflicted pay but little heed to the 
hemorrhages when they occur. One should look for the other stigmata 
of hysteria. In all such cases, however, the exclusion of ulcer is not easy, 
and one will do well to diagnose the more serious antomical lesion until 
further proof of a mere neuropathic origin is possible. 
Vicarious hemorrhages usually occur in the absence of any gastric 
signs, have more or less periodicity, and at best are quite rare. They 
occur either at the time of the menses, or at times quite apart from that 
period. The menses may be absent and replaced by the hematemesis, 
the latter may coincide, with diminished menstrual flow. Legroux had 
a patient in whom monthly hematemesis occurred during the first seven 
months of pregnancy. 
Varices in the stomach are very rare, and doubtless have the same 
causes as those in the oesophagus. Letulle found only two cases in 
sixteen years. 
Venous Stasis.-Although varices are rare, dilatation of veins is 
common, and a rupture of the capillaries of the mucous membrane 
frequently occurs, as in cirrhosis of the liver, inflammation or tumors 
of the pancreas, cancer of the gall-bladder, wounds in the vicinity, etc. 
In the vomitus of peritonitis and intestinal obstruction there may be a 
little showing of blood; perhaps these types are infectious in nature. 
Hemorrhagic Erosions.-These show only bleeding and few or no 
other symptoms. Often the blood is found only in the washings from 
the empty stomach and usually then associated with chronic gastritis. 
The use of the term to indicate a special disease as suggested by Einhorn 
is disputed by Elsner and others. The bleeding may occur by the mouth 
or the rectum, as in latent ulcers. Such cases are rarely fatal, and 
usually occur in men who are in poor condition, with advanced tuber- 
culosis, or alcoholics with cirrhosis, etc. C. H. Miller attributes many 
gastric hemorrhages to erosions from swollen or ruptured lymphoid 
follicles in the stomach mucosa which has become thinned, while the 
basement membrane is unusually thickened. Thus the follicles are less 
covered, and under abnormal conditions, many lymphoid follicles become 
swollen, disintegrated, and softened. They in this way reach the surface, 
and may burst through the mucosa, thus leaving the basement membrane 
temporarily exposed to the gastric juice, which digests some of the 
numerous vessels of the submucosa. Hemorrhage then occurs. 
Miliary aneurisms of the submucous arteries as a part of generalized 
aneurisms cannot be distinguished clinically. 
Simple Ulcer of the Stomach.-Hematemesis coming on in healthy 
individuals or in those who have suffered from stomach disorders is due 
in the majority of cases to ulcer in some stage. The history with the 
symptom complex, the oft-recurring hemorrhage in youthful subjects 
with good appetites and good albumin digestion, the presence of HC1 284 
DISEASES OF THE DIGESTIVE SYSTEM 
in the contents, and the absence of cachexia aid in determining the 
presence of ulcer. The important point is not so much the exact diagnosis 
of the lesion, as the diagnosis of the value and possible success of inter- 
vention. The hemorrhage is often single and fulminating, as happens 
with the type of cases known as "exulceratio simplex." The term should 
become obsolete in the light of modern experience. 
Cancer of the stomach is usually easy to diagnose from the history 
and the findings. The patient is older, with anemia, perhaps cachexia, 
anorexia, no HC1 in the contents, but lactic acid instead, etc. While 
sometimes hemorrhage in cancer is acute and fatal, as a rule, bleeding 
is small, recurrent, and of a coffee-ground appearance. Occult blood 
in the stools is much more constant. However, many exceptions occur, 
and all possible factors must be considered together. 
6. Are the Ulcer and Vessel Accessible for Operation?-Fresh ulcers 
usually erode the superficial vessels in the wall and are readily reached; 
old ulcers may be adherent to the pancreas and liver and are sometimes 
hollowed out. Adhesions form beyond the limits of the organ and are 
deeply situated, fixed in immobile tissues, perhaps hard or friable, the 
vessels are deeper, less accessible, and often larger. In a wmrd, they 
erode rather the extrinsic arteries, such as the splenic, and make operation 
difficult, perhaps impossible. 
Prognosis.-This depends chiefly upon the cause and, to a less degree, 
upon the severity of the hemorrhage. In serious general conditions 
hematemesis is one of the worst prognostic symptoms. When blood 
flows from outside structures into the stomach the prognosis is bad. In 
poisoning cases the amount of hemorrhage itself is of no prognostic 
importance unless the contents be putrid, in which case deep ulceration 
may be suspected and death may follow from sepsis or perforation. 
It is often difficult to differentiate between rupture of the small and 
the large vessels, and statistics vary very much because there is nothing 
in the evolution of the condition or in the antecedent hemorrhage which 
can prognosticate a recurrence or progressive gravity or origin; one 
cannot say from the amount of blood and the area of pain what vessel 
is affected or whether the hemorrhage will recur. The most copious 
hemorrhages may have no visible anatomical lesions of the mucosa. 
Large hemorrhages, however, are rarely fatal (3 to 4 per cent., Lebert). 
Sometimes in gastric ulcer hemorrhage causes cessation of all the 
other signs; in cirrhosis of the liver that organ diminishes in size after a 
hematemesis. The cause is often more serious than the hemorrhage 
itself. In ulceration the prognosis is difficult to determine. Hyperacidity 
after the hemorrhage may act as an irritant and cause renewed ulceration 
and bleeding. For one month after a severe hemorrhage the condition 
continues serious, but from that time onward becomes less so, so far as 
life is concerned, but there is always the same uncertainty as regards 
recurrence. After eight to ten days the prognosis may be given as good, 
because of thrombus formation, although one must always keep in mind 
the possibility of hemorrhage from another part of the ulcer where a 
newly attacked vessel has opened. In cancer, hematemesis may usually 
be considered as a fatal sign because indicating advanced disease, 
although exceptions occur with bleeding at an early stage. ORGANIC DISEASES OF THE STOMACH 
285 
Preble concludes, from an analysis of 60 fatal cases of hematemesis 
with subsequent autopsies, that: (1) While not rare, fatal hemorrhage is 
at all events not common in cirrhosis of the liver. (2) The first hemor- 
rhage in cirrhosis is fatal in only one-third of all cases. (3) (Esophageal 
varices are the source of the bleeding in 80 per cent, of cases; in half of 
these, ruptures were found and are probably much more common than 
is generally realized. (4) Fatal hemorrhages sometimes occur from 
invisible ruptures of numerous capillaries of the gastric mucous mem- 
brane, and, as a rule, there are some accompanying signs of early 
cirrhosis of the liver. 
Treatment.-The indications are as follows: (1) Prophylaxis, when 
the possibilities of hematemesis are recognized. (2) Discovery of the 
etiological factor. (3) Control of the hemorrhage as quickly as possible. 
(4) Prevention of its recurrence. (5) Prevention of injurious sequelae. 
Prophylaxis depends upon the discovery of the possible underlying 
condition and its judicious treatment. Control of the hemorrhage 
requires rest in general and of the stomach in particular. The patient 
should be put to bed with the head low and kept as quiet as possible. 
All tight clothing should be removed and the patient encouraged with 
the explanation that hematemesis of itself is of no very serious import. 
Should faintness supervene, the face should be sprinkled with cold water, 
ammonia placed beneath the nostrils and if necessary camphor oil, ether, 
or caffeine, given hypodermically; a hot bottle may be placed to the feet. 
In the most serious cases an intravenous saline injection may be given 
and the arms and legs bandaged. An ice-bag may be suspended from a 
cradle so that it will come into gentle contact with the epigastrium. 
All food should be stopped for three days and the patient should be 
allowed only some ice to suck, but not to swallow. After three days, 
nutrient enemata may be given, three times daily. No food should be 
given by mouth until after the first week, and then, only gradually, 
boiled milk, broth, or gruel. 
Lavage of the stomach is best avoided, so, too, all local hemostatics. 
General hemastatics are perhaps beneficial; adrenalin, in doses of 25 
drops of the 1 to 1000 solution by mouth daily has apparently been of 
service. One may use rectal injections of calcium chloride, 4 to 8 gm. 
(3j t° 5ij) daily or gelatin is sometimes useful by the mouth. The 
reflex effect of heat as administered by hot rectal injections (115°) has 
been much recommended. 
Accessory Treatment.-Cold water enemata are useful for retained 
blood in the bowel. For the anemia, which may persist, one should give 
good food, and iron if the patient bears it well. 
Surgical Interference.-Indications.-The blood count and estimation of 
hemoglobin per se are of little value. Appreciation of the general condi- 
tion is more important than an estimate of the hematological state. If 
a low blood count has supervened on a. previous chlorosis the condition 
is more grave. The pulse has doubtful value. The amount of hemor- 
rhage is also of little importance as compared with its recurrence, which 
implies an end to medical treatment. For general surgical indications 
see the section on the Treatment of Gastric Ulcer. CHAPTER VI 
DISEASES OF THE INTESTINES 
ALFRED STENGEL, M.D. 
PHYSIOLOGY OF THE INTESTINAL TRACT 
Unfortunately our knowledge of the physiology of the intestines 
has not yet proved of much practical value in the study of intestinal 
diseases or their treatment. The newer physiology of digestion (both 
gastric and intestinal) gives promise, however, of some practical 
applicability in the near future, and for this reason requires to be 
kept prominently in mind. 
Motor Function of the Intestines.-The movements of the intestines 
serve three important purposes: (1) The onward movement of the 
contents; (2) thorough mixture of the chyme with the digestive secretion 
and close contact of the contents with the absorptive mucous membrane; 
(3) the propulsion of the venous blood and chyle away from the bowel. 
The old idea that the purpose of intestinal movements is to cause the 
passage of the intestinal contents toward the rectum has been disproved 
by recent investigations, which show that certain conspicuous move- 
ments of the bowel serve the purpose of thoroughly churning the con- 
tents and thus mixing the chyme and the digestive fluids and at the 
same time bringing the contents of the bowel into more complete contact 
with the mucous membrane. 
Three forms of movement are recognized: (1) Peristalsis proper; 
(2) rhythmic segmentation; (3) antiperistalsis. 
Peristalsis Proper.-Peristalsis proper, or the movement that causes 
the forward flow of the bowel contents, is a wave-like contraction that 
runs for some distance, gradually diminishing toward the end of its 
course, where a new wave starts up. The bowel contracts behind the 
contents and relaxes in front of them (Starling). These movements 
vary in rapidity and strength normally, and may become excessive in 
pathological states. Violent stimulation may cause a tonic contraction 
of a segment or a considerable portion of the bowel. The peristalsis of 
the colon causes an alternate protrusion and retraction of the haustra. 
Rhythmic Segmentation.--In skiagraphic studies of the movements 
of the intestinal contents Cannon found that constrictions occur at 
various places, and the portions of the bowel between the constrictions 
may subdivide by secondary segmentation. The segments subsequently 
reunite and divide with renewed contractions. As many as thirty 
segmentations a minute were observed. These segmentations involve 
the contents of the bowel and do not indicate the kind of contractions 
286 DISEASES OF THE INTESTINES 
287 
that occur in the wall between the segments. Possibly the swaying 
movements or waving movements described by Raiser may be the 
occasion of the segmentation. These are backward and forward con- 
tractions and relaxations affecting a limited part of the bowel and running 
in a direction parallel to its length. There is no appreciable narrowing 
of the lumen of the bowel. Such contractions might very readily divide 
the contents of the bowel into segments. Rhythmic segmentation con- 
tinues during sleep, but may be inhibited by excitement. These move- 
ments cause a churning of the contents of the bowel and perhaps to some 
extent aid peristalsis proper in their onward movement. 
Antiperistalsis.-Cannon has found this to be the important motor 
phenomenon of the large intestine. When the contents of the ileum 
are emptied into the large intestine they are carried forward for some 
distance. Antiperistaltic waves then begin and run to the ileocecal 
valve. A new significance is thus made manifest for the valve. The 
antiperistaltic waves working toward the closed valve churn the fluid 
contents and promote absorption. From time to time proper peri- 
staltic contractions move the contents farther toward the rectum. 
Mechanism of the Movements.-The movements of the bowel are caused 
by the irritating effect of their contents: solid, liquid, or gaseous. When 
empty, the intestines always are quiet. The irritation of the contents 
may be mechanical or chemical. Indifferent substances may act by their 
temperature or mere bulk. Of gases, hydrogen, oxygen, and nitrogen 
are indifferent, while carbon dioxide, sulphuretted hydrogen, and the 
hydrocarbons stimulate peristalsis. 
Englemann believes the stimulus is transmitted through the bowel 
from muscle cell to muscle cell, but Nothnagel insists that nervous 
influences are always necessary, as do Gad and Luderitz. The stimulus 
to peristalsis originates in the plexus of Auerbach. The plexus of Meissner 
is concerned with the contractions of the muscularis mucosae. Bayliss 
and Starling believe the swaying movements are myogenic in origin. 
External Nervous Mechanism.-Stimuli are carried to the intestine 
through the vagus, and irritation of this nerve causes movements of 
the whole small intestine and upper half of the large. Irritation of the 
splanchnic nerves inhibits movements. Cannon, however, has found 
that section of the splanchnics or of the vagi and splanchnics disturbed 
normal peristalsis very little. Other observers, like Bach and Ehrmann, 
found that the splanchnic nerve is the motor nerve of the longitudinal 
fibres and the inhibitory nerve of the circular fibres, while the vagus 
stimulates the circular and inhibits the longitudinal. Bayliss and Starling 
deny any motor functions to the splanchnic. The lower half of the 
colon and rectum are innervated through the inferior mesenteric plexus 
and hypogastric plexus. 
Pathological Peristalsis.-Various modifications of peristalsis may be 
met with. These may consist simply of excessive contractions, but in 
some cases rolling movements (Nothnagel) cause a contracted loop of 
the bowel to rotate like a wheel and then relax, while in other cases tonic 
contractions of a segment of bowel cause a stiffening and narrowing of 
this portion, which may last some time before it slowly relaxes. 288 
DISEASES OF THE DIGESTIVE SYSTEM 
Varieties of Pathological Peristaltic Movements.-(1) Increased peri- 
stalsis, (2) tonic contractions; (3) antiperistalsis. 
Increased peristalsis may occur: (1) When the bowel contents are 
abnormal; (2) after the administration of purgatives; (3) after thermic 
or chemical irritation; (4) after emotional shock; (5) in neurasthenia; 
(6) from inflammations; (7) in cases of stricture of the bowel. 
Tonic Contractions.-When the intestine is empty these convert the 
tube into a solid cord of a pale color. When a large part of the bowel 
is affected the abdomen may be scaphoid, as in certain cases of lead 
colic. Tonic contractions of a loop filled with contents may cause pain. 
Ordinary and even excessive peristalsis alone does not produce pain. 
Pathological antiperistaltic movements are found only in the large 
intestine, according to Nothnagel. Others, however, believe that such 
waves may affect the small intestine as well. Greutzer showed that 
fluid containing free particles introduced into the lower bowel may 
find its way high up, even to the stomach, in a few hours. This upward 
movement seemed to occur most actively when the fluid was a sodium 
chloride solution. It did not occur with potassium chloride or hydro- 
chloric acid solutions. Nothnagel has shown that sodium chloride 
applied to the external wall of the bowel causes upward movements 
running over several centimeters. 
Chemical Processes Occurring in the Intestine.-The digestive pro- 
cesses that take place in the intestinal tract are effected by secretions 
from the glands and lining cells of the intestinal mucous membrane 
itself; but, to a still greater extent, by secretions poured into the intestine 
from the liver and the pancreas. The important secretions are: (1) The 
pancreatic juice; (2) the bile; (3) the intestinal secretion. 
The Pancreatic Juice.-This alkaline liquid is a thin and somewhat 
watery fluid having a specific gravity of about 1007.5. The amount 
varies greatly, and cannot be stated with any certainty. In one case 
in which a permanent fistula existed (Glaessner) the amount was from 
500 to 800 cc. per diem; but there is reason to believe that the fluid may 
not have been a pure pancreatic secretion. The secretion of pancreatic 
juice begins soon after food has been taken into the stomach, and reaches 
its maximum during the second to the fourth hour after that time. The 
character of the food influences, to some extent, the amount of secretion 
and the time of its maximum flow; and the rate of secretion seems to be 
especially dependent upon the promptness with which ingested food 
is discharged from the stomach into the duodenum. 
The mechanism of pancreatic secretion has been determined by 
physiologists. It was first shown by Dolinsky, in 1895, that acids 
brought into contact with the mucous membrane of the duodenum 
promptly excite pancreatic secretion. This effect of the acid is certainly 
to a large extent independent of any influence upon nervous mechanisms, 
since the result occurs after section of the vagus and splanchnic nerves, 
quite as readily as when these nerves are intact. Bayliss and Starling 
have demonstrated the probable mode of action. They found in the 
mucous membrane of the duodenum an enzyme, prosecretin, which, 
under the influence of a 0.4 per cent, solution of hydrochloric acid, is DISEASES OF THE INTESTINES 
289 
converted into secretin. The latter is absorbed and, reaching the pancreas 
through the blood, stimulates it to activity. It is not improbable that 
the HC1 of the gastric contents may also exercise some effect upon the 
secretory and nervous mechanisms of the intestinal mucous membrane, 
but this is not of considerable importance. That secretin is carried to 
the pancreas in the blood has been proved by the fact that the pancreas 
may be stimulated by hypodermic injection of secretin. 
The ferments of the pancreatic juice are: (1) The proteolytic ferment, 
trypsin; (2) a diastasic ferment, amylopsin; (3) a lipolytic ferment, 
lipase or steapsin. 
Trypsin.-It has been claimed by some that this is not a single body, 
but that a variety of trypsins, of different stability, occur. It has also 
been shown recently that trypsin is secreted in the form of a pro-enzyme, 
trypsinogen, which is inoperative as a proteolytic ferment until activated 
or converted into trypsin by an enzyme derived from the duodenal 
mucous membrane known as enterokinase. Bayliss and Starling claim 
that the trypsinogen cannot be converted into trypsin except through 
the action of this duodenal ferment. 
Trypsin acts upon proteins in alkaline, slightly acid, or neutral media. 
Albumins are dissolved by its action without swelling, and, except 
serum albumin, are converted first into a globulin insoluble in water; 
later, into peptones soluble in water. Trypsin probably, however, 
carries the hydrolysis of certain peptones still farther, producing leucin, 
tyrosin, and other simple bodies. According to some recent observations, 
the prolonged action of trypsin destroys all peptones, leaving only end- 
products of a simpler nature. 
Amylopsin.-This enzyme is similar to, if not identical with, the 
ptyalin of the saliva. It hydrolyzes starches, with the formation of 
maltose and achroodextrin. These substances are further acted upon 
by the maltase of the intestinal secretion, and converted by this into 
dextrose. According to Hoffmeister, the maximum amylolytic effect 
occurs in the presence of a moderate acidity. 
Lipase or Steapsin.-This ferment was discovered by Bernard in 1849. 
It has never been isolated. Lipase splits neutral fats, with the formation 
of fatty acids and glycerin. The fatty acids thus liberated unite with 
alkalis to form soaps, the latter being further utilized for the emulsifica- 
tion of other fats. The recent experiments of Kastle and Loewenhart 
indicate that, by reversed action, lipase causes a synthesis of the products 
of the splitting of fat, with the re-formation of the original fat. This 
synthetic action is believed to take place in the intestinal wall, as well 
as in the tissues. Lipase is a widely distributed enzyme, being found 
in the blood and in many tissues. 
Bile.-The quantity of bile varies considerably under different condi- 
tions. The maximum secretion occurs about an hour after a meal. 
Protein foods increase the amount of secretion; fats reduce it; carbo- 
hydrates appear to have little effect. Starling believes that the secretion 
of bile is initiated by the action of a hormone (analogous with secretin) 
formed by the action of the acid gastric contents on the mucous mem- 
brane in the intestines. The total quantity of bile in twenty-four hours 
vol. in-19 * 290 
DISEASES OF THE DIGESTIVE SYSTEM 
varies from 500 to 600 cc. (Ranke, Wittich). Hammarsten found similar 
figures in his observations of seven cases of biliary fistula in man. The 
bile is a clear, alkaline, mucoid liquid, of yellowish to brownish color. 
Its important constituents are bile-acid salts (glycocholates and tauro- 
cholates) and pigments (bilirubin, biliverdin, etc.). The mucoid character 
is due to the presence of a nucleo-albumin or true mucin. Various other 
less important substances are present. There are also ferments, diastasic 
and lipolytic, which supplement the action of the pancreatic secretion. 
The principal action of the bile in digestion and food absorption is 
its relation to the emulsification of fats. The alkalis contained in the 
bile unite with the fatty acids to form soaps, and the bile directly aids 
in the splitting of the fats. It has been held that the bile exercises some 
antiseptic effect on the intestinal tract; and it probably has some influence 
in stimulating intestinal peristalsis. 
Succus Entericus.-The secretion of the intestinal mucous membrane 
is the product of various tubular glands of the small intestine. The 
quantity of the secretion has been estimated by Prigl as being as much 
as three liters a day. It is probable, however, that the amount varies 
greatly in different cases and under different conditions. Investigations 
have shown in the intestinal secretion and in the mucosa of the small 
intestines a number of important enzymes, of which the following have 
been most thoroughly worked out: enterokinase, erepsin, inverting 
enzymes, and secretin. 
Enterokinase.-This has been found in the mucosa of the duodenum, 
and seems to be the ferment that actuates trypsinogen, converting it 
into trypsin. 
Secretin is a stable body existing as a prosecretin in the intestinal 
mucous membrane. Under the influence of the acids of the gastric con- 
tents the latter is converted into secretin, which is absorbed, and reaches 
the pancreas through the circulation, stimulating this organ to activity. 
Erepsin completes the hydrolysis of proteins, acting upon the deutero- 
albumoses and peptones prepared by the preliminary stages of digestion. 
Inverting enzymes convert disaccharids into monosaccharids. 
Besides these substances, a secretin has been thought to exist which 
originates in the intestinal mucous membrane and, after absorption, 
stimulates the liver to activity. • 
ABSORPTION OF FOODS IN THE INTESTINE 
The products of digestion are mainly absorbed by the bloodvessels, 
and, entering the portal system, are carried to the liver. Fats, however, 
after their cleavage in the intestines, are resynthesized in the intestinal 
mucous membrane and absorbed through the lacteals. Carbohydrates 
are absorbed as simple sugars, monosaccharids, the disaccharids being 
converted into the simpler form by the action of inverting enzymes in 
the small intestine. When an excess of sugar is administered there may 
be direct absorption without such preliminary change. Fats are in 
part split into their constituents, fatty acids and glycerin, and in part DISEASES OF THE INTESTINES 
291 
emulsified, after which absorption through the mucous membrane 
occurs. The cleavage products are synthesized and, with the emulsified 
fat, enter the lacteals. Proteins are absorbed after digestion by pepsin, 
trypsin, and erepsin; and are absorbed as peptones or proteoses. To 
some extent, however, simpler bodies, such as leucin, tyrosin, arginin, 
etc., may be formed, and may be later synthesized to reconstruct the 
albumin of the tissues. It has been claimed that proteins may be 
absorbed without preliminary digestive alteration. 
To some extent, products of digestion that have escaped absorption 
in the small bowel are absorbed in the large intestine. Under normal 
conditions the main absorption that occurs in this part of the intestinal 
tract is that of water; and, as a consequence, the fluid contents of the 
upper part of the large intestine become more and more concentrated 
and finally solidified as they approach the rectum. 
THE INTESTINES AS EXCRETORY ORGANS 
The importance of the intestines as excretory organs is not perhaps 
as yet fully recognized. It is well known that in certain diseases large 
quantities of serum may be poured into the bowel, carrying toxic matters 
of various sorts, chemical, bacterial, etc. Certain inflammatory, ulcer- 
ative, and necrotic processes in the mucosa doubtless result from such 
excretions. Investigations with certain drugs and chemical bodies of 
other sorts have given direct proof of this excretory function of the 
intestines. Among other substances, iron, calcium, strontium, lithium, 
and cesium have been found to be largely excreted through this channel. 
AUTOMATIC MECHANISM IN INTESTINAL PROCESSES 
The entrance of chyme into the bowel and the secretion of various 
digestive fluids is regulated in an automatic manner. When the gastric 
contents reach a certain degree of acidity from the presence of free hydro- 
chloric acid a stimulus is exercised which occasions the opening of the 
pylorus and the expulsion of the acid chyme. This next acts upon the 
intestinal mucous membrane, and occasions a stimulus which effects 
the closing of the pylorus. At the same time, the acid acting upon the 
mucosa of the duodenum liberates secretin and possibly a hormone which 
stimulates the liver. To a minor degree, perhaps, the acid excites nervous 
stimuli, which aid in promoting pancreatic and hepatic activity. The 
alkaline bile and pancreatic juice entering the duodenum reduce the 
acidity of the chyme, neutralize it, and render it alkaline, thus establishing 
conditions favorable for the action of the various ferments. When the 
acidity of the duodenal contents has been neutralized, the stimulus 
which caused the closing of the pylorus is removed and a reopening of 
the pylorus with discharge of more chyme follows. 
The inert tripsinogen of the pancreatic juice is converted into trypsin 
by the ferment enterokinase, which like secretion is liberated from the 292 
DISEASES OF THE DIGESTIVE SYSTEM 
intestinal mucosa under the influence of the acid chyme. The other 
ferments derived from the intestinal mucosa are quite possibly secreted 
as a result of the same cause. 
THE FECES 
The feces consist of undigested and indigestible residues of food, 
together with altered digestive secretions, certain excretions from the 
intestinal mucosa, and a notable percentage of bacteria. According to 
the investigations of Strasburger and others, not less than a third of the 
dried substance of the feces consists of bacteria, and in some pathological 
conditions the amount is even greater than this. 
The quantity of fecal matter depends upon a variety of conditions. 
The amount of food, its digestibility, the absorptive power of the intes- 
tines, the quantity of bile or pancreatic juice, or of mucus thrown off 
by the intestinal glands, and the activity of bacterial processes in the 
bowel all influence the amount. Age, occupation, or habits of life, and 
functional conditions or diseases influencing the degree of peristalsis 
also exercise a decided influence. On a mixed diet, 120 to 150 grams, 
representing from 30 to 37 grams of solid residue, are passed in tw'enty- 
four hours. The greater the quantity of indigestible residue, the larger 
the fecal output. The variation of amount in different individuals is 
very considerable, as is shown in a table of Harley and Goodbody,1 
who found among 188 cases variations from 30 to 282 grams with a 
mixed diet. The average was 102.8 grams. 
The color of the feces is largely dependent on the character of the 
food. With a mixed diet the color is a light or dark brown, and is largely 
due to urobilin. Large amounts of meat cause a darker color of the 
stools, on account of the presence of altered blood pigment, hematin, 
and sulphide of iron. The greenish color seen when an abundance of 
green vegetables is eaten is due to chlorophyl. The feces passed by 
persons whose diet consists largely of milk are light yellow, the light color 
being caused by the quantity of fat in the excreta. Bright-green stools 
in children or adults may be due to bacterial pigments or to the passage 
of unaltered bile. Sometimes there is a light color resulting from the 
presence of bubbles of gas mixed with the fecal matter. The light color 
of feces in certain liver diseases is due to absence of bile and its derivatives. 
(See Acholic Stools.) Some medicines, especially iron, bismuth, lead, 
and silver, cause black stools; while others, like senna, rhubarb, and 
hematoxylin, cause a yellowish or reddish color. 
The odor is due to skatol and volatile fatty acids. In fermentative 
and putrefactive conditions various aromatic bodies may impart a sour 
to putrid odor. Sometimes all trace of odor is wanting. 
The consistency is normally dependent upon the amount of water, 
fat, and mucus associated with the insoluble residues. Lack of digestion 
and absorption of fat or excess of fat in the diet, excessive water drinking, 
1 The Chemical Investigation of Gastric and Intestinal Diseases, 1906. DISEASES OF THE INTESTINES 
293 
abnormal excretion of mucus from the intestinal mucosa, and increased 
peristalsis which hurries the contents of the bowels through the large 
intestine, all tend to make the stools soft, semiliquid, or even watery. 
In certain pathological conditions (choleraic diarrhoeas) there is an 
abundant watery outpouring into the bowel, and large watery evacua- 
tions are the result. The stools are more firm than normal when the 
food contains but little indigestible residue or when in the various forms 
of constipation the contents are retained too long in the large intestine. 
The reaction of the normal stool is usually alkaline or neutral. Some- 
times, however, a faint acid reaction is met with. Diet and pathological 
conditions of the bowel may occasion more decided acidity. 
The chemical composition of the feces varies widely. The amount of 
water in the feces of persons on a milk diet was found to vary from 
73.29 to 79.32 per cent., and in persons on a mixed diet was on the 
average 75.72 per cent. (Harley and Goodbody). Of the organic sub- 
stances met with normally, fats and their derivatives, soaps, albumin, 
mucin, phenol, indol, skatol, fatty acids and their salts are important. 
The daily excretion of nitrogen in fasting persons has been found to vary 
from 0.17 gram to 0.446 gram per day, the average being 0.254 gram 
(Schmidt and Strasburger). With a mixed diet Harley and Goodbody 
found a discharge of from 0.30 to 1.55 grams per day, the average being 
0.97 gram. Excess of diet, especially such as contains a large amount 
of residue, causes progressive increase in elimination of nitrogen. The 
percentage absorption of nitrogen of the food, with various forms of diet, 
varies from 90 to 96 per cent. Approximately, one-half of the nitrogen 
of the feces is contained in the bodies of the bacteria. Fat, like nitro- 
genous substances, is excreted in the feces even when the patient is fasting. 
The total excretion per day under these circumstances is from 0.57 to 
1.21 grams (Schmidt and Strasburger). With ordinary diet, either milk 
or mixed, the daily excretion is from 3 to 7 grams, the proportion of 
absorption varying from 91 to 98 per cent. The character of the fats 
ingested, and especially the melting point, determines to some extent 
the degree of absorbability. Phenol, skatol, and indol are products of 
bacterial processes, and their amount is to a large degree dependent on 
the activity of such processes. 
Among the inorganic constituents are chlorides and carbonates of 
alkalis, phosphates of the alkaline earths, and other inorganic salts in 
small amounts. The amount and source of the calcium salts have 
excited special interest. It is generally believed that calcium is to an 
extent eliminated by the large intestine, although some deny this. 
Microscopic examination serves to discover undigested particles of 
food, such as meat fibres, connective tissue, and starch bodies, that 
may be significant of different forms of intestinal or gastric disease. 
In inflammatory conditions mucus, pus cells, epithelium, and blood 
corpuscles may be found, and occasionally portions of exfoliated mucous 
membrane or portions of tumors of the bowel may be recognized. 
Mucus may be found as gelatinous or shred-like particles or as con- 
siderable masses, visible to the naked eye, or as stringy formations 
visible under low powers of the microscope. Mucus from the upper 294 
DISEASES OF THE DIGESTIVE SYSTEM 
bowel is often colored yellow by bile pigments; that from the colon or 
rectum is grayish or white. Certain small masses of gelatinous material 
that resemble mucus on superficial examination, presenting a yellowish 
color, may prove to be albuminous substances, and small globular masses, 
like frog spawn, are found to be derivatives of vegetable matter of the 
diet. Among the crystals found in normal feces triple phosphates are 
the most common. Crystals of neutral phosphate of lime, and of oxalate 
of lime, cholesterin and Charcot-Leyden crystals, may also be found. 
Acholic, Colorless, and Fatty Stools.-Acholic stools are yellowish 
gray or actually white in color. To a large extent this is due to the 
abseiice of hydrobilirubin, the normal pigment which is a derivative of 
bile pigment. In any condition in which complete obstruction of the 
hepatic or common bile duct occurs the feces become of the color de- 
scribed. Sometimes the same stool occurs without jaundice and without 
obstruction of the bile duct. In these cases the light color is usually 
due to the presence of enormous quantities of fat which may be dependent 
upon disease of the pancreas, obstruction of the pancreatic duct, or to 
various diseases of the intestines which interfere with the absorption 
of fat. Chemical analyses have shown in these cases that urobilin is 
present, although its color is obscured by the excess of fat. Another 
explanation of colorless stools in the absence of diminished outflow of 
bile is that the bile pigments are converted into colorless substances 
(leuko-urobilin). In these cases the stools give reactions for bile, and 
may be devoid of an excess of fat. 
Colorless stools may occur independently of any disease of the liver or 
pancreas. In various forms of intense diarrhoea, as in dysentery, or 
certain cases of enteritis, in tuberculous peritonitis in children (Berggriin 
and Katz), and occasionally in various other diseases, the feces may be 
quite colorless. A diminished excretion of bile may play some part in 
these conditions, but in most cases the altered color is the result of the 
amount of unabsorbed fat. 
Fatty Stools.-From what has just been said it will be seen that various 
conditions may occasion excess of fat in the stools. As a rule, however, 
the term fatty stools is applied to cases in which masses of fat can be 
seen in the feces or in which there is a distinctly oily appearance of the 
excreta. When somewhat watery, oil may collect on the surface of the 
liquid. Microscopically, fat crystals in large numbers are discovered. 
Fatty stools may result from: 
1. Increased ingestion of fat, as in persons consuming large quantities 
of milk, cream, olive or cod-liver oil. 
2. When absorption of fat is interfered with (a) by diseases of the 
bowel, such as enteritis, ulceration, etc., or (b) by active peristalsis and 
the prompt evacuation of the upper bowel. 
3. When bile is excluded from the bowel by obstructions of the bile 
duct. The excess of fat associated with acholic stools has been mentioned. 
4. When disease of the pancreas or obstruction of its ducts causes 
deficiency of pancreatic juice. In these conditions the most typical 
fatty stools are met with. A veritable fatty diarrhoea may occur. The 
association of obstructive biliary conditions often aids in the production DISEASES OF THE INTESTINES 
295 
of the fatty stools of pancreatic disease. A difference between the 
fatty stools of biliary obstruction and of lack of pancreatic secretion has 
been indicated by Muller. In the former condition a large percentage 
of the fat present (84.3 per cent.) had suffered cleavage, whereas in 
cases of lack of pancreatic fluid only 39.8 per cent, had been converted. 
Intestinal Sand.-Occasionally gritty, sand-like material is discharged 
from the intestines. This usually consists of granular particles of grayish 
or reddish color, and on chemical examination has been found to contain 
various organic and inorganic substances. Duckworth and Garrod 
found, in a case in which chemical analyses were made, the following 
constituents: water, 12.40; organic matter, 26.29; inorganic matter, 
61.31. The inorganic constituents consisted of calcium oxide, 54.98; 
phosphorus pentoxide, 42.35; carbon dioxide, 2.20; residue, containing 
traces of magnesium and iron, 0.47. Analyses by other investigators 
have given similar results (Harley and Goodbody). The term intestinal 
lithiasis has been applied to this condition, in the thought that there 
is a particular form of catarrh of the intestines with the discharge of 
calcareous matter comparable to the formation of calculi elsewhere. 
Intestinal sand is probably formed in the colon, as it usually contains 
considerable urobilin and little bile-pigment. It must, therefore, be 
produced in a part of the intestines in which the conversion of bile- 
pigment has progressed considerably. The condition with which intes- 
tinal lithiasis is most commonly associated is mucous colitis. 
A condition (false intestinal sand) that requires differentiation is that 
in which various residues of vegetable food are passed. These may have 
a sandy character that suggests true intestinal sand. 
BACTERIOLOGY OF THE INTESTINAL TRACT 
Enormous numbers of bacteria normally occupy the intestinal tract. 
A conception of the number may be gained from the knowledge that 
Strasburger found that one-third of the weight of the dry residue of 
the feces consists of the bacterial bodies. In normal adults the weight of 
the dried bacteria passed in twenty-four hours is as much as 8 grams; while 
in certain dyspeptic conditions it may reach 14 to 20 grams. When habitual 
constipation is present the weight falls to 5.5 or as low as 2.6 grams. 
Distribution of Bacteria in the Intestines.-Billroth recognized that 
there are far more bacteria in the large than in the small bowel. Systemic 
examinations show a progressive increase in number from the duodenum 
to the large intestine. The duodenum and jejunum may be entirely 
free six hours after meals (Cushing and Livingood). Below the jejunum 
bacteria are probably never absent after birth. 
The kinds of bacteria as well as the number vary in different parts 
of the digestive tract. This is doubtless due to changes in the conditions 
in different situations. The gastric secretion, the bile, and the pan- 
creatic juice have probably only a moderate effect .in destroying bacteria 
ingested with food. Smith and Tennant claimed that the secretions 
of the intestinal mucosa have an inhibitory effect on the multiplication 
of bacteria. The condition of the intestinal contents with reference 296 
DISEASES OF THE DIGESTIVE SYSTEM 
to the process of digestion and the presence or absence of oxygen are 
factors that have an influence on the number and kind of organisms 
present in different localities. Herter showed that the conditions are 
practically anaerobic below the middle of the small intestine. 
The organisms generally found in the duodenum and jejunum are 
various forms of micrococci and other varieties swallowed with food or 
saliva. In the lower part of the small intestine are found the obligate 
intestinal bacteria which belong respectively to the groups Bacillus 
lactis aerogenes, B. coli, and B. bifidus communis. These forms remain 
as permanent inhabitants and are not dependent on ingestion with food. 
Although capable of exercising pathogenic properties under certain 
circumstances, they are ordinarily so adapted to the organism, and it 
to them, that their presence is devoid of any pathological effects. An 
evidence of their adaptation to the organism is seen in the fact that 
the serum of normal individuals has little agglutinative influence on 
these organisms. Although within the intestinal tract, they are prac- 
tically outside the body, and whatever products are elaborated by 
their growth apparently have little effect on the system. The most 
abundant of the three forms of microorganisms named is the colon group. 
Cushing and Livingood found the maximum just above the ileocecal 
valve. Their number decreased decidedly in the colon. 
Among the forms met with in the lower small intestine and in the 
large bowel are certain anaerobes, notably B. putrificus and B. aerogenes 
capsulatus. Recently considerable attention has been given to the 
possible pathological results of the growth of such forms (Metchnikoff, 
Herter). Many other microorganisms have been found in the intestinal 
tract under seemingly normal conditions. 
The meconium before birth is sterile. Very soon after birth micro- 
organisms are swallowed or enter the anus, and a considerable flora is 
soon present. In nurslings the Bacillus bifidus is the most abundant 
form in the large intestine, the Bacillus coli being less numerous. In 
bottle-fed children the dominant form, as in adults, is B. coli (Herter). 
The Significance of Bacteria in the Intestinal Tract.-Are bacteria 
in the intestines to be regarded as a normal condition and necessary 
to life? Nuttall and Thierfelder kept young guinea-pigs, that had been 
removed from the maternal uterus by Caesarean section under aseptic 
precautions, for some weeks in a sterile condition by feeding sterile food 
and allowing only sterile air to reach them. The animals gained weight 
and in every way developed as well as the controls. However, con- 
clusions the reverse of those of Nuttall and Thierfelder have been arrived 
at by some other investigators, who found that animals did not develop 
in a normal manner when kept free of bacteria (Schottelius, Madame 
Metchnikoff, Moro). Pasteur and Nothnagel believed that bacteria 
are essential to physiological life, and certainly, whether essential or 
not, they are universally present and exercise a distinct effect on the 
intra-intestinal processes. The role of bacteria in the conversion of 
bile pigments into urobilin, the final decomposition of products of protein 
digestion by bacteria, the possible presence of enterokinase of bacterial 
origin (Dellezenne, Breton), and other evidences may be recalled. DISEASES OF THE INTESTINES 
297 
Under ordinary conditions the bacteria of the feces are practically 
all dead. Klein estimated that a little over 1 per cent, are living forms, 
and Strasburger found even a lower proportion. The causes of this 
practical sterilization of the feces have not yet been determined with 
certainty. Possibly the changing reactions and other conditions at the 
different levels of the bowel may play some part, as may also influences 
exerted by the bowel wall and its secretions. Perhaps products of the 
bacteria themselves occasion their own destruction. 
There is considerable evidence to prove that the normal intestinal 
flora is useful in protecting the individual against accidental pathogenic 
invaders. There seems to be little doubt that B. coli and B. bifidus 
exercise some inhibitory action on the growth of pathogenic organisms 
such as the putrefactive anerobes and various specific pathogenic forms. 
Conradi and Kurpjuweit attribute this effect to antibacterial substances 
elaborated by the B. coli. They believe, also, that the same substances 
destroy the organism itself, thus accounting for the nearly sterile condition 
of the feces. Lactic acid formed in the intestinal tract or swallowed 
with food may exercise a restraining influence on the growth of patho- 
genic (putrefactive) organisms. This may explain the controlling influ- 
ence of a milk diet observed clinically in cases of intestinal putrefaction. 
Growth and Virulence of Intestinal Bacteria.-Various digestive 
disturbances may increase the growth of bacteria by causing large 
amounts of nutritious material to pass down to the lower bowel. In 
habitual constipation, when practically all absorbable material is taken 
up in the small intestine, the number of bacteria in the feces is the 
lowest met with under any conditions. The total bacterial output was 
found to be as low as 2.6 grams as against as much as 20 grams in dys- 
peptic conditions and 8 grams in normal persons (Strasburger). Excessive 
feeding acts in the same manner as digestive disturbances, and in part 
as a result of the dyspeptic conditions caused by it. Catarrhal condi- 
tions of the bowel, the result of excessive multiplication of the bacteria 
or occurring independently, favor further increase of bacterial growth 
and increased virulence of the organisms. When ulcerations, erosions, 
or other lesions of the mucous membrane are present, the ordinarily 
harmless intestinal bacteria may gain access to the tissues and may 
occasion local or general infections. Sometimes a symbiotic relationship 
is established between different bacterial forms or between bacteria and 
protozoa. The Bacillus coli, for example, is said to grow in virulence 
in the presence of staphylococci and streptococci (Coco). 
Diagnosis of the Types of Intestinal Bacteria.-Systematic culture 
methods are of course required to determine accurately the kinds of 
organisms present in the intestinal tract. Such examinations are essential 
in the diagnosis of certain specific disease such as cholera and dysentery; 
and occasionally in typhoid, paratyphoid, and allied infections. In other 
intestinal disorders simpler methods may serve to identify the prevail- 
ing types of invading organisms. Strassburger's method is as follows: 
Mix a portion of the feces with water and centrifugate; dilute the turbid 
supernatant water with two parts of alcohol; centrifugate and spread 
the sediment on glass slides; Gram-stain and counter-stain with fuchsin. 298 
DISEASES OF THE DIGESTIVE SYSTEM 
In such preparations the stools of breast-fed infants show a predominance 
of Gram-positive bacilli, while in bottle-fed children the Gram-negative 
Bacillis coli is conspicuous. In adults the latter type is especially marked, 
while a diet of milk and. carbohydrates occasions the appearance of a 
small proportion of large-sized Gram-positive bacilli and one of meat 
in considerable amount that of Gram-positive micrococci. 
Treatment of Bacterial Invasions of the Intestinal Tract.-The problem 
of disinfecting the gastro-intestinal tract has occasioned much discussion, 
but still remains unsolved. The most important element in treatment 
is the proper regulation of diet and the avoidance of all infection of 
food. This involves the avoidance of all putrefactive contamination 
of food by proper care in its preservation and preparation, and the with- 
drawal of such articles as cheese, uncooked fruit, or milk. The careful 
cleansing of the mouth is also an important element. 
The quantity of food is of importance. Excessive eating occasions 
the passage through the intestinal tract of increased quantities of un- 
absorbed material and favors bacterial multiplication. A strict regulation 
and limitation of the diet is, therefore, desirable; and remedies such as 
hydrochloric acid, pepsin, pancreatin, and the like, which aid digestion, 
may prove beneficial. Sometimes an exclusive milk diet is useful, par- 
ticularly when albuminous decomposition or putrefaction is conspicuous. 
In other cases, a strict limitation of carbohydrate foods is required. 
No general rule can be laid down as individual cases vary widely. 
Intestinal antiseptics of various sorts have been tried; but so far none 
can be said to have a generally useful effect. Small doses of calomel 
may be helpful, and other laxatives or purgatives may be temporarily 
beneficial, by cleansing the intestinal tract. Betanaphthol, ichthyol, 
resorcin, salol, creosote, etc., have been tried, but appear to exercise 
little, if any, useful effect. Sometimes, as Steele showed, these remedies 
may cause more injury to the mucous membrane than to the bacteria; 
and may, therefore, increase rather than decrease the number of organ- 
isms and the activity of the putrefactive process. Sometimes astringent 
remedies, such as bismuth and tannin, may have a useful effect. 
Renewed attention has been called to the possibility of influencing 
intestinal fermentation and putrefaction by the administration of cultures 
of bacteria. An old method was to administer brewer's yeast. More 
recently, Brudzinski, Metchnikoff, and Tissier have employed cultures 
of organisms that occasion lactic acid fermentation. The same principle 
applies to the administration of sour milk, buttermilk, koumyss, etc. 
The value of this form of treatment has not been determined. It is 
doubtful whether the extravagant claims will be substantiated. 
GASEOUS DISTENSION OF THE INTESTINES 
The terms meteorism and tympanites have been applied to the occur- 
rence of abnormal quantities of gases in the intestines, the former signify- 
ing acute, the latter chronic, distensions. Normally there is always a 
certain amount of gas in the bowels, consisting of the constituents of 
atmospheric air that has remained unabsorbed after having been DISEASES OF THE INTESTINES 
299 
swallowed, and other gases derived from the blood or from fermentative 
processes in the intestines. Among the gases present are oxygen, hydro- 
gen, ammonium, carbon dioxide, methane, and sulphuretted hydrogen. 
The oxygen is mainly that which gains access to the bowel from atmo- 
spheric air swallowed with food. It is, however, readily absorbed, and, 
consequently, disappears in the small bowel, the large intestine being 
practically free of it (Herter). Carbon dioxide is largely derived from 
the blood; and the other gases are mainly derivatives of fermentative 
processes. The amount of gas normally present is small, and is regulated 
by the absorptive processes and the discharge of any excess from the 
stomach or bowel. Abnormal accumulations may be due to increased 
swallowing of air, to active gas formation within the bowel, and to 
interference with absorption or escape of the gas from the intestines. 
The formation of abnormal quantities of gas by fermentation is a 
frequent accompaniment of catarrhal conditions of the bowel and of 
functional intestinal indigestion. Various forms of fermentation may 
occur, such as those affecting principally carbohydrates; or others in 
which proteins or fats are involved. Sometimes such fermentative or 
putrefactive conditions are excited by indiscretions in diet, as when 
the patient eats excessively of readily fermentable food. With many 
individuals, milk is a common cause of the condition. 
Gaseous distension due to failure of absorption or inadequate dis- 
charge of gas from the bowel is common in various intestinal diseases. 
Such distensions are habitually met with in cases of partial or complete 
intestinal obstruction. In these cases the interference with the discharge 
of gas from the bowel is the important factor. In catarrhal inflammation 
and intense congestion the accumulation of gas is due largely to the 
failure of absorption. This is strikingly illustrated in cases in which a 
portion of bowel strangulated by volvulus becomes enormously distended. 
The gases in such instances are partly due to fermentation within the 
loop, partly to the liberation of carbon dioxide from the blood and to 
the stagnation of the circulation preventing reabsorption. 
In peritonitis and in certain conditions of nervous or functional 
weakness of the intestinal walls, gaseous distension results from the 
inability of the bowel to remove the accumulations. 
In hysterical individuals, and sometimes in persons not manifestly 
hysterical, extreme distension of the abdomen or localized distension 
may occur. The name phantom tumor has been applied to this condi- 
tion. In many cases it is paroxysmal and transient, but sometimes it 
proves quite lasting. Many of the instances, however, of supposed 
chronic phantom tumor have doubtless been cases of idiopathic dilatation 
of the colon. The explanation of phantom tumors has occasioned some 
difficulty. There is, probably in most cases, an actual increase in the 
amount of gas; but the distension is, in part, more apparent than real, 
being dependent to some extent upon contractions of the diaphragm 
and of the abdominal muscles. In other cases, a paresis of the abdominal 
muscles doubtless plays a part. 
Symptoms.-The important symptom of meteorism, or tympanites, 
is the distension of the abdomen. This is usually uniform; but in some 300 
DISEASES OF THE DIGESTIVE SYSTEM 
cases it affects limited portions of the bowel, and therefore of the abdo- 
men, more than others. Localized collections of gas are not infrequent 
in association with organic conditions of the bowel. The degree of dis- 
tension may vary from slight fulness to enormous enlargement, the 
amount depending upon the resistance offered by the bowel itself and by 
the abdominal walls. Subjective symptoms are rarely wanting. In 
acute cases there is often marked discomfort or severe colicky pain. 
In the more chronic forms constant slight abdominal distress, accom- 
panied from time to time by exacerbations of distension, is complained 
of. Loss of appetite, coated tongue, nausea, and a tendency to vomiting 
after slight indiscretion in diet, and other evidences of disordered digestion 
are frequent. General symptoms, such as drowsiness, listlessness, and 
a variety of nervous manifestations, including headaches, neuralgias, 
and even pronounced neurasthenic symptoms, are common. 
On physical examination, the abdomen presents a certain type of 
elastic resistance that is usually quite characteristic; and on percussion 
the deep note of tympany is more or less pathognomonic. The liver 
and spleen may be displaced, and their normal areas of dulness obscured 
or almost obliterated. This is particularly important in the case of the 
liver, on account of the possibility of mistaking tympany for the accumu- 
lation of gas in the peritoneal cavity. In extreme cases the diaphragm 
is forced upward, and the heart may be displaced, sometimes to the 
extent of two or three intercostal spaces, and the bases of the lungs may 
be somewhat compressed. In these instances signs of pulmonary and 
circulatory embarrassment are usually present. 
In cases of phantom tumor symptoms may be wanting, or the patient 
may complain of various subjective manifestations. A local gaseous 
distension may simulate an actual abdominal tumor. When the dis- 
tension is extreme and the normal tympanitic note gives place to a 
duller tone on percussion, the simulation may be quite confusing. 
Diagnosis.-The diagnosis of meteorism rarely occasions difficulty. 
The important question in the diagnosis is to determine the cause, and 
this requires a careful consideration of the many conditions in which 
such distension may occur. 
Treatment.-In moderate cases due to irritative and fermentative 
conditions in the bowel, restriction and regulation of the diet may 
speedily relieve the condition. Remedies may, however, be required 
to reduce the distension more speedily. Various carminatives, such 
as oil of peppermint, menthol, chloroform, Hoffmann's anodyne, asa- 
fetida, and the like, are employed for this purpose. 
Sometimes the use of laxatives or purgatives may be beneficial, but 
usually evacuation of the bowels is best accomplished by the employment 
of enemata containing asafetida or turpentine in saline solutions, soap- 
suds, etc. When the distension is excessive, a rectal tube may be useful 
in causing a rapid discharge of gas. The peristalsis may be stimulated 
by the use of eserine or pituitrin. Hypodermic injections of the sul- 
phate of eserine, in doses of gr. to repeated at intervals of 
three or four hours, sometimes act promptly and most satisfactorily. 
Puncture of the distended bowel has been practised, but is a dangerous 
mode of treatment and cannot be advised. DISEASES OF THE INTESTINES 
301 
INTESTINAL INDIGESTION 
This term is preferable to the name intestinal dyspepsia, sometimes 
applied to it, because the latter suggests the gastric digestion rather 
than that of the intestines. In a broad sense, intestinal indigestion may 
be used as a term denoting any form of interference with the normal 
intestinal functions, but it is more properly restricted to functional 
derangements, rather than to such as may attend organic disease. In 
inflammatory conditions of the intestines, in obstruction, in cases of 
ulceration, tumors, and the like, the normal digestive processes and ab- 
sorption are interfered with; but these are promptly considered as direct 
consequences of organic troubles. Leaving such cases out of considera- 
tion, there remains a group of conditions in which, without gross organic 
disease, disturbance of the intestinal functions is met with. 
Etiology.-Functional intestinal indigestion may be due to (1) lack 
of bile and pancreatic juice; (2) lack of secretion of the intestinal ferments 
proper; (3) bacterial fermentative processes. 
Attention is directed to the effects of the withdrawal of biliary and 
pancreatic secretion in the discussion of fatty stools, acholic stools, 
and diarrhoea. Usually, in the consideration of intestinal indigestion, 
these conditions are not taken into account. Unfortunately, very little 
can be said regarding the functional results of insufficient secretion of 
intestinal ferments proper. That these secretions play an important role 
in the functions of the intestinal tract is entirely probable, in view of 
our present knowledge; but the clinical significance of derangement of 
these secretions has not been determined with any definiteness. 
Disturbance of the intestinal digestion may be a secondary result of 
the disorders of gastric digestion. In cases of hyperacidity of the gastric 
contents the alkalinity of the bile and pancreatic juice may be insufficient 
to neutralize the acidity of the chyme, in consequence of which the 
reaction of the contents of the duodenum and jejunum remains acid, 
instead of being alkaline. This interferes with the normal pancreatic 
digestion, and at the same time subjects the mucosa of the upper small 
intestine to irritation. A similar effect may follow insufficient secretion 
of bile and pancreatic juice, in which case the normal acid chyme may 
fail of neutralization. Much more common is the development of 
acidity in the small intestine as the result of bacterial invasion. This is 
very common in infants and children. Bacterial decomposition of milk 
and other foods may occasion the formation of lactic, acetic, and other 
acids, and may thus interfere with pancreatic digestion and, at the same 
time, occasion irritations of the mucosa of the small bowel. The effects 
of these conditions are, first, an interference with normal intestinal 
digestion; second, an increased liability to bacterial activity; and, third, 
irritation of the mucosa. 
Symptoms.-These are partly gastric and partly intestinal. Among 
the gastric manifestations, nausea, vomiting, flatulence, and sensory 
disturbances, such as heaviness or pain, may be mentioned. Among 
intestinal manifestations are gaseous distension and diarrhoea. The 
acid contents provoke an irritation of the upper bowel and the formation 302 
DISEASES OF THE DIGESTIVE SYSTEM 
of the excessive quantities of mucus. At the same time, peristalsis is 
increased by the irritation; and the semifluid contents of the upper 
bowel are hurried into the lower bowel and discharged before normal 
inspissation and chemical changes have time to occur. The stools are 
acid instead of alkaline, and frequently cause marked irritation of the 
rectum and anus. In children this becomes an important symptom; 
and intense irritation, sometimes extending to a considerable distance 
over the buttocks, may be met with. The movements are usually some- 
what tenacious, on account of the admixture of excessive quantities of 
mucus, and commonly present a greenish color, on account of the presence 
of bacterial pigments or of unaltered bile. In a special form described 
by Schmidt, under the name of intestinal fermentative dyspepsia, the 
stools are of light color, foamy, and of a musty or sour odor, due to 
the presence of butyric acid. When functional indigestion persists, the 
irritation of the bowel readily passes into catarrhal inflammation. 
Diagnosis.-This often presents great difficulty. In some instances 
the symptoms are vague and indistinct; and it may be difficult to deter- 
mine that a continuous tendency to intestinal flatulence and slight dis- 
order of the bowel is due to functional disturbance rather than to organic 
disease. In more acute cases, especially those occurring in children, 
the evidence is more trustworthy. The occurrence of mucous, gelatinous 
stools of green color, acid reaction, and sour or musty odor, is strongly 
significant of this form of disease. It is always difficult, however, 
to determine that an actual catarrhal enteritis has not supervened. 
Treatment.-This requires close supervision of the diet. In the 
beginning of acute attacks, the withdrawal of all food may be advisable. 
In children, as well as in adults, the substitution of albumin water, 
broths, soups, or barley water for the ordinary diet, and especially for 
a milk diet, is advisable. Later, the food should be regulated according 
to the nature of the case. Sometimes, when fermentative processes 
and gas-formation are conspicuous, it is best to use only animal food, 
such as eggs, soups, jellies, and gelatin preparations; while in other 
cases, in which albumin decomposition predominates, gruels, cereals, 
and farinaceous foods generally, with smaller amounts of albuminous 
food, should be given. 
The medical treatment is directed to the evacuation of the contents 
of the intestines and the removal of fermenting material. A full dose 
of castor oil, or repeated small doses, may accomplish this purpose. 
Calomel in small amounts (gr. 4^ to gr. two or three times daily, 
may exercise an antiseptic effect, as well as a slightly laxative influence. 
Other remedies like salol, betanaphthol, guaiacol carbonate, and ichthyol 
may be useful as antiseptics. After the upper bowel is free of fermenting 
contents, bismuth, chalk mixture, or other mild astringents may be 
desirable to allay existing irritation and check the tendency to further 
diarrhoea. Pancreon, prepared by treating pancreatin with tannin, is 
recommended when intestinal indigestion is due to decreased secretion 
of pancreatic juice. It is administered dissolved in water before meals 
in a dose of gr. vj (gm. 0.4). In cases in which gastric disorders have 
preceded the intestinal disturbance the treatment should be directed 
primarily to the condition of the stomach. DISEASES OF THE INTESTINES 
303 
INTESTINAL COLIC 
Definition.-The term intestinal colic should be restricted to attacks 
of paroxysmal intestinal pain caused by violent tonic contractions of 
the bowel resulting from undue stimulation of the intestinal nerves or 
from obstructive conditions. The more or less continuous pain and 
tenderness of-inflammation of the bowels or peritoneum, and the purely 
neuralgic pain (enteralgia, in the strict sense) should not be included 
under the head of colic. 
Etiology.-The immediate cause of the pain of colic is the excitation 
of the intestinal nerves and the violent tonic contraction of the bowels 
caused by irritating intestinal contents or by obstructive conditions. 
The cases may be divided into those in which there is mainly functional 
disturbance and those associated with organic conditions. 
Colic Due to Functional Disturbances.-Some persons are so sensitive 
that even when the food or other ingesta are wholesome, slight causes 
such as exposure to cold, fatigue, anger, fright, or other emotional 
conditions, occasion attacks of colic. It is probable that under these 
circumstances digestion and absorption of food products are interfered 
with, fermentation or putrefaction occurs, and irritation of the intestinal 
nervous mechanism takes place. More commonly, colic results from a 
definite error in diet. The eating of coarse foods, unripe fruit, indigestible 
substances of all sorts, especially if in excessive quantity, is perhaps the 
commonest cause. The drinking of cold water, beer, or other liquids 
at the same time may add to the disturbance, or may alone suffice to 
bring on an attack. Developmental conditions causing functional 
weakness or chronic conditions of the bowel, such as partial stenosis, 
may predispose to attacks of colic under relatively slight provocation, 
such as overeating. In infants or young children the connection between 
dietetic errors and colic is nearly always apparent. Frequently such 
cooperating causes as exposure to cold, fatigue, or emotional disturbances 
may play an important etiological part. Idiosyncrasy also contributes, 
some persons finding it impossible to eat certain, usually wholesome, 
articles of food without suffering an attack. Whether the ingested food 
is inherently irritating or is rendered so by the conditions of the patient 
at the time, or his idiosyncrasies, the result is a violent irritation of the 
nerves of the intestines and a forcible contraction of the muscles of the 
intestines which causes'the painful paroxysms. If the amount of food 
residue and gaseous accumulations in the intestinal canal is excessive, 
the obstacle thereby offered to the contractions of the bowel becomes 
an added cause of pain. Nearly always some sort of obstacle to the 
free movement of intestinal contents is more or less responsible for 
attacks of colic. In some cases violent irritation of highly noxious sub- 
stances may occasion a spasm or paresis of a segment of bowel which 
thus becomes practically a seat of obstruction. Mere distension of the 
bowel by gases does not occasion colicky pain, as may be seen in the 
comparative freedom from all pain in cases of quite marked meteorism 
and the different type of discomfort or pain in cases of excessive distension. 304 
DISEASES OF THE DIGESTIVE SYSTEM 
Certain special substances may act in a direct way upon the nervous 
mechanism of the bowel. This is seen in the intense colic of lead poisoning 
and the colicky pains caused by certain laxative medicines. 
Formerly much was said about "rheumatic colic." The cases so 
designated were cases of colic following exposure to cold and associated 
with more or less muscular soreness. Some of these doubtless were simply 
instances of painful conditions in the abdominal walls; others cases of 
colic due to intestinal indigestion, fermentation, etc., following the 
eating of indigestible food, and exposure. It is doubtful if any of the 
cases were instances of "rheumatic colic" in a proper sense. 
Fecal accumulations may cause purely functional colic, although they 
are usually associated with some organic condition. When a considerable 
impaction has occurred, the peristaltic efforts of the bowel above the 
accumulation become more and more severe until finally tonic contrac- 
tion ensues and an attack of colic results. 
Colic Due to Organic Conditions.-Foods may prove so irritating to 
the bowel that an actual catarrhal inflammation is occasioned. This 
happens quite frequently in children when tainted milk is taken and in 
adults when bacterial decomposition causes putrefactive changes. The 
catarrhal inflammation adds to the irritability of the intestinal nerves 
and increases the tendency to an attack of colic. Ulceration of various 
sorts of the large or small intestine, such as tuberculous, typhoidal, 
stercoral, or simple follicular, may occasion genuine attacks of colic. 
The association of colic with appendicitis is exceedingly common, and 
may be due to violent contractions of the appendix itself (appendicular 
colic) or the ileum or colon. All these inflammatory lesions may excite 
tonic peristaltic contractions, and the partial obstruction at the site 
of inflammation increases the obstacle to the movement of the intestinal 
contents from above. 
Symptoms.-The ordinary attack of intestinal colic due to functional 
disorder of the bowels is usually sudden in onset, beginning with violent 
cramp-like pains in the umbilical region which spread in various direc- 
tions. As the peristaltic movements advance from one part to another 
the patient experiences a change in the position of the pain, and there 
may be at the same time a sense of movement of gases from one coil 
of intestines to another. In very severe attacks the pain is more fixed 
and cannot be definitely localized. The patient at first moves from 
side to side, draws up his leg, and presses his hands or a pillow against 
the abdomen, and finally assumes a constant position with thighs flexed 
toward the abdomen. Pressure usually affords relief, but if inflammatory 
conditions of the bowel are present, pressure may increase the pain. 
In young children an attack of colic is indicated by crying, restlessness, 
drawing up of the legs, violent contractions of the facial muscles, and 
later by abdominal distension. Rumbling sounds or borborygmi may 
indicate the movement of gases in the bowels. Usually attacks of colic 
subside after a duration of from a few minutes to some hours, and when 
gas has been discharged or the bowels evacuated. In severe cases the 
attacks may continue unabated for several or many hours and the 
patient may grow faint or suffer partial collapse, breaking out into a DISEASES OF THE INTESTINES 
305 
cold sweat and growing quiet from exhaustion. Severe attacks may also 
be attended with nausea and vomiting. The temperature is usually 
little altered, but a moderate degree of fever is not uncommon. 
After relief from the primary attack, exacerbations and remissions 
may follow until the bowels have been thoroughly evacuated or the 
irritation otherwise removed. A certain amount of abdominal sore- 
ness and tenderness may remain after the attacks have ceased and a 
return to normal intestinal conditions may be delayed for several 
days. 
The bowels at the onset of colic are usually constipated. When relief 
begins there is usually some discharge of flatus and evacuation of the 
lower bowel; later, a diarrhoeal condition may follow, particularly if 
catarrhal inflammation has accompanied the attack or occasioned it. 
Attacks of colic in which the irritation has been sufficient to cause 
an inflammatory condition are more severe and lasting than those in 
which the derangement is only functional. Disturbances of the stomach, 
abdominal distension, soreness and fever are also more likely to occur 
in these cases; and after relief from the acute condition tenderness and 
pain, dirrahcea, and sensitiveness are apt to persist for some time. 
Colic, associated with organic diseases of the bowels, such as intestinal 
obstruction from carcinoma, bands, internal hernia, fecal impaction, 
etc., will be considered in the discussion of those conditions. 
Enteralgia or neuralgia of the intestines in the strict sense is a rare 
condition, and to be distinguished from colic by reason of the fact that 
it is probably not dependent on a tonic intestinal contraction, but rather 
on a direct painful irritation of the intestinal nerves. Such a condition 
occurs in hysterical persons and in association with tabes and other 
organic spinal diseases. The attacks are sudden and severely painful, 
but unattended with the usual indications of colic. There is intense 
sensitiveness on pressure, and relief occurs independently of evacuation 
of the bowels. The general appearance of the patient suggesting a 
neurotic origin of the pain is more or less characteristic. 
Diagnosis.-It is often exceedingly difficult to determine the nature 
of an attack of abdominal pain having the general features of intestinal 
colic. The serious character of other conditions which simulate its 
features requires that these be carefully considered before an attack is 
regarded as simply intestinal colic. Among other conditions, biliary, 
renal, and uterine colic must be thought of; the similarity in the symp- 
tomatology of rupture of a gastric or duodenal ulcer must be remembered; 
and above all else, on account of its frequency and seriousness, appen- 
dicitis must be kept in mind. The last-named offers the greatest diffi- 
culty; but if local pain, tenderness and rigidity, fever, leukocytosis, 
marked gastric symptoms, obstinate constipation, disturbances of the 
pulse, and the general condition of the patient be carefully considered, 
a mistake in diagnosis is not likely to be frequent. 
Certain less frequent conditions may require consideration. Among 
these, acute pancreatitis, the passage of a pancreatic calculus, embolism 
or thrombosis of the mesenteric vessels, and referred pains, such as 
those occasionally experienced in the abdomen in cases of thoracic 
vol. in-20 306 
DISEASES OF THE DIGESTIVE SYSTEM 
diseases, as pneumonia, pleurisy or angina pectoris, or in pelvic diseases, 
must be remembered. The onset of acute intestinal obstruction must 
be carefully distinguished. Usually the failure to relieve the attack by 
simple measures establishes the diagnosis. In cases of chronic intestinal 
obstruction the significance of attacks of colic may be overlooked. A 
partial obstruction may be unattended with marked symptoms until 
an attack of acute colic occurs. The possible association of this with a 
chronic condition must be remembered. 
Treatment.-Intestinal colic readily subsides when the bowels are 
evacuated and the local irritation is controlled by various warm applica- 
tions and by the use of sedatives. If the diagnosis is assured, the bowels 
may be emptied by the use of a large injection of warm water or soap- 
suds, to which castor oil or sweet oil may be added; or by the adminis- 
tration of a dose of castor oil if the stomach permits. Salines, calomel, 
or other purges may be used if the urgency of symptoms does not 
recpiire speedier agents. 
Small doses of opium or morphine not only allay pain but relax 
spasm, and thus sometimes aid in securing purgation. Various carmin- 
atives, such as spirit of chloroform, oil of peppermint, menthol, or 
camphor water may be combined with opiates, especially when gaseous 
fermentation is present. A prompt hypodermic injection of morphine, 
followed by measures to relieve the bowels, may cut short an attack of 
threatening severity. Local measures, such as hot-water bags, hot 
fomentations, poultices, etc., give relief, and by relaxing spasm may 
secure evacuation of the bowels. 
In children, hot applications applied locally, hot baths, carminatives 
with paregoric, mild laxatives, such as castor oil with paregoric, magnesia, 
calomel, and enemata suffice for severe attacks, while the milder parox- 
ysms are relieved by using soda-mint, oil of peppermint, aromatic spirit 
of ammonia, or Hoffmann's anodyne. 
Lead Colic.-A peculiar form of colic is that which is met with in 
subacute lead poisoning, and commonly known as lead colic, painter's 
colic, etc. In this form the important symptom is intense cramp-like 
pain attended with obstinate constipation. The abdominal muscles 
are found rigid and contracted, so that the abdomen is flat or even 
hollow. Other indications of lead poisoning are commonly present, and 
a blue line along the edges of the gums where they join the teeth 
is almost pathognomonic. Paralysis of the extensor muscles of the fore- 
arm, causing the characteristic wrist-drop, may or may not be present. 
During the attack of colic the pulse has a peculiar wiry hardness, 
indicating a high tension, which has been ascribed to tonic contraction 
of the bowels and consequent increased resistance to the abdominal 
circulation. 
Treatment.-This is directed to the relief of the symptoms and the 
elimination of lead from the system. In the early stages magnesium 
sulphate should be given freely for the double purpose of converting any 
soluble lead salts in the stomach or bowels into the insoluble sulphate 
and of relieving constipation. At the same time opium may be given 
by the mouth or rectum, or hypodermics of morphine may be used to DISEASES OF THE INTESTINES 
307 
allay pain and relieve intestinal cramps and spasm. Free venesection 
gives prompt relief in some cases. Iodide of potash in doses of from 10 
to 15 gr. (gm. 0.65 to 1) three times daily aids in eliminating the lead. 
INTESTINAL HEMORRHAGE 
Etiology.-The causes of hemorrhage from the bowel are exceedingly 
numerous. In some cases this condition occurs without any definite 
organic lesion of the intestines; but more commonly, hemorrhage signifies 
some definite change. 
Hemorrhage Unassociated with Pathological Conditions of the Bowel.- 
In association with certain hemorrhagic diatheses or diseases, such as 
purpura and scurvy, and in some infections, such as septicopyemia, 
yellow fever, and severe malaria, hemorrhage may occur without preced- 
ing alteration in the mucous membrane of the bowel. At the time of 
the hemorrhage, or before it sets in, extravasation of blood into the 
mucosa may occur; and,the source of the hemorrhage may be such an 
area. Occasionally hemorrhages occur from the mucous membrane of 
the bowel without any discoverable lesion. Cases of this kind have 
been met with in tuberculous individuals by Nothnagel and others. It 
has been claimed that hemorrhages of this sort may take place as a 
vicarious manifestation of menstruation. 
Hemorrhage as the Result of Congestive Conditions of the Bowel.-In 
cases of cirrhosis of the liver, valvular disease of the heart, and hemor- 
rhagic infarction of the bowel following embolism or thrombosis of the 
mesenteric vessels, hemorrhage may result. Similarly, in cases of intus- 
susception, strangulation of the bowel, or hernia, there may be hemor- 
rhage as the result of overdistension of the bloodvessels. 
Hemorrhage as the Result of Diseases of the Bloodvessels.-The most 
frequent cause of hemorrhage from the bowels is hemorrhoids. Other 
diseased conditions of the bloodvessels may, however, occasion hemor- 
rhage. Thus in aneurismal dilatations of the hepatic artery, rupture 
may take place into the bile passages, and discharge of blood from the 
bowel may ensue. Similar conditions of the intestinal vessels occur 
more rarely. Amyloid degeneration of the intestinal vessels is a common 
cause of extravasation into the bowel in local or general amyloid disease. 
In grave anemias and in severe infections, degeneration and rupture 
of the bloodvessels may be the cause of enterorrhagia. Sometimes in 
the course of chronic interstitial nephritis considerable intestinal 
hemorrhage may occur, probably resulting from degeneration of the 
bloodvessels and increase of arterial tension. 
Hemorrhage as the Result of Inflammatory and Ulcerative Conditions of 
the Bowel.-In cases of gastric and duodenal ulceration and in typhoid 
fever hemorrhage occurs frequently. Less marked hemorrhage often 
attends carcinomatous ulceration; while in ulcers of other sorts, loss 
of blood, although less marked and conspicuous, may be met with. In 
inflammatory affections of the bowel without ulceration, hemorrhage is 
much less commonly present. If, however, the inflammation is intense 308 
DISEASES OF THE DIGESTIVE SYSTEM 
and the congestion is marked, some loss of blood may occur, although 
free hemorrhage is unusual. Continued slight bleeding is caused by 
certain parasites, notably ankylostoma. 
Symptoms.-Ordinarily, no difficulty occurs in the recognition of 
hemorrhage from the bowels, but it may be difficult to determine the 
source. As a rule, when the blood comes from the colon or rectum 
its color is a bright red, and on microscopic examination the corpuscles 
are well preserved. When hemorrhage occurs from the upper bowel, 
unless active peristalsis causes its rapid discharge, secondary changes 
are usually observed. The stools become dark and often tarry in appear- 
ance, and are usually highly offensive from decomposition. In many 
cases there may be a gradual loss of blood from the bowel of so slight a 
degree that a naked-eye inspection of the stools does not reveal any 
evidence of hemorrhage. In such cases an examination for occult 
blood may show its presence. In cases of larger hemorrhage a microscopic 
examination may discover crystals of blood-coloring matter and dark 
amorphous pigment. In cases in which inflammatory lesions, ulceration, 
and especially carcinoma, have occasioned hemorrhage from the bowels, 
the blood is often associated with mucus and pus, as well as with 
epithelial cells and other tissue elements. 
Hemorrhage from the bowels rarely occasions pain. If the loss of 
blood is great, the symptoms are those of extensive hemorrhage from 
any source. After a hemorrhage, intestinal symptoms often develop 
as the result of putrefactive changes in the blood retained in the intestinal 
tract. Secondary diarrhoea may be set up as a consequence. Repeated 
small hemorrhages from the bowel may occasion extreme anemia. 
Prognosis.-The result of intestinal hemorrhage depends entirely 
upon its cause. Severe losses of blood are, of course, in all cases serious; 
but sometimes very extensive hemorrhages are followed by no material 
impairment of the patient's health. In cases of hemorrhoids, as well 
as in cirrhosis of the liver or other obstructions of the portal circulation, 
actual improvement may be observed. Repeated losses of blood are of 
more moment; and when intense anemia has developed, the prognosis 
is always very grave. 
Treatment.-This must always depend upon the cause, although 
certain general rules may be formulated. Local applications of cold, 
such as the ice-bag, Leiter's coils, and the like, are commonly employed, 
although their value is extremely doubtful. Injections of ice-water into 
the rectum and colon may, perhaps, be valuable in some cases-of hemor- 
rhage from these parts, but in other instances may be actually harmful, 
by stimulating the peristalsis of the bowel. 
Colonic douches may be beneficial when the source of the hemorrhage 
can be reached in this way. Solutions of nitrate of silver, tannic acid, 
or other astringents, may be employed. If the hemorrhage cannot be 
reached, such injections, however, may be objectionable; because, by 
irritation, they may stimulate active peristalsis and renewed hemorrhage. 
Opium has been universally employed for its effect in controlling 
peristalsis and quieting the patient. The judicious use of this drug is 
advisable in some forms of intestinal hemorrhage but it should not be DISEASES OF THE INTESTINES 
309 
used to such an extent that the bowels are completely locked and the 
blood and other materials therefore retained and permitted to undergo 
putrefactive decomposition. Astringent remedies, such as nitrate of 
silver, acetate of lead, bismuth salts, and tannic acid preparations, are 
sometimes useful. Other hemostatics, like chloride or lactate of calcium 
and gelatin, may be used. In the case of the latter, peristalsis should 
not be checked, so that the gelatin may reach the bowel in an undi- 
gested form. Ergot, hydrastis, and turpentine are of doubtful value. 
CONSTIPATION 
Synonyms.-Habitual constipation; obstipation. 
Definition.-Infrequency in the evacuation of the bowels and a ten- 
dency to abnormal dryness or hardness and reduction in the quantity of 
the feces are the conditions comprised in the term constipation. It is diffi- 
cult to give a positive definition, since the physiological limitations vary 
widely. In most healthy persons there is normally an action of the 
bowels once in twenty-four hours, and when the conditions of life are 
uniform this occurs at approximately the same time of day. When the 
intervals are two or three days, even though symptoms are absent, the 
condition must be regarded as one of constipation. Instances, however, 
have been reported, such as the cases of Reichmann, in which there 
was but one movement in two or three weeks, the patients in the mean- 
time presenting no symptoms of disease. Such cases must be regarded 
as cases of decided constipation. Sometimes, although the movements 
occur daily, the quantity is decidedly below normal and the character 
of the movements inspissated. In other cases, by testing with charcoal 
or carmine, it may be found that, although an approximately normal 
movement is evacuated daily, the duration of time in the intestinal tract 
has been prolonged, so that considerably more time elapses between 
the ingestion of food and the discharge of the residue than occurs in 
normal individuals. This has been defined as latent constipation. 
Essentially, then, delay in the evacuation of food residues and abnormal 
inspissation, with a reduction in the quantity of the excreta, constitute 
the condition under discussion, whether symptoms be present or not. 
Recent authorities tend toward the limitation of the term to purely 
functional conditions, excluding cases in which organic disease of the 
bowel is present. This cannot, however, be fully accomplished; for 
such conditions as ptosis of the transverse colon, movable cecum and 
redundancy of the sigmoid are often encountered in cases admitted 
under the chapter on Habitual Constipation, and other minor intestinal 
lesions cannot be excluded, though it is fully understood that constipa- 
tion resulting from definite intestinal diseases (adhesions, strictures, etc.) 
is to be considered as merely a symptomatic result of such disease. 
Etiology.-Any discussion of the causes of constipation must be 
based primarily upon a knowledge of the physiological processes con- 
cerned in the onward movement of the intestinal contents. These pro- 
cesses are more fully described in the section on Physiology of the 310 
DISEASES OF THE DIGESTIVE SYSTEM 
Intestinal Tract. It will be sufficient here to note that the efficiency 
of the peristaltic movements will depend upon the normal strength of 
the muscles of the bowel, the integrity of the nervous mechanism, the 
amount of residue in the intestinal contents and the character of the 
contents. Solid contents, water and other liquids, or gases, may serve 
as stimulants either mechanically or chemically. Sometimes the irrita- 
tion results from the mere bulk of the contents; more commonly, the 
mechanical nature of the contents determines their effect. Thus, coarse 
and irritating substances and insoluble residues of various sorts are 
practicularly exciting. Of gases, hydrogen, oxygen, and nitrogen are 
said to be indifferent, while carbon dioxide, sulphuretted hydrogen, and 
volatile hydrocarbons stimulate activity. 
The onward movement of the residual matters left in the bowels after 
complete digestion is the result of the peristaltic movements. Through 
this agency the contents traverse the small intestine in the course of a 
few hours and the large intestine in from twenty to twenty-four hours. 
The slower progress in the colon is probably the result of the frequency 
of antiperistaltic waves, which Cannon has found to be the prevalent 
form of motion in this portion of the intestinal canal. 
The final evacuation of the feces is caused by reflex stimuli produced 
by irritation in the rectum resulting from the presence of feces and 
the direct voluntary expulsive efforts which involve contractions of the 
abdominal muscles. The preservation of a normal rectal reflex is of the 
greatest importance and its loss or diminution is the important factor 
in certain cases of constipation. 
The condition of the abdominal muscles plays a further part in the 
whole process of the movement of the intestinal contents in that the 
condition of these muscles and the effect of their normal contraction 
influences very largely the activity of the peristaltic contractions of 
the intestines. The integrity of the abdominal muscles is of course 
highly important also in the act of defecation. 
It will be seen that abnormal sluggishness in the movement of the 
contents of the bowels may be the result of (1) the character of the 
food residues; (2) weakness of the intestinal muscles; (3) weakness of 
the nervous mechanism; (4) weakness of the abdominal walls. 
In addition to the causes of reduction in the normal motor function 
it seems probable that abnormalities in the absorption processes may 
be of importance. Some authors (Schmidt) insist that there is excessive 
digestibility of cellulose as a result of which this most important stimulant 
to peristaltic activity is withdrawn. Others have suggested that rapid 
absorption of water and premature inspissation of the feces in the upper 
part of the large intestine is an important factor. 
Finally, perverted intestinal contractions causing spasms of localized 
or considerable portions of the lower bowel or, on the contrary, seg- 
ments of partial or complete atony, may prevent the onward movement 
of the fecal matters. 
Functional Causes.-There may be considered under this head condi- 
tions which produce torpor of the intestines themselves and conditions 
which cause a weakness of the diaphragm and abdominal walls, and DISEASES OF THE INTESTINES 
311 
thus lead to reduction in the expulsive power or indirectly to weakening 
of the intestines themselves. We may also include causes of spasm of 
the bowrel or of abnormal absorption. 
Intestinal torpor may occur acutely and as a result of various nervous 
conditions. Thus, as a result of fear or other emotions and nervous mani- 
festations in neurasthenia, melancholia, and the like, intestinal atony 
and constipation are not infrequent. Frequently this torpor results 
from habit. The normal individual tends to evacuate the bowel after 
the first meal of the day, probably for the reason that at this time the 
food residue of the previous day has reached the lower bowel and that 
the ingestion of food into the stomach, together with the change of posi- 
tion of a person from the recumbent to the upright, and the exercise taken 
up with the day's work, excite peristaltic contractions and the tendency 
to evacuation. When, as a result of lack of time or inattention, this 
stimulus is ignored or resisted, the desire passes, and with repetition of 
such neglect the habit of longer retention is established. The normal 
stimulus from the lower bowel becomes less and less effective, and 
eventually a state of chronic constipation results. Long retention of 
fecal matter in the lower bowel has the further unfavorable effect of 
causing dilatation of this portion of the bowel and an active organic 
weakening of its expulsive power. In individuals suffering from long- 
continued constipation, considerable pouching of the sigmoid, descending 
colon, and rectum is not infrequent. Certain authors have assumed 
that there is some special form of weakness of the innervation of the 
muscles, especially of the colon and rectum, but fail to make clear the 
manner of its occurrence. Similarly it may be assumed that in certain 
persons there is some inherent weakness of the intestinal musculature. 
Diseases of the stomach frequently occasion chronic constipation. 
In some instances this may be the result of the long retention of food in 
the stomach owing to the reduction of its motor power or obstruction 
of the pylorus, and possibly stimuli normally propagated from the 
stomach to the intestine fail to be generated. In addition, the contents 
of the stomach may be transmitted to the intestine in such condition 
that irritation of the bowel is first produced, and later spasmodic or 
tonic contractions which cause the resulting constipation. 
The dietetic causes are numerous and most important. The habitual 
use of food which leaves little residue is a very frequent cause. The 
constipating effect of a milk diet is thus explained. Similarly, the use 
of highly concentrated food, such as meat, eggs, etc., with little addi- 
tion of such substances as vegetables, which contain a relatively large 
amount of unabsorbable residue, may produce habitual sluggishness of 
the bowels. The neglect of vegetables, besides causing a reduction in the 
amount of residue, has the disadvantage of removing from the dietary 
a large proportion of the neutral salts which are normally active in 
regulating the action of the bowels. Occasionally the bowels become 
constipated as a result of the eating of foods which contain an excess 
of irritating residue, such as berries containing small seeds or vegetables 
rich in cellulose. This form of constipation is due to spasmodic condi- 
tions of the bowel caused by the excessive irritation. In many persons 312 
DISEASES OF THE DIGESTIVE SYSTEM 
the cause appears to be insufficient use of water, and the resulting 
dryness of the intestinal contents; or the drinking of hard water con- 
taining large quantities of lime salts may be at fault. 
Bacteria play an important role in the normal as well as in the abnor- 
mal conditions affecting the intestinal tract. The number of bacteria 
in the feces of constipated persons is decidedly smaller than in those of 
normal individuals. This is, in part, due to the fact that the sluggish 
peristalsis occasions a longer retention of food in the bowel, and con- 
sequently a fuller degree of absorption of the nutritious element. As 
a result, the bacteria which mainly flourish in the lower intestinal tract 
are deprived of pabulum and multiply less freely, in consequence of 
which fatty acids, gases, and other products of bacterial growth are 
wanting and the stimulus to peristalsis normally exercised by these 
products is lacking. To some extent the bacteria also excite mucus 
formation in the normal bowel, and this aids as a lubricant and helps to 
keep the feces soft. 
Congestion and inflammation of the bowels in certain cases cause 
constipation by directly weakening the contractions, but this mode of 
causation is probably far less frequent and important in genuine habitual 
constipation than was at one time assumed. It would appear that chronic 
constipation is more usually the result of disorder of the nervous mechan- 
ism which controls peristalsis than of any direct weakness of the wall 
of the bowel. It cannot be denied that inflammation or congestion, and 
especially such conditions as congenital or acquired dilatation of the 
bowel, may produce constipation by direct weakness of peristalsis, and 
it is contended only that such factors are of relatively little impor- 
tance compared with reduced motility through alterations in the contents 
of the bowel or of the neuro-muscular mechanism. 
Various causes operate to produce constipation by causing weakness 
of the diaphragm or the abdominal walls. A direct effect is probably 
exerted upon the movements of the intestine by the contractions of the 
abdominal muscles, and it is probable that a normal condition of tone 
in the abdominal walls has a certain reflex influence in producing a like 
state in the underlying organs. Furthermore, relaxation of the walls 
of the abdominal cavity allows of dilatation of the contained hollow 
viscera, which interferes with the effectivenss of the contraction of 
these organs. Clinically, it is certain that various conditions which 
cause weakness, either of the diaphragmatic movements or of the abdomi- 
nal parietes, occasion sluggishness of the bowels. Thus in chronic 
diseases of the chest, such as emphysema, pleural adhesion, etc., more 
or less obstinate constipation may occur. The effect of weakness of the 
abdominal walls is evident in the constipation that occurs after repeated 
pregnancies or when large accumulations of fat have been deposited in 
the omentum or abdominal walls, or in the case of various abdominal 
tumors. Intestinal sluggishness may reach high grades in cases of decided 
separation of the recti as a result not only of the weakness of the superficial 
structures but also of displacement of the intestines (enteroptosis). 
Dress probably has a certain amount of influence as a cause of con- 
stipation. The much greater frequency of this disorder in women than DISEASES OF THE INTESTINES 
313 
in men may be attributed to lack of equal exercise, to the more frequent 
neglect owing to inconvenience of surroundings, etc., and possibly to 
certain anatomical considerations; but it is not improbable that the 
character of clothing has something to do with this greater prevalence 
in women. The weakness of the abdominal walls which results from 
constriction of the lower chest and abdomen may quite readily serve 
as a contributing cause. 
Sedentary life and lack of exercise operate in a variety of ways. In 
the first place, there is a tendency to digestive disturbance and a lack 
of general systemic tone, and in a more direct way these conditions may 
operate by producing weakness of the abdominal muscles. Some indi- 
viduals normally perfectly regular become constipated when confined 
to the house or room by some trivial ailment which merely restricts the 
usual exercise. The same result also occurs to persons on long railway 
journeys or sea voyages, and the like, and is especially marked in patients 
confined to bed through some injury or a disease not necessarily affecting 
the abdominal walls directly. 
Organic Causes.-More attention was formerly paid to the importance 
of strictly organic conditions in the development of habitual constipation 
than is now given to such conditions. Undoubtedly adhesions or partial 
obstructions by stenoses of localized segments of the bowel or constrict- 
ing bands surrounding a coil of intestine may be the occasion of intense 
and long-continued constipation. Similarly, uterine displacement, pelvic 
tumors, malpositions of the intestine (enteroptosis), or congenital or 
acquired malformations (idiopathic dilatation of the colon) may be of 
importance in certain instances. Likewise, certain conditions affecting 
the efficiency of the expulsive efforts, such as a weakened perineum from 
lacerations, and diseased conditions or relaxation of the abdominal 
walls, may be of some influence. It is difficult to determine how far 
the term habitual constipation may be extended to include such organic 
conditions. As has been stated before, those who contend rather insist- 
ently for the limitation of this term to functional conditions do not 
exclude ptosis of the transverse colon, which in a sense acts as an organic 
or mechanical cause of delayed peristalsis and of onward movement of 
the intestinal contents quite as much as adhesions. 
Functional Types of Constipation.-Attempts to divide cases of consti- 
pation into different types have not been specially satisfactory, but 
something is gained by recalling such classifications. 
(a) Atonic Constipation.-It is generally admitted that atonic con- 
ditions are the prevailing fault. We may include here various causes 
of intestinal torpor such as that due to dietary errors (alimentary 
constipation) to general or local weakness, to habits of irregularity of 
defecation and reduced form of expulsion, etc. 
(&) Spastic Constipation.-As a result of irritable conditions of the 
bowel itself or reflexly, localized or extensive spasms, sometimes shifting, 
sometimes more fixed in location may occur. 
Fluoroscopic and Skiagraphic Findings.-A study of the movement 
of the intestinal contents in cases of constipation usually shows but little 
retardation of the passage through the small intestine, though the 314 
DISEASES OF THE DIGESTIVE SYSTEM 
complete emptying of the small intestine may be manifestly delayed. In 
the large intestine there is a distinct delay which may be most manifest 
in different localities in different cases. In some the bismuth accumulates 
in the cecum and very little, if any, reaches the hepatic flexure at the 
expiration of eighteen or twenty-four hours; in others, especially when 
there is decided ptosis of the transverse colon, the most marked delay 
is seen in this portion; in a third group the delay is evidently most 
marked in the descending colon or sigmoid flexure. In cases of spastic 
type affecting the descending colon or sigmoid the skiagram of these 
portions may plainly indicate the narrowing of the contracted bowel. 
When constipation is largely the result of retention in the rectum and 
reduced expulsion enormous enlargement of the rectum may be seen. 
Pathology.-In a majority of cases but little structural alteration 
can be detected. Certain resulting conditions are met in a certain number 
of the cases. Nearly always there is some abnormal distension of the 
sigmoid and rectum, and when constipation has been extreme and its 
duration prolonged, distinct pouches or diverticula may be produced. 
In some instances these will be found to contain hardened scybala and 
inflammatory materials, and even ulceration of the mucous membrane 
may occur (stercoral ulceration). Hardened scybala may produce 
severe catarrhal inflammation of the mucous membrane. 
Marked distension of the colon, with thinning of the mucous membrane 
and of all the walls, may result from obstinate constipation, especially 
when accompanied by frequent impactions in the lower bowel. The 
small intestine rarely shares in such distensions. More commonly there 
may be narrowing of the lumen and thickening of the wall in limited 
segments due to long-continued or repeated spasmodic contractions, 
especially in cases in which habitual insufficiency of food has been a 
principal cause. The writer has repeatedly met with such contracted 
areas of the bowel in autopsies in cases of chronic insanity in which there 
has been long-continued insufficiency of food and resulting constipation. 
Sometimes infiltration of the inspissated fecal masses or scybala with 
salts of lime or magnesium may result in the formation of so-called 
"coproliths." These are always found in the large intestine. 
Symptoms.-The important symptom of constipation is the infre- 
quency of evacuation or the inspissated character and reduced amount 
of feces. There is usually a tendency to the formation of hardened masses 
or scybala. The act of evacuation is attended with difficulty and not 
rarely with a certain amount of local pain. When the condition is long 
continued and the masses are of unusual hardness, some mucous coating 
and even blood-streaked mucus may be observed. If the lower bowel 
has become impacted, cramps or colicky pains may, for some time, 
precede the evacuation. Not rarely a certain amount of tenderness is 
found in the left iliac fossa over the sigmoid flexure. 
Various subjective symptoms are met with in persons suffering from 
habitual constipation, and it is at times difficult to determine how far 
these have resulted from the condition, or, on the other hand, the degree 
in which they may have acted as causes of the sluggishness of the bowel. 
Among such symptoms, heaviness, sleeplessness, a tendency to vertigo, DISEASES OF THE INTESTINES 
315 
headaches, and even more severe nervous symptoms, like hypochon- 
driasis, may be mentioned. Undoubtedly all of these may be occa- 
sioned by the existence of obstinate constipation, but,, on the other 
hand, sluggishness of the bowels is frequently the result of such nervous 
conditions and perhaps more remotely of the gastric disorders that 
have occasioned these symptoms. Some authors have suggested that 
neurasthenia is frequently caused by atonic conditions of the bowel, 
with more or less constipation, but more commonly constipation is 
rather a symptom of the neurasthenia than the reverse. 
Local abdominal symptoms are common and significant. A feeling 
of fulness or of pressure, a sense of distension, and sometimes vague 
or acute pains may occur. Pain may be localized to regions where 
accumulated masses of hardened feces have caused irritation or inflam- 
matory conditions. In other instances cramp-like colic affecting the 
region of the descending colon or the entire abdomen may result from 
impaction and from the resulting stimulation of violent peristalsis. 
Rectal impactions occasion sensations of bearing down or perineal 
fulness and even violent tenesmus. Secondary disorders of digestion, 
with loss of appetite, coating of the tongue, sleepiness, thirst, and some- 
times more acute symptoms, such as nausea and vomiting, may, from 
time to time, make their appearance or be more or less constant. 
Fever not infrequently occurs, when the degree of constipation is 
temporarily more marked than usual. This may be the result of the 
direct irritation of retained masses of hardened material or may possibly 
be the consequence of the absorption of products of decomposition 
(stercoremia). The evidence in favor of the latter is rather insufficient, 
as the indications of intestinal fermentation or putrefaction are rarely 
marked in constipation, and other signs of toxemia are wanting. In 
the great majority of cases of constipation fever does not occur. 
Local disorders of various sorts may be encountered, such as palpitation 
of the heart, irregularity of cardiac action, and various nervous symptoms, 
some of which have been already mentioned. These symptoms, like 
fever and cerebral manifestations, have been attributed to auto-intoxica- 
tion, although the evidence in favor of this view is scanty and uncertain. 
The abdomen is sometimes flat or even scaphoid from general con- 
traction of the intestines and insufficiency in the contents of the bowel. 
More frequently there is slight distension with excess of tympany in 
the sides due to dilatation of the large bowel. When the abdominal 
walls are weak and thin, the dilated colon may be seen almost throughout 
its entire course. Hardened fecal masses may be palpable through the 
abdominal walls, especially in the sigmoid region. The character of 
the masses is recognized by their movability, by their disappearance 
after purgation or the use of enemata, and, according to Gersuny, 
pressure upon the fecal tumor causes a characteristic sensation of 
separation of the wall of the bowel from the tumor when the pressure 
is relaxed. Sometimes fecal accumulations occur in the transverse 
colon or even in the cecum, and may be very misleading in their 
resemblance to abdominal tumors. 
Occasionally attacks of diarrhoea may occur in persons subject to 316 
DISEASES OF THE DIGESTIVE SYSTEM 
habitual constipation. Such attacks may result from irritation caused 
by impaction or excessive retention of the intestinal contents from food 
irritation, or other forms of irritation (purgatives), which act excessively 
on account of the retention of fecal matter and its hardened character. 
In cases of fecal impaction in the rectum the real condition may be 
obscured by a continuous diarrhoea caused by irritation. 
The general condition of the patient suffering with habitual con- 
stipation may not be seriously impaired. In some cases, however, 
emaciation, loss of strength, and some anemia may result from the 
gastric disorders that usually attend constipation, from the constant 
use of purgative medicines, and possibly from obscure toxic conditions. 
Complications.-Among the intestinal complications are dilatation 
and pouching of the rectum and sigmoid flexure, formation of diverticula, 
volvulus, and inflammatory lesions in various parts of the bowel (rectum, 
colon, appendix). Constant straining in constipation may lead to weak- 
ening of the abdominal wall and to the formation of hernia. The same 
cause, together with the pressure of masses accumulating in the rectum 
and the direct irritation occasioned by hard scybala, frequently leads 
to the development of hemorrhoids. Severe straining sometimes occa- 
sions thoracic diseases, such as emphysema of the lungs. Apoplexy may 
result from the elevation of blood-pressure caused by severe straining. 
Diagnosis.-This usually offers no difficulty whatever, as the infre- 
quency of the evacuations and their character are distinctive. Some- 
times, however, there may be daily evacuations of comparatively normal 
amount, and apparently normal in other respects, in which a physiological 
test made with the use of charcoal or carmine will show that the time 
that elapses between the ingestion of a certain meal and the discharge 
of the residue is considerably prolonged. The recognition of such cases 
might prove difficult, if one did not recognize the possibility of such 
an occurrence. Fulness of the abdomen, general sluggishness, a ten- 
dency to headaches, digestive disturbances, oppression, and other similar 
indefinite symptoms, may suggest the existence of such latent con- 
stipation; and this may be suspected, also, in cases in which there is 
visceroptosis. 
Another direction in which the diagnosis of constipation frequently 
offers difficulties is in the determination of the cause of the condition. 
The existence of distinct gastric symptoms antedating the tendency to 
constipation may suggest that digestive disturbance is mainly operative. 
A study of the patient's diet may bring out that a too monotonous diet, 
or one lacking in fluid elements, or, on the other hand, foodstuffs that 
by irritation provoke intestinal spasm, lie at the basis of the condition. 
The condition of the abdominal walls, a tendency to gaseous distension, 
and other indications of sluggish peristalsis, may show that constipation 
has resulted from intestinal atony. Hemorrhoids or fissure, pelvic 
diseases, displacements of the uterus, or the presence of abdominal 
tumors, may indicate that the disorder has resulted from reflex atony 
or spasm of the bowel; or, in other cases, from direct pressure upon it. 
Finally, general nervous conditions, such as neurasthenia or other 
depressive conditions, may suggest the importance of the nervous system DISEASES OF THE INTESTINES 
317 
in the etiology. In these instances careful consideration of the possibility 
that the nervous conditions are secondary to the constipation must be 
remembered in attempting to determine the sequence of events. 
No satisfactory treatment can be instituted until the proper causation 
has been investigated and determined. 
Treatment.-The most important element is the establishment of the 
habit of regularity in the evacuation of the bowels. The normal regularity 
of evacuation is due to the fact that the residue of food and the admixture 
of bacteria and secretions which constitute the feces reach the lower 
bowel at a certain interval after the ingestion of food, and there stimulate 
the mucous membrane and bring about a desire for evacuation. A 
habit of resisting this desire may gradually cause a blunted sense, which 
eventually occasions more or less obstinate constipation. A process of 
reeducation is frequently effective, and the most natural and desirable 
method of treatment in the condition is the establishment of a habit of 
regularity. For some time no result may be achieved, but by repeated 
efforts at a certain hour-preferably that which seems to be the normal 
time (that is, the morning)-will gradually prove effective. In some 
cases it seems desirable to choose the evening rather than the morning, 
especially when local rectal conditions, such as hemorrhoids, are present. 
In these circumstances the retention of fecal matter in the lower bowel 
during the night may occasion a reflex spastic constipation. 
Simple measures may be used to supplement the effort at reestablish- 
ing the normal regularity. Among these the use of small enemata of 
plain water or soapsuds, with or without the addition of a little glycerin, 
and glycerin, gluten, or soap suppositories, may be recommended. All 
such aids should be used with caution, as the bowel readily accustoms 
itself to artificial assistance. 
Exercise.-The condition of the abdominal muscles was referred to 
as being important in maintaining regularity. The constipating effect 
of enforced rest in bed, or of an enforced sedentary life in those who 
have before been regular, indicates the importance of this factor. Exercise 
of the abdominal muscles in particular is important, although the 
muscular system as a whole must be considered, since its normal healthful 
condition has a bearing upon the function of the bowels as on other 
visceral functions. The form of exercise must vary according to the 
physique, character, and occupation of the patient. In many, the 
institution of gymnastic movements and the use of pulley weights, rowing 
machines, or other apparatus that will enable the patient to obtain 
vigorous exercise, particularly of the muscles of the abdomen and trunk, 
answer the purpose. In others, a better result is accomplished by direct- 
ing the patient to occupy himself with such labors as will secure the 
proper amount of exercise. In obstinate cases, passive exercise or 
massage must be employed. The patient may knead the abdominal 
muscles in the direction of the large intestine, or may use a cannon ball 
covered with felt or leather, which is rolled about the abdomen in the 
same direction as that used in massage. The weight of the ball may vary 
from two or three to ten pounds. Various implements have been devised 
for producing vibrasage, and these may give useful results in the treat- 318 
DISEASES OF THE DIGESTIVE SYSTEM 
ment of constipation. Active stimulation over the head of the colon 
and sigmoid, and a continuous treatment along the line of the large 
intestine, will give the best results. 
A skilled manipulator combines all these forms of exercise by using 
stroking, kneading, and rotary movements and vibrations on the points 
indicated or along the entire length of the colon. Sometimes it is well 
to combine with the manipulations of a masseur high injections of plain 
water, which still further stimulate intestinal contraction. 
Electricity and hydrotherapy have been used to supplement exercise 
or other forms of direct treatment. A slowly or rapidly-interrupted 
faradic current may be applied over the colon, beginning at the cecum, 
and following the entire length of the large intestine. Galvanism has 
also been employed, the current being interrupted from time to time. 
Ordinarily one electrode is placed under the back, while the other is ap- 
plied to the surface of the abdomen. 
Baths of various sorts have been employed to stimulate the abdominal 
muscles, as well as the intestinal peristalsis. Cold douches, wet com- 
presses to the abdomen, and general hydrotherapy may be useful. 
Diet.-It is impossible to make any general statement regarding the 
character of diet that should be prescribed for patients suffering with 
this condition. In general, it may be said that such forms of food as 
furnish a considerable amount of residue are likely to prove useful, 
while those foods which are susceptible of complete digestion and absorp- 
tion tend to occasion constipation if they form too large a proportion 
of the whole dietary. It has, therefore, become customary to prescribe 
for patients with constipation -various vegetable foods that leave a 
large residue. Other things bring equal, this plan proves satisfactory; 
but sometimes unabsorbed portions of food may act as irritants and 
tend to increase rather than to counteract the condition. In the same 
way, fruits, berries, and the like, which contain seeds or other non- 
absorbent constitutents, may be helpful or hurtful, according to the 
nature of the case. All kinds of fruits have been advised, and frequently 
aid in combating the trouble. Sometimes, by causing disturbance of 
gastric digestion, fruits may have an opposite effect. Sweets, honey, 
milk-sugar, and other saccharine or carbohydrate foods sometimes prove 
efficacious. Stewed fruit at night, or a few dried plums, may have a 
useful effect. Milk-sugar has been largely employed in the same way. 
In some cases the regular administration of water in increased amounts, 
and especially one or two glasses of warm or cold water in the morning 
before breakfast, may be helpful. Certain inert substances, such as 
agar-agar, which swells from imbibing water and is not digested or 
absorbed, liquid paraffin or petrolatum, are sometimes added to the 
diet with advantage. The regular use of olive oil in doses of from 
a teaspoonful to an ounce after each meal acts somewhat similarly. 
Various kinds of bread made of coarse flour or containing bran may 
aid by supplying a certain degree of desirable irritation. Certain foods 
have a recognized constipating effect. Among other things, acid wines 
or tea, on account of the astringent effect of the constituent tannic acid, 
are undesirable. Milk is usually constipating, but only when it forms a DISEASES OF THE INTESTINES 
319 
considerable portion of the whole diet, and when, as a rule, the amount 
of residue left after digestion is inconsiderable and insufficient. 
Medical Treatment.-Medicinal agents should be used in the treatment 
of constipation only when a regulation of the daily life of the patient, 
or of his diet, and the employment of various physical means of stimula- 
ting peristalsis have failed of the desired result. Undoubtedly, the 
common cause of increasing constipation is the employment of remedies 
without reference to the individual conditions, and usually without 
medical advice. Often, however, some kind of direct medical treatment 
seems necessary, and drugs may be required. These may be divided 
into those which exercise a helpful influence on digestion and peristalsis, 
without having a direct laxative effect, and those which are laxatives 
in a narrower sense. 
Among the remedies that are correctives of digestion and stimulate 
peristalsis without irritating, nux vomica, belladonna, physostigma, 
and digestive ferments may be considered. Recently a preparation made 
from gastric mucosa and spleen, called hormonal, has been recommended 
for hypodermic administration as a peristaltic stimulant or hormone. 
Its usefulness and safety are still in question. In some cases a small 
dose of tincture of belladonna may suffice to aid the condition. 
Of the direct laxatives, aloes and cascara are probably most generally 
useful. The well-known combination of aloes with belladonna and 
strychnine in pill form, to be taken at night, is useful, and if carefully 
controlled by other measures rarely requires such increases in the quantity 
of the remedies as to make it distinctly undesirable. Aloes may also 
be combined with podophyllin, extract of rhubarb, or cascara. Cascara, 
in the form of the fluid extract or solid extract, or of various elixirs, is 
a favorite remedy, and, like aloes, does not seem to increase the ten- 
dency to constipation. It is difficult to determine without experiment 
the required dose, individuals differing very widely in this respect. The 
combination with aloes or other purgatives often acts more happily 
than the drug without addition. Phenolphthalein is often useful and 
may be given with cascara. 
Senna is a remedy widely used in domestic practice, and forms the 
basis of many proprietaries. An old practice used in many institutions 
is to administer stewed prunes, to which a few leaves of senna have 
been added; and senna teas, decoctions, etc., are extensively used. The 
official confection of senna, or one containing senna, rhubarb, sulphur, 
and glycerin, taken before bedtime, may be used. Sulphur may be used 
as a laxative, although its potency is rather limited. 
Saline waters of various sorts, such as those of Marienbad, Carlsbad, 
Bedford, or Saratoga, may be useful. One or two drams of saturated 
solution of magnesium sulphate or Rochelle salt have a similar effect. 
As a rule, these waters are most efficacious when taken before breakfast 
or at night. The continued use of waters in regulated amounts may 
have a permanently useful effect, correcting digestion or catarrhal con- 
ditions of the gastro-intestinal tract, but the unrestricted use of any 
kind of saline water must be condemned. 
Rectal medication is often highly beneficial, and in cases in whic 320 
DISEASES OF THE DIGESTIVE SYSTEM 
some form of remedial agent seems to be necessary, the substitution 
of enemata, suppositories, etc., for remedies given by the mouth has 
the effect of preventing the development of a habit. The habit of 
employing enemata regularly or daily is quite common with some persons. 
It is not harmless, as the effect upon the mucous membrane of the lower 
bowel sometimes proves distinctly deleterious. As temporary expedients, 
enemata of plain water, saline solution, soapsuds, or more powerful 
combinations, such as solutions of sulphate of soda, Rochelle salt, or 
other salines, may be employed. In some cases, the injection of a small 
quantity of olive oil at night, to be retained until morning, has a useful 
effect, particularly in cases in which larger enemata are irritating. In 
cases of spastic constipation, such injections of oil or enemata of large 
quantities of oil may be employed. The addition of glycerin to enemata 
renders them more powerful, and specially efficacious in acute cases. 
Sedatives may be useful in the treatment of constipation when the 
condition is more or less dependent upon spastic states of the bowel. 
In these circumstances the milder sedatives, such as bromides, valerian, 
and especially asafetida, given in the form of pills, each containing 
gr. ij, or administered by enemata in the form of milk of asafetida, 
serve a useful purpose. 
Some attempts at correcting । constipation due to a deficiency of 
microbic action have been made by the employment of cultures of 
microorganisms, such as lactic acid bacilli, etc. These methods have not 
proved especially valuable. 
Surgical Treatment.-Attempts have been made to correct consti- 
pation by eliminating the large bowel from the intestinal tract. Among 
others, Lane has practised anastomosis of the small intestine with the 
sigmoid flexure or the rectum. Complete removal of the large intestine 
has been practised, but is obviously too radical a procedure to warrant 
recommendation. Even the more conservative forms of surgical treat- 
ment are justifiable only in cases of unusual obstinacy. 
IDIOPATHIC DILATATION OF THE COLON 
This term is used to define certain cases of more or less extensive 
and persistent dilatation of the colon, probably dependent upon structural 
abnormalities, and not due to ordinary obstructions and to consequent 
accumulations of gaseous or fecal contents. The cecum, colon, and 
sigmoid may be enormously distended throughout their entire lengths. 
In some cases, however, the sigmoid alone is involved, and may be so 
greatly enlarged that it fills the entire abdominal cavity, pressing other 
viscera out of the way. The diameter of the bowel may reach as much 
as eight to ten inches. When the colon is involved, the abdomen is 
filled with the enormously distended ascending and descending colon, 
occupying either half of the abdominal cavity, which itself is so greatly 
enlarged that the patient presents the appearance of a monstrosity. 
Formad's celebrated case has been exhibited in various places under 
the name of the "balloon man." DISEASES OF THE INTESTINES 
321 
Etiology.-A distinction may perhaps be made between cases in 
young children and those met with in the elderly or aged. The former 
group probably represents cases in which some congenital defect has 
been the occasion of the dilatation, which gradually progresses until 
the patient succumbs. In the cases occurring after childhood, contrib- 
uting causes, such as partial obstruction, habitual constipation, and 
weakening of the bowel by chronic inflammatory affections, probably 
more frequently play a part. In a case reported by Treves the dilatation 
was due to congenital narrowing of the rectum; and this author con- 
cluded that idiopathic dilatation is usually due to obstruction with 
resulting fecal impaction. This view has not been sustained by later 
investigations, such as those of Crozer Griffith, who analyzed the post- 
mortem findings in eighteen cases in children. Marfan suggested that 
a congenital abnormality in the form of the sigmoid flexure might be 
the cause, and a number of cases have been described in which the 
sigmoid was abnormally long and therefore distorted. Other causes 
of impediment in either the sigmoid or the rectum may occasionally 
play some part in the causation. Some form of muscular weakness of 
the entire bowel has also been assumed as the basis; but idiopathic 
dilatation is not the result merely of atony of the bowel, as the walls 
are invariably found hypertrophied. 
The important features are the great distension, a thickening of all 
the coats of the bowel, and especially hypertrophy of the muscle. The 
mucosa is usually swollen, congested, and ulcerated. As a rule, it con- 
tains large quantities of fecal matter; in Fonnad's case the contents 
of the colon weighed forty-seven pounds. 
Symptoms.-The most conspicuous feature is the abdominal enlarge- 
ment, which, on examination, proves to be due largely to gaseous con- 
tents. The distension may be uniform and globular, or may be more 
decided on one side-particularly on the left side-when the sigmoid is 
specially involved. The coils of intestines may be visible through the 
abdominal wall, and peristaltic waves may be seen. Interference with 
breathing and with the circulation is commonly the result of the upward 
displacement of the diaphragm. The patient complains of abdominal 
distress, but acute pain is usually wanting. Gastric disturbances, head- 
aches, and intense constipation are usually encountered. Sometimes 
there are paroxysms of colicky pain, and occasionally attacks of diarrhoea 
may set in, especially toward the end of life. In some instances the 
bowels have been regular throughout, although there was nevertheless 
a gradual accumulation of retained fecal matter. The patient suffers 
with increasing malnutrition, which finally may become extreme; and 
death may be due to inanition and exhaustion. In other cases a fatal 
termination is due to volvulus of the sigmoid or to perforation of the 
bowel. Sometimes the fatal result appears to be due to the extensive 
associated colitis. 
The clinical course in congenital cases begins within the first few days 
of life. The abdomen begins at once to enlarge, and increases progres- 
sively. At the same time, obstinate constipation attracts attention, 
practically no fecal matter being discharged, except at long intervals. 
vol. in-21 322 
DISEASES OF THE DIGESTIVE SYSTEM 
In some cases a history has been obtained that the child had had but 
few bowel movements since birth, although some months or a year 
or more old. The child usually dies early; in Griffith's series only three 
out of twenty-four cases reached adult years. In other cases the symp- 
toms do not begin until a year or more after birth. Milder forms and 
sometimes even extreme cases may go on to adult or middle life. 
Treatment.-In some cases the administration of purgatives may 
cause evacuation of retained contents; but this is followed by a speedy 
recurrence of the condition, and is attended with little relief, even for a 
time. The same unsatisfactory result attends the use of enemata. In 
a number of cases surgical treatment has been employed, and in a few 
has been followed by satisfactory results. The operation most generally 
employed has been colostomy, which in several cases has been quite 
successful. More extensive operative procedures, such as excision of parts 
of the bowel, have been resorted to with variable results. Richardson's 
case, in which excision of the sigmoid flexure was followed by the form- 
ation of a new sigmoid, is instructive in illustrating that inherent struc- 
tural defects may lie at the basis of the etiology in some instances. Prob- 
ably in most cases operation has been undertaken at too late a day. 
DIARRH(EA 
Definition.-The term diarrhoea is usually applied to the too frequent 
discharge of more or less fluid stools. In many persons two or three 
daily evacuations of the bowels occur without disturbance of health, and 
without any marked alteration in the character of the feces from the 
normal. This does not constitute diarrhoea in the ordinary acceptance 
of the term. Usually, however, when more than one daily movement 
occurs, the feces are also less solidified; and although active symptoms 
may be wanting, the condition is really diarrhoea. 
Etiology.-As the essential condition is the presence of an abnormal 
amount of water in the feces, the causes will be found to be such as 
occasion the rapid evacuation of the intestinal contents, with consequent 
reduction in absorption or an oversupply of water or increased secretion 
from the mucous membrane of the bowel. 
The forms of diarrhoea may be classified as those without definite 
organic lesion and those associated with various intestinal diseases. 
In the latter group the condition is symptomatic, and more appropriately 
considered in connection with the various diseases that cause it. 
Diarrhoea Due to the Excessive Ingestion of Water and Other Fluids.- 
Sometimes the mere drinking of excessive quantities of water may be 
the cause of looseness of the bowels. In some individuals in whom there 
is normally a constipated condition excessive water drinking may correct 
the difficulty or even produce a temporary diarrhoea. The drinking of 
other fluids, such as wines, malt liquors, etc., may act in the same way, 
although there is probably here an associated cause, the digestive dis- 
turbance resulting from the overuse of the fluids named. Diarrhoea is 
sometimes produced by the use of large quantities of oil, butter, or fatty DISEASES OF THE INTESTINES 
323 
food. In this case the amount of unabsorbed fat may occasion looseness, 
or digestive disturbance may result from the excess of fat consumed, and 
the fatty acids or other products of decomposition may act as irritants. 
Diarrhoea Due to Food.-Various foods may occasion diarrhoea, through 
their mechanically irritating character, through their ready decom- 
position in the gastro-intestinal tract, and sometimes through their 
mere bulk. It is well known that fresh fruits, certain vegetables contain- 
ing abundant cellulose, and berries containing small seeds may, in some 
individuals, readily provoke an attack of diarrhoea that can be explained 
by the mechanical irritation occasioned by the unabsorbable residue. 
Other foods, such as fish, shell-fish, cheese, milk, etc., may easily undergo 
decomposition in the bowels or may contain preformed products of 
decomposition, particularly in hot weather, and thus may excite more 
or less acute or violent diarrhoea. Various microorganisms have been 
found in association with cases of this sort. Mere excess of food may 
set up a diarrhoea as a result of derangement of the gastric and upper 
intestinal digestion and secondary bacterial fermentation. 
Diarrhoeas Due to Purgative Substances.-Any of the various purgatives 
used in practical medicine may occasion active diarrhoea. The majority 
of these act upon the muscle of the bowel and its nervous mechanism 
without influencing the secretions or absorptive processes. Their effect 
is simply to stimulate peristalsis, especially that of the large intestine, 
and thus to hasten the contents of the bowel through the tract. The 
salines increase watery secretion from the intestinal mucous mem- 
brane; and some exercise a stimulating effect upon peristalsis. 
Diarrhoea Due to Nervous Influences.-A. variety of conditions may 
excite increased peristalsis by directly affecting the nervous mechanism 
of the bowels. The influence of shocks, fright, fear, and various kinds 
of excitement, is well known. In some diseases attended with disorders 
of the nervous system, like Graves' disease, hysteria, or neurasthenia, 
attacks of diarrhoea or continued looseness of the bowels may occur. 
In some persons the nervous mechanism of the intestines appears par- 
ticularly susceptible, and slight influences, such as emotional conditions, 
exposure to cold, or various forms of irritation ordinarily having little 
effect, may readily increase peristalsis. The condition known as morning 
diarrhoea, in which several evacuations occur in the early norming, after 
which the bowels remain quiet until the next day, may be explained by 
assuming the existence of an irritable state of the nervous mechanism 
in the lower bowel, and the consequent prompt evacuation of contents 
that usually reach this portion of the tract twenty-four hours after the 
beginning of ingestion. 
Diarrhoea Due to Diseases of Other Organs and Disordered Conditions of 
the Blood.-In some cases of heart disease, congested conditions of the 
mucous membrane of the bowel may occasion a proneness to diarrhoea, 
or may cause it directly by increasing intestinal secretion. The associa- 
tion of diarrhoea with renal disease is more important than either of the 
others. In this case the vicarious excretion of urea from the intestinal 
mucous membrane and the decomposition of this, with the production 
of ammonium, occasion irritation, sometimes of intense character. In 324 
DISEASES OF THE DIGESTIVE SYSTEM 
all cases of severe kidney disease the development of diarrhoea must 
be regarded with suspicion. 
More or less intense diarrhoea may be associated with various infections 
not necessarily involving the intestinal tract itself. Thus, in cases of 
septicopyemia and pneumonia, and in various other infections with 
lesions at a distance from the bowel, diarrhoea may occur. There is 
reason to believe that such attacks are due to the elimination of toxic 
matters from the intestinal mucous membrane, just as urea is eliminated 
in cases of disease of the kidneys. Recent experiments have shown that 
the toxins of such organisms as the Bacillus dysenteries injected hypo- 
dermically may be eliminated through the bowel, causing secondary 
lesions of the mucous membrane. The same is true of injections of 
cholera toxin. Even in infections of the intestinal tract, therefore, such 
as cholera, dysentery, etc., the attending diarrhoea may be due to the 
toxic state of the blood and the secondary elimination of the toxins 
through the mucous membrane of the bowel. 
Diarrhoea of Gastric Origin.-In certain diseases of the stomach, 
especially in achylia gastrica, a tendency to diarrhoea may sometimes 
be a marked feature of the clinical history. In achylia this has been 
attributed by some to the absence of free hydrochloric acid and con- 
sequent failure of the normal anti-bacterial action of the gastric juice, 
while others believe it results from the lack of sufficient stimulus for 
efficient pancreatic secretion and consequent failure of digestion. The 
offensive character of the stools and the presence of large numbers of 
bacteria lend some color to the former view, while the amount of 
undigested food residue, especially meat fibres, supports the other 
view. 
Diarrhoea may also occur in cases of marked hyperacidity of the 
stomach, though in this case it is usually only a temporary occurrence 
in persons usually constipated. 
Diarrhoea Due to Intestinal Indigestion.-Certain persons are liable to 
attacks of fermentative diarrhoea apparently of intestinal origin and 
particularly after taking some particular kind or kinds of food. The 
gastric conditions are found to be normal, but distension, colicky pains 
and the passage of fermenting, highly offensive and acid stools of a 
crumbly character occur during the attacks. At times this condition is 
quite obstinate. The stools are often light from admixture of gases of 
fermentation and float in water; they may be light yellowish or brownish 
in color and contain abundant microorganisms of fermentation. 
Diarrhoea Due to Organic Diseases of the Bowel.-In connection with 
enterocolitis and other catarrhal and inflammatory conditions of the 
mucous membrane, in the descriptions of the various ulcerations of the 
bowels and of malignant disease, diarrhoea will be discussed. 
Bacteriology of Diarrhoea.-Bacteria and their products are sometimes 
the direct causes of diarrhoeal conditions. A considerable variety of 
microorganisms may be concerned and it is difficult to determine with 
certainty in many cases which of the abundant intestinal flora is mainly 
operative. Certain facts have been learned by observations of the pre- 
dominant organisms in different cases, by the discovery of forms in DISEASES OF THE INTESTINES 
325 
abundance that normally are not present and that have been traceable 
to tainted food, and by the application of agglutination tests to the 
serum of individuals suffering with diarrhoea. 
Certain of the normal organisms of the intestines to which the system 
has grown accustomed may under peculiar circumstances undergo 
unusual multiplication or increase of virulence, so that they become 
pathogenic. Among these the Bacillus coli communis is most important. 
The fact that this organism is largely present in cases of diarrhoea does 
not necessarily imply its etiological relation, although other considera- 
tions may establish it. There is little doubt that under some con- 
ditions diarrhoeal diseases are caused by this group of organisms. 
Closely allied organisms, such as the Bacillus enteritidis of Gaertner, 
and members of the intermediate group, the paratyphoid and paracolon 
bacillus, are important causes of certain diarrhoeal conditions. Diarrhoea 
due to the Bacillus enteritidis has been found in some cases of meat 
poisoning and sometimes also in cases not directly traceable to the 
consumption of tainted meat. In some cases, especially in the diarrhoeas 
of childhood, streptococci and staphylococci appear to be the active 
agents and may cause intense forms of enteritis. Among less frequent 
causes are various others of the organisms named as inhabiting the 
intestinal tract normally which may operate by their direct action or 
by causing fermentative processes with the liberation of fatty acids and 
other irritant substances that secondarily occasion intestinal disturbance 
and diarrhoea. In the disorders of intestinal fermentation organisms of 
fermentation may be conspicuous-among these the clostridium butyri- 
cum or granulobacillus, saccharobutyricus, and long bacilli (Oppler- 
Boas?), Bacillus pyocyaneus, Friedlander's bacillus, the Bacillus botulinus, 
and other forms occur more rarely. Certain organisms of specific diseases, 
such as typhoid fever, tuberculosis, syphilis, etc., occasion characteristic 
lesions and often an associated diarrhoea. 
Diarrhoea is sometimes occasioned by protozoa, including amoebee 
and a variety of flagellate and ciliated forms. 
Symptoms.-The clinical manifestations of diarrhoea depend largely 
upon the nature of the condition and the part of the bowel involved. 
In cases of irritation of the upper intestine due to overloading with 
food or functional derangement, diarrhoea may not occur if the peri- 
stalsis of the colon remains normal; but usually an increase of activity 
occurs in this part of the tract as well, and some looseness results. In 
such cases the stools are likely to present features that indicate that 
the upper bowel is at fault. Undigested food, with the admixture of 
considerable mucus, rendering the feces pasty, sticky, or viscid, and a 
yellowish or greenish coloration, due, in part, to unaltered bile and 
largely, often, to pigment derived from bacterial action, are characteristic. 
Excessive acidity may render the discharges highly irritating, and may 
occasion secondary inflammatory conditions of the rectum, anus, or 
even of the skin externally. This is commonly met with in diarrhoeas 
of this type in childhood. 
In cases of widespread irritation of the bowels, involving Jboth the 
large and the small intestine, more copious watery discharges are the 326 
DISEASES OF THE DIGESTIVE SYSTEM 
rule. There is usually an admixture of fecal matter, and the color of 
the movements may vary from a dark brown to a light yellow; or, when 
abundant serous outpourings occur, as in choleriform types, almost 
watery discharges are seen. 
When the large intestine is particularly involved there is usually 
considerable mucus of whitish color, and more frequently in masses 
than in cases involving only the upper intestine. It may be seen as 
jelly-like particles or as large accumulations; and sometimes, alternating 
with the discharges of ordinary diarrhoeal type, the evacuation of almost 
pure mucus or mucus streaked with blood may be encountered. 
The subjective symptoms in cases of moderate diarrhoea may be very 
slight. As a rule, however, when the small intestines are involved, colicky 
pains and abdominal tenderness are usual. In some instances this may 
be intense, and the patient may become prostrated from the severity of 
the pain, as well as from the loss of water and other causes. In cases 
of diarrhoea involving special irritation of the lower bowel, local tender- 
ness in the left flank or above the pubis may signify involvement of the 
descending colon and sigmoid. In these cases, also, tenesmus is not 
unusual. 
Soon after the onset of diarrhoea a certain degree of weakness or 
prostration is usual. In mild cases this is of little consequence. In 
severe forms extreme prostration or collapse may occur. The 
circulation becomes enfeebled; a little cyanosis may be present; and 
in children, sinking of the eyes and fontanelles, pinched features, and 
other indications of the Hippocratic facies are seen. 
Fever is rarely found in mild cases, but slight elevations are not 
unusual in the more severe. On the other hand, the prostration may 
be such that the temperature soon becomes subnormal. 
Disturbance of the stomach sometimes attends diarrhoea, either as 
a result of the original dietary disturbance or other irritation that has 
occasioned the diarrhoea, or as a reflex result of pain and irritation. 
The clinical course of cases of diarrhoea varies with their cause and 
nature. In ordinary instances due to digestive disturbance a few evacua- 
tions succeeding each other at intervals of a half hour to several hours 
may terminate the condition. In more severe cases, and particularly 
when more intense irritation of the intestines has occurred, the diarrhoea 
may increase in severity for a day or two, or may reach its maximum 
only after several days. In such instances the stools tend to become 
more and more watery as the contents of the bowel are evacuated, 
while in cases in which the large bowel is involved there may be, in the 
later stages, only discharges of mucus. In most instances the entire 
duration is not above several days, unless secondary enteritis or colitis 
has complicated the condition. 
Diagnosis.-This is mainly concerned with the recognition of the 
cause. Ordinary diarrhoea must be distinguished from various forms 
of specific intestinal disease or general infections accompanied with 
intestinal manifestations. 
Treatment.-Prophylaxis is of great importance. The avoidance of 
irritating or tainted foods, particularly during hot seasons of the year 327 
DISEASES OF THE INTESTINES 
when decomposition is apt to occur, is the most important measure. 
Uncooked fruit, shell-fish of various sorts, berries, and cold drinks are 
among the articles of diet to be scrutinized with greatest care. Residents 
of hot climates have found it advantageous to wear an abdominal band 
of flannel or some woven material, to secure warmth and protection, 
particularly when cool nights succeed hot days. Local applications of 
heat over the abdomen, in the form of hot-water bags, hot fomentations, 
and binders of various sorts, are often quieting in the onset and may 
moderate the severity of the attack by controlling peristalsis. 
Diet.-The diet during an attack of diarrhoea should be extremely 
moderate in the beginning, and often it is necessary to avoid food 
altogether. Later, and particularly in cases in which prompt control 
is not secured, a cautious increase of food is requisite, lest the patient's 
strength be too greatly impaired. Thirst, which may be complained 
of severely, should be controlled by the swallowing or eating of small 
bits of ice and the sipping of small amounts of cold water. Frequently, 
merely holding water in the mouth is satisfying. Albumin-water, barley- 
water, rice-water, or toast-water may be used to quench thirst and, at 
the same time, to supply a certain amount of nourishment. If the 
stomach is irritable, these liquids may be better tolerated than plain 
water. After preliminary evacuation of the bowels has been secured, 
a diet of pasteurized or boiled milk, given in small quantities, or milk 
with well-cooked farinaceous foods, such as arrow-root, rice boiled in 
milk, milk toast, etc., may be given. Later soft-boiled eggs, gelatin 
preparations, such as meat jellies, and, still later, scraped beef or minced 
chicken, may be allowed. It is usually advisable to avoid giving vege- 
tables until the signs of gastro-intestinal irritation have subsided. 
Medicinal Treatment.-After the onset, the first consideration in the 
treatment is the evacuation of irritating material, if the spontaneous 
discharges are not enough to carry these off. Nearly always it is desirable 
to use some unirritating and rapidly acting purge, such as castor oil. 
It is a common practice to add to this a small amount of tincture of 
opium or paregoric, to allay irritation and prevent unncessary griping. 
Other purgatives, such as calomel, salines, magnesia, and the like, may 
be used instead of castor oil; but they are less prompt in their effects. 
After evacuation of the irritants the use of sedatives is desirable. Bismuth 
powders, to w'hich may be added pepsin, if digestive disturbances are 
present, chalk mixture, cerium oxalate, lime-water, or other alkalis 
may be used to quiet intestinal irritation and neutralize acidity. A 
combination of chalk mixture with paregoric and some astringent, like 
tincture of kino or catechu, is frequently used. 
When cramp-like or colicky pains are present, some form of sedative 
and carminative may be added or substituted for the remedies named. 
Chlorodyne or improvised mixtures containing other carminatives, 
such as spirit of chloroform, compound tincture of cardamom, or spirit 
of ginger, with opium, may be employed for this purpose. When intense 
pains occur and collapse threatens, the timely use of a hypodermic 
injection of morphine, followed by the various remedies already named, 
may cut short an attack that promises to be serious. Sometimes sup- 328 
DISEASES OF THE DIGESTIVE SYSTEM 
positories of opium may be substituted for these, or repeated doses of 
paregoric or of tincture of opium may be given by the mouth. 
Sudden diarrhoeas, attended with marked evidences of intestinal 
irritation, should be treated with promptness; and active remedies, 
astringent, sedative, and protective, should be given early. As a rule, 
the evacuations are so free that little is gained from a preliminary 
administration of purgatives; and these may, at times, be actually 
harmful. Bismuth in fairly large doses (gr. xxx, gm. 2), in the form of 
the subnitrate, subgallate, or salicylate, with vegetable astringents, 
such as kino or catechu, repeated doses of opium, and an occasional 
hypodermic of morphine, may be given. Mineral astringents sometimes 
have a greater controlling effect than the vegetable forms. Small doses 
of subacetate of lead or nitrate of silver may be employed. 
When diarrhoea becomes obstinate or chronic, persistence in the use 
of the same kind of treatment, using small doses of the various drugs 
named, will gradually control the disorder. Diet here, however, plays 
a more important role than does the medicinal treatment. No general 
rules can be laid down regarding the most desirable diet, as individual 
peculiarities play an important part and therefore require individual 
consideration. In most cases the use of pasteurized or boiled milk, 
with or without small amounts of farinaceous food, proves most suitable. 
In some persons, however, milk is not tolerated; and even forms of food 
prepared with milk may protract the diarrhoea. In such individuals, 
eggs and rare meat, with a farinaceous diet, may proVe more acceptable. 
Occasionally the use of some astringent water, like the Rockbridge 
alum water, aids in controlling a persistent diarrhoea. 
Nervous diarrhoeas are best treated with remedies directed to the 
general nervous system and careful regulation of the diet, so that any 
undue taxing of the digestive functions may be obviated. 
Diarrhoea attended with irritation of the lower bowel sometimes 
requires local treatment. In the acute stages, if tenesmus, pain, and 
other local symptoms are marked, relief may be obtained from ice 
suppositories or from the injection of small quantities of cold water or 
larger amounts of starch water containing tincture of opium. WThen a 
residual catarrhal condition persists, the cautious use of colonic injec- 
tions of weak solutions of nitrate of silver (1 to 5000) may be useful; 
but repeated injection and stronger solutions may easily do harm. 
ACUTE ENTERITIS 
Definition.-This term may be employed to designate acute catarrhal 
inflammation of the mucous membrane of the small intestine as well as 
the upper portion of the large bowel. The terms acute inflammatory 
diarrhoea, enterocolitis, and ileocolitis are synonymous with that here 
preferred. It is impossible to distinguish this condition sharply from 
irritative diarrhoeas due to digestive disturbances and certain infectious 
diseases with intestinal manifestations. In the former group are cases 
in which actual enteritis results from the highly irritating character of 
products of intestinal fermentation. In the latter group are many DISEASES OF THE INTESTINES 
329 
infections often situated at a distance from the intestinal tract, in which 
complicating enteritis results from irritating toxins in the blood, excreted 
into the bowel. There must also be remembered the specific infectious 
diseases, such as typhoid fever, cholera, dysentery, etc., in which enteritis 
is an important lesion. 
Etiology.-Individual susceptibility often plays a part, certain persons 
being exceedingly liable to this form of disease. Enteritis is more common 
in hot weather and in hot climates than at other times or elsewhere, 
owing to the greater likelihood of the contamination of food in these 
circumstances, and because certain easily tainted foods like fruit are 
more commonly used. As in childhood, chilling of the surface during 
cool nights following hot days plays some part in the etiology. 
The direct cause is usually some chemical irritant contained in food. 
The irritants, however, may reach the intestines through the circulation. 
They are quite varied, depending upon the character of the food, its 
preparation, and its preservation. Sometimes, although wholesome 
when swallowed, excessive quantities of food or digestive disturbances 
may occasion fermentation in the intestinal tract and the formation of 
irritants that directly excite a catarrhal inflammation. Bacteria probably 
rarely cause catarrhal inflammation directly. Usually their relation 
is that of agents causing fermentative changes in food or intestinal 
contents, and the products of such fermentation are the immediate 
causes of the resulting enteritis. 
Among other causes of enteritis must be named mineral poisoning, 
or poisoning by toadstools or other noxious substances. Overdoses of 
lead, mercury, arsenic, copper, and other mineral substances may 
occasion intense forms of enteritis with violent symptoms. 
Pathology.-The mucous membrane of the bowel may be involved 
with almost equal severity from the stomach to the upper portion of 
the large intestine, but usually certain areas are more seriously implicated 
than others. The mucosa is swollen and reddened. Often the crests 
of the valvulse conniventes alone present an inflammatory appearance. 
The surface is usually covered with mucus, which may be blood-tinged, 
and sometimes hemorrhagic extravasations occur in the mucosa. The 
lymphatic follicles are swollen and stand out prominently as light areas 
against the inflamed surface. The Peyer's patches may be swollen, 
and occasionally show small rounded ulcerations. 
In exceptionally violent forms, pseudomembranous or diphtheritic 
inflammation of the mucous membrane of the small and large intestine 
may occur. Sometimes this is primary, in the sense that no preceding 
infective lesion can be discovered; but much more commonly it is second- 
ary to infections originating elsewhere. The same form may be met 
with in cases of chronic nephritis or uremia, following cirrhosis of the 
liver and other conditions producing portal obstruction, and in associa- 
tion with obstructions of the bowel caused by carcinoma or other lesions. 
Sometimes an intense enteritis with pseudomembrane formation occurs 
as the result of mineral poisoning, such as is caused by mercury. 
Symptoms.-The clinical manifestations vary with the intensity of 
the cause and the part of the intestinal tract principally affected. In 330 
DISEASES OF THE DIGESTIVE SYSTEM 
milder cases the symptoms are those of ordinary diarrhoea due to dietetic 
errors and functional disturbances. In severe cases the manifestations 
are sudden and violent. 
The stools, as a rule, are of ordinary diarrhoeic character, liquid, 
brownish, and more or less offensive, according to the degree of putre- 
factive change taking place. In the beginning there may be merely 
pultaceous movements which evacuate the lower bow'd; later the move- 
ments become more watery, and frequently contain a certain amount 
of visible mucus. When the large intestine is especially affected, the 
amount of mucus may become considerable; but in most cases the 
discharges remain thin, watery, and brownish. When enteritis is due 
to irritants of great intensity, very frequent and abundant watery 
movements result; and an excessive diarrhoea, approaching in severity 
that of an attack of true Asiatic cholera, may occur. Sometimes con- 
stipation instead of diarrhoea is met with in cases of enteritis, the explana- 
tion of this being that inhibition instead of stimulation of peristalsis 
has resulted from the irritation. Undoubtedly many cases of acute 
constipation following indiscretions in diet and irritation of the upper 
part of the small intestine are produced in this manner. When actual 
enteritis is present, and especially when it is extensive, diarrhoea prac- 
tically always results. In some cases of intense and localized enteritis 
paresis of the affected segment of bowel may occasion intense constipation 
or even complete obstruction of the bowel. 
The patient usually suffers with colicky pains and more or less abdomi- 
nal soreness from the beginning. As a rule, this is of moderate severity, 
but sometimes it becomes extreme. Distension of the abdomen from 
gaseous accumulations may occur, and loud rumbling or gurgling sounds 
(borborygmi) are frequently heard. In some cases, owing to great 
severity of inflammation in a certain restricted part of the bowel, intense 
pain and tenderness may be found in a localized area of the abdomen. 
When the lower part of the ileum is involved the local symptoms may 
suggest appendicitis. In these cases rigidity of the abdominal muscles 
in the area of pain and tenderness, the occurrence of fever, of vomiting, 
and of leukocytosis may still further confuse diagnosis. The develop- 
ment of diarrhoea is usually the determining symptom in the establish- 
ment of a proper diagnosis, but this may be wanting in enteritis, and 
in exceptional cases is met with in appendicitis. 
In the beginning, irritation of the stomach is usually met with, and 
vomiting may be a disturbing symptom at the onset. Later, this 
subsides, as the intestinal symptoms become more pronounced. Some 
gastric disturbance, however, usually persists. The tongue becomes 
coated and dry, appetite is wanting, there is more or less nausea or 
distress after eating, and frequently vomiting is easily provoked through- 
out the course. When the upper part of the small bowel is especially 
involved, active gastric symptoms may be a conspicuous feature of the 
clinical manifestations. Continuous nausea and vomiting and localized 
pain in the upper part of the abdomen are marked. Sometimes moderate 
jaundice indicates a special involvement of the duodenum. DISEASES OF THE INTESTINES 
331 
Fever is more or less high from the beginning, some elevation of tempera- 
ture rarely being absent. The temperature bears no relation to the 
severity of the intestinal manifestation. In extensive enteritis of mod- 
erate severity a continuous febrile temperature resembling that of typhoid 
fever may occur, and the diagnosis is therefore at times quite uncertain. 
The patient suffers with loss of strength and general debility, in 
proportion to the degree of irritation and the intensity of the diarrhoea. 
In cases in which large, watery evacuations are frequently repeated 
the patient may fall into a state of rapid prostration or collapse. In 
such instances the surface becomes cold and moist, cyanosis of the 
extremities may be noted, or there may be complete collapse. 
The physical signs, as a rule, indicate nothing beyond a slight abdomi- 
nal distension, with more or less tenderness on pressure. In some 
cases, however, marked tympany is observed. 
The secretions become scanty, the urine particularly being reduced 
in quantity, and often presenting a certain amount of albumin with 
hyaline or granular casts. In intensely infective cases, acute nephritis 
may occur. Examination of the blood reveals moderate grades of 
leukocytosis. 
In cases of diphtheritic enteritis secondary to infective lesions else- 
where, high fever, intense intestinal symptoms, and rapid prostration 
of strength are usually encountered. The evacuations in these cases 
may contain shreds of pseudomembrane or of exfoliated mucosa, and 
sometimes blood and pus. 
Cholera Nostras.-Cholera nostras, or cholera morbus, is an intense 
form of acute enteritis, bearing the same relation to ordinary cases of 
enteritis of adults as cholera infantum bears to ordinary enterocolitis 
in childhood. 
Etiology.-This occurs with greatest frequency in the summer months, 
and is usually, although not always, traceable to some error in diet. 
Probably in many cases bacterial infection plays an important part, 
although no particular form of organism is associated with it. In some 
cases, preformed products of bacterial decomposition in the food are 
active; in other cases it is probable that, as the result of digestive dis- 
turbance after errors in diet, bacterial decomposition takes place in 
the stomach or intestinal tract. Chilling is an important etiological 
factor. Exposure during cool nights following hot days, and when the 
surface has been relaxed and moistened by active perspiration, is par- 
ticularly important. 
The pathological anatomy does not differ essentially from that of 
other forms of enteritis. There is, however, a tendency to marked exfolia- 
tion of the mucous membrane and follicular infiltration; and, as the 
consequence of intense serous outpourings, desiccation and anemia of 
various organs may be discovered. 
Symptoms.-The onset is sudden and violent, usually beginning 
with nausea and intense vomiting and violent abdominal pain. The 
patient speedily falls into a condition of prostration from the intensity 
of the suffering and the violent nausea and vomiting. The contents 
of the stomach are soon evacuated, after which bilious vomiting takes 332 
DISEASES OF THE DIGESTIVE SYSTEM 
place; and finally, watery liquid is discharged, or intense unproductive 
retching may ensue. Soon after the onset diarrhoea begins. After the 
discharge of the contents of the lower bowel the movements become 
copious, watery, and frequently repeated. They are discharged without 
special effort or tenesmus, and may finally become almost or quite 
involuntary. From beginning to end the tendency to large, watery 
evacuations is a marked feature. 
The abdomen is tender, and sometimes excessively so. The patient 
in the beginning lies upon the side, with the legs flexed to relieve pressure, 
or upon the back, with the thighs flexed upon the body. Later, sensation 
becomes less acute, owing to prostration, and pain and tenderness become 
less marked. At the onset the temperature rises, and sometimes reaches 
a considerable degree of elevation. Exceptionally, hyperpyrexia may 
occur. Later, as prostration increases, the surface temperature falls; 
and finally the extremities, the face, or the whole body may become 
cold. The rectal temperature, however, may remain elevated to the 
end. The secretions, and especially the urine, become scanty. Albumin 
and casts are generally present. 
In severe cases the patient falls into a condition of collapse, hardly 
distinguishable from that of true Asiatic cholera. The face is cold 
and cyanosed, the lips dry, the tongue parched, the breath cold, respira- 
tions feeble, the voice suppressed, the pulse weak and thready, and the 
general condition is one of intense prostration, stupor, or collapse. 
In mild cases, after a sudden onset and somewhat intense symptoms, 
the diarrhoeic discharges become less severe, the vomiting ceases, fever 
subsides, and a gradual amelioration of other symptoms occurs. After 
a day or two practical recovery may ensue. In severe cases the symptoms 
continue unabated or increase in severity, and finally collapse occurs. 
Diagnosis.-The recognition of enteritis offers no great difficulty in 
most cases. The history, onset, abdominal pain, and diarrhoea are 
characteristic. When the large bowel is considerably involved it may 
be difficult to determine whether the enteritis is one of ordinary type 
or dysenteric. Bacteriological examination of the stools and serum 
reactions may in these cases be required to establish a correct diagnosis. 
Sometimes enteritis presents a puzzling resemblance to typhoid fever. 
The suggestive features in these cases are continued fever, diarrhoea, 
general prostration, loss of appetite, coated tongue, and headache. 
The occurrence of splenic enlargement, rose spots, and the characteristic 
serum reaction eventually establishes the diagnosis in typhoid fever, 
but a week usually elapses before these occur. Before that time leuko- 
cytosis, negative blood culture, general abdominal soreness, and the 
urgency of the diarrhoea may aid in excluding typhoid fever. 
There may be difficulty in distinguishing some cases of enteritis from 
appendicitis. As a rule, the correct interpretation will be made possible 
by the persistence and increase of the local signs (tenderness, rigidity, 
tumor), by the occurrence of repeated nausea and vomiting and perhaps 
chills, and by increasing leukocytosis. Obstinate constipation, while 
not necessarily diagnostic, is strongly suggestive of appendicitis. 
The diagnosis of cholera nostras usually offers no difficulty whatever. DISEASES OF THE INTESTINES 
333 
In times of epidemics of Asiatic cholera, however, cases occur in which 
the diagnosis cannot be made. Under these circumstances no safe rule 
can be adopted other than to regard all choleraic diarrhoeas as of the 
specific type, particularly as it is well known that mild cases of true 
Asiatic cholera are frequently seen in epidemics of that disease. 
Prognosis.-This is favorable in cases of ordinary enteritis in adults. 
Unless the cause is one of unusual severity, recovery usually takes 
place. In the old or enfeebled, however, as in children, the disease is 
one of considerable gravity. Usually after a few days of urgent symp- 
toms, gradual amelioration takes place, terminating in complete recovery. 
Sometimes the condition ends in a subacute, or even a chronic disease. 
Treatment.-Prophylactic treatment is of the first importance. 
Among important preventive measures are the avoidance of irritants, 
tainted food, and the like, especially in hot seasons; in institutions in 
which numbers of persons are closely associated, or in camps, barracks, 
and the like, the closest scrutiny of the food and water supply during 
the hot seasons of the year is necessary. Careful attention to the dress, 
especially the wearing of abdominal bands, is of importance in susceptible 
individuals and is a useful precaution. 
The treatment of acute enteritis is practically the same as that of 
ordinary diarrhoea, and therefore needs no extended discussion. The 
patient should be kept strictly at rest. The temptation to remain out 
of bed occurs only in mild cases, as the symptoms in severe forms are 
usually marked enough to make the patient take to bed at once. In 
the beginning of mild cases, however, matters may be made more serious 
by any attempt to continue at ordinary occupations, and in severe 
cases premature release from the bed may cause recurrences. The diet 
should be restricted to liquids, such as boiled milk, broths, gruels, albumin- 
water, and the like, or should be interdicted entirely. When vomiting 
or gastric symptoms are present, it is, as a rule, advisable to withhold 
all food in the beginning. 
Warm applications, such as fomentations, hot-water bags, poultices, 
or the like, not only give great comfort but have a controlling effect on 
peristalsis, and thus aid in checking diarrhoea. When distension of the 
abdomen is troublesome, turpentine stupes may be advantageous. 
As soon as the nature of the disease is recognized, the first care must 
be the removal of irritants from the intestinal tract. Unless diarrhoea 
is active from the first, a full dose of castor oil or some saline may be 
used to evacuate the contents of the bowel. If the symptoms in the 
beginning are not urgent, calomel followed by a saline may be employed. 
After copious evacuation has been secured, measures should be taken 
to control the diarrhoea and the intestinal inflammation. Bismuth 
salts, chalk mixture, lime-water, and other alkalis are advisable when 
acid fermentation is active. Astringents, such as kino, catechu, or various 
other tannic acid preparations, may be used. The addition of opium 
in the form of Dover's powder, laudanum, or paregoric is advisable 
when diarrhoea is severe and pain is marked. A timely injection of 
morphine in the beginning may control the severity of the attack. In 
later stages, when the diarrhoea has become less urgent and the general 334 
DISEASES OF THE DIGESTIVE SYSTEM 
symptoms are less pronounced, such astringents as silver nitrate or 
acetate of lead may be used in combination with opium. 
In cholera morbus the prompt use of opium by mouth or rectum, or 
of hypodermics of morphine, is advisable. The intensity of the vomiting 
usually precludes the administration of remedies by the mouth until 
the condition has been somewhat controlled. After this result has 
been secured, the treatment may be conducted as in ordinary cases. 
When symptoms of collapse appear, hot applications over the abdomen 
are advisable; hot drinks, with the addition of small doses of brandy 
or other stimulants, may be given; and hypodermic injections of strych- 
nine, camphorated oil, tincture of digitalis or digitaline, etc., should 
be employed. When the symptoms have somewhat subsided, great 
care should be exercised in resuming ordinary diet. Small quantities 
of liquid food alone should be permitted, and these should be given at 
short intervals and cautiously increased. If a tendency to nausea persists, 
cerium oxalate with fractional doses of cocaine or codeia may be admin- 
istered before food, so that the stomach may be less irritable. 
CHRONIC ENTERITIS 
This is a condition of catarrhal inflammation of the small intestine 
and the upper part of the large intestine, with or without ulceration. 
It usually follows as the sequel of acute attacks. 
Etiology.-This disease may result from a severe attack of acute 
enteritis or may be caused by repeated slight attacks. Not infrequently 
it is an accompanient of other conditions of the bowel, as carcinoma, 
intestinal obstruction, etc. Certain individuals show a distinct tendency 
to repeated or chronic catarrh of the bowel. 
Pathology.-The intestines usually present evidences of long-continued 
inflammation of the mucous membrane. The surface is covered with 
excessive secretion (mucous or mucopurulent), and there are areas of 
thickening of the mucosa or of erosion and atrophy. Ulcerations and 
stellate cicatrices of healed ulcers may be found, especially in the large 
bowel. Sometimes polypoid formations are found surrounding ulcers 
or independent of any ulceration. The mucosa may be of a normal 
color or hyperemic and more or less pigmented. 
Symptoms.-The conspicuous symptom is persistent or intermittent 
diarrhoea. The movements are extremely variable in character, some- 
times being nearly normal, at other times soft and pultaceous, or foamy, 
from the occurrence of fermentative processes. In still other cases 
they are large and liquid, and their color varies from a light yellow to 
a dark brown. Frequently they become highly offensive during exacer- 
bations, when increased bacterial putrefaction occurs. In some cases, 
instead of diarrhoea there is persistent constipation. In these caSes 
light-colored or gray scybalous masses, more or less coated with mucus, 
may be passed; while at intervals attacks of diarrhoea, with soft or 
liquid movements, occur. When the large intestine is specially involved, 
mucus is always a pronounced feature in the movements, and at times DISEASES OF THE INTESTINES 
335 
masses of mucus may be passed without any fecal matter. Blood-streaked 
movements or decided losses of blood may occur in cases attended with 
ulcerations or polypoid conditions of the mucosa. 
The abdomen is usually distended when chronic enteritis affects a 
large part of the intestinal tract. In cases in which the process has 
become limited to a restricted area, distension may be wanting, and 
local discomfort or tenderness alone may be discovered. 
The general state varies greatly. In many individuals this condition 
persists for years without great impairment of the health. In others, 
emaciation, general depression, and a variety of nervous symptoms 
significant of a lowered vitality are met with. Hypochondriac and 
neurasthenic symptoms are not unusual, as in cases of mucous colitis. 
The patient may become extremely emaciated, anemic, and weakened, 
and not rarely sinks into a state of semi-invalidism. The highest grades 
of anemia are observed in cases in which ulceration causes loss of 
blood or in those in which bacterial putrefaction occurs actively. 
Diagnosis.-It is difficult to distinguish chronic enteritis from func- 
tional disturbances of the intestine on the one hand, and from mucous 
colitis or certain primary nervous disorders on the other. In enteritis 
affecting the upper bowel the stools are found to contain undigested 
food, and are often acid in reaction, as in cases of intestinal indigestion. 
The intensity of the symptoms and the associated indications of inflam- 
matory trouble alone make a distinction possible. No absolute line of 
division can be drawn between the two conditions. When the large 
intestine is specially involved and mucus is abundant in the stools, 
chronic enteritis closely resembles mucous colitis. The latter, however, 
is usually so closely associated with primary conditions of nervous 
debility, and the evidences of intestinal irritation are so inconspicuous 
as compared with those in enteritis, that a distinction is usually easily 
made. The history of onset is also of importance in the diagnosis. 
Many individuals suffering with nervous diseases, such as neurasthenia, 
are liable to attacks of diarrhoea, or may suffer with more or less con- 
tinued looseness of the bowels, which may suggest an intestinal origin 
for the nervous condition. In these cases, however, acute symptoms 
of irritation of the bowels are generally wanting and the manifestations 
are those of intestinal indigestion, rather than of enteritis. When a 
chronic form of enteritis occurs in tuberculous or syphilitic persons it 
may be difficult to determine whether it is a simple enteritis or one of 
specific character. The clinical course and the results of treatment 
must determine. 
Prognosis.-Chronic enteritis may continue for weeks, months, or 
years. The prognosis is always uncertain but persistent treatment is 
generally helpful, though not always completely effective. 
Treatment.-The removal of all sources of irritation is the first care; 
sometimes an established error of diet may be discovered and corrected. 
In other cases a modification of the habits of life and the avoidance of 
exposure, fatigue, and similar causes are important. A close supervision 
of the patient's diet and an individual study may discover idiosyncrasies. 
Sometimes the correction of gastric digestion and the use of remedies 336 
DISEASES OF THE DIGESTIVE SYSTEM 
such as nux vomica or other stomachics and digestive ferments may 
relieve the condition. Usually, however, some form of astringent 
medication is indicated. Of all remedies of this class nitrate of silver 
is the most important. This may be combined with extract of opium 
or extract of nux vomica and administered in the form of pills coated 
with salol or keratin, which secure the passage of the pill through the 
stomach and its solution in the alkaline secretions of the intestine. Other 
astringents such as acetate of lead and bismuth salts may be employed. 
All the remedies are best given in small doses frequently repeated. 
When fermentative processes are active, guaiacol carbonate or salol 
may be employed in small doses, as such remedies, by irritating the 
mucous membrane, may increase rather than decrease bacterial pro- 
liferation. 
In cases involving the large intestine local treatment is advisable, such 
as repeated irrigations of the colon with water or saline solution. When 
mucus formation is abundant, astringent injections, as solutions of 
nitrate of silver (1 to 5000), quinine (1 to 5000), or the addition of fluid 
extract of hamamelis to a saline solution (1 to 125), may be employed. 
COLITIS 
Inflammation of the colon frequently occurs as an accompaniment 
of general catarrhal inflammation of the bowels or enteritis and is a 
common accompaniment of organic diseases of the large bowel. It is 
also met with as a manifestation of certain specific infections, such as 
dysentery. Occasionally, however, colitis occurs as an independent 
disease. This form alone is now under consideration. The term simple 
colitis has been applied to such cases by Hale White. 
Etiology.-The causes are similar to those of enteritis, and no adequate 
explanation can be given for the limitation of the disease to the large 
bowel. Some cases seem to follow the dislodgment of hardened masses 
of fecal matter from the sigmoid flexure. Doubtless the retention of 
scybala in the pouches of the large bowel is quite sufficient to cause 
inflammation. Dietary errors and various irritants doubtless play a 
part, and often infections are concerned. No specific microorganism, 
however, is operative in these cases. Colitis sometimes occurs as a 
secondary manifestation in certain general infectious diseases, such as 
pneumonia, septicopyemia, etc., and also in nephritis and uremia. 
Pathology.-The mucous membrane of the bowel presents the usual 
appearances of inflammation with thickening of the mucosa, excessive 
mucus formation, and follicular ulceration. In persistent cases polypoid 
formations may be met with, and pigmentation or hemorrhagic extrav- 
asation may be seen. In the colitis attending violent infections pseudo- 
membranes are sometimes observed. 
Symptoms.-The principal manifestations are diarrhoea, local pain, 
and tenderness. The stools contain an abundance of mucus, and are 
often blood-tinged. Sometimes considerable hemorrhage may occur. 
In severe cases, small mucous, blood-tinged discharges, resembling those DISEASES OF THE INTESTINES 
337 
of simple dysentery, occur and may be frequently repeated. In sub- 
acute cases fecal matter, with mucus and blood, is passed. Abdominal 
pain, especially in the region of the sigmoid flexure, is usually complained 
of, and sometimes there is extreme tenderness on pressure. This may be 
so great that the patient lies with the left thigh flexed; and even the 
weight of the bedclothes may be intolerable. The pain is increased 
at the time of the movements, and active tenesmus may occur. 
Fever and general prostration of more or less intensity are usually 
present, and gastric disturbances may occur, although these are not, as 
a rule, severe. In old and debilitated persons extreme prostration fre- 
quently presents itself. In the pseudomembranous colitis accompanying 
infections a rapid loss of strength, high fever, and prostration result. 
Diagnosis.-The acute onset, local tenderness, and mucous discharges 
are the most characteristic features. It is extremely difficult to dis- 
tinguish a simple colitis from dysentery or from enterocolitis with special 
involvement of the large bowel. It must be remembered that colitis 
occurs as a symptom of malignant disease and other organic conditions. 
Prognosis.-This is usually favorable, although a tendency to chronic 
inflammation sometimes results. In persons weakened by age or previous 
disease a fatal termination may occur. 
Treatment.-Rest and warm applications to the abdomen, with careful 
regulation of the diet and the administration of remedies to check 
intestinal irritation, are the important features. All of these have been 
considered in the discussion of the treatment of diarrhoea and enteritis. 
Special mention may, however, be made here of certain local methods 
of treatment. When the inflammation in the sigmoid flexure and rectum 
is pronounced, and tenesmus is a troublesome symptom, ice suppositories, 
injections of small quantities of cold water, or of starch-water containing 
opium, cocaine, or other sedatives, may be used with advantage. Cases 
marked by more extensive irritation, or in which hard scybala tend to 
form, are benefited by repeated injections of small quantities of olive 
oil. In subacute cases and during the later stages of acute attacks 
astringents of various sorts may be used in larger colonic irrigations. 
DIARRHCEA IN CHILDHOOD 
The diarrhoeas of infancy and early childhood require special con- 
sideration, on account of their greater urgency and their distinctive 
features. As the digestive and metabolic functions are relatively pre- 
dominant at this age, any derangement of the gastro-intestinal tract 
naturally involves a greater disturbance of health. 
Etiology.-The causes of diarrhoea in children are practically the 
same as those in adults, but the difference in the character of the food, 
in the routine of life, and in susceptibility give a greater prominence to 
certain conditions. 
Food.-Probably the most generally active cause of diarrhoea in 
children is improper feeding. A mere excess of food may be sufficient 
to derange digestion and occasion intestinal irritation; but overfeeding 
vol. in-22 338 
DISEASES OF THE DIGESTIVE SYSTEM 
is particularly harmful because it furnishes favorable conditions for 
bacterial growth and fermentative processes in the intestinal tract. 
This is particularly seen in young children past the nursing age, in whom 
a single overloading of the stomach may occasion an attack of diarrhoea, 
afterward prolonged by secondary conditions. The more indigestible 
the food the more promptly will diarrhoea follow and the more serious 
its type. In sturdy, bottle-fed infants an appetite somewhat too keen 
may readily tempt the mother or nurse to overfeed the child, and diar- 
rhoea frequently results. The quality of food, especially milk, must be 
considered. Diarrhoea in young infants is frequently caused by milk 
containing too high a percentage of fat. 
Much more commonly the cause is some qualitative changes in the 
food, especially the use of tainted milk. Attempts to improve conditions 
by pasteurization or sterilization of the milk are of questionable utility, 
although the former plain is preferable. Sterilized milk should be con- 
demned, because its constant or repeated use undoubtedly occasions nutri- 
tional disturbances, infantile scurvy, and other diseases. Pasteurization, 
although less objectionable, cannot be relied upon to destroy all micro- 
organisms, and thus often gives a false sense of security. Experimental 
investigations have shown that after thorough pasteurization bacterial 
multiplication occurs even more rapidly than in raw milk; and when 
the food is prepared in the morning, the bottles given later in the day 
may be in worse condition than if pasteurization had not been practised. 
The addition of any bactericidal agent to milk, even in minimal quantities, 
must be unreservedly condemned. Intense forms of diarrhoea and general 
infection are sometimes followed by the use of milk obtained from cows 
suffering with mastitis. 
Safety in milk feeding lies in the careful supervision of dairies, the 
handling of the milk in the cleanest possible manner, prompt delivery 
at the home, and careful refrigeration after its delivery. 
Sometimes, although the milk used has been fresh and pure, diarrhoea 
may follow its use on account of disturbance of digestion and secondary 
fermentative processes caused by bacteria already present in the intestinal 
tract. Often this is caused by the use of milk mixtures that are too 
strong and therefore indigestible. Every attempt at correcting such 
diarrhoea by modifications of the milk may be futile. 
Diarrhoeas due to milk may be the result of the action of bacteria 
present in the milk, or may more directly result from poisoning by 
bacterial products present in the milk. The latter forms are particularly 
severe and more properly merit the term milk poisoning, which is often 
used in a general sense to indicate diarrhoeal disease due to milk feeding. 
Investigations have shown the presence of an organism closely allied 
with the Bacillus dysenteries of Shiga in cases of infantile summer diarrhoea 
of the enterocolitis type. There is little doubt that this organism plays 
an important part in the etiology of some cases and of occasional exten- 
sive outbreaks in institutions or in certain communities. It is quite 
as certain, however, that cases or outbreaks clinically indistinguishable 
from these are caused by other microorganisms. Among these are 
various closely allied organisms differing mainly in their capacity to DISEASES OF THE INTESTINES 
339 
ferment different forms of sugar. Other organisms, however, such as 
the Bacillus lactis aerogenes, the Bacillus coll and close allies of this 
group, streptococci and staphylococci are concerned in some cases. 
In many cases several forms seem to be associated. The most intense 
diarrhoeas of the cholera infantum type seem to be caused by products 
of bacterial decomposition either occurring in the food or formed in 
the intestinal tract. No special microorganisms have been connected 
with these cases. 
In older children various other foods may be the cause of attacks of 
diarrhoea. Unripe or spoiled fruit, particularly, takes high rank. In 
certain epidemics it has seemed probable that the source of infection 
was water. The careless use of impure water in the washing of milk 
cans or bottles may cause infection of the milk, or the drinking water 
given the child may cause direct infection. 
Age.-The time of greatest susceptibility is from the sixth to the 
twentieth month, the period of the primary dentition. Dentition itself, 
by causing reflex disturbances, excessive secretions, or fever, increases 
the liability to all forms of diarrhoea, although not the direct cause. 
Season.-Diarrhoea is distinctly a disease of warm weather, although 
it may occur at any period of the year. In the summer months it is 
always more difficult to preserve milk and other foods. In addition, 
the children are rendered susceptible by free action of the skin and 
chilling at night. 
Environment.-Surroundings play an important part. Children in 
crowded cities and amid surroundings of destitution and squalor are 
much more liable to severe diarrhoeas than those in the country or 
living under more wholesome conditions. In institutions in which a 
number of children are in close contact direct infections frequently 
occur. The greatest care is necessary, in the handling of children, to 
avoid the communication of diarrhoeal conditions; particularly should 
the handling of the diapers be scrutinized with care. Food standing in 
the same room may easily become infected, and the preparation of the 
food should be carried out away from any danger of contamination. 
Pathology.-The lesions in the various forms of infantile diarrhoea 
vary considerably; quite commonly the character of the anatomical 
manifestations is not in keeping with the seriousness of the symptom. 
Three types may be distinguished, although no sharp dividing line can 
be drawn between them. These are: (1) simple or dyspeptic diarrhoea; 
(2) enterocolitis; and (3) choleraic diarrhoea or cholera infantum. 
In the first of these the bowel may present no evidences of disease 
postmortem. When the manifestations have been severe, some indica- 
tion of catarrhal irritation or inflammation may be found in the upper 
small intestine and stomach. Congestion, slight thickening, and excessive 
mucus formation may be discovered. In the enterocolitis of childhood 
more definite changes in the mucous membrane are seen. Redness and 
swelling, and frequently enlargement of the lymphatic follicles, are 
usually met with. Sometimes small follicular ulcerations, and less 
commonly swelling and slight ulceration of Peyer's patches, may be 
seen, especially in subacute or chronic cases. In cases of excessive 340 
DISEASES OF THE DIGESTIVE SYSTEM 
severity pseudomembranes or extensive ulceration may occur, more 
particularly in the large bowel. After long-continued attacks of entero- 
colitis, a thinned, atrophic mucous membrane may be found. Various 
secondary changes in other organs expressive of depletion of the system 
occur. In cholera infantum evidences of intense inflammations of the 
mucous membrane, with exfoliation of epithelium and swelling of the 
glands and lymphatic follicles, may be seen. 
Symptoms.-Simple or Dyspeptic Diarrhoea.-Usually evidences of 
gastric disturbance precede the attack of diarrhoea, and attend it more 
or less continuously. The child regurgitates food or is attacked by 
active vomiting. At the same time he becomes restless and distressed, 
with abdominal pain and distension. The facies and actions suggest 
griping abdominal pain. Later, diarrhoea sets in, the movements being 
offensive or sour-smelling, and characteristically containing undigested 
food, such as curds of milk, together with more or less mucus. The 
color of the stools varies greatly, sometimes being white or light colored, 
at other times green. Lesage, in particular, has shown that chromogenic 
bacteria are active in producing green stools in certain cases. The number 
of movements may be merely a slight increase over the normal, or may 
reach ten or more in the twenty-four hours. In some cases the evacuation 
of the bowels is closely dependent upon the taking of food, one or more 
movements quickly following each feeding. In such cases there is apt 
to be a considerable amount of undigested food in the motions. 
The general condition is one of moderate prostration, although fre- 
quently there is but little weakness until the diarrhoea has lasted for 
some time. If long continued, emaciation, pallor, and other signs of 
depletion are met with. 
Enterocolitis.-The term inflammatory diarrhoea is also applied to this 
variety. The symptoms are distinctly more intense, and in marked cases 
reach high grades of severity. Nearly always the child loses strength 
rapidly, and when repeated, and especially watery, stools are discharged, 
extreme prostration may speedily occur. Fever is practically always 
noted, and in severe cases is very high. Temperatures ranging from 
103° to 105° are not unusual, and hyperpyrexia is a common manifesta- 
tion of the enterocolitis of the hot summer season. 
The onset is usually abrupt, and is attended with evidences of general 
distress, and especially abdominal pain. Vomiting frequently occurs, 
but is less conspicuous than in the dyspeptic form, and sometimes, 
especially in older children, may be wanting. Often, however, obstinate 
vomiting is a marked symptom. The stools are numerous, and vary in 
color from brown to green. After the contents of the bowel have been 
evacuated, more watery movements, with less and less color, may occur, 
so that the condition approaches, in the character of the discharges, 
to the choleraic type. When the large bowel is especially involved, 
considerable mucus may be mixed with the discharges. 
The general condition of the child is one of rapid exhaustion. The 
face becomes pinched, the eyes grow hollow and are surrounded by 
circles, the temples are sunken, and when severe exhaustion has devel- 
oped the hands and feet may grow cold and cyano^ed, while the internal DISEASES OF THE INTESTINES 
341 
temperature as determined in the rectum remains excessively high. The 
abdomen is often distended and the skin tensely drawn and harsh. 
The child becomes more and more feeble, its movements less active, 
its cry more and more faint, and its lips dry. Finally, it sinks into a 
state of complete collapse. An apathetic, stuporous, or even comatose 
condition, now and then interrupted by a cry, betokens a condition re- 
sembling that of meningitis and designated as spurious hydrocephalus. 
In cases involving the large intestine to a considerable degree, violent 
straining occurs with each evacuation of the bowels, and prolapse of 
the rectum is not unusual. In all cases the bowel movements may be 
irritating and cause inflammations of the skin about the anus or buttocks. 
The urine early becomes scanty, and occasionally the secretion is almost 
suppressed. Actual nephritis occurs in the intensely infective cases. 
When the temperature remains persistently high, various nervous 
symptoms, such as restlessness, slight twitching, and even convulsions, 
may occur; but the tendency to prostration usually supplants all other 
nervous indications, and the child sinks into a condition of lethargy or 
coma. The loss of flesh and strength sometimes increases with startling 
rapidity. Complications, such as bronchopneumonia, hyperpyrexia, 
and extreme nervous symptoms, often precede the fatal termination, but 
more commonly this results directly from exhaustion. 
Diagnosis.-The recognition of this form of diarrhoea offers little 
difficulty. In the beginning, high fever and the absence of characteristic 
intestinal manifestations may suggest infectious diseases of various 
sorts, but usually the characteristic symptoms speedily present them- 
selves. It is practically impossible to separate cases due to ordinary 
causes from instances of epidermic diarrhoea produced by the Bacillus 
dysenteries, except by bacteriological methods. 
Prognosis.-Enterocolitis is always a serious disease in childhood, 
particularly in young infants. Older children more commonly exhibit 
enough resistance to withstand the attacks. 
Choleraic Diarrhoea or Cholera Infantum.-This form, usually met 
with in early infancy, is of the most extreme gravity. The onset is 
sudden, and the child becomes prostrated very early. After a few 
movements, in which the bowel contents are evacuated, a choleraic form 
of diarrhoea occurs, the stools being large and watery, and containing 
but little fecal matter. The whole body undergoes a rapid shrinking, 
and the features present the shrunken, hollow appearance described 
as occurring in the most violent cases of enterocolitis, but coming on 
with even greater rapidity. Extreme dryness of the tongue and mouth 
and excessive thirst are evidences of the desiccation. The urine is 
scanty or suppressed. The blood becomes inspissated, and the circulation 
is interfered with, so that cyanosis of the hands and feet, or of the whole 
surface, becomes marked. The eyes sink in their sockets, the fontanelle 
is depressed, and within a few hours the child's face assumes the wrinkled 
appearance of senility. The surface is cold, and stupor or coma develops 
rapidly. The surface temperature is greatly reduced, while the internal 
temperature, as observed in the rectum, may rise to 105° or more. 
The course is brief, and in a large proportion of cases terminates 342 
DISEASES OF THE DIGESTIVE SYSTEM 
fatally. When improvement occurs there is a subsidence of temperature, 
a gradual cessation of diarrhoea, and a slow restoration of strength. 
Not rarely a less degree of diarrhoea persists for some time, due to a 
residual enterocolitis. 
Prognosis.-The mortality from this form is exceedingly great. 
When it occurs in institutions containing large numbers of infants, a 
fatal termination may take place in above 90 per cent. In older children 
the outlook is less grave, although it is always a condition of extreme 
severity. 
Treatment.-The prophylactic treatment is of the greatest importance. 
Greater care in the preparation and preservation of food and increased 
knowledge of the causes of diarrhoea have led to a decided diminution 
in the frequency of these conditions, although much remains to be 
accomplished. In hot seasons of the year all forms of food, but par- 
ticularly milk, should be kept with the strictest care. When chil- 
dren are bottle-fed, the food if prepared in the morning for the whole 
day should be kept in a refrigerator. Careful pasteurization is often 
necessary when the freshness of the milk is doubtful. In the early 
morning some other form of food, such as barley-water or prepared 
foods, may be used with advantage until the new supply of the day 
has been received. In the cases of older children rigid care should be 
taken to avoid the use of stale foods of all sorts. 
The susceptibility of the child may be lessened by the avoidance of 
exposure. In the summer, when the nights are relatively cool, care in 
the dress is of importance, particularly the protection of the abdomen 
and legs. Infectious diarrhoeas may be avoided in institutions by the 
separate management of the children and by the closest care in the 
handling of the napkins. 
Medicinal.-After the onset, treatment should be directed to the 
removal of irritants, the control of the diarrhoea, and the support of 
the patient's strength. In the milder dyspeptic diarrhoeas the prompt 
administration of a dose of castor oil and the withdrawal of the accus- 
tomed food, substituting for this barley-water, rice-water, albumin- 
water, weak broths and the like, may speedily terminate the condition. 
If the tendency to diarrhoea persists, mild astringents, such as powders 
of bismuth subnitrate, subgallate, or subcarbonate, with or without the 
addition of pepsin, may be sufficient. More active astringents, like 
chalk mixture with kino or catechu, and tannic acid preparations of 
other sorts, may be used. Frequently, small doses of calomel, alter- 
nating with bismuth, chalk mixture, or other astringents, appear to 
have a good effect. When the movements are acid and irritating, alkalis, 
such as magnesia, soda, or lime-water, may be employed. 
In cases of enterocolitis, preliminary purgation may be desirable, 
although it must be used with greater caution than in the dyspeptic 
diarrhoea, because the tendency to spontaneous evacuation of the 
irritating matters in the bowel is greater and prostration is more immi- 
nent. Sometimes, however, the prompt administration of castor oil 
or magnesia is desirable. When vomiting is severe, all food should 
be withheld for a time, or only diluted barley-water, rice-water, or thin DISEASES OF THE INTESTINES 
343 
gruel given. At the same time, small doses of calomel, alternating with 
bismuth powder, may be employed. In later stages, astringents, such 
as have been mentioned before, are useful. Opium in the form of lauda- 
num, Dover's powder, or paregoric is often necessary to check obstinate 
diarrhoea; and sometimes, when violent purgation threatens speedy 
collapse, a hypodermic injection of morphine (gr. to gr. gm. 
0.0013 to 0.003) may exercise a rapid controlling effect. 
When the temperature is high and prostration is severe, colonic 
irrigations are most serviceable. With the hips elevated, the colon 
may be flushed without exciting irritation of the bowel, and the effect 
upon the general condition of the child is frequently surprising. The 
water used for irrigations should be of a temperature of from 90° to 80° 
or 75° F.; the amount may vary, according to the age of the child, from 
half a pint to a quart. A catheter or small-sized rectal tube, passed 
high into the bowel, and a fountain syringe, elevated not above a foot 
or two, suffice for the injections. If the colon and rectum are irritable, 
the first injection may be at a higher temperature; and a few drops of 
laudanum may be added to the fluid. Sometimes a small amount of oil 
or a little starch-water containing laudanum, cocain, or other sedatives, 
may be injected first. In later stages, if colitis persists and slight diarrhoea 
with abundant mucus continues, injections of fluid extract of hamamelis 
in normal saline solution (1 to 65) or nitrate of silver (1 to 8000) may 
be employed. Stimulants and other supporting measures' may be 
necessary; hypodermics of strychnine (gr. to gr. ^-jy) and small 
doses of brandy, tincture of digitalis, or tincture of nux vomica may 
be used. If the external temperature has remained high, sponging or 
cold packs may be employed with advantage. 
In cholera infantum the tendency to speedy collapse requires the 
prompt administration of stimulants. External heat may be needed when 
the surface temperature sinks, and injections of fluid under the skin may 
be necessary to counteract the loss of water. The diarrhoea may be con- 
trolled by the use of astringents administered as freely as the condition 
of the stomach permits. In many cases the prompt administration of 
a hypodermic injection of morphine will check vomiting and diarrhoea, 
and permit of the administration of other remedies. When the diarrhoea 
is under control the cautious increase of nourishment and the use of 
stimulants are required to restore the patient's strength. The greatest 
care must be taken to prevent a recurrence of the intestinal disturbance. 
Serum treatment has been employed since the discovery of organisms 
resembling the bacillus of Shiga in cases of infantile diarrhoea, but the 
results have not proved encouraging. 
ULCERATION OF THE BOWEL 
A classification of intestinal ulceration is difficult, and from many 
standpoints unsatisfactory. The most rational is that of Nothnagel: 
First Group.-Ulceration as the result of necrotic processes: Simple 
duodenal ulcer (including peptic ulcer of the jejunum); ulcer following 344 
DISEASES OF THE DIGESTIVE SYSTEM 
cutaneous burns; embolic and thrombotic ulcer (the peculiar ulcers seen 
in patients with multiple neuritis belong to this class); amyloid ulcers. 
Second Group.-Ulceration as the result of inflammatory processes: 
Catarrhal ulcer; follicular ulcer; simple ulcerative colitis; stercoral or 
decubital ulcer. 
Third Group.-Ulceration as the result of acute infectious diseases: 
Typhoid; dysentery; diphtheria; anthrax; sepsis; erysipelas; varioloid. 
Fourth Group.-Ulceration as the result of chronic infectious diseases: 
Tuberculosis; syphilis; erysipelas; leprosy; pellagra. 
Fifth Group.-Ulceration as the result of constitutional diseases: 
Gout; scurvy; leukemia. 
Sixth Group.-Toxic forms of ulceration: Uremic ulcer; mercurial 
ulcer. 
Duodenal Ulcer.-The duodenal mucous membrane is frequently the 
seat of ulceration resembling that found in the stomach, and known as 
gastric or peptic ulcer. The form under consideration is that which 
results from digestive action rather than from infectious, toxic, or 
inflammatory processes. It has been designated simple duodenal ulcer 
or peptic duodenal ulcer. 
Etiology.-Duodenal ulcer is found associated with certain diseases, 
notably of the stomach. As to the association of gastric with duodenal 
ulceration, according to the Fenwicks, 1.7 per cent, of cases of gastric 
ulcer were accompanied by a lesion of the duodenum, but Mayo and 
Moynihan have found that half their cases of duodenal ulcer were 
associated with gastric ulceration. The clinical history of cases indi- 
cates that chronic gastritis with excess of acid secretion is a factor of 
considerable importance in the development of duodenal ulcer. Nearly 
all patients give a history of antecedent gastric disorders. 
In recent years some surgeons have maintained that chronic appen- 
dicitis is a common cause of gastric and duodenal ulceration. The exact 
mode of operation, however, is uncertain. 
Ulcer of the duodenum is more common in men than women and 
occurs most frequently in the third and fourth decades. 
Duodenal ulceration appears to be associated with tuberculosis rather 
more frequently than it is found in persons free of this disease or suffering 
with other maladies. Ulceration of the duodenum has also been referred 
to as occurring in chronic nephritis. These ulcers, however, are some- 
what different in their general character from ordinary duodenal ulcers. 
Extensive burns of the skin are associated with duodenal ulcers, but 
these differ in character and causation from true duodenal ulcers. 
Pathology.-Duodenal ulcers, like those of the stomach, may be dis- 
tinguished as acute or chronic. The former are circular and punched- 
out in appearance, and the floor and edges are congested* and soft. The 
chronic or indolent ulcer presents thickened, indurated, and sometimes 
undermined and irregular edges, and not infrequently has a sloping 
form, which gives the ulcer a funnel shape. Acute ulcers may be quite 
superficial, presenting themselves as mere erosions of the mucous mem- 
brane. The more chronic forms are deeper, extending to the submucous 
or even to the muscular coat, and occasionally penetrating through all 345 
DISEASES OF THE INTESTINES 
the coats, when the liver, the head of the pancreas, or some other neigh- 
boring structure may form the floor of the ulceration, adhesions having 
prevented an open rupture into the abdominal cavity. The mucosa 
surrounding an ulcer, although usually normal, may present evidences 
of irritative change, and is sometimes irregularly elevated or polypoid. 
Microscopically the floor and edges of the ulcer present necrotic changes, 
with some increase in connective tissue, but without the evidences of 
active inflammatory conditions, such as are found in ordinary ulcerations. 
The situation of duodenal ulcers is usually in the first part of the 
duodenum, near to the pylorus. The majority of the ulcers in the first 
part of the duodenum are situated quite near the pylorus, and are deepest 
at the upper part where the gastric contents are projected with greatest 
force against the duodenal wall. The anterior wall of the duodenum 
seems to be affected more frequently than the posterior, although 
observers do not agree upon this point. 
Secondary Changes.-Duodenal ulcers may undergo a process of 
gradual cicatrization; but apparently this termination is less common 
than in gastric ulcers. Chvostek insists that cicatrization is more common 
than has been generally believed. Perry and Shaw estimate it as occur- 
ring in 11 per cent, of all cases. When it occurs there may result a stenosis 
or deformation of the duodenum similar to the stenoses produced by 
cicatrizing gastric ulcers. Progressive dilatation of the stomach with 
symptoms of food stagnation result. Cicatricial stenosis of the lower 
end of the duodenum or the parts adjacent to the papilla of Vater may 
occasion obstruction of the biliary and pancreatic ducts. Occasionally 
diverticula of the duodenum follow the cicatrization of an ulcer. Deep 
ulcers may cause severe hemorrhage, from involvement of the large 
arteries adjacent to the duodenal wall. 
Perforation of the duodenum occurs in about half the fatal cases. 
Ulcers upon the anterior wall are more apt to terminate in this way 
than are those upon the posterior wall, owing to the absence of adhesions. 
When a perforation takes place without the previous formation of any 
adhesions the contents of the stomach and duodenum have ready access 
to the peritoneal cavity, and usually occupy the right side of this sac, 
extending along the colon toward the pelvis. When adhesions have 
formed, or when the perforation is minute, a localized abscess may 
develop. In such cases secondary perforation of the abscess into the 
liver, the stomach, other portions of the intestines, or the gall-bladder, 
or through the diaphragm into the pleura, the mediastinum, or the 
pericardial sac, may occur. In a few instances, rupture into the aorta, 
portal vein, vena cava, or gall-bladder has been recorded. 
Symptoms.-In a large proportion of cases duodenal ulcers are chronic 
in course and the symptoms are slow in development. Occasionally 
acute ulceration occurs, and the symptoms make their appearance 
suddenly, intense pain and acute disturbance of digestion, followed by 
the rapid development of hemorrhage or perforation, being met with. 
In the great majority of cases, however, such acute onset is wanting, 
the symptoms being slow in development and without characteristic 
significance in the earlier stages. In these cases the patient suffers with 346 
DISEASES OF THE DIGESTIVE SYSTEM 
gastric manifestations and resulting emaciation, loss of strength and 
appetite, and finally attacks of pain suggesting hyperacidity. Very 
commonly the clinical course of duodenal ulcer is characterized by 
periods of active symptoms followed by remissions, in which complete 
relief from all discomfort and restoration of strength and normal weight 
occur. In many instances the condition may be entirely latent until 
hemorrhage or perforation take place, and cicatrices of old duodenal 
ulcers may be found at autopsy in cases in which no evidences had 
been manifested during life to indicate the disease. The most marked 
symptoms are pain, dyspeptic manifestations, and hemorrhage. 
The pain is frequently paroxysmal, like that of gastric ulcer. It may 
be of intense severity or merely a dull discomfort at certain periods 
after the ingestion of food. In other cases, whether severe or dull, it 
is more lasting, and sometimes a constant sense of burning or of sharp 
pain is experienced. The pain is situated to the right of the middle 
line, and usually a little above the umbilical level. It may radiate 
toward the right, or in other cases extend toward the left side. Some- 
times it is described as having a deep-seated location, being rather 
unlike the characteristic pain of gastric ulcer in this particular. The 
time of its appearance varies. Sometimes it follows immediately after the 
taking of food, but more commonly it does not occur, or does not reach 
its acme, until two, three or four hours after meals. The character of 
the food may have a certain relation to the occurrence and the intensity 
of the pain. Generally speaking, heavy meals occasion more severe 
pain; although it may be somewhat later in appearing. The drinking 
of copious draughts of water or the taking of other liquids, such as 
milk, beer, wine, etc., may relieve the paroxysm for a time. 
Tenderness and rigidity of the abdominal muscles may be met with 
over the seat of duodenal ulcers, especially those situated anteriorly. 
Pressure usually increases the pain, although not invariably. 
Gastric symptoms are rarely wanting in typical cases. In a great 
many instances there is a history of long-standing gastric disturbance. 
The patient will state that he has gone from one form of diet to another 
in the vain endeavor to relieve himself of recurring pain after the ingestion 
of food. The symptoms usually complained of are gaseous distension, 
acidity, the regurgitation of sour liquid, and especially dull or sharp pain 
after the taking of food. Loss of appetite may occur, but more commonly 
the patient refuses food or restricts his dietary from the fear of causing 
pain and other discomfort. In other cases there is an intense craving 
for food, which is controlled only by the pain that follows its ingestion. 
Vomiting sometimes occurs. The general condition of the patient is 
suggestive in the later stages. He is emaciated, sallow, or anemic in 
appearance, the latter being striking when a slow and continued oozing 
of blood has occurred; and frequently he presents a desiccated, shrivelled 
appearance. The bowels are usually constipated, but may be variable, 
short attacks of diarrhoea alternating with longer periods of constipation. 
Often constipation is the most marked symptom presented. Examination 
of the stomach contents shows hyperacidity and excess of free hydro- 
chloric acid in perhaps a half of all cases, with normal or moderate acidity DISEASES OF THE INTESTINES 
347 
in most of the other half. Exceptionally a quite low acidity may be 
found. The symptoms suggestive of hyperacidity are not always found 
associated with actual excess of acid. 
Hemorrhage may occur from the stomach or from the bowel, or the 
blood may be evacuated in both ways. More frequently than severe 
hemorrhage there is slight oozing of blood, which may occasion a dis- 
coloration of the stools that is just sufficient to be observable; or there 
may be so little blood that it can be recognized only by chemical tests 
(occult blood). The continuous presence of small amounts of blood, 
when associated with suggestive symptoms, is a diagnostic indication 
of great value. 
Perforation of a duodenal ulcer may occasion symptoms similar to 
those met with in the perforation of gastric ulcers. Usually the onset 
of this complication is attended with sudden prostration and pain. 
The patient may sink at once into a condition of shock or collapse; 
later he may revive and pain in the abdomen, especially toward the 
right side, tenderness, and distension, due to the development of peri- 
tonitis, may then set in. In a great many instances the diagnosis of 
appendicitis has been made, on account of the acuteness of onset and 
the tendency to right-sided situation of the symptoms. 
Complications.-Among the complications are those which result 
from extension of the ulcerative process through the duodenal wall, 
and those which are due to cicatrization of the ulcerated area. In the 
former group, the most important condition is localized peritonitis. In 
the case of slowly growing ulcers a certain amount of localized peritonitis, 
causing adhesion with neighboring organs is frequent. When these 
adhesions fasten the duodenum firmly to some solid structure and the 
ulceration penetrates to the serous coat, a localized abscess may occur; 
or a further penetration into the various structures with which the 
duodenum has become adherent may take place. 
Among the results of cicatrization of the ulcer the most important 
is partial stenosis of the duodenum, which, in turn, occasions an enlarge- 
ment of the stomach. Occasionally, when the ulceration has been 
situated near the papilla of Vater, obstruction of the common bile duct 
may occasion jaundice or an obstruction of the pancreatic ducts. 
Carcinomatous change may take place secondarily and clinical indica- 
tions of carcinoma may be recognized. 
Diagnosis.-A positive diagnosis of duodenal ulcer is frequently 
impossible. In particular, the distinction from gastric ulcer cannot be 
made with certainty. This is of minor consequence, as an ulceration 
just within or just outside the pyloric ring is, to all intents and purposes, 
of the same consequence. Duodenal ulcer must also be distinguished 
from gall-stones and occasionally from chronic appendicitis. Reflex 
hyperacidity and gastritis may simulate ulcer very closely. 
The history of long-continued digestive disturbance with occasional 
remissions is of some importance in the diagnosis. The most suggestive 
symptoms upon which a diagnosis is usually established are pain and 
gas, occurring from two to four hours after meals and often at quite 
a fixed hour in the night, and not rarely yielding temporarily when food 348 
DISEASES OF THE DIGESTIVE SYSTEM 
or an alkali such as bicarbonate of soda is taken; sour stomach; belching, 
nausea and later vomiting; constipation. 
Fluoroscopic and skiagraphic examinations show active peristalsis 
with discharge of the bismuth in large masses; peristence of the duodenal 
cap; later distinct gastric retention. Not rarely, however, the stomach 
throughout the case shows premature emptying of its contents. In 
cases of gastric ulcer the symptoms are less remitting, the pain occurs 
earlier after the taking of food and is often higher up and more superficial; 
nausea and vomiting are more pronounced, at least in the earlier stages. 
Gall-stones frequently occasion gastric symptoms very similar to those 
of ulcer, but the intensity of pain is greater, its relation to food usually 
less definite, and the relief from taking food less frequent. Jaundice and 
tenderness in the right hypochondriac region are more common. 
Sudden rupture of a duodenal ulcer, with resulting peritonitis, may 
be mistaken for appendicitis, intestinal obstruction, acute pancreatitis, 
and sometimes cholelithiasis. The tendency of the pain and tenderness 
to extend to the right, and thus suggest appendicitis, should be noted. 
The withered, emaciated condition of a patient who has had long- 
standing ulceration of the duodenum may suggest the existence of 
carcinoma at the pylorus, particularly when pyloric spasm, constant or 
paroxysmal, has occasioned enlargement of the stomach and visible 
peristalsis. There may even be a palpable mass due to periduodenal 
adhesions and inflammation. In such cases a positive diagnosis is 
sometimes impossible. 
Treatment.-This is practically identical with that of gastric ulcer. 
In acute cases, prolonged abstinence from feeding by the mouth is the 
most important element. The patients can, without difficulty, abstain 
from all food for days or a week or more; some nourishment, perhaps, 
being derived from nutrient enemata and water being administered by 
the bowel; later, carefully regulated diet composed of milk, eggs, farina- 
ceous foods. Subsequently, moderate additions of meat and vegetables 
as free as possible form irritating residues may be added. Such a dietary 
should extend over a period of several weeks and should be increased 
very gradually. Bismuth subnitrate, olive oil, or nitrate of silver may 
be given by the mouth for the purpose of neutralizing acidity, protecting 
the ulcerated surface, and through an astringent effect stimulating 
cicatrization. If bismuth is used and complete starvation is practised, 
small doses will suffice, gr. 10 to 15 (gm. 1) being administered several 
times daily in suspension. Olive oil, in doses of from 2 drams to | 
ounce or 1 ounce, may be given several times daily; and nitrate of silver, 
in solution in distilled water, or in the form of freshly made pills. The 
doses of this drug should be small, not exceeding gr. | (gm. 0.016), and 
preferably administered a number of times daily, rather than large doses 
at longer intervals. Belladonna or atropine in full doses is decidedly 
efficacious in controlling hyperacidity and pyloric spasm. 
Occasional lavage of the stomach with plain water, or with water 
containing bicarbonate of soda may have a temporarily useful effect; 
but, as a rule, lavage should be avoided. 
In less acute cases a more prolonged treatment of the same sort, with DISEASES OF THE INTESTINES 
349 
very carefully moderated feeding by the mouth, may prove successful. 
As a rule, however, subacute and chronic ulcers of the duodenum tend 
to persist, and eventually will require surgical treatment. It is wiser, 
therefore, to resort to surgical measures as early in such cases as a positive 
diagnosis is made. When perforation of a duodenal ulcer takes place, 
immediate surgical operation is imperative. 
Duodenal Ulceration following Extensive Cutaneous Burns.-As yet 
no satisfactory explanation for the relationship of the two phenomena 
has been presented. Theories that would rationally explain the occur- 
rence of intestinal ulceration after extensive burns have been advanced, 
but none satisfactorily explains the fact that the duodenum alone is 
usually the seat of the phenomenon. From this standpoint the theory 
proposed by Hunter is the most rational. He explains the condition 
by assuming that, following the burns, toxic substances are secreted 
with the bile, which, on coming in contact with the duodenal mucous 
membrane, induce ulceration. He found substantiation for this view 
in the experimental occurrence of duodenal ulceration after the sub- 
cutaneous injection of toluylendiamin into dogs. However, Fenwick 
was able to produce the same lesions on repeating the experiment after 
ligation of the common bile duct. Another view is that the condition 
is a result of emboli localizing themselves in the duodenal vessels, thus 
lowering the nutrition of the parts involved and subjecting them to 
digestion by the gastric juices. Cooke offers the theory that the violent 
trauma to the skin destroys the antiferments present in the mucous 
cells, and as the digestive powers of the gastric juice are most potent 
in the duodenum, digestion of the mucous membrane occurs here. A 
discussion of the various theories has been presented by Bardeen.1 
The ulcers differ in many features from the peptic duodenal ulcers. 
There may be but one ulcer or from three to six present. They are 
usually located in the inferior horizontal portion of the duodenum. 
They may be irregular in outline or, as is usually the case, are long and 
narrow, varying in width from 1 to 5 mm. and in length from 5 to 15 
mm. In exceptional cases, ulcers in the stomach or the lower part of 
the intestinal tract have been found associated with such duodenal 
ulcers. Usually the ulcer develops from the sixth to the twelfth day 
after the burn, but they have occurred as early as the second day and 
as late as the seventeenth. They are met with chiefly in young subjects, 
rather oftener in females than in males and more frequently after burns 
of the trunk than on the extremities. They are almost invariably fatal. 
According to the Fenwicks they occur in 6.2 per cent, of all fatal burns. 
Jejunal Peptic Ulcer.-Jejunal peptic ulcer occurs after gastrojejunos- 
tomy from the same causes that induce duodenal peptic ulcer. It occurs 
just beyond the point of attachment of the jejunum to the stomach. 
For some unexplained reason this condition is met with much more 
frequently in males than in females. Of 31 cases collected by Gorset, 
29 were males. Jejunal ulcer results more commonly from anterior than 
from posterior gastrojejunostomy. This probably results from the fact 
1 Journal of Experimental Medicine, vol. ii, p. 501. 350 
DISEASES OF THE DIGESTIVE SYSTEM 
that the motor activity of the stomach is less impaired in the posterior 
operation, and consequently there is a lessened tendency to hyperacidity, 
which is the important factor in the production of the ulcers. Jejunal 
ulcer manifests the same tendency to perforation as does duodenal ulcer, 
but the resulting peritonitis is more frequently circumscribed. According 
to Mayo Robson, general peritonitis is more likely to follow perforation 
after posterior gastrojejunostomy than after the anterior operation. 
Uremic Ulcers.-Difference of opinion prevails as to the probable 
cause of this ulceration. It has been variously attributed to capillary 
thromboses, to arteriosclerosis of the intestinal arteries, and to submucous 
hemorrhages. In all probability the excretion of irritating substances 
into the intestinal tract is more or less responsible. A feature lending 
considerable weight to this view is the fact that in the vast majority of 
cases of nephritis some degree of catarrhal enteritis is found, undoubt- 
edly caused by the irritation of excretory products; and various degrees 
of catarrhal and even diphtheritic enteritis are usually associated with 
the ulceration. The ulcers are most frequently found and most num- 
erous in the rectum, colon, and lower ileum, although occasionally they 
are almost or entirely limited to the duodenum. They vary greatly in 
size. The smaller ones have regular and somewhat undermined edges. 
They frequently coalesce, forming large, irregularly outlined areas of 
ulceration. The condition is usually met with in chronic interstitial 
rather than in the parenchymatous forms of nephritis. 
Embolic and Thrombotic Ulcers.-The intestines are subject to 
changes dependent upon alterations of the blood supply, just as other 
tissues. The resulting lesions are dependent not only upon the char- 
acter of the obstruction but also upon its extent. If a large arterial 
branch be occluded so as to alter seriously the blood supply of a con- 
siderable part of the intestine, phenomena will result, which are dis- 
cussed elsewhere. If smaller branches be occluded, especially those 
running in the intestinal wall itself, ulceration will often ensue. Although 
thrombosis induced by sclerotic changes in the vessel walls may be the 
cause of such lesions, a much commoner cause is embolism. The char- 
acter of the lesion in the intestinal wall will depend upon the character 
of the embolus, whether it be bland or infectious. 
If an embolus occludes one of the smaller branches of an intestinal 
vessel, a hemorrhagic infiltration of the submucous tissues soon develops 
and later extends to the mucosa. The area involved becomes swollen, 
firm, and dark or grayish red. The tissues in the area of distribution 
of the vessel soon become necrotic, and the mucous membrane with 
more or less of the underlying tissues is cast off and an ulcer results. 
Usually the central portion of the area involved shows the most advanced 
changes. Frequently the visceral peritoneum corresponding to the area 
of involvement is the seat of a hemorrhagic infiltration. If the occlu- 
sion has been such that the entire thickness of the wall is involved, the 
ulcer becomes much deeper and early perforation may result. Usually 
the ulcers are of small size and involve only the mucous membrane and 
submucosa. They are usually multiple. If the embolus be septic, a local- 
ized submucous infiltration of leukocvtes occurs and a small abscess forms. 351 
DISEASES OF THE INTESTINES 
This increases in size and finally ruptures into the intestinal lumen. 
If the involvement of the wall be more extensive, perforation may occur 
and peritonitis result. 
Catarrhal Ulcers.-However inappropriate this term may be, it ex- 
presses well enough the nature of the condition-an ulceration occur- 
ring in conjunction with and apparently the result of catarrhal inflam- 
mation. It is seen especially in catarrhal enteritis of rather long duration, 
and more frequently in children than in adults. The ulcers are present 
in both the small and large intestines, but are more numerous in the 
latter. They are usually minute, round ulcers with very slightly in- 
durated edges. Larger ones may occur which are frequently the result 
of the confluence of several small ulcers. These larger areas generally 
have an irregular outline. The ulceration usually involves only the 
mucous membrane, and at times not even its entire depth. The ulcers 
are usually numerous, and at times the process is so extensive that only 
islands of mucous membrane are left between the ulcerated areas. The 
mucous membrane that remains free of ulceration is the seat of catarrhal 
inflammation. Since the process is limited to the mucous layer, per- 
foration practically never occurs; but it is not unusual to find various 
degrees of cicatrization when the condition shows a tendency to heal. 
The mode of formation of catarrhal ulcers has been the subject of 
some discussion. The specially mooted question has been whether 
the primary stage of the process is in the mucosa itself, inducing ulcera- 
tion by direct action upon the epithelium, or whether there is originally 
a submucous infiltration inducing ulceration by interference with the 
nutrition of the overlying parts. Since the catarrhal changes preceding 
the ulceration are most marked in the mucous layer, and since only 
the most superficial portions of the mucosa may be ulcerated, the former 
theory is the more rational. 
Follicular Ulceration.-This occurs as a result of the same conditions 
that induce catarrhal ulceration. In the latter condition the mucous 
membrane is the portion specially affected, whereas in follicular ulcera- 
tion the solitary lymphatic follicles are the seat of the process. The 
inflammation induces a hyperplasia of the lymphatic elements of the 
follicles which later undergo central softening. The swelling of the 
lymphatic follicles interferes with the nutrition of the overlying mucosa 
and subjects it to mechanical irritation, so that it undergoes necrosis, 
and the softened elements of the lymphatic follicles escape, leaving an 
ulcer. As the extent of the follicle is usually greater than the area of 
superficial ulceration, the resulting ulcer has usually a more or less 
undermined edge. The ulcers are usually numerous, at times giving 
a typical honey-comb appearance to the part involved. Perforation 
seldom occurs. The colon and lower ileum are much more frequently 
the seat of the process than the upper portion of the intestinal tract, and 
the condition is more common in children than in adults. 
Stercoral or Decubital Ulcers.-These result from the irritant action 
of inspissated fecal masses on the intestinal wall. This action may be 
purely mechanical, or, what is more probable, the mechanical injury 
to the mucosa serves only as the occasion for ingress of pathogenic 352 
DISEASES OF THE DIGESTIVE SYSTEM 
organisms. The condition naturally is found only in the large intestines, 
and especially at the points where stagnation occurs, at the hepatic 
and splenic flexures, in the rectum, sigmoid, cecum, and appendix. The 
ulcers are usually circular in outline and have an inflamed suppurating 
base. The condition is more frequently met in elderly individuals 
subject to constipation. Perforation of a stercoral ulcer has been known 
to occur. Not infrequently these ulcers lead to cicatrization and stenosis, 
and Grawitz remarks that probably not infrequently these stenoses 
have been mistaken for carcinomatous strictures, while Nothangel calls 
attention to the possibility of carcinoma developing as a secondary 
manifestation in the edges of the cicatrices. 
Leukemic Ulcers.-In leukemia, and especially in the more acute 
form, it is possible for lymphatic hyperplasia in the intestinal wall to 
occur of such a degree as to induce ulceration of the overlying mucous 
membrane. Such ulcers are more commonly found in the ileum than 
in other portions of the intestinal tract, although usually some other 
portions of the digestive tract, especially the mouth and pharynx, are 
involved. 
Trophic Ulcers.-In various nervous and mental disturbances, ulcera- 
tion of the intestines has been observed. Nothnagel refers to cases 
reported by Kussmaul and Maier, Minkowski and Lorenz, in which 
extensive intestinal ulcerations occurred in conjunction with multiple 
neuritis. In most of these cases sclerotic or thrombotic changes in the 
vessels were found, so that Nothnagel concludes that the intestinal 
lesions were the result of the vascular changes associated with the 
neuritis. Others consider it possible for the intestinal ulceration to 
result from disease of the brain and spinal cord. The cases of Targett 
and Ogle are particularly striking. In both of them there was fracture 
of the spine followed shortly after by diarrhoea, and at autopsy extensive 
ulceration of the colon was found. It is not improbable that these 
lesions were the result of the same factors inducing the superficial trophic 
ulcerations so common in spinal disease. 
Symptoms of Intestinal Ulceration.1-There may be a complete 
absence of symptoms, even in cases of extensive ulceration, especially 
when the lesions mainly occupy the small intestine. When the colon 
is involved, and particularly when its lower portions or the sigmoid and 
rectum are affected, symptoms are less frequently wanting. Even in 
these cases, however, there may be a striking absence of clinical mani- 
festations. Among the symptoms in the different forms of ulceration 
of the bowels, diarrhoea, hemorrhage, or the passage of small amounts 
of blood, the discharge of pus and shreds of tissue, anemia, pain, fever, 
and general disturbances of health are the most important. 
Diarrhoea is perhaps the most frequent symptom and is caused 
by the direct irritation of the intestinal nervous mechanism by the 
ulcerative process or by interference with intestinal absorption. Its 
character varies with the location of the ulcers. When these are situated 
in the small bowel, in the cecum, or in the upper portions of the colon, 
1 Duodenal ulcer, tuberculosis, and syphilis, as well as the ulceration of specific 
infections are excluded. DISEASES OF THE INTESTINES 
353 
diarrhoea, if present, is of the ordinary kind with more or less fluid or 
unformed movements. No special characters distinguish the diarrhoea 
in such cases from that in simple irritation or catarrhal conditions. 
When the lower part of the large bowel is the seat of the ulcers, there is 
a greater tendency to admixture of mucus and blood, and the diarrhoea 
partakes of the nature of dysentery in proportion to the intensity and 
extent of the ulcerative processes. Intense straining at stool or tenesmus 
is sometimes met with in such cases, and marked soreness or tenderness 
over the descending colon or sigmoid flexure may occur. 
Hemorrhage is less common in the forms now under consideration 
than in simple duodenal ulcer and typhoid ulceration. Sometimes, 
however, considerable hemorrhage or the passage of blood with each 
stool may occur, especially when the ulcers are in the lower bowel. 
Small amounts of blood and occult bleeding are more common. When 
sloughing attends extensive ulceration, blood, pus, and shreds of tissue 
may be passed together. Pus and portions of tissue are highly suggestive 
of ulcerative processes. They are more common in cases of dysentery 
than in other ulcers, but may occur in any extensive form of ulceration. 
When intestinal ulceration is attended with large or repeated hemor- 
rhages the patient becomes highly anemic. In the earlier stages, and 
especially after large hemorrhages, the anemia has the ordinary char- 
acters of posthemorrhagic secondary anemia, but in cases of long-con- 
tinued slight bleeding a more intense anemia results, and often one of 
a type that is highly suggestive of pernicious anemia. 
Pain is a symptom of no regularity of occurrence. Closely grouped 
ulcers in the sigmoid or rectum are commonly attended with marked 
local tenderness and pain of a constant or paroxysmal colicky type. 
Ulcers elsewhere in the bowel are less frequently attended with pain, 
and those in the small intestine rarely cause greater discomfort than that 
of occasional attacks of colic or vague soreness in the abdomen. When 
the ulcers are in the rectum or sigmoid, tenesmus may be pronounced. 
Fever is less pronounced than might be expected. In stercoral and 
catarrhal ulcerations some degree of fever is usual, and at times it 
becomes marked. In other forms it is not regularly present. 
The general condition of the patient is by no means indicative of 
the presence or degree of ulceration. Sometimes, despite extensive 
lesions, the patient presents no evidence of great disorder of health. 
In other cases, especially when diarrhoea, fever, and hemorrhage occur, 
there may be emaciation, loss of strength, and severe anemia. 
Diagnosis.-It is extremely difficult to recognize intestinal ulceration 
in many cases. The occurrence of diarrhoea, the discharge of blood or 
pus and blood, and local pain or tenderness are highly suggestive symp- 
toms. When ulcers are situated in the rectum or sigmoid region they 
are readily demonstrable with the enteroscope. It may be doubted, 
however, whether the routine use of this instrument is advisable. Injuries 
to the ulcerated areas, even perforation of the bowel, have occurred in 
expert hands, and the cases in which a diagnosis can be made with 
certainty by the. aid of the enteroscope are usually cases in which it 
can be made with almost equal certainty without this instrument. 
vol. in-23 354 
DISEASES OF THE DIGESTIVE SYSTEM 
Prognosis.-Ordinary intestinal ulcers tend to heal in time, provided 
the proper hygienic, dietary, and medicinal measures are adopted. In 
cases in which extensive ulcers of the large bowel are present there is, 
however, a likelihood of great obstinacy to treatment. When extreme 
anemia and emaciation have occurred the prognosis is rather unfavorable. 
Treatment.-The treatment of ulcers in the upper part of the intestinal 
tract does not differ from that of diarrhoea due to other conditions. 
Careful regulation of diet, rest, local warmth and protection of the 
abdomen, mild astringents, such as bismuth salts, chalk mixture, vege- 
table preparations containing tannic acid, nitrate of silver, or salts of 
lead, are the remedial measures. 
Ulcers in the lower bowel can often be treated with advantage by 
injections or by direct topical applications through an enteroscope. 
Among the useful forms of injection may be mentioned solutions of 
nitrate of silver (1 to 5000 to 1 to 1000), weak solutions of salicylic acid, 
boric acid, thymol, or other antiseptics, astringent lotions, or flushings 
with simple salt solution. Sometimes nightly injections of an ounce or 
several ounces of olive oil may be advantageous. In conjunction with 
such measures the regular use of mild laxatives is useful in preventing 
the formation of scybalous masses. 
Direct treatment of the ulcers with stronger solutions of nitrate of 
silver and other astringents, suspensions of iodoform, and various anti- 
septics, may prove effective in cases of limited ulceration which can be 
reached through the enteroscope. 
PERICOLITIS 
Occasionally inflammation occurs in the tissues surrounding the colon 
resembling pericecal and peri-appendicular inflammation. 
Etiology.-The causes are numerous. Sometimes it results from 
direct injury; at other times, from organic lesions within the colon or 
perforation by foreign bodies. Probably in the majority of cases obstinate 
constipation and stercoral ulceration are the causes of extension and 
involvement of the tissues surrounding the colon. Various foreign 
bodies, such as pieces of bone, needles or pins, fragments of straw or 
wood, and the like, have been discovered penetrating the wall of the 
colon or lying in an abscess that has formed outside. Attention is 
called, in the section on Diverticula, to the occurrence of inflammations 
within and surrounding such extensions from the bowel. 
Pathology.-Whatever the original cause of the condition, the resulting 
lesions are similar, although varying in extent. Sometimes there is 
merely an inflammation or ulceration within and some reactive inflam- 
matory thickening on the outer surface of the bowel. When more 
extensive destruction of the mucosa has occurred, or when complete 
penetration by a foreign body or perforation has taken place, more 
extensive external inflammation occurs. This may result in a chronic 
inflammatory thickening; or, if active infection has occurred, an abscess 
may follow. Sometimes, as Bland-Sutton has shown, such abscesses DISEASES OF THE INTESTINES 
355 
may discharge into the bowel, and the tumor, which was before palpable, 
spontaneously disappears. In many cases the final result of the condi- 
tion is the formation of fibrous thickenings or of adhesions which may 
attach the bowel to neighboring structures or cause contraction. 
The usual situations in which pericolitis occurs are the hepatic and 
splenic flexures of the colon or the sigmoid flexure. The term pericolitis 
sinistra has been specially applied to cases occurring in the last-named 
situation. Perityphlitis of cecal origin is practically identical with the 
condition now under discussion; but, on account of its close relation- 
ship with appendicitis, it has been referred to in the discussion of that 
condition. 
Recently considerable attention has been paid to a form of pericolitis 
in which the colon is surrounded by a veil-like membrane (Jackson's 
membrane). Some of these cases are probably the result of preceding 
inflammatory conditions in the bowel and local infection; others are 
probably developmental in origin. 
Symptoms.-The clinical manifestations indicate an acute inflam- 
matory trouble with local pain and tenderness on pressure, more or 
less fever, and disturbance of the function of the bowel. In some cases 
constipation occurs as the result of inflammatory weakening of the 
affected segment of bowel or of pressure upon the bowel. In other 
cases diarrhoea occurs, and sometimes mucus and blood appear in the 
feces. Sometimes a localized induration or mass may be discovered. 
In rare instances spontaneous disappearance of the mass may occur in 
consequence of rupture into the bowel. 
Diagnosis.-The condition presents practically the same symptoms 
as those met with in appendicitis. The location of the lesion usually 
excludes this condition; but the possibility of a misplaced, and even 
a left-sided, appendix should be remembered. Some cases in which a 
tumor has been felt through the abdominal wall have been regarded as 
cases of carcinoma; and the diagnosis has been disproved only after 
operation or spontaneous recovery. The acute symptoms and the indi- 
cations of inflammation and infection should aid in excluding carcinoma, 
when the possibility of pericolitis is borne in mind. 
Treatment.-The treatment of the condition is purely surgical. 
APPENDICITIS 
Definition.-In a strict sense the term appendicitis should be used to 
define inflammations of the vermiform appendix. It has, however, 
obtained a broader clinical significance, embracing various inflammatory 
affections of the right iliac fossa with which inflammation of the appendix 
is associated as a more or less important factor. Formerly the term 
typhlitis was much in use, and was based upon the idea that inflam- 
mations of the region designated originated in the cecum and head of 
the colon and spread from these structures to the surrounding tissues 
(perityphlitis). Modern investigations have shown that in the great 
majority of instances perityphlitis has its origin in primary appendicitis, 356 
DISEASES OF THE DIGESTIVE SYSTEM 
and for practical purposes it may be accepted as established that inflam- 
mations around the head of the colon originate in the appendix, and 
should be dealt with as cases of appendicitis. The term appendicitis 
is sometimes loosely applied to diseased conditions of the appendix, 
such as cysts, mucoceles, etc., which are not necessarily inflammatory, 
although secondary inflammatory conditions may subsequently associate 
themselves. When used in this way, the term must be recognized as 
having a clinical rather than a pathological applicability. 
Notwithstanding the fact that various surgical writers have denied 
the existence of primary localized inflammations of the cecum without 
appendicitis, there is abundant evidence that such a condition does 
occur. MacWilliams1 reviewed a number of cases and showed con- 
clusively the existence of both acute and chronic typhlitis independent 
of appendicitis, tuberculosis, dysentery, cancer, or other like conditions. 
These forms of typhlitis are due to obscure causes or to coprostasis. 
The disease of the cecum may go on the ulceration, perforation, and 
the formation of perityphlitic abscess or general peritonitis, the appendix 
meanwhile remaining normal. H. A. Kelly has reported 14 such cases. 
For practical purposes, however, the comparative rarity of this condi- 
tion justifies the physician in disregarding it, unless the development 
of the case has strongly suggested the retention of fecal matter in the 
cecum and the physical signs indicate stasis in that region. 
Anatomy.-Embryologically the appendix is a derivative of the 
cecal pouch, originating as a small process from that structure in the 
seventh or eighth week of fetal life. In the early stages of the develop- 
ment of the intestinal tube the cecum is situated rather high up, near 
the under surface of the liver, but subsequently by elongation of the 
colon it assumes a lower position, carrying with it the developing appen- 
dix. Occasionally, the fetal situation of the cecum and appendix is 
observed in later life. Usually in the adult the appendix lies in the right 
iliac fossa, its base or point of attachment to the cecum being beneath 
the point described by McBurney and generally known by his name. 
This point is situated " exactly between an inch and a half and two inches 
from the anterior spinous process of the ileum in a straight line drawn 
from that process to the umbilicus." The attachment of the appendix 
to the cecum varies considerably. In the majority of cases, or according 
to Treves, in 90 per cent., a medioposterior position is discovered. Fre- 
quently the point of attachment is at the lower portion of the cecum 
on the anterior or posterior surface, or on the outer or right surface. 
To some extent the position assumed by the whole appendix is deter- 
mined by its point of attachment. The position, according to Kelly 
and Hurdon, is as follows: Horizontally, toward promontory or pointing 
laterally, 32 per cent.; oblique, toward spleen, 10 per cent.; ascending, 
34 per cent.; descending, 24 per cent. 
The direction is determined not alone by the point of attachment, 
but also by the length and character of the meso-appendix, as well 
as by the size and character of the appendix itself. It is of clinical 
1 Annals of Surgery, June, 1907. 357 
DISEASES OF THE INTESTINES 
importance that the appendix not rarely occupies a position posterior 
to the cecum and colon (in the retrocolic fossa). It is also important 
to recall that the appendix frequently extends down into the pelvis, and 
may be attached by its tip to pelvic structures. 
Meso-appendix.-The mesentery of the appendix is a triangular or 
quadrilateral fold of the peritoneum arising from the under layer of 
the mesentery of the ileum and attached by its right border of the cecum 
and by its inferior margin to the appendix itself, usually extending 
about two-thirds the length of that organ from the cecum toward the 
free tip. The left border of the meso-appendix is free and semilunar 
or concave in outline. The shape of the mesentery varies to a great 
extent in different cases, and determines very largely the position of the 
appendix. Especially important in this direction is the length of its 
left or free border. The bloodvessels and nerves of the appendix traverse 
its mesentery, and there may be contained within this structure variable 
quantities of fat. Occasionally a lymphatic gland (Clado) is found near 
the root of the meso-appendix. 
Considerable variation may be encountered in the shape and position 
of the meso-appendix, and these variations may determine certain 
peculiarities in the clinical manifestations of appendicitis. An extension 
of a serous fold from the appendix to the ovary (appendiculo-ovarian 
ligament of Clado) is of possible etiological importance. It is supposed 
to carry bloodvessels and lymphatics, which establish a communication 
between the circulations of the appendix and ovary. This vascular 
connection has been denied by some observers (Kelly and Hurdon). 
Coats of the Appendix.-These are four in number: (1) The peritoneal 
or serous; (2) the muscular, including an external longitudinal and an 
internal circular coat; (3) the submucous; and (4) the mucous. 
The Serous Coat.-The peritoneal layer is a rather firm membrane 
closely applied to the outer muscular coat excepting along the mesenteric 
attachment. Occasionally, also, on the side of the appendix opposite 
the attached mesentery, the serous coat is raised as a fold extending 
for some distance along the length of the organ. The superficial blood- 
vessels, lymphatics, and nerves of the appendix lie in a looser sub- 
serous tissue. Normally the bloodvessels can be easily seen beneath 
the peritoneal coat, and when congestion occurs their injection is 
striking. 
The longitudinal muscular coat is a continuation of the muscular bands 
of the large intestine. This connection is of considerable practical im- 
portance, particularly as the anterior longitudinal band of the colon and 
cecum is a direct guide to the root of the appendix. Contractions of the 
longitudinal coat may considerably shorten the appendix. 
The circular muscular coat, somewhat less in diameter than the longi- 
tudinal, encircles the appendix, but according to Lockwood is deficient 
at the attachment of the meso-appendix (hiatus'). This gap transmits 
vessels, nerves, and lymphatics from the interior to the serous coat. 
The submucous coat is of variable thickness from 0.2 to 0.8 mm., and 
is composed of loose connective tissue containing wide lymph spaces, 
lymphatics, and veins. It is separated from the mucous membrane by 358 
DISEASES OF THE DIGESTIVE SYSTEM 
a thin muscularis mucosa. The submucosa contains a considerable 
amount of elastic tissue, and the lymphadenoid tissue of the mucosa 
extends well into the submucosa in places. 
The mucous coat is a redundant mucous membrane presenting on 
transverse section a folded appearance and having a thickness of about 
0.75 mm. On transverse section it is found to contain normal tubular 
glands or crypts of Lieberkuhn and lymphatic follicles lying between 
the glands and extending from beneath the surface epithelium to and 
into the submucosa. The surface epithelium is of columnar form, and 
many of the cells are of the goblet type. 
Circulation.-The arterial supply is derived mostly from the posterior 
ileocecal artery. The vessels supplying the appendix traverse the meso- 
appendix, running toward the tip of the organ distributing branches 
at various intervals. After reaching the appendix, according to Lock- 
wood, they divide into external branches, which supply the serous coat 
and the muscular tunics, and internal branches which, penetrating 
the muscular hiatuses, terminate in branches supplying the mucosa 
and submucosa. The veins accompany the arteries and terminate in 
the ileocolic and eventually discharge into the superior mesenteric vein. 
The return circulation, therefore, extends to the portal system. To 
a slight extent some communication is established with the systemic 
circulation through the external colic veins. 
The lymphatic circulation is of great clinical importance. The capil- 
laries begin under the epithelium of the mucosa and beneath the lymph- 
atic follicles, and extending from the submucosa pass through the 
muscular coats to the peritoneal surface, where they terminate in large 
trunks accompanying the bloodvessels. They usually extend to the 
lymphatic glands lying posterior to the cecum, and eventually pass 
onward to the mesenteric glands along the inner side of the colon. 
Reference has been made to the small lymphatic gland described by 
Clado, situated in the base of the meso-appendix close to its attachment 
with the ileum and cecum. In cases of appendicitis, lymphatic glands 
in other situations have been sometimes found enlarged, such as those 
along the external or common iliac vessels, and on this account other 
lymphatic connections have been assumed to exist. It is not improbable, 
however, that such enlargements of neighboring lymphatic glands may 
be the result of diffusion of soluble products of infection, independent 
of the regular lymphatic channels. 
Nerve Supply.-The nerves are derived from the superior mesenteric 
plexus and terminate in a plexus of Auerbach and a plexus of Meissner 
comparable to those met with in other portions of the intestinal tract. 
Through the solar plexus the nervous mechanism of the appendix is 
connected with the cerebrospinal system and with the right vagus. 
Etiology.-Among the causes of appendicitis we may recognize those 
which are general and those which are determinative. The disease is 
distinctly one of early life, as is shown by all tables of statistics. The 
majority of cases occur from the eleventh to the thirtieth year inclusive. 
Between thirty-one and forty a fair proportion occur, while after forty 
years the disease rapidly diminishes in frequency, being rarely met 359 
DISEASES OF THE INTESTINES 
with in the aged. It occurs in the first decennium of life in a small 
number of cases, and has even been recognized as a prenatal disease. 
Sex plays a certain part, as the disease occurs in males two or three 
times more frequently than in females, according to all observers. Some 
speculation has been indulged in to explain the relatively greater fre- 
quency in males, but no satisfactory explanation has been reached. 
Some authors have believed that the additional blood supply obtained 
in females through the appendiculo-ovarian ligament prevents oblitera- 
tion of the circulation, thus obviating an important cause of the disease. 
Occupation is of no special importance, although it has sometimes 
been claimed that those whose occupation leads to irregularities in 
eating and to exposure are more liable to the disease than are others. 
Nationality probably plays little part. A number of writers have 
pointed out the comparative rarity of the disease in the negro. 
Heredity is of no special consequence, although families have occa- 
sionally been described in which repeated cases have occurred. In this 
connection the possibility of simulation must be remembered. 
Digestive disturbances are perhaps important in a general way, and 
have often a direct bearing upon the occurrence of the disease. Doubtless 
chronic gastric disorders may occasion catarrhal conditions of the bowel 
and favor the development of appendicular infections. A more direct 
and local relation of gastro-intestinal disease to involvement of the 
appendix operates in cases in which the cecum becomes distended. 
Local Conditions.-Among these, various anatomical conditions require 
consideration. The appendix normally opens by a relatively narrow 
mouth, guarded by a reflection of the mucous membrane of the cecum 
known as the valve of Gerlach. In some instances the valve is wanting 
or the mouth of the appendix is larger than usual, so that the intestinal 
contents readily find access to the organ, and may be retained in con- 
sequence of narrowing lower down or of weakness in the musculature 
of the walls. In other instances the mouth, or opening, is contracted, 
and such contents as gain entrance to the lumen of the appendix in a 
fluid state may be retained after undergoing inspissation or solidification 
by the admixture of mucus, epithelial cells, and bacteria, so as to form 
hardened masses or concretions. In still other cases the arrangement 
of the meso-appendix or abnormal bands of adhesions that surround 
the organ at some part of its length, or stenoses and angulations, may 
similarly prove the cause of retention of material within the lumen. 
Sometimes such constricting conditions are so disposed that, while 
ordinarily of little effect in the direction of obstructing the discharge 
of the contents of the appendix, they may become wholly obstructive 
when the cecum or other neighboring part of the intestine is distended. 
Whatever the cause of the obstruction, the result of retention of 
material is, according to some authorities, a rapid multiplication of the 
bacteria contained and possibly, also, an increase in their virulence. 
This may occasion an infection of the mucous membrane and the sub- 
sequent changes that have been described as characteristic of the disease. 
There can be little doubt that conditions that obstruct the lumen of 
the appendix at any part of its course are a frequent and potent cause 360 
DISEASES OF THE DIGESTIVE SYSTEM 
of inflammations of the organ. Not rarely cases are met with in which 
the distal end, or half, of the appendix alone is involved, while the 
proximal portion, separated from the former by some obstructing band, 
angulation, or stenosis, is uninvolved. Cases are met with in which 
repeated attacks of moderate severity have occurred, with digestive 
disturbance and distension of the cecum and colon, and in which the 
occasion of the appendicular involvement appears to be a temporary 
increase of angulation and retention of contents, without extensive 
infection or involvement of the mucosa and other coats. After a repeti- 
tion of such attacks, a more severe involvement may occur; and the 
obstructed distal portion may undergo rapid necrosis or gangrene. 
Fecal Concretions.-They do not of necessity occasion any inflamma- 
tory change, although always a menace, and their relation to appen- 
dicitis is, in many cases, a very direct one. Concretions are formed by 
the inspissation of fecal matter retained in the appendix and by the 
admixture of mucus, desquamated and exudative cells, and multiplying 
bacteria. According to some investigators, the concretions are always 
the result of bacterial growth. They are mainly composed of fecal 
material, with mineral salts, such as phosphate and carbonate of lime 
and magnesia, and mucus. Not rarely they are stratified in much the 
same way as gallstones. Such concretions are met with in a relatively 
large proportion of cases of appendicitis. Deaver found them in about 
16 per cent, of his cases; Treves states that they occur in about 30 per 
cent, of cases; and in some other series the proportions have been even 
greater. According to Ribbert, they occurred in 38 of 400 appendices. 
Foreign Bodies.-Various bodies, such as pins, small nails, portions of 
bone, seeds, and fruit pips, as well as other other insoluble substances, 
may find their way into the appendix, and are occasionally met with in 
cases of appendicitis. Not rarely parasites have been found, such as 
Trichiurus trichiura, Oxyuris vermicularis, and Ascaris lumbricoides. 
Effects of Concretions and Foreign Bodies.-Although concretions may 
be met with in appendices that show but little, if any, evidence of inflam- 
matory change, it must be considered that they are a potent cause of 
inflammatory conditions. In the first place, they are capable, through 
the direct pressure exerted upon the mucous membrane, of causing 
destructive changes in the epithelium, and thus opening the way for the 
invasion of microorganisms. This pressure effect is most likely to occur 
when a concretion has reached a considerable size and when, as the 
consequence of distension of the cecum or other local conditions, an 
angulation is produced at the point of lodgement of the concretion. 
Again, the presence of a concretion may explain the retention of contents 
within the appendix, and thus may occasion multiplication of bacteria 
and infection of the mucosa of the obstructed organ. Frequently when 
gangrenous changes occur in the appendix it is found that the lesions 
have begun at the point of pressure from a concretion; and when per- 
foration takes place, the opening is opposite the foreign body. In cases 
of peri-appendicular abscess, the concretions are not rarely found in 
the abscess cavity, having escaped from the appendix through a per- 
foration. With respect to foreign bodies of other sorts, it is undoubted DISEASES OF THE INTESTINES 
361 
that they are capable of exercising irritative and more or less destructive 
effects upon the mucous membrane and thus of initiating an attack. 
Influence of the Lymphoid Tissue.-The lymphoid tissue of the appendix 
is undoubtedly a factor of importance in the occurrence of the intense 
inflammation of this part of the intestinal tract. Not unlikely, the 
immunity of the aged to the disease is due to the involution that takes 
place in the lymphoid tissue, and its more or less complete disappearance 
in later life. No part of the gastro-intestinal tube is so abundantly 
supplied with lymphoid tissue except the tonsillar region, and it is 
noteworthy that these two situations are common seats of intense 
inflammation in young subjects. Sahli has introduced the phrase 
"angina of the vermiform appendix," in recognition of this fact. It is 
not improbable that the rich supply of lymphoid tissue occasions a 
local susceptibility to inflammatory conditions. 
It is possible, also, that some as yet undiscovered function of the 
appendix, perhaps of a secretory nature, may play a part in the etiology. 
It has been shown that lesions of the colon may be caused by the sub- 
cutaneous injection into animals of soluble toxic bodies derived from 
cultures of dysentery bacilli, and it may be that lesions of the appendix 
may result from the excretion through its mucous membrane of poisons 
generated by bacterial activity elsewhere in the gastro-intestinal tract. 
The Bacteria of Appendicitis.-The microorganisms met with in cases 
of appendicitis are varied. By far the most frequent form is the Bacillus 
coli communis. In many cases it has been found in pure culture; but 
usually some other organism is associated with it. Streptococci or 
staphylococci may occasionally be found without any associated germs. 
More commonly, however, they are found with other forms. The 
Bacillus lactis aerogenes, the Bacillus capsulatus aerogenes, the Bacillus 
pyocyaneus, the influenza bacillus, the bacillus of Friedlander, and a 
variety of others, have been found alone or in various combinations. 
In the majority of cases appendicitis probably represents a mixed 
infection, the most important organisms being the Bacillus coli communis, 
the Streptococcus pyogenes, and the anaerobic forms. Some observations 
make it seem probable that the milder cases with localized peritonitis and 
relatively benign symptoms are principally due to colon infection, while 
the more intense cases are of streptococcic or anerobic nature. 
Pathology.-Various terms have been employed to designate what are 
sometimes described as different forms of appendicitis, such as simple, 
catarrhal, perforative, gangrenous, interstitial, obliterative. While these 
terms are applicable to different stages, they are undesirable if they 
convey an impression that they refer to different kinds of disease. 
In addition to this objection, it has been pointed out that unfortunate 
results have occurred from the impression that mild or moderate symp- 
toms indicated a milder form of disease, such as would be suggested 
by the terms simple or catarrhal, whereas, in truth, the most serious 
pathological states of the organ may be present when symptoms have 
been practically wanting. 
The beginning lesion may be assumed to be practically always in 
the mucosa itself, and in the great majority of all cases there is found 362 
DISEASES OF THE DIGESTIVE SYSTEM 
in the appendix removed at operation merely a catarrhal or an ulcera- 
tive condition of the mucous membrane. In the least advanced cases 
slight changes are observed, such as shallow erosion with some accumula- 
tion of mucopurulent exudate and congestion of the small vessels in 
and beneath the mucous membrane. In the more serious grades extensive 
ulceration of the mucosa will be encountered. At the same time, involve- 
ment of the submucosa and of the other tunics may be met with. There 
may be very pronounced changes in the mucous membrane, with but little 
visible alteration of the exterior of the organ and but little if any increase 
in its size. To this form or stage, with its almost exclusive involvement 
of the mucous membrane, the term catarrhal appendicitis is most appli- 
cable. Nearly always, however, when the mucosa has been considerably 
involved, extension to other coats will be found to have taken place. 
Microscopic examinations show in all stages and grades a tendency to 
necrosis of the lining epithelium with erosion or ulceration and infiltra- 
tion of the deeper layers with polymorphonuclear leukocytes. Hyper- 
plasia of the lymph follicles and infiltration with inflammatory cells are 
regularly present. The lumen of the appendix may become distended 
with accumulated secretions of a mucopurulent character, and some- 
times the exudation becomes hemorrhagic from admixture of blood from 
the ulcerated surfaces. The accumulation of material within the lumen 
is favored by obstruction or foreign bodies within the appendix. 
In all but the mildest cases the submucosa is involved early; congestion 
of the vessels and, later, stasis of the blood and thrombosis with oedema- 
tous swelling constitute the most conspicuous lesions. In severe cases 
small or considerable hemorrhages in the submucosa are generally seen. 
The thrombosis of the vessels may occasion secondary hemorrhagic 
infarctions of the mucous membrane, and thus advance the process. 
The swelling and infiltration of the mucous and submucous coats soon 
occasion a hardening and rigidity of the muscular and serous coats in 
a direct mechanical way. This is particularly marked when obstructions 
near the mouth of the organ prevent the discharge of accumulating 
exudation, and thus occasion distension of the lumen. 
Whenever the mucous membrane and submucosa are considerably 
involved, it is customary to find at least slight disease of the serous 
membrane. In milder cases a little roughening of the usually smooth 
and glistening surface is observed, and is found to be due to inflammatory 
changes in the endothelial cells with beginning fibrinous exudation. 
The extension of the inflammatory process from the interior of the 
appendix possibly occurs, as Lockwood has suggested, through the 
normal gaps in the muscular layer. It thus happens that a considerable 
degree of peritoneal involvement may occur before the muscular coat 
is to any great extent involved, except by distension and slight infiltra- 
tion near the submucous junction. Eventually in many cases the 
muscularis becomes markedly infiltrated and degenerated, and necrotic 
changes cause a weakening by destruction of the muscle cells. There 
is rarely extensive necrosis of the muscularis except when complete 
occlusion of the circulation through twists, bands, or other forms of 
obstruction has occurred. DISEASES OF THE INTESTINES 
363 
Extensive purulent infection may occasion considerable involvement 
of the tunics or total gangrene of the organ. In other cases there may 
be considerable change in the mucosa and submucosa and considerable 
involvement of the serous coat, with relatively small grades of destructive 
change in the muscularis. Infiltration with leukocytes and other evi- 
dences of inflammatory change between the muscle cells is more usually 
encountered. 
The contents of the appendix increase with more or less rapidity and 
in varying ways, according to the nature of the case. In some instances, 
with stricture or other complete obstruction of the outlet, an increasing 
purulent exudate may accumulate within the lumen and cause distension 
of the walls, eventually forming a pus-containing sac (empyema of the 
appendix). More often the amount of exudation is less abundant, 
and there is a tendency to solidification of portions of retained fecal 
matter with exfoliated epithelium, mucus, and masses of bacteria form- 
ing small or large concretions. In many instances there are found within 
the appendix or within abscesses formed around this organ after perfo- 
ration hardened fecal concretions evidently of older date. 
The effect of increasing accumulation of contents in the lumen upon 
the walls of the organ is manifested in the obliteration of the folded 
plicse of the mucous membrane and the conversion of the lumen from 
an H-shape to a more or less circular outline. With this stretching of 
the mucous membrane, there is a flattening of the various structures, 
follicles, glands, etc., and at the same time a similar effect is produced 
on the submucosa and outer tunics. In some instances the disease 
becomes quiescent after this stage. 
Obstruction of the lumen of the appendix antedating the attack or 
the result of inflammatory conditions of its walls has an important 
etiological relation. Similarly, congenital narrowing of the outlet, 
acquired changes in the mucous membrane of the cecum involving the 
mouth of the appendix, or obstructions caused by strictures of the wall 
of the appendix due to previous attacks or by foreign bodies or fecal 
accumulations within the lumen play an important part. In all of these 
conditions retention of the contents may occur, the bacteria multiply 
and probably gain in virulence, and inflammatory conditions result. 
In other cases, the mouth of the appendix may be open and its lumen 
wide enough throughout its entire length to permit of discharge of the 
contents under ordinary circumstances; but there may be at some point 
a slight narrowing due to a stricture, a band of adhesion on the outside, 
a twist or a kink caused by a short mesentery, which may become 
increased by inflammatory swelling of the distal portion of the organ. 
As a consequence of this increased obstruction the contents and accu- 
mulating exudates are confined to the appendix. 
Extensive necrosis and gangrene may occur very rapidly and some- 
times with very slight involvement of surrounding parts. Complete 
occlusion of the organ at some one point, and especially by anatomical 
conditions or old adhesions, which exercise a constricting effect both on 
the organ and circulation, and unusual intensity of the microorganisms 
concerned in the etiology, may be determining factors. The contents 364 
DISEASES OF THE DIGESTIVE SYSTEM 
of the appendix are a fetid putrefying mass of mucopus with 
exfoliated epithelium and other tissue elements and bacteria. The 
appendix presents the black or grayish and black appearance of necrosis 
and gangrene, and hemorrhagic extravasation under the serous coat and 
more or less fibrinous exudation upon the serosa are observed. The 
organ is friable and may tear upon the slightest manipulation. In 
many instances spontaneous rupture occurs. 
Involvement of Surrounding Structures.-The most important local 
result of appendicitis is peritonitis involving the folds and fossae in the 
immediate vicinity of the appendix. In mild cases and when the infective 
cause is of a relatively low grade of virulence the serous coat of the 
appendix is covered with a slight deposit of fibrinous exudation. Such 
localized peritonitis does not of necessity indicate actual perforation 
of the organ with escape of infective material, but may occur from 
invasion of the organisms into the peritoneal coat through the muscular 
tunics. The peritoneal inflammation may extend to surrounding parts, 
and a more or less firm agglutination may take place. The process 
may advance no farther and many cases of appendicitis after reaching 
this stage subside, leaving behind adhesions to adjacent structures. In 
more intensely infectious cases the exudation is greater, and localized 
abscess cavities are formed between the appendix and the neighboring 
coils of intestine or the abdominal and pelvic walls. Minute perforations 
of the appendix after the formation of preliminary attachment by 
fibrinous exudate to adjacent parts hasten the formation of abscesses. 
On the other hand, a perforation of the organ without preliminary 
adhesion, and especially a sudden extensive perforation, may be followed 
by a widespread peritonitis with but little tendency to limitation. Doubt- 
less the virulence and nature of the infective cause play a considerable 
part in the liability to rapid softening and necrosis of some part of the 
wall of the appendix, and at the same time determine the amount of 
fibrinous exudation that may be present. In the more virulent purulent 
infections, destructive effects upon the tissues are more marked and 
exudation of fibrin less pronounced. 
Peri-appendicular Abscess.-The situation of abscesses resulting from 
appendicitis varies according to the position of the appendix and of 
the adjacent parts of the intestine. In the majority of cases the pus 
cavity is found between the appendix and the ileum at its attachment 
to the cecum, between the appendix and the head of the cecum, behind 
the cecum, or between the appendix and head of the cecum and the 
right abdominal wall and iliac fossa. Less commonly it may be found 
in the pelvis, in the retrovesical fossa, or in Douglas' pouch. Extension 
of the infection to the upper part of the abdominal cavity is usually 
prevented by the omentum and small intestine. In some instances a 
long appendix lies posterior to the ascending colon and appendicitis 
may occasion an abscess at some part of its course behind the colon. 
The wall of the abscess is formed by the adherent appendix, adjacent 
intestines, other surrounding structures, and by more or less firm masses 
of fibrinous exudate. The contained pus is usually of ordinary con- 
sistence and frequently of fetid odor. DISEASES OF THE INTESTINES 
365 
The abscess may rupture in various directions. Most frequently it 
breaks through the abdominal wall. Next in order of frequency is 
perforation into the cecum or other portions of the intestinal canal, 
into the general peritoneal cavity, into the pleural cavity, or into the 
bladder or uterus. In rare instances extension and perforation into the 
gall-bladder or ureter have been described. After such rupture inspissa- 
tion of the remaining contents may occur and cure result. 
General peritonitis may result from the rupture of a primary abscess, 
or more immediately from perforation of the appendix in rapid gangrenous 
or necrotic types of infection. In some cases without perforation of 
the appendix virulent organisms may escape through the walls of the 
organ and occasion a general peritonitis, or after the formation of an 
abscess extension of the infection may occur without discoverable gross 
rupture of the abscess wall. In these cases of extensive and spreading 
generalized peritonitis the pus is apt to be thin and serofibrinous from 
the beginning, and there is but little formation of fibrinous exudate on 
the surface of the intestinal coils. 
Remote Lesions.-Aside from the lesions associated with any form of 
intense infection, such as myocarditis, infective nephritis, etc., various 
remote lesions may result from invasion of the infective organisms from 
the appendix into various surrounding structures. Septic thrombosis 
of the venules of the appendix is a common occurrence, but fortunately 
does not frequently extend beyond the smallest branches. In some 
cases, however, ascending thrombosis takes place and may occasion 
involvement of the larger mesenteric vessels and the portal vein. In 
these cases secondary pyemic abscesses of the liver result. Extension 
may also take place through the retrocolic veins and sometimes through 
new-formed collateral branches of the systemic circulation, and may 
occasion secondary abscesses of the lungs. 
Chronic Appendicitis.-After a severe attack of appendicitis, or more 
frequently after repeated attacks, changes may occur in the wall of the 
appendix and in the surrouding structures which have been described 
as chronic appendicitis. In a certain measure this term is justified, 
because the adhesions, distortions, and other conditions met with serve 
to maintain a state of congestion and lasting catarrhal inflammation of 
the mucous membrane, and perhaps also a slight chronic inflammation 
of the outer walls of the appendix. It would be more correct, however, 
to regard the conditions under consideration ordinarily as results of 
acute appendicitis rather than as a chronic inflammation in the strict 
sense. In cases of moderately severe non-perforative appendicitis, with 
formation of a limited amount of fibrinous exudate, adhesions probably 
frequently result after the acute inflammation has subsided. Even 
quite intense inflammations of the appendix and neighboring peritoneal 
folds may resolve, as is indicated by the discovery in many cases of 
dense fibrous adhesions that must have followed a previous intense 
attack of appendicitis with localized peritonitis. 
Besides the adhesions which are found uniting the appendix to neigh- 
boring structures, and which incite to subsequent attacks of appendicitis, 
the organ itself is frequently found thickened, bent, or otherwise altered 366 
DISEASES OF THE DIGESTIVE SYSTEM 
by the preceding acute inflammations. Appendicitis of this description 
furnishes most of the instances of so-called relapsing appendicitis, the 
thickened sclerotic walls in a measure protecting against perforation 
and the complications so commonly met with in more acute types. 
Obliteration.-This may be the result of previous inflammations, and 
is thus a form of chronic appendicitis. Some authors insist that oblitera- 
tion may be purely the result of involution in some instances. In cases 
of post-inflammatory obliteration, the lumen of the appendix is replaced 
by a cord of irregularly distributed cells and fibrous connective tissue 
surrounded by muscle and a serous outer coat. Sometimes areas of 
atypical disorganized mucous membrane are found, but in cases of 
complete occlusion all resemblance to the normal structure is lost. 
Symptoms.-In a great majority of the cases of appendicitis the 
symptoms of onset and the clinical course are more or less similar and 
distinctive; so that, as a rule, but little doubt exists in the mind of the 
physician regarding the nature of the disease. A small minority furnishes 
a sufficient number of instances of irregular onset and course to give the 
impression that the features are quite as often puzzling as otherwise. 
In typical instances, pain in the abdomen, diffuse at first, and limited 
to the right iliac region after a greater or lesser duration; rigidity of 
the abdominal walls, especially on the right side; nausea and perhaps 
active emesis; constipation; rigors, or definite chills, accompanied with 
or followed by fever, acceleration of the pulse, and a general feeling of 
profound illness, characterize the initial symptoms and the stage of 
fully developed appendicitis. Wide variations are frequently encount- 
ered, and the symptomatology may be said to be as variable as that of 
any other inflammatory condition affecting the internal structures. 
Pain.-Probably the most frequent symptom is pain, which is rarely 
absent at any stage. It must not be forgotten, however, that even in 
intense forms, such as those in which necrosis and gangrene occur, pain 
may be absent from the beginning to the end of the process. Nearly 
always the patient suffering with appendicitis is seized with a sudden 
cramp-like abdominal pain, which at first occupies the central or umbilical 
portion of the abdomen, and subsequently moves toward the region of 
the right iliac fossa. There are cases in which, from the beginning, 
whatever pain is encountered is strictly localized in the right iliac region. 
In other cases the initial pain is vague and difficult to locate. 
The nervous mechanism of the appendix explains to some extent 
the localization of the pain. The afferent nerves are connected with 
the solar plexus through the superior mesenteric, and thus a connection 
is established with the splanchnic and the right vagus. The pain of 
beginning appendicitis is referred to the mid-abdominal region on account 
of the distribution of the terminals of the splanchnic system to this 
area. Not rarely, especially in cases in which the appendix has a position 
posterior to the cecum, pain in the back and in a region posterior to the 
liver, and even as high as the right shoulder, may be encountered. When 
the appendix extends downward toward the pelvis, suprapubic, perineal, 
and ischiorectal pain may be complained of in the beginning, or after 
a preliminary period of general or mid-abdominal distress. DISEASES OF THE INTESTINES 
367 
After the full development of the disease, pain and tenderness, as a 
rule, are in the right iliac region. There is often a lack of correspondence 
of the tenderness with the pain. The most extreme tenderness seems 
to occur in those cases in which the appendix lies relatively near to the 
anterior abdominal wall, and especially when it is bound by adhesions 
to the parietal peritoneum. In cases in which the appendix extends 
downward toward the pelvis and is attached to the bladder or the rectum, 
or to other pelvic structures, the degree of pain experienced during 
defecation, micturition, or digital rectal examination may be excessive. 
Sometimes the pain is referred to distant parts, such as the thorax, the 
right thigh, the lumbar region, the back, or the upper portions of the 
abdomen. The position and attachments of the appendix may, to some 
extent, determine such referred pains, but this is not invariable. 
In the fully developed stage, when pain, previously diffuse, has become 
localized in the iliac region, the area of involvement is usually limited, 
and, generally speaking, centres at McBurney's point. The character 
of the pain varies from a steady ache to a paroxysmal, cramp-like or 
colic-like condition. Tenderness in the same area is usually, but not 
necessarily, present. 
Cutaneous hyijeralgesia appears to occur in nearly all primary attacks 
at some stage except, perhaps, in the most violent acute forms. The 
cause of the sensory condition is probably the distension of the appendix. 
It has frequently been noted that the hyperalgesia suddenly subsides 
when perforation of the appendix has occurred. In non-perforative 
cases the symptom gradually disappears. It is frequently present in 
second or subsequent attacks, but is often absent when the original 
attack has been sufficiently severe to destroy nervous tissue in the wall 
of the appendix. The area of hyperalgesia centres about McBurney's 
point, although it is not strictly confined to this region. More properly 
it may be said to occupy the region of the eleventh dorsal area of 
Head, a band extending on the right side from the middle line below 
the umbilicus to the lumbar spine posteriorly. The hyperalgesia is deter- 
mined by pinching or stroking the skin, beginning outside the suspected 
area and working toward it. 
Tenderness must be distinguished from pain, although the two usually 
coincide. The degree of tenderness varies, as has been pointed out, 
with the character of the case and the location of the appendix. Its 
intensity varies from the mildest grades, in which it can scarcely be 
determined, to such severe degrees that the lightest touch or even the 
weight of the bedclothes is intolerable. In these cases, as in all those 
in which painful sensations are prominent, the position occupied by 
the patient in bed is quite distinctive. He lies upon his back or lightly 
inclined to the right side, and flexes the right thigh upon the body so 
as to relieve tension upon the affected portion of the abdomen. 
Intense pain of a peculiar character is found in those cases of acute 
appendicitis in which intestinal obstruction has occurred as a com- 
plication. The violent pathological peristalsis with tonic contraction 
of the bowel that occurs in this condition occasions intense paroxysms 
of pain, recurring from time to time with greater or less frequency. In 368 
DISEASES OF THE DIGESTIVE SYSTEM 
the beginning these pains may be strictly located near the seat of 
obstruction; but later they often become generalized. 
Rigidity.-There may be a generalized rigidity in the early stages, 
when pain also is of a diffuse or generalized character. Later, when 
the sensory symptoms have localized themselves in the right iliac region, 
rigidity also becomes limited in its extent and affects the muscles over- 
lying the inflammatory area. A careful comparison of the abdominal 
walls on the right and left sides will-in most cases of appendicitis, at 
least-disclose a slight resistance, if not a definite rigidity, affecting 
the muscles over the diseased area. The degree of this depends upon 
the location of the appendix and the character of the surrounding lesions. 
When the organ lies anteriorly and in close relation with the abdominal 
wall, and when inflammation involves the structures between the 
appendix and the abdominal wall, the greatest degree of rigidity as 
well as of tenderness may be expected. There are, however, instances 
in which, notwithstanding an immediate relation of a diseased appendix 
with the abdominal wall, muscular rigidity is totally absent. When 
the appendix lies posterior to the cecum some spasm of the lumbar 
group of muscles on the right side may occur. 
Reflex Symptoms.-Those affecting the stomach and the bowel are 
of greatest frequency and significance. Nearly always, in typical cases, 
nausea occurs. This may be attended with vomiting at the onset, or 
some time later, and repeated vomiting may take place. Not rarely 
nausea occurs without vomiting, and may persist until the disease is 
well developed. Sometimes repeated vomiting may be a very conspicuous 
feature and may overshadow pain, tenderness, rigidity, and other 
symptoms usually more distinctive. The character of the vomiting 
in the early stages is not peculiar. The contents of the stomach are 
ejected, with perhaps some bile. Intense, uncontrollable vomiting may 
terminate in stercoraceous discharges; but this is more usually the result 
of complicating conditions occurring in the later stages. 
Constipation is usually a symptom of importance, although not 
invariably present. In the beginning its cause is found in the reflex 
nervous influences occasioned by intense pain. Later, inflammatory 
conditions in the right iliac fossa are mainly operative by causing a 
local paresis of coils of intestine involved in the inflammatory area, 
cooperating with nervous inhibition due to pain. In the final stages, 
when diffuse or generalized peritonitis has occurred, constipation may 
be the result of a general paralytic condition of the bowels. Various 
local conditions connected with appendicitis may operate in a purely 
mechanical way. Thus adhesions between the appendix and the small 
or large bowel may produce obstruction; or large abscesses may compress 
and practically obliterate the lumen of the bowel. In some instances 
there is at first no disturbance in the action of the bowel, one or more 
normal movements occurring after the onset. In some cases a diarrhoeal 
condition may exist for a time, but such cases are rare. 
Symptoms of Infection.-These usually occur, although there are cases 
in which, despite the existence of a definite infective lesion, generalized 
symptoms fail to make their appearance. Rigors and chills occur at the DISEASES OF THE INTESTINES 
369 
onset of many cases. Sometimes these are pronounced and repeated 
from time to time. 
Fever usually appears, although it must be recognized as a symptom 
of uncertain value. In many cases, in spite of the seriousness of the 
local lesions, the temperature remains low, while in other conditions simu- 
lating this disease fever is of at least as great frequency as in ordinary 
attacks of appendicitis. In the average cases the temperature soon 
rises after the onset, being as high as 100° to 102° F. within a few hours. 
Subsequently, a variable temperature is apt to mark the course. Often 
the temperature falls to the normal soon after the onset, without refer- 
ence to the character of the local lesions. Sometimes a continued fever 
may be present for several days, and may terminate in an irregular 
fever when peri-appendicular inflammation or abscess has developed. 
In most instances fever is an uncertain indication; the severest forms of 
appendicitis may be unaccompanied by elevation of temperature. 
Occasionally subnormal temperatures are encountered, and are 
usually significant of rather intense infections. On the other hand, 
extremely high temperatures may occur in severe infections with marked 
local reaction. Even extensive peritonitis may be unattended with 
elevated temperature. In the later stages, when localized abscesses 
have formed, irregular movements of the temperature curve are usual 
but by no means invariable. 
The pulse indicates the general condition of infection with somewhat 
more reliability than does the temperature. In many cases in which 
fever has been absent, rapidity of the pulse has, from the beginning, 
indicated the existence of a serious lesion. The character of the pulse 
varies with the nature of the infection and the local conditions. Acute 
inflammatory lesions with marked reaction are usually attended with a 
rapid but relatively full and tense pulse. On the other hand, infections 
extending to the peritoneum, and especially diffuse peritoneal involve- 
ments, are accompanied by increasing rapidity of the pulse, often with 
irregularity and loss of quality. Less intense peritoneal involvement 
sometimes affects the quality of the pulse in a different manner. In 
such cases a hard or wiry pulse of moderate rapidity and without any 
irregularity may be met with. Increasing rapidity of the pulse, loss of 
quality, and the occurrence of irregularity are grave indications. 
Chills are sometimes met with at the onset or at various times through- 
out the course. A considerable proportion of cases begin with rigors 
or a sense of general coldness, after which nausea and the other symp- 
toms set in. The chills usually cease after the disease has been fairly 
established, and there is no tendency to recurrence until extension of 
the infective process has caused invasion of the peritoneum. In peri- 
appendicular abscess, regularly or irregularly recurrent chills may 
continue for a long time. Still more marked is the tendency to chills 
accompanying widespread infection, as in instances of pylephlebitis. 
Leukocytosis.-The condition of the blood is usually significant of an 
infective inflammatory lesion. In the great majority of the cases of 
appendicitis there is a definite leukocytosis, the number of leukocytes 
usually exceeding 12,000 to 15,000 per cmm. The differential count 
vol. m-24 370 
DISEASES OE THE DIGESTIVE SYSTEM 
shows a marked preponderance of the polymorphonuclear elements. 
Sometimes the proportion of these forms may reach extreme grades, 
such as 90 to 95 per cent. When localized peritonitis has developed, the 
leukocytosis may be increased to even greater figures; but a spreading 
peritonitis with intense general infection is apt to declare itself by a 
falling leukocyte count after a preliminary leukocytosis. An increased 
number of the leukocytes is not, however, invariably present and even 
in cases of abscess formation the leukocyte count may be normal or 
subnormal. Such cases are rare, although there are a considerable 
number of reported instances. It has been maintained by some that 
a preponderance of polymorphonuclear elements without an actual 
numerical leukocytosis may occur in appendicitis. Such a condition of 
affairs is at least rare, and its significance may be questioned. 
Physical Signs.-Among the objective manifestations of appendicitis 
those which attend the earliest stages are of the greatest importance, 
as prompt diagnosis is most essential to proper treatment. Rigidity 
is undoubtedly a sign of extreme value. Somewhat later than this 
other objective evidences may be found, among which tumor and 
abdominal distension are most significant. 
Tumor.-At the time of the primary rigidity a certain fulness in the 
right iliac fossa is usually detected. In part, this is the result of the 
rigid condition of the rectus muscle, which opposes a certain resistance 
to the palpating hand; and this gives the impression of a mass. If the 
tenderness is not too great, this rigidity may be overcome and the 
suggestion of a mass disappears. Very frequently, however, there will 
be found below the rectus muscle a rounded and somewhat yielding 
tumor-like resistance, caused by gaseous distension of the caput coli. 
The nature of this mass may usually be detected by percussion over it, 
when the tympany discloses the fact that the mass is an air-containing 
one. The percussion note, however, is not so purely tympanitic as that 
found on the opposite side, over the sigmoid flexure; probably on 
account of the thickening by congestion of the surrounding bowel walls 
and perhaps also the rigidity of the abdominal muscles. 
In the later stages, when a peri-appendicular abscess has formed, 
this may be readily detected as a more or less resilient swelling, or some- 
times as a firm mass, without any discoverable indication of fluctuation; 
but the character of the tumor differs mainly in consequence of its 
varying situation. When placed anteriorly to the appendix and cecum, 
extreme tenderness to touch usually renders palpation more difficult and 
uncertain in its results; but, at the same time, more frequently enables 
the examiner to determine the existence of fluctuation, as well as the 
suggestive dusky discoloration of the skin and the subcutaneous oedema. 
Abscesses on the inner side and posterior to the cecum and appendix 
cannot be felt so readily, usually cause less superficial tenderness, and 
are more likely to give the impression of considerable hardness. Not 
rarely it is difficult to distinguish such from solid growths by palpation 
alone. Abscesses extending downward toward the pelvis may be so 
deeply situated as to escape detection through the abdominal wall, 
but may be felt, upon vaginal or rectal examination, as resistant, elastic, DISEASES OF THE INTESTINES 
371 
or boggy swellings to the right of the vaginal or rectal wall. The size 
of peri-appendicular abscesses varies greatly, the majority not exceeding 
the size of a lemon or an orange before rupture takes place. Sometimes, 
however, masses considerably greater than this are encountered, and 
may by their very magnitude prove deceptive. When external pointing 
takes place, the appearances are those usual in deep-seated collections 
of pus that have burrowed and reached the surface. 
The Appendix May Sometimes be Palpable.-Some authors have 
claimed that this is frequently the case. Most writers, however, agree 
that a positive recognition of the enlarged or diseased appendix is seldom 
possible. In exceptional cases it is exceedingly easy to feel some 
portion of the appendix or a large part of it. It is not difficult to 
be deceived and to mistake inflammatory exudates, distended coils 
of intestine, etc., for the appendix itself. Occasionally, when the 
appendix is attached to the anterior abdominal wall, the attached 
portion may be felt as a mass that seems surprisingly near the surface. 
In other cases the tip of the appendix has been felt high up on the 
right side of the rectum. More commonly masses here palpated are 
peri-appendiceal abscesses. 
Abdominal Distension.'-Distension of the intestines is usually an 
early symptom, and sometimes increases with great rapidity. Reference 
has been made to the fact that the caput coli is often slightly dilated 
in the beginning. At the same time, slight general meteorism may be 
observed. In later stages, increasing distension may take place from 
one of several causes. If the appendix is ruptured, or if an extension 
of the infection has occurred through the wall of the unruptured appendix, 
the result is peritonitis with more or less rapidly increasing tympany. 
In other cases the distension is the result of obstruction of the lower 
portion of the ileum, in consequence of violent local inflammation or of 
ileus resulting from inflammatory or other forms of obstruction. Rapidly 
increasing general distension occurs in these cases, as in other forms of 
acute obstruction of the bowel. The absence of distension by no means 
excludes extensive local inflammation; and even when peritonitis has 
occurred the abdomen may remain comparatively flat. 
Vesical Symptoms.-These are frequent. In the beginning there may 
be pain in the region of the bladder or retention of urine, as the result 
of nervous reflexes caused by the acuteness of the pain; and retention 
may persist throughout the whole course of acute cases. As a rule this 
disappears after the first day. Subsequently, and at times from the 
beginning, there is, on the contrary, a continuous desire for micturition, 
especially in those cases in which the appendix extends downward 
toward the pelvis, and in which pericystitis is present. In such instances 
the vesical symptoms may completely dominate the clinical picture. 
Actual cystitis may develop as the result of a direct extension, or in 
consequence of general infection. 
The urine frequently presents small quantities of albumin, with a 
moderate number of hyaline or granular casts. In some instances of 
greater severity a well-defined infectious nephritis may occur, especially 
in cases of extensive abscess formation. Albumosuria is of no regularity 372 
DISEASES OF THE DIGESTIVE SYSTEM 
of occurrence and of no diagnostic value. In rare instances peri-appen- 
dicular abscesses have ruptured into the bladder or ureters. 
General Peritonitis.-This is the most ominous of the results of acute 
appendicitis. Unfortunately, this condition may develop very promptly 
in patients who have presented no symptoms of great gravity; and it is 
equally unfortunate that it may arise in the late stages after a somewhat 
benign course. In a small proportion the disease apparently begins 
with general peritonitis. The onset of the trouble is usually marked by 
somewhat abrupt indications, significant of rupture of the diseased 
appendix or of extension of infection to the peritoneum through the 
unruptured wall. Sharp pain or suddenly increased local tenderness 
and rigidity, rigors or chills, a rapidly increasing acceleration of the 
pulse and elevation of temperature, or, in cases of marked infection, 
a fall of temperature with prostration and symptoms in general signifi- 
cant of shock, are mostly those which indicate the beginning of this 
grave condition. Soon board-like rigidity of the abdominal muscles, 
intense tenderness or hyperesthesia over the affected area, sometimes 
involving the whole abdominal wall, an anxious expression, a hard, 
small pulse with increasing rapidity, and a dorsal decubitus with a ten- 
dency to flexion of the right thigh, are significant of its further extension. 
Still later, the acute symptoms may ameliorate with the advancing 
infection and the overwhelming of the system with toxemia. At the 
same time increasing abdominal distension takes place, and the patient 
presents the facial and general appearance of one profoundly septic 
and having spreading abdominal disease. Vomiting may mark the 
onset, and may continue throughout the course until extreme prostration 
from septicemia puts an end to this as well as to other acute symptoms. 
Septicemia.-General septic infection may occur with or without 
extensive local lesions. As a rule it is most marked in those cases in 
which the local infective lesion is decided. Irregular chills and high and 
irregular fever, with a rapid, weak pulse and a tendency to drenching 
sweats, indicate this complication. Septic symptoms are most marked 
in those cases in which infective thrombosis extends from the diseased 
area through the mesenteric into the portal veins, establishing a suppura- 
tive pylephlebitis. In these cases, in addition to the evidences of a 
general septic process, pain is met with in the region of the liver; swelling 
of the liver may be detected, and jaundice appears. The last-named 
symptom may occur without pylephlebitis or pyemic abscess, as the 
consequence of an intense septic infection, but is rarely marked in such 
instances. Pyemic abscess in other organs, such as the lungs, spleen, 
kidneys, acute swelling of the parotid gland, and acute infectious neph- 
ritis, occasionally occur. Subphrenic abscesses have been encountered 
in some cases, mainly as a result of extension of cellulitis behind the 
cecum and colon. Pleurisy may follow or occur independently. 
Clinical Varieties.-The nature of the process is not essentially dif- 
ferent in mild and severe cases, and such terms as "simple appendicitis," 
"simple catarrhal appendicitis," "gangrenous appendicitis," and the 
like, are in a certain sense mischievous if they create an impression that 
there are forms of appendicitis of essentially u alerent character, and 373 
DISEASES OF THE INTESTINES 
that mild symptoms point to the existence of a benign process, while 
severe symptoms indicate more serious disease. Practical experience 
has shown beyond question that the mildest of symptoms may be encoun- 
tered in cases in which extensive necrosis or gangrene has occurred, while 
severe symptoms may be met with in cases in which a relatively slight 
disease .of the appendix exists. However much the symptoms and 
pathological lesions fail to harmonize in certain cases, it cannot be denied 
that there are many instances of appendicitis in which the mucosa is 
involved to the practical exclusion of the other parts of the organ. Such 
cases are, properly speaking, catarrhal appendicitis. Doubtless many 
such cases occur without clinical symptoms of any sort, in proof of 
which the experience of the postmortem table might be cited. A second 
group of cases is that in which all the walls of the appendix are involved, 
with little or no extension outside; cases in which, in other words, the 
disease is confined to the appendix itself. A third group is that in which 
the disease has extended beyond the appendix and has involved the 
peritoneum or other surrounding structures. Finally, there are cases 
in which a general peritonitis is associated with appendicitis. 
The infective agent may be the same in all of these forms, and the 
pathological changes do not differ in kind. The different clinical and 
pathological course is dependent upon varying local conditions affecting 
the circulation in the appendix and its drainage, and perhaps upon 
anatomical conditions promoting in some and preventing in other 
cases rapid extension of the infective process. 
Lesions Limited to the Interior of the Appendix.-There are cases of 
simple catarrhal appendicitis in which sudden abdominal pain, at first 
somewhat general, later limited to the right iliac fossa, slight tenderness 
and rigidity in the same regions, chilliness followed by slight fever 
and acceleration of the pulse, a little nausea and perhaps an attack of 
vomiting and constipation, make up the clinical picture. Sometimes, 
indeed, little beyond pain and tenderness occurs. After a variable 
period extending from a few hours to twenty-four or thirty-six hours 
the symptoms subside, leaving a variable degree of soreness that may 
persist for several days longer. The subsidence of symptoms is often 
coincident with evacuation of the bowels. Many such cases are instances 
of merely catarrhal inflammation, and the pathological lesions are often 
confined to the mucosa or mucosa and submucosa. The contents of the 
appendix consist of a scanty viscid mucus mixed with some soft fecal 
matter and bacteria. At times, when some interference with the drainage 
of the appendix exists, the contents may be more abundant and com- 
posed of inspissated fecal matter with mucus and cellular exudates. 
Formerly cases of this sort, in which sudden abdominal pain and 
tenderness are the principal symptoms, were described by some as 
cases of "appendicular colic," especially when fever and other manifest 
indications of inflammation were wanting. At the present time there 
seems little reason for believing that cases presenting the symptoms 
indicated are other than actual appendicitis, and even the possibility 
of a colic of this description arising in an uninflamed appendix must be 
doubted. Nor is it certain that the colicky pains of actual appendicitis 374 
DISEASES OF THE DIGESTIVE SYSTEM 
are even due in large measure to peristaltic efforts on the part of the 
muscular layers of the appendix. 
Unfortunately, the pathological conditions are not always as limited 
as have been described in cases presenting the symptoms indicated. 
There may be, with symptoms no more intense than these and with 
no greater duration so far as can be discovered, extensive necrosis or 
gangrene of the appendix and the presence of fecal concretions. Indeed, 
there is every reason to believe that appendicitis of the greatest gravity 
may be entirely latent, the first symptom appearing when perforation 
and peritonitis have occurred. 
Involvement of the Whole Thickness of the Organ.-In cases in which a 
rapid extension of infection causes almost immediate involvement of 
the entire wall of the appendix the symptoms are usually more intense, 
the initial rigor or nausea more pronounced, the fever higher, the local 
symptoms more pronounced, and, in general, the patient's condition 
seems more serious. If subsidence of the symptoms occurs, this is more 
gradual and the local tenderness and rigidity are more prolonged. In 
the simpler cases there is often a temporary amelioration of symptoms 
after free evacuation of the bowels, even though the purgation has no 
permanent good effect. Such relief is much less likely in the cases of 
extensive involvement of the walls than in cases of the catarrhal type. 
Associated involvement of the serous covering adds to the gravity, 
and in a considerable proportion is followed by a localized peritonitis. 
Involvement of Surrounding Structures.-In some instances, after an 
acute onset, moderate symptoms may continue for a period of from 
one to three or even five days, when an exacerbation sets in and evidences 
of extension of the infection present themselves. In these cases the local 
symptoms, as well as the fever, nausea, and vomiting, subside, and a 
few evacuations of the bowels may add to the apparent improvement. 
Gradually, however, or sometimes quite suddenly, a renewed chill or 
vomiting and the reappearance of sharp pain initiate the extension to 
the peri-appendicular structures. Such cases are probably in most 
instances caused by organisms of relatively low virulence, and occur 
in individuals whose general or local conditions offer considerable resist- 
ance. Unfortunately, however, the sequence of events is often far 
from being as satisfactory as this. In many instances there is a rapid 
extension with constantly increasing symptoms, and considerable 
localized peritonitis develops before any adequate amount of exudate 
can form to limit the spread of the infection by causing adhesions. After 
spreading to a certain distance, however, further extension may be 
prevented by exudation and agglutination of the bowels. In this manner 
general peritonitis may be prevented, and eventually a peri-appendicular 
abscess of considerable size may be formed. The symptoms significant 
of such extensions are usually quite marked, consisting of increasing 
local tenderness, rigidity, and swelling, increased but often irregular 
fever, general meteorism with obstinate constipation, indications of 
cessation of local peristalsis, and finally increased vomiting, perhaps, 
becoming stercoraceous in character. 
In many cases the involvement of surrounding structures occurs 375 
DISEASES OF THE INTESTINES 
suddenly after perforation of the wall of the appendix. Time of rupture 
may be indicated by an attack of renewed and severe pain, by a sudden 
feeling of sinking or prostration, nausea or vomiting, or fall of tempera- 
ture and acceleration and arrhythmia of the pulse. In other cases no 
special symptoms occur, but the general features take on an aspect of 
greater gravity and the local symptoms become more marked. Soon 
the indications of a circumscribed or general peritonitis appear. 
Chronic Appendicitis.-Two types may be recognized. The first is 
one in which, as the result of a previous acute attack, general thickening 
of the walls of the appendix has remained, or a narrowing of the outlet, 
an angulation, or some other condition interfering with proper drainage. 
In these cases local or general abdominal symptoms may be more or 
less continuously present. In the second group, as a result of shortening 
or abnormal attachments of the meso-appendix, or in consequence of 
angulations or adhesions, the appendix, although ordinarily free from 
inflammatory conditions, is prone from time to time to suffer when 
sluggishness of the bowels, gaseous distension of the cecum, and especially 
fecal accumulations in the caput coli or cecum occasion increased tension 
upon the appendix, increased angulation, etc. Under these abnormal 
conditions frequent mild acute attacks may occur, and may be quickly 
relieved by free evacuation of the bowel or correction of the other con- 
ditions named. With each recurring attack, however, the appendix 
tends to become more distorted and damaged, and eventually a violent 
acute attack may terminate the condition with all the manifestations 
of a severe acute appendicitis. It is this form to which the term relapsing 
appendicitis has been particularly applied. While this name is used 
especially to designate cases in which acute appendicitis is supposed 
to occur from time to time in a relapsing manner, and without any 
special local condition persisting between the attacks, it is important 
to recognize that the type above described is probably equally common, 
or more common, namely, that in which recurring attacks of increased 
tension or angulation take place without necessarily marked inflammatory 
conditions, until more severe lesions of the organ are finally established. 
In chronic appendicitis of the first type, due to general thickening, 
adhesions, etc., persistent local soreness, increased from time to time when 
distension of the bowels occurs, a tendency to more or less troublesome 
constipation, sometimes an associated mucous or membranous colitis, 
and evidences of intestinal indigestion, with furred tongue, disturbed 
appetite, nausea, tympanitic distension, and vague generalized abdominal 
pains, are met with. Not infrequently attacks of severe cramps or 
colic may occur when the intestines are particularly sluggish. 
In the relapsing type attacks occur indistinguishable from those of 
acute appendicitis, arising without any previous history of involvement 
of this region. In other cases there are, occasionally, short seizures in 
which intense localized pain and tenderness, with perhaps slight muscular 
rigidity, make their appearance without much fever, disturbance of 
the pulse, or constitutional disorder. When the attacks subside, the 
return to normal conditions is often so rapid that the thought of a severe 
local inflammation can hardly be entertained; and an examination of 376 
DISEASES OF THE DIGESTIVE SYSTEM 
the blood in these cases usually reveals but little, if any, leukocytosis. 
It is frequently observed that the acute attack follows some very definite 
derangement of digestion; and the association of the latter, with the 
consequent localization of symptoms in the epigastrium or upper portions 
of the abdomen, and the presence of symptoms suggesting " biliousness," 
may readily lead to an overlooking of the appendicular disease. 
The outcome of chronic appendicitis may be the development of a 
chronic intestinal disorder, such as membranous or mucous colitis or 
habitual constipation. In cases of the recurrent type there may be 
a subsidence of the attacks after several have occurred, and even after 
attacks of intense violence. There is always, however, the danger that 
finally a very severe condition may develop; perforation or extension 
of inflammation to the peritoneum may occur; and the disease may 
terminate as do instances of violent primary appendicitis. 
Diagnosis.-The symptoms of acute appendicitis, when marked, are 
so typical that a diagnosis can scarcely fail to be made. There are, 
however, many instances of obscure and even of latent appendicitis, in 
which no amount of clinical acumen or painstaking care will enable the 
practitioner to determine correctly the nature of the patient's disease, 
although suspicion may attach to the appendix. On the other hand 
there is unfortunately a tendency that sometimes makes itself manifest 
to regard every form of abdominal pain as appendicitis, unless the 
evidence clearly points to some other disease. However common 
appendicitis is and however important its early recognition, it would 
be a misfortune if physicians generally disregarded all that has been 
learned respecting the diagnosis of this disease by its symptoms, the 
physical signs, and the clinical examinations, to such an extent as to 
suspect its presence in all cases of abdominal pain, unless clear evidence 
of something else were at hand. 
The development of sudden pain in the abdomen, followed by a 
localization in the right iliac region, and attended with rigidity of the 
muscles over this part, must be looked upon as having great significance. 
If, in addition, there has been a primary rigor, or nausea and vomiting, 
with constipation, the diagnosis becomes fairly assured. Fever is a 
symptom of little importance, and rapidity of the pulse, although a 
little more trustworthy as an indication, is not necessarily met with. 
When the pain becomes sharply localized in McBurney's point, and 
muscular rigidity is found in the same area, the diagnosis is practically 
established. The existence of leukocytosis is often an aid in differen- 
tiating between appendicitis and other affections in the same region. 
The Diagnosis of the Character and Stage of the Disease.-Attention 
has been called to the fact that it is often impossible to distinguish 
between mild appendicular lesions limited to the inner lining or to the 
walls of the appendix alone and cases of a severer grade, with beginning 
or even extensive peri-appendicitis. In many instances, however, a 
diagnosis df the grade of the disease is possible. Simple catarrhal 
appendicitis is usually recognized by the mildness of the symptoms, 
by the tendency to rapid amelioration after evacuation of the bowel, 
and by the early return to normal condition. In cases, however, in DISEASES OF THE INTESTINES 
377 
which the symptoms are of equal moderateness, but tend to persist in 
spite of purgation, and in which even slight tenderness and fever persist, 
the probability of a more serious condition must be considered. Cases, 
too, in which the severity of the constitutional condition of the patient 
is distinctly out of proportion to the local manifestations may properly 
be suspected of being due to more intense, and perhaps necrotic or 
gangrenous, lesions of the appendix. Distinctly marked leukocytosis 
is an additional indication of severity and of probable peritonitis. 
Peri-appendicular infection and the development of abscess may be 
indicated by the continuous increase of local symptoms and the appear- 
ance of tumefaction in the right iliac fossa; or by the recurrence of 
fever, pain, and rigidity after an interval of quiescence succeeding the 
initial attack. Sometimes the development of peri-appendicular abscess 
is so gradual and insidious, and the exudative material and agglutinated 
coils of intestine so thoroughly walled around the focus of disease, that 
an abscess of considerable size may develop with relatively no local 
symptoms; and there may be but little fever and other constitutional 
reaction. In such instances, leukocytosis may be wanting, even though 
an abscess of considerable dimensions has formed. 
Extensions of the infective inflammation to neighboring veins or 
lymph channels, causing an ascending .suppurative phlebitis of the 
mesenteric veins, and finally of the portal vein, or a lymphangitis of 
the retrocecal region, are indicated by evidences of intense toxemia and 
septicemia and by localized symptoms of marked gravity. In the case 
of retrocecal inflammation the pain may be confined to the back, and 
may extend upward toward the posterior aspect of the liver. 
The development of a spreading peritonitis is indicated by intense 
constitutional disturbance. The general appearance of the patient is 
usually somewhat significant. Increasing local tenderness and swelling, 
with recurring rigors and elevation of the temperature, and with marked 
disturbance of the pulse rate, followed by general abdominal distension 
and a cessation of peristalsis, are among the important indications. 
Leukocytosis may at first rise to higher levels; but in many instances, 
especially those of severe infectiousness, the leukocyte count suffers 
an early fall. This may set in so promptly that, by the time the first 
examination of the blood can be made, a normal count, or even leuko- 
penia, may be discovered. 
Differential Diagnosis.-The onset must be distinguished from that 
of a variety of abdominal conditions, any one of which may bear so 
puzzling a resemblance as to make a certain diagnosis impossible. 
Painful gastro-intestinal conditions of various sorts must be distin- 
guished. An attack of simple gastric indigestion or of acute gastritis 
frequently begins with symptoms like those of appendicitis. As a rule 
the relation to some indiscretion of diet is more immediate and certain; 
the localization of the pain is more likely to be in the region of the 
stomach, and to remain in that place; nausea and vomiting and tender- 
ness in the epigastrium are conspicuous; while fever and leukocytosis 
are less likely to be found. The latter symptoms, however, may occur, 
especially in children, and the local symptoms may be referred to lower 378 
DISEASES OF THE DIGESTIVE SYSTEM 
parts of the abdomen, particularly when the gastric disturbance has 
been occasioned by a sluggish condition of the bowels. 
Acute, painful affections of the small intestine more frequently bear 
a striking resemblance, and usually in proportion to the nearness of the 
approach of the irritative or inflammatory conditions of the lower part 
of the small intestine. Usually the pain and tenderness are more diffuse, 
and throughout the attack fail to become limited to the right iliac fossa. 
Rigidity is more general, when present; and the pains are of a more 
distinctly generalized colic-like character. Disturbance of the stomach 
is less marked, and diarrhoea more likely to occur. The condition is 
less liable to present the rapid development of grave symptoms met 
with in severe cases of appendicitis, and is less likely to undergo the 
amelioration after free purgation seen in the mild cases of appendicitis. 
Intestinal colic, whether due to digestive disturbances or to inflam- 
matory conditions of the intestines, may suggest an attack of appendicitis. 
(See Acute Enteritis.) The resemblance of lead colic is often very strik- 
ing, on account of the association of obstinate constipation with the 
acute abdominal pain. The indications of localized inflammation, 
however, are wanting, and a careful scrutiny of the history and a con- 
sideration of the occupation usually enable the physician to arrive at 
a satisfactory diagnosis. 
Acute enteritis due to mineral poisoning, such as lead, mercury, or 
arsenic, as well as attacks of food poisoning, may simulate appendicitis, 
like other varieties of gastro-intestinal irritation or inflammation. They 
are distinguished by the general extensiveness of the abdominal symp- 
toms, the absence of localized tenderness or rigidity, and the prostration. 
Usually, also, there is more or less, and sometimes intense, diarrhoea. 
Acute colitis resulting from stagnation of the contents of the large 
intestine and the accumulation of fecal masses in the cecum, or following 
exposure to cold or digestive disturbances, may simulate an attack of 
appendicitis. This is particularly the case when the cecum or the head 
of the colon is especially involved. In some instances an accurate 
diagnosis is impossible; and it is certain that in some of the cases the 
appendix becomes secondarily involved, when it must be obvious that 
the symptoms would bear even a more puzzling resemblance to those 
of independent appendicitis. Attacks of typhlitis due to stercoral 
accumulations usually present a less intense degree of local tenderness 
and rigidity, and are less acute in onset than appendicitis; but cases 
have been reported in which the local conditions have been violent, and 
in which stercoral ulcerations have caused perforation with the secondary 
development of perityphlitis. 
Typhoid Fever.-1The intestinal conditions in the early stages of 
typhoid fever may simulate appendicitis. Rigidity of the abdominal 
walls, marked local tenderness, and tumefaction occur in these cases; 
while fever and the general constitutional symptoms of the onset resemble 
those of many cases of appendicitis. The gradual onset after a week 
or more of indefinite malaise and gradually increasing fever, the complete 
anorexia, the dilated pupil, and the absence of leukocytosis, may aid 
in the recognition. Unfortunately, some instances of typhoid fever DISEASES OF THE INTESTINES 
379 
with the particular localization of the lesions referred to, come on very 
abruptly, with marked symptoms closely resembling those of appen- 
dicitis. To add to the confusion, there is, in a certain number of cases 
of typhoid fever, an early involvement of the appendix, with the develop- 
ment of specific typhoid lesions in the lymphoid tissues of that structure. 
In a certain number of cases ordinary appendicitis may complicate 
the onset of typhoid fever. It is not improbable that in these cases the 
specific lesions as in the cecum and the consequent interference with 
drainage of the appendix may have an important part. The manifesta- 
tions are similar to those met with independently of typhoid fever, 
but it may be said that, as a rule, these cases usually pursue a relatively 
benign course and become quiescent or are resolved. 
Acute intestinal obstruction may in the beginning suggest appendicitis. 
The early development of indications of more or less complete intestinal 
obstruction with marked distension and without the usual evidences 
of inflammation found in appendicitis, will aid in the distinction. 
Acute pancreatitis, the rupture of a gastric or duodenal ulcer, and acute 
peritonitis following rupture of ulcers of other parts of the intestinal 
tract, suggest appendicitis in the suddenness of onset, the intense abdomi- 
nal pain, the tendency to nausea and vomiting, the occurrence of fever, 
and in the constitutional condition of the patient. The localization of 
the symptoms and the profound character of the disturbance, especially 
the speedy development of early collapse, enable one to arrive at a 
proper diagnosis, in the majority of cases, before the condition has 
proceeded to its more pronounced grades. 
Pneumonia.-Not rarely the pain in the early stages is referred to 
the abdomen, especially in children, and a considerable number of cases 
have been observed in which the resemblance to appendicitis was so 
puzzling that operation was undertaken. A careful physical examination 
will, in most instances, prevent this error; but there are cases in which, 
owing to the lateness of the appearance of distinct physical signs, the 
diagnosis of pneumonia may be difficult. 
Malaria.-Attention has been called to the occasional onset of malaria 
with abdominal symptoms. In these cases the occurrence of a rigor 
and sudden fever, with intense abdominal pain, suggests appendicitis. 
There may even be rigidity and localized tenderness. In some instances 
the diagnosis has been possible only after an examination of the blood. 
Cholecystitis.-The pain may be referred to the lower right quadrant 
of the abdomen, and whatever tenderness is discovered may be most 
decided in the same region. The symptoms of onset may be practically 
the same as those of acute appendicitis. On the other hand, in cases of 
appendicitis, the pain may be referred to the region of the gall-bladder; 
or, when the appendix lies posterior to the cecum, it may be most marked 
in the back, posterior to the liver. Difficulty in diagnosis may, therefore, 
arise from the mistaking of cholecystitis for appendicitis, or the reverse. 
Usually the location of the pain and other symptoms and the discovery 
of tenderness and swelling in the region of the gall-bladder or in the 
right iliac fossa, make a proper diagnosis possible. 
When empyema of the gall-bladder has followed a cholecystitis the 380 
DISEASES OF THE DIGESTIVE SYSTEM 
tumor or mass may be found in a relatively low position, owing to the 
gradual increase in the size of the gall-bladder. Pain and tenderness are 
also situated in a lower position than is usual in the acute stages of 
cholecystitis. As a rule, however, the mass can be found to have a 
certain pyriform shape and to be dependent from the under surface of 
the liver; and the point of maximum pain or tenderness is usually above 
the transverse umbilical line. 
Biliary colic simulates appendicitis in the suddenness of its onset, 
the intensity of the pain, and the associated rigidity of the abdominal 
muscles, together with nausea and other gastric symptoms. As in other 
hepatic and biliary conditions, however, the pain is situated higher up; 
and the development of jaundice is an important distinctive indication. 
Intense and repeated vomiting is never as frequent in biliary colic as 
in the average case of appendicitis. 
Biliary cholelithiasis without definite attacks of biliary colic has often 
been mistaken for subacute or chronic appendicitis. The frequent 
occurrence of slight or severe pain in the right half of the abdomen, the 
pain .not rarely being referred to the lower right quadrant, and the 
tendency to disturbance of the intestinal tract and to more or less gastric 
disorder, are the suggestive symptoms. Not infrequently, in these cases, 
an enlargement of the gall-bladder is present. Suggestive tenderness in 
the region of the gall-bladder is one of the most important symptoms 
upon which a diagnosis may be made. 
Nephrolithiasis and Renal Colic.-In acute attacks of renal colic 
the intense pain radiating from the loin to the external genitalia and 
disturbances in micturition (temporary obstruction, followed by the 
appearance of blood-stained urine) are the symptoms of special impor- 
tance. When a calculus has worked its way to the lower portion of the 
ureter and has become fixed in this position it may occasion acute 
attacks which are most difficult to distinguish from appendicitis. The 
pain and localized tenderness, if the right side is affected, may be in 
precisely the region of the appendix, and may show less tendency to 
radiation downward. The character of the pain, however, is often of a 
distinct cutting nature; disturbances of micturition, the appearance of 
crystals or blood in the urine, and finally the result of x-ray examina- 
tion, may establish the diagnosis. 
Acute pyelitis and other inflammatory conditions of the kidney may be 
attended with considerable pain, and may, therefore, simulate appen- 
dicitis. The situation of the pain, the discovery of tenderness in the 
loin and perhaps enlargement of the kidney, and the results of an exami- 
nation of the urine, make the diagnosis possible. 
Movable kidney has frequently been mistaken for appendicitis, the 
sudden occurrence of painful attacks (Dietl's crises) being the principal 
occasion of confusion. These attacks may be indistinguishable in their 
character or location from the cramp-like pains of a beginning appen- 
dicitis. A careful physical examination usually makes the diagnosis 
possible by discovering the more or less movable enlarged kidney. The 
greatest difficulty occurs in persons in whom the abdominal walls are 
sufficiently thick to prevent careful palpation, or in whom muscular DISEASES OF THE INTESTINES 
381 
rigidity is unusually pronounced. Among the distinguishing symptoms 
the most important are those arising from disturbance of micturition. 
Acute peritonitis from various causes other than those before men- 
tioned may simulate appendicitis. Thus tuberculous peritonitis, or 
peritonitis following perforations of the intestines or other hollow viscera 
of the abdomen, or consequent upon extension of pelvic infection, may 
resemble appendicitis superficially and even on most careful examination. 
Preceding conditions, the location of the symptoms, the early evidence 
of more or less extensive involvement of the peritoneum, and the absence 
of the more or less localized involvement of the right iliac region, enable 
the physician to arrive at a correct diagnosis. 
Salpingitis and oophoritis, with or without localized peritonitis, may 
offer considerable difficulty in some instances. In these cases the fre- 
quency of pain in the pelvic region and back, the occurrence of other 
pelvic symptoms, and the location of the acute tenderness, are suggestive 
indications, while the results of vaginal examination usually give a 
correct diagnosis. The early development of a localized peritonitis in 
these cases increases the difficulty of diagnosis, especially when the 
history of the earlier symptoms cannot be obtained or is uncertain. 
Ovarian Neuralgia.-In some patients, particularly in neurotic young 
women, attacks of intense pain in the right lower quadrant of the abdomen 
may occur at the beginning of menstruation, and may persist through 
the whole period. Sometimes these seem to be dependent upon over- 
loading of the cecum, when a certain fulness will hs detected on palpation. 
Moderate fever occasionally occurs. The resemblance to acute appen- 
dicitis may be very puzzling especially when, as a result of apprehensive- 
ness, nervous mimicry of other symptoms, such as gastric disturbances 
and muscular rigidity, occur. A careful study of the general condition, 
the absence of leukocytosis and of a characteristic clinical course, may 
establish the diagnosis; but in some cases doubt must remain even after 
subsidence of the symptoms at the end of menstruation. 
Nervous mimicry of appendicitis may also occur in women at other 
times and perhaps with nearly equal frequency in neurotic males. It 
must be remembered that there is a certain degree of physiological 
sensitiveness at the ileocecal valve which may readily increase under 
nervous conditions, and abdominal rigidity is not infrequently met 
with under the same circumstances. The general indications of infection 
and local inflammation, however, are wanting, and if the nervous char- 
acter of the patient is recognized a proper diagnosis is usually easy. 
Prognosis.-Although the majority of patients with acute appendicitis 
recover, the disease must be regarded as one of decided seriousness, 
because it is often impossible to determine that an unfavorable extension, 
which may terminate in rapidly fatal peritonitis, is about to take place; 
and because, in cases of recovery, such after-results remain that recurrent 
attacks will probably recur. 
Treated in a purely medical or tentative manner, the great majority 
of patients with appendicitis recover. It is impossible to quote figures 
that may be relied upon to express the exact truth, since it is extremely 
difficult to recognize milder cases with certainty, and sometimes even 382 
DISEASES OF THE DIGESTIVE SYSTEM 
the severest forms would pass undiagnosed but for the character of the 
terminal conditions. The greatest difficulty is caused by the fact that 
there is a very large group of cases of extremely mild character in which 
pain, slight gastro-intestinal symptoms, possibly moderate fever, and 
rigidity in the side may occur, but in which the physician may hesitate 
to make a diagnosis of appendicitis. Practically all these recover, and 
very many of them certainly are never classified as instances of appen- 
dicitis. The result is that tables of prognosis fail to include at least a 
large number of instances, and consequently present a less favorable 
impression than would be the case if all were included. Even with this 
error, which tends to make the outcome of the disease seem somewhat 
less favorable than it should be, the recoveries from appendicitis treated 
by ordinary medical means or by expectant methods constitute a very 
large proportion of the total number of the cases. 
Sahli collected 7213 cases, of which 473 were operated on; while 6740 
were not. Of the latter group, 91 per cent, recovered. Recurrences 
took place in 4593 cases; and of these, 3635 recovered without further 
recurrences. It must be recognized, in connection with such statistics, 
that it is probable that the cases in which operation was performed 
represented a disproportionately large percentage of the serious cases. 
On the other hand, cases in which the disease had advanced rapidly 
and operative measures seemed futile would be classified in the group 
of those not operated on. 
A study of the surgical literature convinces one of the fact that the 
mortality from acute appendicitis treated by prompt and skilful surgical 
methods is probably lower than that recorded in most of the statistics 
bearing upon the results obtained from medical or expectant methods. 
In a measure these statistics may be somewhat deceptive in that they 
fail to include some of the most serious cases in which operation has 
been deemed inadvisable, and, on the other hand, include some cases 
of doubtful diagnosis. Objections of a similar nature might, however, 
be urged against statistics pointing the other way. 
The liability to perityphlitis is always very great. Some instances 
occur of appendicitis without extension beyond the walls of the organ, 
but the tendency to extension through the walls or to perforation is 
extremely great. In those cases in which, as the result of an angulation, 
bend, adhesion, or other form of stenosis, temporary interference with 
drainage occurs when the cecum is distended, mild catarrhal attacks 
may be met with from time to time, without very great liability to 
extension. Eventually, however, in these a severe attack may occur 
and may terminate in the usual manner. 
The liability to diffuse peritonitis is decidedly less marked than that 
to perityphlitis. The mode of extension of the infection is such, and 
the reactive process in the neighboring peritoneum so prompt, that 
limitation of extension is usually brought about by the agglutination 
of neighboring coils of intestine and the formation of a restraining wall 
of more or less firmness. It is unfortunate that no method of diagnosis 
enables the physician to determine the existence of conditions that may 
lead to the sudden rupture of an inflamed or a necrotic appendix. DISEASES OF THE INTESTINES 
383 
The liability to relapse after recovery from acute appendicitis is very 
great, although it cannot be accurately estimated in figures. There are 
many instances of recovery with no subsequent tendency to recurrence, 
especially in those cases in which a total obliteration occurs. The usual 
manner of recovery is by the formation of more or less fibrous thickening 
or adhesion, and such conditions predispose to subsequent reinfection. 
Treatment.-It is difficult to state in a categorical manner whether 
this should be invariably surgical, or only in selected instances. Medical 
men, as well as surgeons, recognizing that it is often impossible to deter- 
mine when an apparently benign case will terminate in sudden extension 
or rupture, with the development of peritonitis, believe that it is usually 
wiser to regard every case of appendicitis as demanding surgical treat- 
ment. A few years ago it was urged by many surgeons that every case 
in which the diagnosis had been established demanded immediate 
operation, unless some unusual contra-indicating circumstance prohibited 
that method of treatment. This attitude was supported by statistical 
evidence that seemed to show that, taken all in all, more cases would 
recover if all were subjected to immediate operation than if an attempt 
were made to select those in which operation was desirable and to post- 
pone operation in other cases. However much it may be urged, on the 
ground of such statistical evidence, that every case of appendicitis 
should be subjected to immediate operation, nearly all physicians and 
surgeons of experience do hesitate in certain cases with mild and perhaps 
doubtful symptoms, and sometimes even in cases of frank although not 
threatening character, preferring to await the development of more 
definite evidences or of more imperative indications for operation in the 
hope that, when the inflammation has become limited or has subsided, 
the safer interval operation may be performed. Recently, moreover, 
some surgeons of large experience, as Ochsner, advocate delay in operation 
in some cases of appendicitis with spreading infection. This view was 
formerly advocated mainly by European surgeons. 
It happens, therefore, in practice that among any series of cases a 
certain number will be regarded by both the physician and the surgeon 
as proper cases for non-operative treatment. In other instances the 
existence of some complication or coincident disease of a prohibitive 
character may prevent operation; and finally, certain patients positively 
refuse operation when it is proposed. Leaving out these exceptional 
cases the only safe plan is immediate or prompt operation. 
Medical Treatment.-The first appearance of symptoms suggestive of 
appendicitis demands immediate rest in bed and the utmost possible 
relaxation of the patient. In many cases the character of the symptoms 
of onset is such that the administration of a purgative may seem indicated 
before the symptoms have become marked enough to be more than 
suggestive. In view of the possibility of an acute appendicitis, the 
physician should in such instances select gentle measures, so as to avoid 
any unnecessary violence of peristaltic action. Enemata are more 
desirable than purgatives; and of the latter, small doses of calomel, or 
the cautious use of salines administered at short intervals until effective, 
are preferable to a single large dose of the same remedies or to more 384 
DISEASES OF THE DIGESTIVE SYSTEM 
active purgatives. After symptoms definitely indicative of appendicitis 
have appeared, the use of purgatives, even of the milder sort, requires 
careful consideration. The present view of most surgeons is opposed 
to their administration. Perhaps, however, such a generally sweeping 
rule is unwarranted. There are undoubtedly cases of mild type accom- 
panying constipation and retention of feces or of gas in the cecum and 
colon in which gentle purgation is both satisfactory and effective. Not 
rarely, in such instances, the free evacuation of the bowel may reestablish 
adequate drainage and cut short an attack that might otherwise proceed 
to a more serious extent. 
Pain is one of the symptoms that usually requires special considera- 
tion when medical treatment is demanded. In the beginning, when 
the nature of the pain is still somewhat doubtful, warm applications, 
such as large fomentations, hot-water bags, poultices, or stupes, may 
relieve pain as well as gastric irritability. When the symptoms have 
become more localized in the region of the appendix, applications of 
cold are preferred, because of a possible controlling influence on the 
inflammation itself, and because they are rather more effective in con- 
trolling the pain. Ice-bags, cloths moistened with ice-cold water, ice 
poultices, etc., may be employed. They may be left in place continu- 
ously, or may be applied from time to time, for such periods as the 
tolerance of the patient will permit. 
The use of opium has been generally discredited because of its ten- 
dency to mask the symptoms and because in case of subsequent operation 
it so interferes with peristalsis as to complicate seriously postoperative 
conditions. Sometimes, however, despite theoretical and practical 
objections, the degree of pain is so great that small doses of opium are 
demanded when the diagnosis is still in doubt or when operation is 
contra-indicated. Certain surgeons advocate minimal doses, even in 
cases in which the diagnosis has been made and operation is contem- 
plated. In no circumstances should this drug be used in large amounts. 
Occasionally, when gastric irritability, meteorism, and general intes- 
tinal colic are conspicuously associated with the other symptoms, 
carminatives, such as spirit of chloroform, Hoffmann's anodyne, menthol, 
oil of peppermint, phenol, etc., may give relief. Excessive gastric irri- 
tability may be controlled by small doses of cocaine, phenol, dilute 
hydrocyanic acid, cerium oxalate, or aromatic spirit of ammonium. In 
some cases in which operation cannot be performed, or in postoperative 
gastric distension and distress, lavage will occasionally put an end to 
troublesome or threatening symptoms. 
Diet.-In the beginning stages, all food, and even water, should be 
withheld. If excessive thirst is complained of, small pieces of broken 
ice may be allowed; or, after evacuation of the lower bowel, enemata 
of warm water may be given to supply the needs of the system. If 
acute symptoms have subsided after forty-eight hours, a cautious return 
to liquid diet may be advisable. Milk or broth, in doses of from a dram 
to half an ounce, may first be given, and increased as the tolerance of 
the patient becomes apparent. A return of local symptoms, fever, or 
gastric disturbance should suggest the immediate withdrawal of food. DISEASES OF THE INTESTINES 
385 
Treatment of Chronic Appendicitis.-Cases in which a history pointing 
to one or more previous attacks of appendicitis is obtained, and in 
which local symptoms and physical signs or disturbances of bowel 
function indicate the probability of adhesions, thickening, angulations, 
or other chronic alterations in and about the appendix, must be carefully 
considered with reference to the desirability of operation in the interval 
before the occurrence of another acute attack. When the diagnosis is 
certain, operation should be unhesitatingly recommended; and even if 
somewhat uncertain, operation is the safer plan when the occupation 
or life of the patient is liable to take him beyond the reach of immediate 
surgical aid should another acute attack occur. The risk from operation 
in the interval is exceedingly small, but the slight danger incident to 
general anesthesia, the possibility of other accidents in the course of or 
following the operation, and the danger of postoperative hernia (not to 
mention the inconvenience, expense, and other undesirable features 
connected with an unnecessary operation) should prohibit exploratory 
incisions in cases with doubtful, even though somewhat suggestive, 
symptoms. It is better to await developments. Operations are some- 
times recommended in cases in which obstinate abdominal symptoms 
of obscure character but not strongly indicative of appendicitis have 
occurred. Exploration will more likely fail than succeed in revealing 
any chronic disease of the appendix. In the great majority of cases 
chronic conditions of the appendix furnish sufficiently clear indications 
to establish at least a presumptive diagnosis. 
TUBERCULOSIS OF THE APPENDIX 
Tuberculosis of the appendix is occasionally met with at operations 
and at autopsy. It is said to be found in 2 per cent, of the operation 
cases (Lockwood). The condition is, like other forms of intestinal 
tuberculosis, usually secondary to tuberculosis of the lungs. It may 
occur independently of other involvement of the intestines, but is more 
commonly found in association with tuberculosis of the cecum. In a 
few instances primary tuberculosis of the appendix has been met with. 
The lesions are of variable character. Usually there is a simple tuber- 
culous ulceration; in other cases, extensive invasion of the walls of the 
appendix, with secondary caseation and pus-formation, may be found; 
while extensions to the peritoneum, in the form of miliary tubercles, 
or a more diffuse localized peritonitis, may be seen. Crowder has de- 
scribed a case of primary hyperplastic tuberculosis limited to the 
appendix, and similar to hyperplastic tuberculosis of the cecum (7. v.). 
Symptoms.-These may be indistinguishable from those of ordinary 
appendicitis; and a large number of the cases that have been reported 
have been discovered upon surgical operation for supposed appendicitis. 
In some cases a suspicion of the nature of the process might arise from 
the fact that there is, at the time, decided enlargement of the regional 
lymphatic glands. A case of this sort has occurred in the experience of 
the writer, and the nature of it was readily recognized before operation. 
In some cases secondary tuberculous abscesses form. 
vol. in-25 386 
DISEASES OF THE DIGESTIVE SYSTEM 
ACTINOMYCOSIS OF THE APPENDIX 
A number of instances of this condition have been reported. Spicken- 
baum collected 27 cases from the literature (Kelly and Hurdon). The 
symptoms are those of a sudden or gradually developing lesion in the 
right iliac fossa, with the development of persistent soreness and a 
tender swelling. Rarely the process remains limited to the appendix. 
Usually it tends to spread to the neighboring structures. 
CYSTIC DISTENSION AND MUCOCELE OF THE APPENDIX 
Retention cysts of the appendix are not uncommon. They result 
from the gradual transformation of the contents of the appendix, in 
cases of obstruction of its mouth or of obstruction of its lumen, into 
liquid of a serous or watery character. Considerable dilatation of the 
distal portion of the appendix may occur, and a cyst of sufficient size 
to be detected through the abdominal walls may be formed. The wall 
of the appendix suffers attenuation, and sometimes hernial protrusions 
of the mucous membrane between the separated fibres of muscularis 
may be seen. In most instances such dropsical cysts have been found 
at operation or at autopsy, not having been suspected during life. In 
some cases operations have been undertaken for suspected abdominal 
or pelvic tumors, and the condition described has been found. 
Mucocele.-This is a condition in which the appendix is found dis- 
tended with grayish or whitish gelatinous material of a mucoid character. 
In some instances this may be the result of an inflammatory condition 
resulting from occlusion; in other cases the histological features suggest 
a neoplastic process. In some of these cases the condition was found 
in association with papillomatous disease of the ovary. 
TUMORS OF THE APPENDIX 
Polyps.-Rarely polypoid outgrowths from the mucous membrane 
occur in the appendix as in other situations. 
Myxoma.-One instance, shown by Churton and removed by Mayo- 
Robson, is referred to by Kelly and Hurdon. 
Myoma.-A few instances are described in the literature. Small 
nodular masses, about 5 mm. in diameter, occurred in the case described 
by A. O. J. Kelly. There was chronic inflammation of the appendix. 
Malignant Tumors.-Primary carcinoma of the appendix occurs more 
frequently than is commonly believed. Kelly and Hurdon state that 
there are now on record 49 cases, including 2 designated as endo- 
thelioma. In most instances in which the situation was noted the growth 
occurred at or near the tip. The tumor is usually small, having been 
in 15 cases from 5 to 12 mm. in diameter. Larger masses have, however, 
been reported up to the size of a walnut. The gross appearance may be DISEASES OF THE INTESTINES 
387 
that of a fibrous tumor. Sometimes it has presented caseation, and has 
suggested tuberculosis. Microscopically, the appearances are those of a 
glandular intestinal carcinoma. Sometimes infiltration as far as the 
meso-appendix occurs, as in a case reported by Norris; 9 of the 11 cases 
studied by Kelly were of this description. Carcinoma of the appendix 
is somewhat peculiar in the early age at which it presents itself. Of 25 
instances of primary carcinoma, 4 occurred under twenty years of age, 
and 11 between twenty and thirty years. The youngest reported case 
is that of a girl, aged twelve. 
The clinical symptoms are practically indistinguishable from those 
of chronic appendicitis or of appendicitis with perforation. A fatal 
termination may be due to perforation and secondary peritonitis. Peri- 
appendicular abscesses are not uncommon. Extension of the carcino- 
matous process to surrounding structures occurs in a certain number. 
The prognosis after removal has not, as yet, been certainly determined, 
because the time that has elapsed since the first operation for this condi- 
tion was undertaken is relatively short. Halsted's patient, according 
to Kelly and Hurdon, was living five years after operation. 
Secondary carcinoma of the appendix is occasionally met with, especially 
in association with carcinoma of the pelvic organs. 
Sarcoma.-Sarcoma has been found in a few instances. 
TUBERCULOSIS OF THE INTESTINE 
Intestinal tuberculosis may result from the ingestion of tuberculous 
meat or milk (primary intestinal tuberculosis), as distinguished from 
secondary intestinal tuberculosis, which results from an infection of 
some part of the intestinal tract from a previously existing focus. This 
is, in most cases, pulmonary tuberculosis, the intestinal lesion usually 
resulting from the swallowing of bacillus-bearing sputum. Less fre- 
quently secondary tuberculous enteritis results from the extension of a 
tuberculous focus in the peritoneum, the abdominal lymph nodes, or 
one of the abdominal viscera. 
Concerning the relative frequency of primary and secondary intestinal 
tuberculosis, Zahn1 places the occurrence of primary intestinal tuber- 
culosis at 2.27 per cent., while Ciechanowski,2 on the basis of 13,203 
autopsies, figures it at 1.04 per cent. Secondary intestinal tuberculosis 
Zahn found in 63.21 per cent, of cases of pulmonary tuberculosis, 
In this connection the results of the investigations on the frequency of 
tuberculosis, especially of the digestive tract, in children dying of 
diphtheria are interesting. Among 714 cases dying of diphtheria 
Heller3 found tuberculosis in 140 (19.6 per cent.), in 53 (7.4 per cent.) 
of which it was primary in the digestive tract. Councilman, Mallory, 
and Pearce4 in 220 cases found tuberculosis in 35 (16 per cent.), in 13 
(5.9 per cent.) of which it was primary in the digestive tract. Among 
1 Munch. med. Wochenschrift, 1902, Nr. 2, p. 49. 
2 Wien. klin. Wochenschrift, 1907, Nr. 37. 
3 Deutsch, med. Wochenschrift, 1902, Nr. 39, p. 696. 
4 Diphtheria, Boston, 1901. 388 
DISEASES OF THE DIGESTIVE SYSTEM 
806 diphtheria cases Baginsky1 found 144 (17 per cent.) to be tuberculous, 
and in only 6 (0.7 per cent.) was it primary in the digestive tract. 
Although the commonest lesion of intestinal tuberculosis is the tuber- 
culous ulcer, other processes may present themselves either in con- 
junction with ulceration or independent of it. Certain clinical distinc- 
tions may differentiate these cases and make it profitable to consider 
separately the ulcerative, the stenotic, and the hyperplastic varieties. 
Clinically, it may be found difficult to classify all cases strictly according 
to these types, and frequently combinations exist. 
Tuberculous Ulcers.-The most frequent localization of tuberculous 
ulcers is in the ileum just above the ileocecal valve. They occur, how- 
ever, as high up as the duodenum and as low down as the rectum. The 
ulcer usually begins in a solitary follicle or Peyer's patch, although it 
may occur in the mucous membrane itself. It commences as a small, 
shot-like, gray nodule just below the mucous surface. This enlarges 
and later its centre undergoes caseation. Microscopically it consists 
of a number of typical tubercles composed of giant cells, epithelioid 
and lymphoid cells, or of a diffuse caseating mass. Finally, the entire 
nodule becomes caseous and subsequently breaks through the overlying 
mucous membrane, the caseous material is discharged into the bowel, 
and the tuberculous ulcer results. At this stage it has a small, crater- 
like opening, elevated caseous edges, and a caseous base. Frequently 
a number of these primary ulcers unite to form a larger ulcer. In 
other cases the larger ulcers result from the simple increase in size of 
the single original ulcer, by the caseation of miliary tubercles deposited 
about its margins. Since this extension is by means of the lymph 
channels, the longest diameter of the ulcer is usually at right angles 
to the long axis of the intestine, and at times the ulcer extends as a 
girdle about the entire lumen of the bowel. The margins are elevated, 
irregular, and usually slightly undermined. Frequently tubercles can 
be seen with the naked eye in the elevated thickened edges. The peri- 
toneal coat of the ulcer is usually thickened, of a dark, bluish-gray color, 
and frequently contains miliary tubercles. At times the peritoneum cor- 
responding to the area of ulceration is covered by a fine exudation that 
may lead to adhesions between adjacent coils of intestines. The extent 
to which the ulceration may proceed varies greatly. Usually ulcers of 
varying size and age will be found in the same case. 
Terminal Changes.-Complete healing with the disappearance of all 
tubercles is unusual. The ulcers frequently undergo partial organiza- 
tion, so that while some ulceration remains, a moderate degree of stenosis 
is also present. Perforation is seldom a complication of tuberculous 
ulceration, except in the rectum. Two factors tend toward this infre- 
quency: the thickening of the peritoneal covering and the tendency 
to the formation of peritoneal adhesions. It is consequently especially 
in young, rapidly progressive ulcers that the tendency to perforation is 
greatest. If perforation occurs, either a general peritonitis results, or, 
if adhesions between adjacent coils of intestines have formed, walling 
1 Deutsche med. Wochenschrift, 1902; Vereinsbeilage Nr. 35, p. 270. DISEASES OF THE INTESTINES 
389 
off the seat of perforation, a localized peritoneal abscess results. On 
account of the fact that the ulcers are most frequent about the ileocecal 
valve and usually most advanced in this area, the site of the perforation 
is relatively most frequently found in the right iliac fossa, or in the pelvis 
where the coils of the lower ileum usually lie. Occasionally multiple 
perforations have been found. Perforation has been known to occur 
into neighboring organs, as the bladder or uterus. Ulcers in the rectum 
not rarely perforate and cause ischiorectal abscesses. Carcinoma has 
been known to develop in the site of an old tuberculous ulcer. 
Symptoms and Diagnosis.-The symptoms of ulcerative tuberculous 
enteritis do not differ materially from those of simple enteritis or of 
other forms of ulceration of the bowels. The most constant and char- 
acteristic symptom is diarrhoea, but this is by no means invariably 
present even with quite extensive ulceration. The stools are either 
soft and unformed, although presenting no special alteration from the 
normal in other respects, or thin and watery. Mucus may be found in 
small masses, or as strings or shreds, especially in the cases in which 
the feces are semisolid. There may be admixture of blood in small 
quantities, and occasionally considerable hemorrhage occurs. When 
formed stools are passed, or when the feces are hard from constipation, 
they may be coated with blood-streaked mucus and pus, provided the 
ulceration is situated in the lower bowel. Continued diarrhoea causes 
rapid emaciation and loss of strength, although occasionally the patient 
maintains his flesh and strength surprisingly. Soreness and localized 
tenderness are not usually marked unless extension to the peritoneum 
has occurred. Ordinarily the temperature is not much influenced and 
any fever is usually due to the primary pulmonary lesion. 
Since the symptoms do not differ materially from those of most of 
the chronic inflammatory and ulcerative conditions in the intestines, 
the diagnosis must rest to a great extent on the associated phenomena. 
Due attention must be paid to the fact that in children primary intestinal 
tuberculosis is much more common than in adults, and that more than 
50 per cent, of the cases of pulmonary tuberculosis in adults are com- 
plicated by intestinal ulceration. Consequently the occurrence of diar- 
rhoea and other symptoms of enteritis in an adult suffering from pul- 
monary tuberculosis would justify strong suspicions of the existence of 
intestinal ulceration. At the same time amyloid disease of the intes- 
tines, the most prominent symptom of which is diarrhoea, is a common 
complication of tuberculosis. The diarrhoea of amyloid disease is usually 
more watery than that of tuberculous enteritis, and is less commonly 
associated with the presence of occult or visible blood. 
In children the diagnosis is usually more difficult than in adults. A 
persistent diarrhoea, with progressive wasting, abdominal pain and 
distension, and enlarged glands without determinable cause, would 
warrant a tentative diagnosis of tuberculous enteritis. In both adults 
and children the diagnosis would be greatly strengthened by the discovery 
of tubercle bacilli in the stools or a positive tuberculin reaction. When 
infected sputum is swallowed tubercle bacilli may possibly be found in 
the feces before an intestinal lesion has occurred. 390 
DISEASES OF THE DIGESTIVE SYSTEM 
Stenosing Tuberculous Enteritis.-Stenosis of the intestines of tuber- 
culous origin without ulceration results when the tendency to organiza- 
tion as a result of the inflammation exceeds the tendency to destruction 
of tissue. It is by no means frequent, but probably not so uncommon as 
has been formerly considered. A distinction must be made between 
those cases in which stricture has succeeded upon ulceration and those 
in which the stenosis is the primary and predominating feature. The 
latter constitutes the type now specially under discussion. The tuber- 
culous nature of these strictures is sometimes determined only with the 
greatest difficulty. Fibiger reports two such cases which were shown to 
be tuberculous only after exhaustive microscopic examination. He thinks 
that in the past many of these cases have been looked upon as syphilitic 
The strictures are most frequently found in the ileum and colon and are 
usually multiple. The symptoms are those of chronic intestinal obstruc- 
tion, and the tuberculous nature of the condition can be diagnosed only 
by the associated lesions or by exclusion of other etiological factors. The 
tuberculin reaction may be of great assistance. 
Chronic Hyperplastic Intestinal Tuberculosis.-This is characterized 
pathologically by varying degrees of stenosis and ulceration, but primarily 
by a proliferation of tuberculous granulation tissue in the intestinal wall. 
This leads to a great increase in thickness of the wall and consequent 
stenosis, which produces one of the predominating clinical manifestations. 
The condition may originate in either the mucosa or the serosa, and is 
usually secondary to tuberculosis elsewhere. Its almost invariable site 
is the ileocecal region. The predominance of the hyperplastic over 
the destructive processes is probably a result of decreased virulence of 
the tubercle bacillus. 
According to Conrath the majority of the cases occur between the 
ages of twenty and forty years. The active symptoms are preceded by 
a long duration of vague, rather mild intestinal disturbances. Not 
until the stenosis is sufficient to produce symptoms of obstruction is 
the condition possible of diagnosis. These obstructive symptoms are 
of insidious onset and form one of the most constant features that the 
condition presents. A tumor presents itself sooner or later, and the 
resemblance to carcinoma is often marked. Obrastzow looks upon the 
slow and late development of the stenosis as pointing to tuberculosis 
rather than to carcinoma. The mass usually has a cylindrical form, 
giving the impression of a greatly thickened intestinal wall. Occult 
blood is usually present in the stools, and frequently the feces contain 
visible quantities of admixed blood. Fever usually occurs. The diagnosis 
is substantiated by tuberculosis elsewhere, by a positive reaction to 
tuberculin, or by the discovery of tubercle bacilli in the stools. 
Treatment of Intestinal Tuberculosis.-The prevention of intestinal 
infection is to some extent possible. Patients suffering from pulmonary 
tuberculosis should be made to realize the danger of swallowing sputum. 
Unfortunately, this occurs during sleep and cannot then be prevented. 
The main purpose of treatment after ulceration has occurred should 
be to save the patient's strength by controlling diarrhoea and as far as 
possible the ulceration itself. There is some tendency toward healing, DISEASES OF THE INTESTINES 
391 
but the object is not so much to secure this result as to control the 
waste of the patient's vitality. Careful regulation of the diet is an 
essential. This may necessitate some diminution in the amount of 
food that might otherwise be desirable, but careful consideration is 
necessary to decide whether it is wisest to limit feeding on account of 
the bowels or to continue overnutrition on account of the pulmonary 
and general infection. No set rules can be laid down. Pasteurization 
or predigestion of the milk is often desirable. 
So far as remedies are concerned, it is always well to use those that 
are least likely to disturb the stomach. Small doses of bismuth subnitrate, 
subgallate, or salicylate given rather frequently and continued for some 
time may have a useful effect. Among the antiseptics, guaiacol carbon- 
ate, creosote, carbolic acid, ichthyol, or iodoform may be used. When 
diarrhoea is excessive, small doses of nitrate of silver, acetate of lead, 
and vegetable astringents may be administered temporarily or until 
the bowels become more settled. Sulphur seems to exercise a useful 
effect in some cases. When ulcers are found in the rectum, direct treat- 
ment may aid healing and prevent extension to the perirectal tissues. 
The stenosing and hyperplastic forms demand surgical treatment if 
the symptoms are pronounced and the condition of the patient permits 
of operation. The results in some cases have been very satisfactory. 
SYPHILIS QF THE INTESTINES 
Intestinal lesions of syphilis are rare. They occur in both congenital 
and acquired syphilis but are much more common in the former. The 
intestinal lesions of congenital syphilis are always associated with 
syphilitic phenomena in other organs. They usually take the form of 
multiple small gummata, and are found almost solely in the small 
intestines, and especially in the ileum. They take the form of flat, 
grayish elevations, at times involving the solitary follicles or Peyer's 
patches, at times not. Superficial necrosis frequently occurs, leaving 
an ulcer with a fibrous base and very slightly elevated edges. The 
ulcers usually extend in a direction at right angles to the axis of the 
bowel, and at times lead to stenosis. Kundrat and Moerck have reported 
the perforation of a syphilitic ulcer. 
In acquired syphilis, symptoms of enteritis at times occur early in 
the disease, which may be of the nature of intestinal manifestations 
comparable to the secondary cutaneous manifestations. Pathological 
observations of the condition are wanting. Later in the disease intestinal 
lesions are observed similar to those observed in congenital syphilis, 
excepting that they are more common in the large intestine than in the 
small.* They appear first as grayish-red, smooth, gummatous elevations, 
which later undergo necrosis resulting in flat, sharply marginated ulcers, 
with a smooth, translucent, gray or yellow base. . As in the congenital 
lesions, they tend to extend around the lumen of the bowel and cicatrize, 
thus producing stenosis. Occasionally perforation occurs. 
The most frequent situation of syphilitic ulceration of the intestines 392 
DISEASES OF THE DIGESTIVE SYSTEM 
is in the rectum and particularly in its terminal portion just above the 
sphincter. The ulcers are distinguished from those of dysentery by 
their smooth, gray base and the tendency to induration of the edges and 
extensive stenosis. It is probable that stenosing tuberculous ulcers 
of the rectum have been frequently mistaken for syphilitic lesions. 
Syphilitic rectal stenoses are more common in women than in men. 
They may result from the cicatrization of a primary lesion, of mucous 
patches, or of ulcers caused by necrotic gummata. 
The symptoms of syphilitic involvement of the intestines are those of 
simple intestinal ulceration or stricture and permit a probable diagnosis 
only on the basis of the history or the associated findings of syphilis, 
and possibly their response to the therapeutic test. Syphilitic stenoses 
of the rectum are distinguished by the marked induration and extensive 
cicatrization. 
The treatment is directed to the general infection and to the control 
of the diarrhoea. The latter often persists in spite of ordinary treatment 
and until active antisyphilitic remedies are employed. 
AMYLOID DISEASE OF THE INTESTINES 
This occurs as a result of the same causes that produce amyloidosis 
elsewhere. The most prominent causes are chronic tuberculosis, syphilis, 
chronic suppuration, and the various cachexias. In point of frequency, 
the intestines stand fourth among the organs affected, the kidneys, 
spleen, and liver being the organs more frequently involved. Usually 
the entire intestinal tract is diffusely affected, but at times the ileum 
only is the seat of the disease. More rarely the colon alone is affected. 
The process may involve any or all of the tissues composing the intestinal 
wall, but seldom affects the mucous membrane itself. The lymphoid 
follicles usually remain entirely free from the amyloid involvement. 
The diseased intestine presents a pale, shiny, translucent appearance, 
and gives the typical amyloid reaction. 
A feature of amyloid disease of the intestines requiring special mention 
is the so-called amyloid ulcer. These are described as ulcers varying 
in size from that of a pinpoint to that of large areas involving the entire 
circumference of the intestines in a girdle-like fashion, and from 5 to 
15 cm. in length. They have smooth, slightly thickened edges and a 
pale base with numerous small striations. It is possible that a simple 
ulceration occurs as a result of the insufficient nutrition of the surface 
epithelium caused by the amyloid degeneration of the underlying vessels. 
It is not improbable that some of the ulcers described as amyloid were 
tuberculous ulcerations occurring as one of the manifestations of the 
disease producing the amyloidosis. 
Mild degrees of amyloid disease present no symptoms by which it can 
be recognized clinically. More severe grades present one constant 
feature-diarrhoea. The stools are moderately frequent and watery, 
but present no characteristic features. The cause of this watery diarrhoea 
has been variously attributed to anemia of the intestinal wall, to increased DISEASES OF THE INTESTINES 
393 
permeability of the vessel walls, and to decreased absorptive powers 
of the intestinal mucosa. The question of the presence of blood in the 
stools in amyloidosis of the intestines is one of considerable importance. 
Colberg, claiming amyloid ulcers to be a common association of diffuse 
amyloid disease of the intestines, looks upon the presence of blood in 
the stools as a diagnostic feature. The probabilities are, however, that 
the presence of blood in the stools points to the existence of other con- 
ditions than simple amyloidosis. Pain and tenderness play no part in 
the symptomatology of uncomplicated amyloid disease of the intestines. 
The treatment resolves itself into that of the primary disease and an 
attempt to control the diarrhoea, which is best accomplished by the 
mineral and vegetable astringents and opium. 
SPRUE 
Sprue, or psilosis, is a form of chronic inflammation of the gastro- 
intestinal tract met with in certain tropical countries-notably in the 
Orient-characterized by great weakness and wasting, anemia, and a 
chronic form of diarrhoea. 
Etiology.-The essential nature of the disease has not yet been deter- 
mined. According to Scheube, it never occurs epidemically and is not 
contagious. The disease occurs only in hot climates and affects Europeans 
who have resided for some time in such climates more frequently than 
natives. The disease may occur without any predisposing cause, but 
often follows exhausting conditions. 
Pathology.-The lesions consist in a catarrhal inflammation, followed 
by erosions and atrophic changes affecting the whole gastro-intestinal 
tract. The mucous membrane of the mouth may present an inflamed 
surface, with erosions and aphthous spots. The small intestine is usually 
extensively involved, and the colon may present distinct ulcerations. 
When it has continued for some time, secondary changes may be met 
with, such as marked atrophy of the mucous membranes, areas of 
distinct erosion, and sometimes small, cystic dilatations of the intestinal 
glands. Enlargement of the mesenteric lymph nodes is frequent. 
Symptoms.-The onset may be gradual or abrupt. In many cases 
it occurs in the course of other diarrhoeal diseases. The patient presents 
a wasted, anemic appearance, and the evidences of severe secondary 
anemia are found. Abdominal distension occurs and may cause a 
reduction in the extent of liver dulness. 
The most characteristic features are those affecting the gastro-intestinal 
tract. The tongue and mouth become sore from exfoliation of the mucous 
membrane and the formation of herpetic or aphthous lesions. The term 
"Ceylon sore mouth" has been applied to this condition. Dyspeptic 
symptoms and flatulent distension of the stomach are frequent. The 
characteristic diarrhoea soon develops, and continues, with exacerbations 
and periods of quiescence, throughout the disease. The stools are large, 
usually loose, of a light grayish or white color, and frequently frothy. 
Chemical examinations show an increase of mucus and some albumin, 394 
DISEASES OF THE DIGESTIVE SYSTEM 
as well as an excessive quantity of fat. Quantitative analyses indicate 
that intestinal absorption is much diminished. The clinical course 
is a chronic and remitting one, periods of active intestinal symptoms 
alternating with intermissions of quiescence. 
Prognosis.-Cases recognized and treated early usually recover, 
although the tendency to relapse is very pronounced. Fatal cases termi- 
nate as the result of continued diarrhoea, lack of digestion and absorption 
of food, and consequent inanition. 
Treatment.-Strict regulation of the diet offers the best chance of 
recovery, particularly if instituted early. A strict milk diet kept up 
for several weeks appears to be most generally advisable. Cantlie has 
recommended a pure meat diet, and sometimes the administration of 
fresh fruit or berries. Drugs, excepting such as are used for symptomatic 
treatment, have little value. 
INTESTINAL OBSTRUCTION 
Definition.-The term intestinal obstruction is here used to signifiy 
incomplete or complete interference with the onward movement of the 
intestinal contents and their eventual discharge, occasioned by some 
form of mechanical or structural impediment of more or less limited 
extent. The term does not apply to interference with the passage of 
the intestinal contents caused by the general weakness or paralysis of 
the bowels or by the conditions of the contents themselves, which are 
referred to in the discussion on Constipation and Intestinal Obstruction 
due to Motor Paralysis of the Bowel. A variety of terms have been 
introduced to designate different kinds of obstruction: 
Ileus is an ancient name, variously applied to paralytic conditions 
of the intestines, to obstruction in a general sense, or to obstruction 
with feculent vomiting. It is rarely used at the present day, and on 
account of its indefiniteness should be abandoned. 
Occlusion implies a complete closure of the intestinal lumen. 
Stricture signifies a contraction of the lumen caused by disease of the 
wall, usually involving its entire circumference in a more or less limited 
section. 
Constriction signifies a narrowing by adhesions, fibrous bands, or 
similar conditions outside the bowel. 
Obturation signifies an obstruction of the lumen of the intestines by 
contents, foreign bodies, or other conditions inside the bowel. 
Compression indicates obstruction due to the pressure of tumors, 
misplaced organs, or other conditions outside the bowel. 
Incarceration indicates an obstruction, more or less complete, from 
the retention of a coil of intestine beneath fibrous bands within hernial 
sacs, etc. 
Strangulation indicates the constriction of a coil of intestine in which 
more or less complete obstruction of the bloodvessels supplying this 
coil has taken place, causing intense venous stasis. 
Intestinal obstruction may be acute or chronic. Frequently, after DISEASES OF THE INTESTINES 
395 
partial chronic obstruction, there is an acute increase of the obstruction, 
and clinically, difficulty is experienced in distinguishing such cases from 
acute obstructions. 
General Pathology.-Certain conditions affecting the bowel and its 
immediate connections, the peritoneum, the mesentery, etc., result 
from obstructions of all sorts without reference to the precise morbid 
condition that has occasioned the obstruction. Characteristic differences 
are met with in the anatomical conditions occurring in chronic cases, 
as contrasted with those of acute character. 
Chronic Obstruction.-A striking contrast is seen in the condition of 
the bowel below and above the point of obstruction. Below the obstruc- 
tion the intestinal coils are empty and contracted, and their color more 
or less grayish or white. The condition is that seen in the empty intestine 
of persons who have died of inanition. Sometimes remnants of the 
intestinal contents remain in the contracted bowel below the obstruction, 
especially when hardened fecal masses had been present at the time of 
the obstruction and, on account of their physical character, could not 
readily be transported onward. Above the obstruction the bowel is 
distended, and, after a certain length of time, elongation, thickening 
from hypertrophy of the walls, ulceration, and other inflammatory 
changes in the mucous membrane and serous coat may be met with. 
The first effect is the accumulation of contents above the constricted 
area, and a resulting dilatation of the bowel. Later, this distension 
seeks higher and higher levels, until almost the entire intestinal tract 
above the constriction may be involved. The distended bowel contains 
fluid or somewhat consolidated fecal matter, according to the situation 
of the obstruction. In cases involving the small intestine, fluid contents 
alone are met with. In obstruction of the large intestine there may be 
semisolid or even solid fecal masses. This, however, is not invariable, 
as the contents may be fluid even in obstruction of the lower part of 
the large bowel. A certain amount of gas may be present, but distinct 
accumulations of gas are unusual, as the gases are absorbed from the 
mucous membrane so long as the circulation of the bowel has not been 
seriously disturbed. Moreover, gases are usually able to pass beyond 
the obstructed area after any onward movement of fluid or solid feces 
has become impossible. 
Hypertrophy of the wall of the bowel follows and this affects the 
muscularis especially, and may be confined to this part, although some 
thickening of the other tunics may also occur. Experiments in animals 
have shown that the hypertrophy begins as early as the fourth or fifth 
day after obstruction of the bowel has been established, and is quite 
marked by the ninth day (Herczel). The hypertrophy is due to an 
increase in the width of the muscle fibres rather than to increase in 
their number. It is a functional hypertrophy which, to a certain extent, 
enables the bowel to overcome the obstruction. 
Changes in the mucous membrane result from the stasis of the con- 
tents and secondary fermentative or putrefactive changes. As a result 
of the irritation, inflammatory conditions and finally ulceration of 
the mucous membrane and submucosa occur. Formerly the direct 396 
DISEASES OF THE DIGESTIVE SYSTEM 
mechanical irritation of retained contents, and especially of hardened 
masses, was considered of prime importance in the development of such 
ulcers, and the names stercoral ulcer and decubital ulcer were applied. 
According to Kocher, a better term would be distension ulcer, as he 
regards the ulceration as due to overdistension of the intestines with 
consequent disturbance of circulation. When inflammatory changes 
are pronounced the mucous membrane may be somewhat thickened, 
but nearly always it is thinner than normal. The serous coat is thinned 
by the distension, and more or less stretched in a longitudinal direction 
as the result of a shortening of the mesentery by the dilated bowel. 
Acute Obstruction.-When this has followed a chronic but only partial 
occlusion, more marked distension of the bowel above the obstruction 
occurs as the result of suddenly increased pressure and interference 
with the movement of the contents, causing the accumulation of gases. 
In purely acute cases there are quite marked differences from those 
met with in chronic obstruction. Below the obstructed area the bowel 
is empty and contracted, as in chronic cases. Above the obstruction 
the principal change is distension, with great thinning of the walls 
of the bowel. There is no evidence of hypertrophy, such as occurs in 
the chronic cases owing to the acuteness of the condition. The con- 
tents of the bowel are, in the beginning, liquid or semiliquid, but after 
a relatively short time gaseous accumulations occur as a result of 
interference with the circulation and consequent cessation of absorption 
from the mucous surface, and also as a result of the inability of the gases 
to pass the acutely obstructed portion. Paresis of the bowel is favored 
by interference with the circulation and a hyperemic condition of the 
walls of the gut. When complete stasis of the circulation has developed, 
absorption of accumulating gases ceases and increasing dilatation occurs. 
The gases are partly derived from the air swallowed with food and in 
part from fermentative processes. A considerable part of the distension 
may, however, be due to carbon dioxide derived from the venous blood. 
The condition of the bowel in strangulated coils is of particular impor- 
tance. The obstruction of the circulation in such portions produces 
a rapid hyperemia, and eventually a complete stasis of the circulation. 
The coil becomes of a deep red or purplish color and is tensely distended. 
Hemorrhagic extravasation may occur within the lumen or on the 
outside. A gangrenous condition may develop, when the intestine 
becomes of a greenish or grayish color. Occasionally obstruction of 
the arteries as well as of the veins may cause a somewhat different 
appearance, the bowel in these cases remaining flaccid and becoming 
gangrenous in a very short time. The strangulated coil undergoes rapid 
distension from the accumulation of gases. 
Affections of the peritoneum may occur in cases of strangulation or 
in other forms of intestinal obstruction due to the escape of micro- 
organisms through the wall of the bowel in the area of obstruction, or 
immediately adjacent to it. The local conditions (compression of the 
tissues by bands, intussusception, etc.) and the complete stasis of the 
circulation cause degenerative changes in the wall of the bowel and 
make them more readily permeable, and thus a rapid involvement of DISEASES OF THE INTESTINES 
397 
the peritoneum becomes possible. In cases of gangrene and perforation 
of the intestines a violent local or perhaps general peritonitis quickly 
supervenes, and foul-smelling collections of inflammatory exudates and 
necrotic material with escaped intestinal contents are encountered. 
General Symptomatology.-The important clinical manifestations 
of obstruction of the intestines are pain, distension, nausea and vomiting, 
constipation, prostration, and collapse. A variety of secondary symp- 
toms or variations in the manifestations occurs in the different types. 
Pain.-This differs greatly in manner of onset, severity, and character, 
according to the acuteness of the case. In acute obstruction sudden 
abdominal pain, usually of considerable violence, is the rule. This 
may be occasioned by the direct irritation of the nerves in the affected 
segment, by the sudden compression or obstructive cause, and by the 
violent peristaltic efforts above the obstruction. As acute obstruction 
more commonly involves the small intestine than the large, the pain is 
more likely to be general than localized, as it is well known that the 
nervous mechanism prevents an accurate localization of pain involving 
the small bowel. In the majority of cases the pain of onset is referred 
to the middle portions of the abdomen. At first it is intense and may 
continue so until, as a result of exhaustion, or possibly of toxemia caused 
by the absorption of putrefactive products, a cessation is brought about. 
The pain may be so severe in the beginning that nausea, vomiting, or 
profound prostration may result. After an interval of cessation, second- 
ary pains of cramp-like or colicky character due to violent peristalsis 
set in. These, however, are rarely prolonged, as are the pains met with 
in chronic obstructions. Very soon the bowel becomes fatigued, or 
prostration reaches a grade that puts an end to the patient's suffering. 
Extension of infection to the surrounding peritoneum may add a 
new form of pain, sometimes distinguishable by its stabbing character 
and by its association with local tenderness and other symptoms. In 
other cases rapid abdominal distension may be the occasion of general 
abdominal pain described as of a rending character. 
In chronic obstruction, pain may be wanting for a long time, and 
nearly always its onset is somewhat gradual. The patient first becomes 
aware of slight abdominal discomfort due, apparently, to some inter- 
ference with the movement of the contents of the bowel, and especially 
gases. Later, these sensations increase to a more definitely painful form; 
or, when there is a sudden increase in the degree of obstruction, intense, 
cramp-like paroxysms may set in. Not rarely the earlier symptoms 
have been so indefinite and uncertain that the occurrence of an entirely 
acute obstruction is suggested. The attacks of pain may become so 
severe that the patient screams or doubles up in agony. He is conscious 
of a more or less fixed location, and may feel the cramps begin at one 
portion and move more or less quickly to the place of obstruction, where 
the bowel becomes tensely distended, sometimes forming a visible hard 
mass. This indurated segment of the bowel may be so hard that on 
palpation it seems almost like a solid tumor. After a variable duration 
it relaxes, and relief may be obtained for a greater or less period of time. 
After a certain duration the colicky pains of chronic obstruction may 398 
DISEASES OF THE DIGESTIVE SYSTEM 
subside and there may be an interval of hours, days, or even weeks before 
another attack sets in. 
Associated with the paroxysmal pains of chronic obstruction is a 
symptom of extreme importance, namely, visible peristalsis. This 
may be seen through thin abdominal walls in persons not suffering with 
intestinal obstruction, but these movements are slow vermicular con- 
tractions, visible over a greater or less extent of the abdominal surface. 
They differ very decidedly from the intense and usually rapid waves 
met with in obstruction, and on palpation there is never the stiffening 
and evident tonic contraction found in cases of occlusion. 
Meteorism is usually somewhat late in development, except in acute 
cases with strangulation and rapid interference with the circulation of 
more or less extensive segments of the bowel. In chronic cases there 
may be but little distension until near the termination of the case, when 
complete obstruction has developed and paresis of the bowel above the 
obstructed area has caused interference with the circulation. Up to 
the very end the amount of distension mav be relatively small. In 
acute cases, with marked interference of the circulation, rapid and 
intense meteorism may cause early abdominal distension. In conditions 
of strangulation of coils of the intestine, paralytic distension of the 
strangulated area may occasion local meteorism of marked grade. 
Constipation.-All forms of intestinal obstruction interfere with the 
onward movement of the intestinal contents. The resulting conditions 
vary considerably in different cases. In acuie obstruction a sudden 
cessation of all intestinal movements may occasion an immediate absolute 
constipation, although frequently a movement or two may empty the 
lower bowel before the constipation becomes absolute. The higher in 
the intestinal tract the seat of obstruction, the more likely are some 
movements of the bowel to occur, after the development of the condition. 
The reasons for this are that the contents in the bowel below the point 
of obstruction may be discharged after the obstruction has taken place, 
and also that the fluid contents of the upper intestine are more likely 
to pass a partial obstruction than are the semisolid or solid masses of 
the lower bowel to escape through an obstruction in that region. In 
partial obstructions in the small intestine continuous diarrhoea with 
passage of peculiarly offensive stools is not unusual. 
In chronic obstruction, especially that involving the large intestine, 
constipation is sometimes absent or insignificant. In these cases the 
gradual development of the obstruction and the compensating hyper- 
trophy of the musculature above the occlusion make it possible for the 
contents to escape in an approximately normal manner. Sometimes 
considerable accumulations of fecal matter may be found above an 
area of obstruction in cases in which the movements of the bowels have 
seemed approximately or wholly normal. Much importance has been 
thought to attach to the character of the stools in cases of partial obstruc- 
tion of the lower bowel. Among other forms, small, separated, spherical 
masses and ribbon-shaped formations, or narrow, pencil-like stools, 
have been particularly noted. It is undoubtedly true that partial 
intestinal occlusions do occasion formations of this character; but exactly DISEASES OF THE INTESTINES 
399 
the same conditions may occur without any organic obstruction whatever, 
especially in cases of constipation due to local spasm of the bowel in 
cases of spastic contraction of the sphincter, etc. The presence of 
blood, pus, and mucus with the bowel movements is not infrequent in 
obstructions due to organic conditions involving the lower bowel, 
especially in carcinoma and intussusception. 
Diarrhoea.-This may occur in intestinal obstruction, instead of 
constipation, and easily occasion a mistake in diagnosis. This is par- 
ticularly liable to occur in chronic cases and is occasioned by the occur- 
rence of inflammatory conditions of the mucous membrane above the 
obstruction. Some have believed that diarrhoea is always significant 
of ulceration, a view that is certainly not invariably correct. The 
diarrhoea may be continuous and chronic, or may be recurrent. The 
character of the movements varies, but there is usually a tendency to a 
considerable admixture of mucus. When ulceration exists, blood and 
pus may also occur in the movements. 
Vomiting.-Soon after the development of intestinal obstruction, 
whether complete or only partial, nausea and disturbance of the stomach 
occur, and in many cases vomiting sets in quite promptly. In cases in 
which there has been marked pain, the nausea and vomiting are in a 
measure dependent upon the intensity of the suffering, and are clearly 
reflex. The character of the vomiting varies at different stages. At 
first the contents of the stomach are brought up, and sometimes, when 
the stomach has been overloaded at the moment of an acute obstruction, 
considerable relief follows the primary vomiting. Usually, however, 
vomiting continues without cessation, and after the food contained in 
the stomach has been discharged, watery fluid or bile is brought up. 
Eventually stercoraceous or fecal vomiting takes place, and is the most 
characteristic symptom. In the beginning the fecal odor is merely 
suggested. Soon, however, it becomes unmistakable. Finally, quantities 
of liquid vomit, of the foulest character, are discharged, sometimes with 
violence, while in other cases it gushes from the mouth. 
A great deal of discussion has taken place regarding the causes of the 
fecal vomiting. Formerly various theories were entertained, such as 
those which attributed it to reversal of the peristalsis and to transporta- 
tion of intestinal contents to the stomach from portions of the intestine 
just above the obstruction. There is no doubt that such antiperistalsis 
may occur, and that accumulated matter in the lower part of the small 
intestine may be brought to the stomach and vomited. Brinton sug- 
gested that, while the ordinary peristalsis carries the contents adjacent 
to the walls of the bowel forward in the usual manner, a reversed axial 
current is taking place at the same time. Investigations regarding 
the whole subject, and a consideration of the functions of the different 
portions of the intestinal tract, suggest that the symptom is due to the 
accumulation of secretions in the small intestine, and eventually an 
overflow. Obstruction in the large intestine, especially when low down, 
may be unattended with this symptom from first to last, or accompanied 
by it only late in the course, because absorption still goes on in the 
portion of the large bowel above the obstruction. 400 
DISEASES OF THE DIGESTIVE SYSTEM 
Occasionally stercoraceous vomiting may occur in gastro-intestinal 
diseases, unattended with intestinal obstruction, functional or organic. 
In these cases bacterial decomposition of gastric contents, and especially 
of blood mixed with other gastric contents, may cause the suggestive 
odor. The organism most likely to produce this is the Bacillus 
coli. 
In cases of obstruction situated near the upper end of the small 
intestine, the vomiting may be characterized by the intense violence 
of the straining efforts, by the comparatively small amount of matter 
brought up, and by the tendency to speedy collapse. In cases of obstruc- 
tion of the large intestine, and in chronic obstruction generally, vomiting 
is much less pronounced than in acute cases and those in which the 
small intestine especially is involved. Sometimes there may even be 
little nausea until a late stage has been reached, and the vomiting is 
usually rather closely dependent upon the taking of food, attempts 
at sitting up, or other movements or efforts. In the late stages, when 
violent attacks of colic have developed, vomiting of the same character 
as occurs in acute obstruction develops. 
Prostration and Collapse.-In acute cases collapse may set in very 
promptly. In chronic forms of obstruction it may be absent until the 
final stages have been reached. The most intense and sudden collapse 
occurs in cases in which the obstruction is situated high up in the small 
intestine. It is due to the sudden injury sustained by the nerves of the 
bowel, and is proportionate to the pain, retching, and other symptoms 
caused by the same nerve injury. It is, therefore, in the nature of a 
shock to the abdominal nervous system. There may be equally sudden 
prostration and collapse in obstructions situated lower in the small 
intestine; but more usually in these cases the patient becomes gradually 
weaker until finally he passes into a state of collapse. In chronic obstruc- 
tion collapse may be late, and does not usually present itself until 
decomposition of retained products and toxemia have occurred. 
The appearance of the patient suffering with prostration and approach- 
ing collapse from intestinal obstruction is often characteristic. The 
skin is cold, pale, and generally bathed in sweat. The face wears an 
expression of anxiety and is pinched. The temples appear sunken. 
The eyes are depressed in their sockets and surrounded with dark rings. 
The respirations are shallow and often sighing. The temperature of 
the body falls. The pulse becomes rapid, feeble, and finally thready 
and irregular. The mucous membrane becomes dry, so that the mouth 
is literally parched. Urinary excretion diminishes until it may become 
suppressed. Finally, the patient sinks into a state of torpor, or complete 
stupor or coma. Before this stage is reached the increasing toxemia and 
infection cause a cessation of all sensation, and the acute sufferings of 
the earlier stages subside. Sometimes the obtunding of sensory acuity 
develops without other manifest evidences of collapse, and may occasion 
a deceptive appearance of improvement. 
The causes of collapse in intestinal obstruction are: (1) the primary 
shock to the nervous mechanism of the intestine; (2) repeated vomiting 
and loss of wrater from the system; (3) intoxication and infection. The DISEASES OF THE INTESTINES 
401 
loss of water through vomiting and sweating may operate directly by 
reducing the strength of the patient, and indirectly by inspissation of 
the blood. According to Nothnagel, the concentration may reach 24 
per cent, of the total volume of blood. 
The toxemia of the late stages is doubtless caused by a large variety 
of substances generated by the decomposition of retained materials in 
the intestinal tract. As this takes place with greatest activity in the 
large bowel, toxemic prostration and collapse are more marked in the 
cases in which the obstruction is situated in some part of the large bowel. 
Repeated vomiting and consequent inanition may lead to acid intoxica- 
tion by the destructive decomposition of the fats of the body and the 
manufacture of acetone bodies or in other ways. Direct bacterial 
infection adds to the prostration of the patient and cooperates with 
the toxemic causes of collapse. 
Diagnosis.-General Diagnosis.-The existence of intestinal obstruc- 
tion is usually rather easily determined, when the symptoms that have 
been mentioned present themselves. In acute cases the sudden occur- 
rence of pain and the development of nausea and characteristic vomiting, 
the obstinate constipation, and the final prostration or collapse leave 
little doubt. There are cases, however, in which, although the develop- 
ment of obstruction has been acute, some of these symptoms are poorly 
developed. On the other hand, there are conditions in which very similar 
symptoms are occasioned by diseases outside the intestine itself, although 
doubtless affecting the bowel in an indirect or reflex manner. 
Differential Diagnosis between Intestinal Obstruction and Conditions 
Simulating It.-1. Various conditions may occasion sudden intense 
pain, with nausea, vomiting, and collapse. Among such conditions are 
the passage of biliary or renal calculi, the rupture of gastric and duodenal 
ulcers, torsion of the pedicle of a movable spleen, crises in cases of movable 
kidney, pancreatic hemorrhage and acute pancreatitis, embolism or 
thrombosis of the mesenteric vessels, and nervous crises associated 
with locomotor ataxia or other nervous diseases. In all these cases 
the symptoms of onset may be similar to those met with in cases of 
intestinal obstruction. If, as a result of the violent irritation of the 
nervous system, a reflex paralysis of the intestine occurs, an actual 
intestinal obstruction may develop. Usually, however, in the conditions 
named, although there is some weakening of motility of the bowels and 
consequently a certain degree of constipation, the obstruction is not 
absolute, and enemata rarely fail to bring away a certain amount of 
fecal matter. Distension of the abdomen, if it occurs, is only of moderate 
grade. The vomiting, although perhaps urgent in the beginning, does 
not persist as in obstruction, and rarely is fecal. 
2. In a second group intestinal obstruction is suggested by the occur- 
rence of absolute constipation. In a certain sense these cases are truly 
instances of actual obstruction, although the conditions differ from 
those of intestinal obstruction in the ordinary sense. In this group may 
be included the paralytic condition of the bowel following pronounced 
forms of peritonitis. The onset of such cases, the early development 
of fever, the leukocytosis, and other evidences of infectious inflammation 402 
DISEASES OF THE DIGESTIVE SYSTEM 
are important. The vomiting rarely becomes fecal and constipation 
is not, as a rule, absolute. 
In chronic and tuberculous peritonitis, intestinal distension, constipa- 
tion, and vomiting may suggest obstructed conditions of the bowel. 
The clinical course, however, is more prolonged; there is less vomiting 
than in obstruction, rarely ever fecal vomiting; and the degree of con- 
stipation is rarely as great as in obstruction. Direct examination of 
the abdomen will usually detect local indurations, fluid exudate, or 
enlarged mesenteric glands. 
3. In a third group of cases intestinal obstruction is suggested by the 
marked degree of abdominal distension, associated with some other, 
although less conspicuous, symptoms suggesting obstruction. Thus 
in cases of infectious disease, such as typhoid fever, pneumonia, and 
violent acute intoxications, and infections of the bowel itself (entero- 
colitis), progressively increasing abdominal distension, together with 
nausea, vomiting, and constipation may cause a close simulation of 
certain forms of obstruction. In these cases, however, vomiting never 
becomes fecal in type, the degree of prostration and collapse is less 
pronounced, and the constipation is rarely absolute, so that the use of 
enemata usually suffices to obtain some fecal discharge. 
In the case of certain nervous conditions, notably hysteria, marked 
distension of the abdomen (phantom tumor) may occasionally occur. 
In these cases there is often a striking lack of other symptoms, and the 
distension not rarely varies very quickly. Under psychic influences, 
and when the patient is asleep or is anesthetized, such abdominal dis- 
tensions may suddenly subside. Similar distension of the abdomen 
may occur in patients suffering with locomotor ataxia; but in these 
cases severe abdominal pain and sometimes associated gastric crises 
attended with vomiting are more apt to be present. 
Diagnosis of the Situation of the Obstruction.-Obstruction in the 
uppermost portion of the duodenum may present the features of pyloric 
obstruction. When the occlusion is below the outlet of the bile-duct 
intense vomiting with constant presence of bile is a striking feature. 
The vomit does not in this case become stercoraceous. When the point 
of obstruction is in the jejunum or ileum the gastric symptoms though 
often marked do not so wholly dominate the symptomatology. The 
pain is less definitely localized, the vomiting becomes stercoraceous 
earlier, and suppression of urine is a more marked and earlier mani- 
festation than when the obstruction is situated in the large bowel. 
Stiffening of segments of the bowel in the central portion of the abdomen 
and the narrowness of the palpated coils may indicate that the obstruc- 
tion affects the small intestine. Obstruction in the large bowel usually 
occasions a more reliable localization of pain and tenderness, and the 
passage of mucous movements or blood and mucus are significant. 
When tonic peristaltic contractions of the bowel, with violent attacks 
of colic, set in, these may sometimes serve to locate the place of obstruc- 
tion, as the wave of contraction may move indefinitely through the 
abdomen until it reaches the point of obstruction, where it produces a 
stiffening from tonic spasm, and sometimes a hard tumor-like mass. DISEASES OF THE INTESTINES 
403 
This point may be recognized by the patient himself and accurately 
located by him; or it may be seen through the abdominal walls or felt 
in palpating the abdomen. Obstructions in the lower part of the large 
intestine, especially in the rectum, may occasion ribbon-shaped or 
pencil-like stools for some time before the obstruction is complete. 
Fluoroscopic and Skiagraphic Methods of Diagnosis.-The diagnosis 
of the site and sometimes the kind of obstruction has been greatly 
facilitated by these methods, which are particularly available in cases 
of partial and chronic obstruction. In cases of obstruction in the small 
intestine or in the upper part of the large intestine examinations at 
various time intervals after administration of bismuth meals give the best 
results. When the obstruction is low down in the large intestine bismuth 
enemata may prove more satisfactory. In the study of the plates care 
must always be exercised to determine whether the point of obstruction 
is indicated in several plates so as to avoid confusing a temporary stagna- 
tion for a fixed condition. Fluoroscopic examinations are particularly 
valuable in enabling the examiner to determine adhesions between 
neighboring coils of intestine or between the bowel and other structures. 
They are also helpful in showing delayed emptying of the stomach in 
cases of duodenal stricture or obstructions to the entrance of the bismuth 
enema in cases of obstruction in the lower bowel. 
Urine.-The time of occurrence and the degree of indicanuria have 
been utilized as indications of the seat of obstruction. The early appear- 
ance of indican is undoubtedly of value in locating the obstructed point 
in the small intestines provided that other causes of indicanuria can be 
excluded. The amount of urine has been referred to as sometimes 
significant. The higher the obstruction is situated in the small intestine 
the more intense will be the vomiting, and, consequently, the greater 
the loss of water from the system. At the same time, there is a failure 
of the absorption of liquid from the lower bowel. Therefore, an early 
reduction in the quantity of urine is significant of obstruction high up 
in the small intestine. 
Obstruction Due to Foreign Bodies or Fecal Masses.-Among the 
causes included under this heading are gall-stones, intestinal calculi and 
parasites, various foreign bodies, and masses of fecal matter. 
Gall-stones.-These are a rare cause of intestinal obstruction, as their 
size is only infrequently sufficient to obstruct any portion of the intestinal 
tract. They may, aside from direct obstruction, be the occasion of 
volvulus or of obstruction resulting from adhesions between the gall- 
bladder and some portion of the intestinal tract. The proportion of 
cases found by various authors ranges from 1 in 15 (Fitz) to 1 in 28 
(Leichtenstern). The gall-stone usually finds its way into the intestine 
through a fistulous connection between the gall-bladder and the intestinal 
tract. Less commonly, it slowly works its way along the common duct, 
ulceration opening the way before, and cicatrization contracting the 
channel behind the calculus. After reaching the intestine, the stone 
may cause obstruction of the duodenum, or it may move downward 
into the jejunum or ileum and become impacted there. The most 
common situation of lodgement is in the lower part of the ileum, near 404 
DISEASES OF THE DIGESTIVE SYSTEM 
the ileocecal valve. In some cases the stone caused obstruction of the 
large intestine. 
Symptoms.-The clinical manifestations may be divided into two 
stages: the first, in which active symptoms result from the escape of 
the calculus from the gall-bladder or the biliary passages into the bowel; 
and the second, in which intestinal obstruction occurs. In the first 
stage, violent attacks of colicky pain attended with jaundice are char- 
acteristic. These symptoms may have been preceded by a clinical 
history suggestive of the presence of biliary calculi. After entering the 
bowel, evidences of partial and temporary, followed by complete, 
occlusion may present themselves. As the stone usually finds its way 
first into the upper part of the small intestine, the symptoms, such as 
vomiting and colicky pain, are comparatively severe. After a little 
while these may be relieved, but they may be renewed with each succes- 
sive lodgement in positions lower down, until finally a complete impaction 
occurs in the ileum, and the evidences of total obstruction make their 
appearance. Even after complete impaction the calculus may be dis- 
lodged, the symptoms relieved, and the stone discharged from the bowel. 
In cases in which relief does not occur, death usually takes place between 
the fifth and the tenth day, but sometimes later. The outlook is always 
grave, as approximately half of the patients succumb. 
Intestinal Concretions.-Intestinal concretions of sufficient size to 
produce obstruction are exceedingly infrequent. They consist of organic 
substances such as mucus, masses of bacteria, and fatty constituents 
impregnated with calcium and magnesium salts. Such concretions are 
usually formed in cases of enteritis, and the symptoms are therefore 
preceded by those of this condition. Gradually, as the foreign body 
enlarges, the attacks of colic, diarrhoea, and other evidences of enteritis 
become altered and give place to the evidences of more or less complete 
occlusion. In case of the formation of concretions in pouches of the 
bowel, especially of the large intestine, evidence of partial obstruction 
are met with, and a continuous intestinal irritation or colitis is encount- 
ered. 
Foreign Bodies.-Foreign bodies other than those described are com- 
paratively rare causes of occlusion. Fruit-stones, masses of intestinal 
parasites, hardened accumulations of mucus, balls of hair or vegetable 
fibre, and accumulations of medicinal substances, such as bismuth, salol, 
chalk and other insoluble substances taken by the mouth, may occur. 
Such obstructions are at first partial, and may continue so for a long 
time. Hardened masses located in the lower part of the large intestine 
may set up catarrhal irritation and occasion a diarrhoea which confuses 
the diagnosis. More commonly, fecal matter accumulates above and 
around the foreign body until more or less total obstruction has resulted. 
Obstruction Due to Bands.-Intestinal obstruction may result from 
the constriction of a portion of the bowel by a band or adhesion formed 
by a previous inflammatory condition, or by various abnormal bands 
of fibrous tissue that result from developmental conditions. In a similar 
manner a Meckel diverticulum may be the occasion of this form of 
occlusion. Subsequently a coil of intestine may become constricted by DISEASES OF THE INTESTINES 
405 
passing beneath or over such a band, and the distension of the portion 
of the coil beyond the band may prevent its escape. 
A Meckel diverticulum is quite a frequent cause of obstruction, 
having been met with in 21 of the 669 cases at the London Hospital. 
If the diverticulum remains connected with the umbilicus, the conditions 
are such that obstruction of a coil of intestine may readily be produced; 
still more, when the free end of a diverticulum has formed a new attach- 
ment to the mesentery or some other part in the abdomen. A coil of 
bowel passing over or beneath the diverticulum may become twisted 
upon itself (volvulus), or may become variously knotted or contorted. 
Besides Meckel's diverticulum, bands may be formed by the attachment 
of the tip of the appendix to the appendices epiploicse, the Fallopian 
tubes, or other structures within the abdomen, and strangulation of a 
loop of intestine may be the result. Occlusion by internal bands usually 
involves some part of the small intestine. The large bowel is relatively 
fixed and the lumen is such that strangulation beneath a band is infre- 
quent. A coil of bowel may be held beneath a band for some time 
without symptoms. When, however, fecal accumulation or gaseous dis- 
tension has increased its size, obstruction may occur and may rapidly 
increase from pressure upon the veins and consequent stasis. 
Symptoms.-These are usually sudden and acute, and frequently 
follow after some strain or effort, or after acute digestive disorders with 
distension of the intestinal tube. The symptoms are those of acute 
obstruction from any cause, beginning with sudden pain and marked 
nausea and disturbance of the stomach. The evidences of obstruction 
follow rapidly, and the patient suffers early prostration and collapse. 
In many cases, however, the onset is less acute, and the symptoms are 
less violent. In these instances, pain and gastric disturbance may 
develop gradually and distension increases progressively. Evidence of 
more or less obstruction may be found, but the nature of the obstruc- 
tion may be quite uncertain. When a coil of intestine is strangulated 
by a band, the occluded portion tends to undergo pronounced distension 
from the accumulation of gases and the retention of its contents; and a 
painful swelling may be felt through the abdominal walls. The distension 
may be so great that this is quite hard, and the percussion note over it 
may be relatively dull, from the tenseness of the walls. 
Obstruction Due to Internal Hernia.-The term internal hernia is 
applied to hernial displacements of the intestines into the subperitoneal 
or retroperitoneal spaces without any protrusion externally. Among the 
situations in which they may occur are: (a) The subperitoneal tissue 
in the region of the inguinal rings, when the hernia may be associated 
with external hernia or independent of the latter. Not rarely such 
hernias have resulted from the reduction en masse of an external hernia. 
(&) Duodenojejunal hernia, a protrusion of part of the jejunum into the 
retroperitoneal tissues on the left side of the abdomen, beneath the 
crescentic fold of peritoneum, the plica duodenojejunalis. A number 
of such instances have been reported, and occasionally strangulation 
has occurred, (c) Pericecal hernise, in which group are included hernias 
into the various pericecal or retrocecal pouches, (d) Intersigmoidal 406 
DISEASES OF THE DIGESTIVE SYSTEM 
hernia, a form of considerable rarity, in which the hernial sac occupies 
the fossa occasioned by the sigmoid artery, (e) Herniae of the foramen 
of Winslow, in which portions of the small intestines or, more rarely, 
of the large bowel extend through Winslow's foramen, (f) Herniae 
into Douglas' pouch. (^) Herniae projecting into the broad ligament of 
the uterus. (^) Diaphragmatic herniae. 
The last-named is the most frequent and most important form of 
internal hernia. Leichtenstern compiled 252 cases, and Grosser published 
anatomical descriptions based upon 433 cases reported in the literature 
up to 1899. Struppler found the number of cases reported up to 1901 
to be 500. A distinction is made between true and false diaphragmatic 
hernias, the former being cases in which the abdominal viscera extend 
through an opening in the diaphgram covered by a sac composed of 
peritoneum, pleura, or both. The false variety is that in which a free 
connection exists between the thoracic and the abdominal cavity 
(eventration). The latter variety is the more common. Diaphragmatic 
herniae may be classified, also, as congenital or acquired, the latter 
being more frequent, and usually the result of traumatism causing 
rupture of the diaphragm. They are usually found on the left side, 
and among the positions most commonly involved are the opening for 
the oesophagus and an area immediately behind the stomach. The 
stomach is most frequently displaced through the abnormal opening, 
next to which in point of frequency the colon, the omentum, or other 
parts of the intestinal tract may be involved. In exceptional cases 
the spleen, pancreas, or kidney is displaced into the thoracic 
cavity. 
Symptoms.-Sometimes these are wholly wanting and a diagnosis may 
be made by the signs indicating the presence in the pleural cavity of 
air-containing viscera, and the restriction of respiratory movements on 
that side. Displacement of the heart may be more or less conspicuous. 
The condition resembles most closely a pneumothorax, which, however, 
is usually distinguished by the fact that it commonly involves the whole 
pleural cavity, and is frequently right-sided. The auscultatory phe- 
nomena, especially the occurrence of amphoric breathing when a fistulous 
communication with the pleural sac exists, are quite distinctive. Diffi- 
culty in swallowing, vomiting, and other gastric symptoms, and some- 
times intestinal obstruction, may occur in diaphragmatic herniae, and are 
not met with in pneumothorax. Transillumination of the stomach and 
skiagrams may be helpful. 
Obstruction by Incarceration of the Bowel in Slits or Holes.-An 
occasional cause of intestinal obstruction is the passage of a loop of 
the bowel through a hole or slit in the mesentery or omentum. The 
mesentery is the most frequent site of such imperfections and Treves 
has described a spot between the ileocolic and terminal mesenteric 
artery which is normally thin and readily becomes patulous. A gradual 
perforation of such a weak space may occur, but more commonly the 
perforation results from some violent injury that forces a portion of the 
bowel through the weakened area. Occasionally congenital holes are 
encountered. Sometimes, after inflammatory conditions, adhesions DISEASES OF THE INTESTINES 
407 
of the omentum and other structures may be so arranged that spaces 
are left between the adherent portions, and the bowel may be involved 
in these. The symptoms of obstruction due to this cause are similar 
to those of incarceration by bands of adhesions. They develop with 
great acuteness, and usually are violent in their manifestations. 
Obstruction Due to Peritoneal Adhesions.-In this group are included 
cases in which the bowel is narrowed by peritoneal adhesions resulting 
from chronic peritonitis without strangulation of the circulation. The 
adhesions that produce such constriction may result from any form of 
peritonitis, such as that attending disease of the appendix, the pelvic 
organs, the mesenteric or other abdominal glands, or that associated 
with tuberculosis, cancer, etc. Similar adhesions may follow after 
operations, particularly when drainage has been required. 
Pathology.-The constriction may be annular, causing a limited 
contraction of the bowel similar to that due to stricture of the bowel, 
or a kinking or irregular contraction may be produced by looping over 
the bowel. In some cases the obstruction is due to a matting together 
of neighboring coils of intestine, or to close attachments to the parietal 
peritoneum by adhesions or by contraction of the mesentery. Annular 
adhesion or cicatricial formation in the peritoneum may result from 
ulceration within the bowel, or may follow peritonitis. 
Kinking of the bowel without any distinct annular stenosis may 
occur under a variety of conditions, in which, following a localized 
peritonitis, short and firm adhesions have formed between the bowel 
wall and the abdominal parietes or one of the abdominal viscera. In 
many instances such kinks are multiple. In some cases, although 
adhesions occasion no sharp angulation, they may interfere sufficiently 
with peristalsis to result in partial obstruction. 
Symptoms.-There may be no symptoms despite very extensive 
adhesions or deformations, and sometimes, even in cases in which almost 
universal agglutination is met with, very little interference with peri- 
stalsis is encountered. When obstruction occurs, the symptoms are 
those of gradually developing intestinal stenosis. As in other forms of 
organic obstruction, the symptoms may come on in a gradual manner, 
or may develop rather suddenly with attacks of pain, violent and visible 
peristalsis, and distension. Tumefaction may be found at the seat of 
obstruction, owing to the distension of coils of intestine adjacent to or 
included within the zone of adhesion. 
Obstruction Due to Stricture of the Intestine.-By this term is meant 
a narrowing of the bowel by changes in its wall. This definition would 
include all forms of new growths involving the bowel, as well as other 
disease processes affecting it. As here employed, it will be limited to 
cicatricial strictures which in the great majority of cases follow ulceration. 
Tumors and some other conditions causing narrowing of the lumen of 
the bowel (diverticula) will be discussed elsewhere. Of the various 
forms of intestinal ulceration those due to tuberculosis, stercoral accu- 
mulations, ulcer of the duodenum, dysentery, and syphilis are the ones 
that are prone to be followed by cicatricial strictures. Not rarely the 
strictures following tuberculosis are multiple. The hyperplastic form 408 
DISEASES OF THE DIGESTIVE SYSTEM 
has been considered in a separate place. In this there may be marked 
encroachment upon the lumen of the bowel, just as in carcinoma or 
other tumors. In cicatricial ulceration of tuberculous nature, annular 
contractions occur without great thickening of the coats of the bowel. 
Stricture following duodenal ulcer have the same general characters as 
the constrictions of the stomach or its pylorus resulting from gastric 
ulceration. Jejunal ulcers may have the same termination. 
Strictures following stercoral ulceration are met with in various parts 
of the large bowel, especially at the flexures, in the cecum, and in the 
rectum. An annular scar, with more or less thickening of the wall of 
the bowel, is usually found in such cases. It is not improbable that 
secondary carcinomatous change occasionally originates in such lesions. 
Strictures following syphilitic ulceration are most common in the rectum. 
Marked thickening, with irregular scar formation and constriction, 
characterize these cases. Strictures following dysentery were formerly 
regarded as very common. Woodward found not a single case of stricture 
in the 9431 fatal cases of dysentery occurring among the Union troops. 
A few instances have, however, been reported in the literature. Strictures 
following various traumatic injuries of the bowel, or after sloughing due 
to intussusception, hernia, etc., are occasionally met with. 
Symptoms.-When a stricture occupies the small intestine, the symp- 
toms may be relatively inconspicuous, owing to the fact that the intestinal 
contents in this portion of the bowel are normally fluid, and, therefore, 
unlikely to become stagnated. The occurrence of diarrhoea in some of 
these cases has been referred to in discussing the general symptomatology. 
A stricture in the large bowel much more readily produces obstruction 
by the gradual accumulation of hard fecal matter. 
Diagnosis.-This offers greatest difficulty in cases of stricture of the 
large bowel, with hyperplasia of the intestinal walls. In such circum- 
stances a differentiation from carcinoma may be very difficult. 
Treatment.-This is purely surgical, unless the stricture is of small 
calibre or situated high up, when careful attention to the condition of 
the bowel may prevent difficulty. 
Congenital Stenosis of the Intestine.-This is not uncommon and 
the great majority of cases occur at the ano-rectal junction. Leichten- 
stern found the proportion of cases as follows: 375 at the ano-rectal 
junction, 75 in the small intestine, and 10 in the colon. 
Compression of the Bowel.-Intestinal obstruction is sometimes 
caused by the pressure on relatively fixed portions of the bowel by tumors, 
displaced organs, etc. Frequently localized peritonitis, with the forma- 
tion of adhesions, contributes largely to the obstruction. The rectum 
is the portion of the intestine most frequently compressed, 60 per cent, 
of Leichtenstern's cases having this location. Among the causes, fibroid 
tumors, carcinoma, and misplacements of the uterus are the most fre- 
quent, but abscesses, extra-uterine pregnancy, and other causes are 
also met with. Compression may also occur in other parts of the large 
intestine, or even in the small bowel. The symptoms are sometimes 
acute but in the majority of cases some evidence of chronic obstruction 
precedes the acute symptoms. DISEASES OF THE INTESTINES 
409 
Intussusception.-Intussusception, or invagination, is a condition 
in which one portion of the bowel extends into a neighboring portion in 
such a manner that the former is ensheathed by the latter. The part of 
the bowel within the ensheathing portion is known as the intussusceptum, 
the outer portion as the intussuscipiens. On transverse section there 
will be found three thicknesses of bowel: (1) the outer, or ensheathing; 
(2) the returning part of the intussusceptum; and (3) the entering part. 
The term neck is applied to that portion of the intussusception where 
the intussusceptum passes within the ensheathing bowel. The doubling 
of the bowel where the intussuscipiens joins the returning layer of the 
intussusceptum is known as the collar. Occasionally an intussusception 
is incomplete, lateral, or partial when only a part of the circumference 
of the bowel is drawn into another part Usually the intussusceptum 
extends downward into an intussuscipiens, but ascending or retrograde 
intussusceptions sometimes occur. The term compound intussusception 
has been applied to cases in which a second intussusception extends 
into the first, so that a section would show five or more layers of bowel. 
Etiology.-A distinction should be drawn between agonal intussuscep- 
tions and the pathological variety. In the former, which are multiple, 
violent peristaltic contractions doubtless play an important part. In 
pathological intussusception independent of the agonal period, the 
explanation is usually to be found in some organic defect which occasions 
a prolapse of a segment of the bowel into a portion beyond; or in some 
pathological lesion of a part of the bowel which is carried downward into 
a portion beyond. Thus if a direct prolapsus of a portion of the bowel 
into a segment beyond occurs, the prolapsed portion is seized by the 
peristaltic contractions of the part into which it extends, and is carried 
forward in the same manner as intestinal contents are usually transported. 
In the same way a polypoid or other tumor of the bowel, an inverted 
Meckel diverticulum or appendix, or some other pathological condition, 
may occasion the beginning of an intussusception. A prolapsus of the 
ileocecal valve is a common cause. 
Various investigations of the etiology of intussusception in cases in 
which no antecedent pathological lesion of the bowel has been found 
have indicated that the primary condition is a spasm of the circular 
muscle of the bowel in some portion. This constricted area is grasped 
by the segment immediately below, and thus starts the process that 
terminates in a complete invagination. A number of different develop- 
mental defects may predispose strongly to this condition, and may be 
the initial cause, as when there is an undue size of the large intestine 
as compared with the small and a consequent tendency to prolapsus. 
Abnormalities of the mesentery similarly predispose by permitting of 
the more ready invagination of one part of the bowel into another. 
Immediate Causes.-The study of large series of cases of intussusception 
shows an absence of any definite immediate cause in half or even a 
larger proportion of the cases. In a relatively small number, some 
history of acute intestinal disturbance or of injuries is met with. 
Age.-Intussusception is the most common form of intestinal obstruc- 
tion in childhood and infancy. Among Leichtenstern's 593 cases, 131 410 
DISEASES OF THE DIGESTIVE SYSTEM 
occurred during the first year of life. In Weiss' 321 cases, 177 occurred 
during the first year. In the latter series, 85 occurred in the second to 
the fourteenth year, and 59 after that time. 
The Location of Intussusception.-The agonal invaginations are usually 
found in the small intestines. Pathological intussusception may occupy 
any part of the intestinal tract, but much more commonly originates 
at the ileocecal valve than at any other point. In the majority of cases, 
especially in childhood, the ileocecal valve prolapses into the cecum and 
thus becomes the apex of the intussusceptum, dragging the ileum after 
it. The cecum and colon form the outer and middle layer, the ileum the 
inner. The term ileocecal intussusception is applied to such cases. 
Less frequently the ileum prolapses through the valve into the colon 
and is carried farther on. The name ileocolic is given to this form, which 
is certainly rare. Leichtenstern found, in an analysis of cases at all 
ages, that invagination of the small into the large bowel occurred in 
52 per cent., iliac intussusception in 30 per cent., and colic in 18 per 
cent. In adults the iliac and the ileocecal varieties were of approximately 
equal frequency. Other large series have shown about similar pro- 
portions; but in small groups of cases great variations have naturally 
been encountered. 
Pathology.-Secondary changes take place in the intussuception, 
according to the degree of constriction at the neck. There is practically 
always more or less interruption of the circulation in the mesentery 
entering into the invagination, and a consequent intense congestion of 
the intussusceptum. This becomes dark red, purplish, or blackish, 
and is swollen as the result of the hyperemia and attendant oedema. 
Ecchymotic hemorrhages occur within the bowel wall, and exudation 
of hemorrhagic fluid into the lumen of the bowel takes place. The most 
marked change occurs in the middle layer of the invagination. 
In the later stages, when the swelling of the invaginated portion has 
become extreme, complete obstruction of the lumen of the bowel occurs, 
and at the same time an increase of circulatory interference with resulting 
gangrene. In acute cases this may develop as early as the end of the 
first day; although it is usually not met with, even in the acute cases, 
before the expiration of three or four days. In the chronic cases gan- 
grenous changes may be delayed for a long time, sometimes not appearing 
until a number of months after the onset. The gangrene usually first 
affects the apex of the intussusception, but in other instances it begins 
at the neck. As the result of the gangrenous necrosis, portions of 
sloughed-off bowel may be passed from the rectum. 
Peritonitis affecting the enfolded portion of the serous covering of the 
bowel (that is, the serous coat of the innermost and middle reflection 
of the bowel, where they lie in contact) sets in rather promptly; usually 
becoming marked by the end of the second or third day. This may be 
confined to the region of the neck of the invagination, or may be extensive, 
and involve the entire serous coating within the sac. The invaginated 
portions become agglutinated, and reduction of the intussusception is 
more difficult. In the late stages, especially in the chronic cases, firm 
adhesions may form between the two layers of peritoneum adjacent to DISEASES OF THE INTESTINES 
411 
one another. When such adhesions have formed at the neck of the 
sac, and the intussusceptum has been discharged after sloughing or 
gangrene, relief may occur. More commonly a stenosis of the bowel 
results from cicatrization, and a partial intestinal obstruction, which 
later may become complete, is the terminal condition. 
Symptoms.--The symptomatology varies widely, some cases being 
comparatively slow in development and chronic in course, and others 
highly acute in onset and terminating rapidly. In the great majority 
the onset is sudden and occurs without any apparent predisposing con- 
dition. Sudden violent pain of a cramp-like character usually initiates 
the disease, and is speedily followed by nausea and vomiting. In many 
instances tenesmus and one or more movements of the bowels follow, 
and sometimes a diarrhoeal condition sets in. The movements may be 
composed of mucus alone, of mucus mixed with blood or of pure blood. 
The degree of tenesmus and of diarrhoea depends to some extent upon 
the situation of the intussusception, being more marked when this 
involves the lower portion of the bowel or the rectum. 
Distension of the abdomen may appear, but is not, as a rule, a marked 
condition. Direct physical examination discloses a palpable tumor in 
many cases. This is usually felt in the left side of the abdomen, when 
the intussusception has become extensive and has reached that point. 
The tumor may, however, be felt at the ileocecal region, where the 
intussusception, as a rule, begins. It is usually elongated, cylindrical, 
or sausage-shaped. Contractions of the bowel ensheathing the invagi- 
nated portion may cause a change in the consistency as well as in the 
size of the mass. Occasionally an intussusception extends so far as to 
protrude through the anus. In chronic or slowly developing cases the 
tumor may be found to change its position, moving in the direction of 
the intestinal tract. 
In the acute cases, after an onset of this character, symptoms of 
depression and collapse occur, usually within from one to three days. 
At the same time the vomiting, as in other cases of intestinal obstruction, 
becomes fecal in character. In chronic cases, if the onset has been acute, 
the symptoms gradually subside and may become relatively incon- 
spicuous. In other cases, the clinical course is of a chronic character. 
The most important symptoms are the pain, the tumor, and the 
peculiar behavior of the bowels. The pain in the early stages may be 
intense-so severe, indeed, that it occasions collapse. This is particularly 
marked in the acute forms in early childhood. Later, paroxysms of 
colicky pain recur from time to time, with more or less frequency. 
Attending this there may be a tonic contraction or stiffening of the 
segment of the intestine above the point of intussusception, and in other 
cases of intestinal obstruction. Tenesmus is more frequently met with 
in this form of intestinal obstruction than in any other; it is earlier in 
its appearance, and more intense the nearer the invagination approaches 
the rectum. The character of the stools is a highly important diagnostic 
indication. There may at first be a discharge of fecal matter from the 
lower bowel, but soon the movements, if they continue, become mucous, 
bloody, or of mixed mucus and blood, while the discharge of fecal matter 412 
DISEASES OF THE DIGESTIVE SYSTEM 
ceases. The evacuations may be attended with sharp recurrences of 
the characteristic tenesmus. Sometimes large hemorrhagic movements 
or actual hemorrhages may occur. 
Prognosis.-The termination of intussusception varies greatly. A 
rapid course with a fatal termination is more frequent in infants than 
in the intussusception of later life. Subacute and chronic cases, running 
a course of weeks or even months, occur as a rule in the older subjects. 
Even in these, however, the eventual termination is usually fatal. 
Reference has been made to occasional spontaneous cures; but, taking 
the number of these in large series, this outcome is exceedingly rare. 
Occasionally complete cure by spontaneous or induced disinvagination 
may take place in cases in which peritonitis and adhesions have not 
developed or have been so slight that the invaginated portion was 
able to escape. A few instances have been met with in which such 
relief occurred after the condition had persisted for a considerable 
time. 
Treatment.-In cases of intussusception recognized early, and especially 
in infants, manipulation combined with enemata may effect relief in a 
considerable proportion of instances. The mass is grasped in the fingers 
of one hand (the patient being anesthetized) and gentle traction made 
with the other hand in a direction to effect disinvagination, or pressure 
is made against the apex of the invagination to cause its release. Follow- 
ing this, or between the efforts of manual relief, enemata of water (from 
| liter in children to 2 liters in adults) may be allowed to flow into the 
rectum through a soft rubber tube and under a pressure of four or five 
feet, great care being taken to lower the funnel should undue distension 
seem to occur in the lower bowel. In adults these methods of treatment 
are less often satisfactory. In them as well -as in infants, if the simpler 
plan of treatment has failed, surgical treatment must be adopted before 
too long a time has elapsed. 
Volvulus.-This term is applied to various kinds of twisting, knotting, 
or rotation of segments of bowel, resulting in partial or complete obstruc- 
tion. A loop of intestine may become obstructed by rotating about 
its mesenteric attachment, which acts as a sort of pedicle; in other cases 
volvulus is due to a twisting or rotation of the bowrel on its owm longi- 
tudinal axis, wdiile in still other cases one loop of intestine twdnes about 
the mesenteric attachment of another, or intertwining may take place 
between two or several coils. 
Etiology.-Abnormal length of the mesenteric attachment of a loop 
of bowTel, especially when combined with a lateral contraction of the 
mesentery, is the most important cause of volvulus. The mesentery 
may be elongated congenitally or it may become stretched as a result of 
continued constipation and overloading of the affected portion of the 
bowTel, and some stretching may result from adhesions of some part of 
the intestinal canal to fixed abdominal structures. A not uncommon 
cause of elongation is the inclusion of a coil of intestine in a hernial 
sac. Narrowing or contraction of the mesentery may occur without 
special elongation as a result of inflammatory conditions. A laxness 
and relative elongation of the mesentery may be caused by a loss of fat DISEASES OF THE INTESTINES 
413 
in the abdominal walls and in the mesentery itself. In women, after 
repeated pregnancy, these conditions frequently occur. 
The conditions which predispose to volvulus are more frequently 
found in persons of advanced years than in the young, and volvulus 
is therefore most common in the aged or those past middle life. The 
immediate cause may be a strain or some effort, as in lifting, or a trau- 
matism, such as in compression of the body. Sometimes overloading of 
the intestinal tract combined with some effort or strain is of importance. 
Thus in old people who have suffered from habitual constipation the 
sigmoid flexure becomes elongated and its mesentery stretched. 
Pathology.-In simple volvulus, a loop of intestine twists about its 
mesenteric attachment. There may be a partial turn or several complete 
turns. In the former case the obstruction of the bowel is partial or 
incomplete; in the latter it is almost certainly complete, and in addition 
the bloodvessels become so compressed that intense venous engorgement 
results. Whether the obstruction is partial or complete, but especially 
in the latter case, distension of the obstructed portion of the bowel 
rapidly ensues. The bowel becomes dark red or purplish in color, and 
its walls are deeply engorged with blood and swollen by oedema. Then 
extravasations of blood are seen upon the surface and blood-stained 
liquid exudes into the lumen of the bowel as well as into the peritoneal 
cavity. Finally gangrene takes place. The striae of the bowel are obliter- 
ated by the overextension, and rents of the serous coat may occur. 
Rupture of the bowel, however, rarely takes place. It is more likely 
to be found above the volvulus than in the affected portion. 
Peritonitis sets in rather promptly as a result of the escape of bacteria 
through the injured, congested, and oedematous walls of the bowel. 
When bloody extravasation is present in the peritoneal cavity the 
escaping bacteria may occasion putrefactive changes. 
Seats.-Volvulus most frequently involves the sigmoid flexure, but may 
occur at the junction of the small and large intestine or in some portion 
of the small intestine. In volvulus of the sigmoid there is usually a simple 
rotation of the flexure about its mesenteric attachment. The rotation 
is usually in such a direction that the rectum is carried posteriorly to 
the descending colon, but sometimes the twist is in the opposite direction, 
so that the rectum is carried forward and lies in front. Occasionally 
the sigmoid may become coiled about a loop of the small intestine or 
about the pedicle of a pelvic or abdominal tumor. 
Volvulus at the junction of the small and large intestine usually 
involves both the ileum and colon and is occasioned by an abnormal 
length of mesentery. Simple rotation of the colon on its own axis has 
been described, but is probably rare. 
Volvulus of the small intestine resembles that of the sigmoid. Rarely 
two or more loops may be intertwined. Unusual length of the mesentery 
is the ordinary cause; but some other pathological condition, such as 
the passage of a loop of the bowel through an internal hernial orifice 
or under a band, may be the direct cause of the volvulus. In these 
conditions the loop of bowel after incarceration becomes twisted upon 
itself at the point where it is engaged in the hernial opening or under a 
band. A foreign body within the bowel may occasion the twist. 414 
DISEASES OF THE DIGESTIVE SYSTEM 
Symptoms.-These are usually those of an acute intestinal obstruction. 
When the obstruction is only partial in the beginning, there may be a 
subacute onset which goes on to complete obstruction as the volvulus 
increases. The symptoms vary according to the location of the lesion. 
In volvulus of the sigmoid there is usually sudden severe pain followed 
by paroxysms of cramp or colic, and, as a rule, by absolute constipation. 
Reflex disturbances, such as vomiting, are often wanting because of the 
low situation of the obstruction. Sometimes, instead of constipation, 
there is a tendency to mucous discharges with tenesmus, and occasionally 
ordinary diarrhoea may occur. The abdomen soon becomes intensely 
tender and enormously distended. The superaddition of peritonitis, 
which usually occurs within twenty-four to forty-eight hours, causes 
increased tenderness and swelling and adds greatly to the prostration. 
In volvulus affecting other portions of the intestine the symptoms 
are similar; vomiting is more conspicuous, especially in cases in which 
the small intestine is involved in its upper portions. In all cases the 
distension of the coil of the bowel included in the volvulus causes a 
localized tumefaction, which may be so hard that it simulates a solid 
mass. The situation of this may indicate the location of the volvulus, 
although it must be remembered that the length and mobility of a 
cecum and even of the sigmoid may readily cause confusion. 
Prognosis.-This is usually very grave. In some instances the con- 
dition relieves itself spontaneously. This is probably more common 
in the case of the small intestine, but certainly occurs even when the 
sigmoid is involved. Usually, unless speedily relieved by surgical means, 
localized peritonitis and gangrene of the involved area soon take place, 
and death speedily follows. 
Differential Diagnosis of the Conditions Causing Obstruction.-It 
is often impossible to distinguish between the different causes of acute 
or chronic obstruction, although sometimes antecedent conditions, 
the manner of development of the symptoms, and the clinical course 
may furnish fairly reliable evidence of the nature of the condition. 
Among foreign bodies the most common cause of obstruction is gall- 
stones. When a biliary calculus enters the duodenum and causes obstruc- 
tion, the vomiting and prostration at once reach grades of the highest 
severity. Relief may follow the dislodgement of the stone and its trans- 
portation to lower levels but if it remains high up, early fecal vomiting 
and collapse usually result. A preceding history of gall-stones and jaun- 
dice or other significant symptoms may make the diagnosis fairly certain. 
Obstruction by bands usually involves some portion of the small 
intestine and causes symptoms of a decidedly acute character, with 
early development of fecal vomiting, prostration, etc. Internal hernia 
also involves the small intestine, and cannot usually be distinguished 
with accuracy from the former. 
Intussusception usually involves the ileum or the ileum and cecum, 
and is more frequently found in childhood or early life than at or after 
maturity. The symptoms of onset are decidedly less acute than in 
obstruction of the small bowel by bands. Localization of the place 
of obstruction is sometimes readily made by the situation of the pain, DISEASES OF THE INTESTINES 
415 
the development of a local tumefaction, and the situation of stiffening 
or tonic contraction of the bowel. The localization of the obstruction, 
the discovery of a sausage-shaped tumor, the characteristic stools, 
and especially the occurrence in childhood may establish the diagnosis. 
In acute cases, however, especially those occurring in young infants, 
the intense pain and sudden collapse may mask other indications, and 
the nature of the condition may be difficult to determine. 
Volvulus usually involves the sigmoid flexure, and occurs in persons 
of somewhat advanced years, and especially in the aged. The symptoms 
are slow in development and often inconspicuous until a late stage in 
the disease. The localization of the point of obstruction may often be 
established, although sometimes a redundant sigmoid may occasion 
confusion. Strictures and partial obstructions of the bowel may be 
suggested by the occasional occurrence of attacks of abdominal disten- 
sion, with relief after active movements of flatus. 
Obstruction by carcinoma and other tumors usually occurs in the 
large bowel. Although tumors in their general relations are considered 
elsewhere, some of the features that indicate a neoplasm as the cause of 
intestinal obstruction may be appropriately referred to in this place. 
Attacks of distension with active peristalsis and movements of flatus 
may occur from time to time, followed by more severe seizures, marked 
by violent abdominal colic. In these cases the patient himself may be 
able to recognize the point of obstruction by feeling the place of spasmodic 
contraction above the lesion. On palpation the physician may discover 
a hardening which appears at a certain place, and after a moment or 
two or a longer period of time relaxes. When the growth is situated 
favorably for palpation, or has reached considerable size, it may be 
discovered on abdominal palpation. When situated in the rectum, a 
digital rectal examination or the enteroscope may disclose its presence. 
As in other forms of obstruction involving the large bowel, the passage 
of stools of characteristic form some time before complete obstruction 
has developed and the occurrence of mucous, mucopurulent and blood- 
streaked or bloody passage may aid. Bloody and mucous movements 
are more frequent in carcinomatous obstruction than in any other form. 
Obstructions due to fecal accumulation rarely occur independently 
of other causes of obstruction, except when the accumulation takes 
place in the rectum as the result of habitual constipation. In these 
cases the development of the condition is so gradual that the existence 
of obstruction may not manifest itself until, more or less suddenly, after 
the upper bowel has exhausted itself in efforts to maintain the onward 
movement of its contents, sudden paralysis takes place. In the earlier 
stages the most characteristic indication is the increasing difficulty of 
securing evacuations and the insufficiency of these. With this there 
may be a gradual increase in abdominal girth from general meteorism; 
and on careful palpation the colon throughout its length may be found 
distended beyond normal dimensions. Hardened masses may also be 
discovered in the left iliac region, or, on digital exmination, in the rectum. 
If the abdominal walls are thin and the peristalsis maintains itself 
actively, visible peristalsis may be seen for some time before the degree 416 
DISEASES OF THE DIGESTIVE SYSTEM 
of contractions and the grade of obstruction cause sharp attacks of 
colic. In many instances of gradually developing impaction, fairly regular 
movements, seemingly adequate in quantity, may occur for some time 
after the onset. Still more puzzling are the cases in which a continuous 
diarrhoea is maintained as the result of catarrhal inflammation of the 
bowel by retained fecal masses. A similar condition occurs in some 
instances of carcinoma of the lower bowel. 
Prognosis.-The termination of intestinal obstruction depends upon 
the nature of the obstruction and its completeness. In acute occlusions 
that cannot be relieved death may occur within a few hours, or not 
until several or many days have elapsed. Leichtenstern estimates the 
average duration at six days. Partial or chronic obstructions may 
persist for very long periods of time; in some cases for years. Repeated 
vomiting, excessive shock, prostration, and collapse are the usual con- 
ditions that precede death in acute cases; the persistence of such condi- 
tions is, therefore, a prognostic indication of great gravity. Another 
cause of death in acute cases is peritonitis. In cases of greater duration, 
toxemic manifestations usually set in before death ensues. 
Recovery from intestinal obstruction may occur spontaneously in 
cases of fecal impaction or compression of the bowel; and sometimes in 
cases in which the obstruction is due to adhesions, bands, internal hernia, 
or the presence of foreign bodies within the bowel. In intussusception, 
spontaneous disinvagination may occur, or the intussusceptum may 
slough off and recovery may take place; while in volvulus the twisted 
loop of bowel may be spontaneously restored to its normal condition. 
A recurrence of obstruction after a primary relief sometimes takes place. 
Treatment.-Practically all forms of intestinal obstruction demand 
surgical treatment. In cases of partial obstruction, however, and in 
some conditions like impaction of feces or the presence of foreign bodies 
within the bowel, medical treatment deserves a careful trial. In the 
early stages, before an absolute diagnosis of obstruction has been made 
and before surgical intervention can properly be advised, certain indica- 
tions must be met by medical means. In cases, however, in which it 
has thought well to institute medical treatment, this form of manage- 
ment should not be persisted in longer than a day or two, if relief of 
the obstruction is not apparent. It is far better to err on the side 
of too early operation than the reverse; and in all cases of doubt, 
surgical rather than medical measures should be adopted. 
In the beginning the patient should be placed at as complete rest as 
possible, and the diet should be restricted or completely withheld even 
if marked gastric disturbances are not present. Small particles of ice 
may be allowed to quench thirst; but the unrestricted use of ice may 
occasion disturbance of the stomach and is objectionable. Enemata of 
water and hypodermic injections of saline solutions may be given. 
The use of laxatives must be condemned, except in certain special 
conditions. If they are effective at all in stimulating peristalsis, they 
will increase, instead of relieve, the abnormal conditions. Fortunately, 
when administered in error of diagnosis, vomiting usually causes their 
prompt expulsion. In fecal impaction purgatives are often desirable, DISEASES OF THE INTESTINES 
417 
although they must be employed with caution. Small doses of calomel 
or salines are preferable to more active remedies, because they produce 
serous outpourings without stimulating violent peristalsis. In cases of 
partial occlusion the accumulation of feces may be prevented by the 
occasional use of the same or other laxative remedies. 
Enemata and colonic flushings are specially advisable in cases of 
obstruction due to fecal impaction. The repeated use of warm water, 
saline solutions, or oil may break up an impaction that threatens to 
cause complete obstruction. The injections must be given cautiously 
and without undue force, as the irritation caused by them may stimulate 
violent peristalsis above the point of obstruction. The same plan of 
treatment is sometimes effectual in dislodging a foreign body; but the 
use of forced injections of fluids in cases of intussusception, volvulus, 
etc., cannot be too strongly condemned. Formerly inflation of the 
bowel with atmospheric air or various gases was practised for the relief 
of intussusception and other kinds of organic obstruction. This method 
also merits condemnation. 
Opium and atropine are administered with advantage in some cases 
of obstruction for the purpose of quieting spasm or excessive peristaltic 
efforts. Thus in cases of internal hernia or occlusion by bands the 
obstruction may become more complete as the result of the violent 
peristalsis stimulated at the point of occlusion. Complete rest, the 
use of poultices or other warm applications, and small doses of opium 
or atropine, may relieve active peristalsis; and a release of the incar- 
cerated bowel may take place, although this can rarely be hoped for. 
Similarly in cases of obstruction by foreign bodies the same remedies, 
especially atropine, may aid in relaxing spasm and thus facilitate the 
passage of the occluding body. Besides these indications, opium or 
morphine is sometimes necessary, even though operation is decided on 
to control the pain. The doses should be no greater than are required 
to allay suffering; and, generally speaking, hypodermic injections are 
preferable to administration by the mouth or by the rectum. 
External treatment to the abdomen may be useful in cases of obstruc- 
tion which can be relieved, such as those due to foreign bodies or impac- 
tion, and some cases of incarceration by bands, through slits, etc. Large 
poultices or warm fomentations of various sorts may be used for this 
purpose. Even though ineffectual in accomplishing a relief of the 
obstruction, such applications frequently give comfort. Massage of 
the abdomen is particularly helpful in cases of partial obstruction, such 
as are caused by adhesions after operations, or those due to the presence 
of foreign bodies. After relief from impaction in cases of narrowing of 
the lumen of the bowel, subsequent accumulations may be prevented 
by systematic manipulations combined with the administration of 
laxatives and the injection of warm saline solution or oil into the bowel. 
In acute obstruction, external manipulations must be used with the 
greatest caution. 
Certain symptoms may require treatment before or after operation 
has been decided on. Among these, gastric disturbances are most 
important. Nausea and vomiting may greatly complicate the difficulties 418 
DISEASES OF THE DIGESTIVE SYSTEM 
under which the patient labors and contribute largely to prostration. 
When laxatives are permissible, small doses of calomel placed upon 
the tongue may have a controlling effect. When the disturbance of 
the stomach is more intense, lavage of the stomach is advisable. If 
resorted to early, this method of treatment may reduce subsequent 
difficulties materially. Sometimes an actual cure of obstruction has been 
obtained from gastric lavage, as Kussmaul, who introduced this method 
of treatment, first pointed out. Surgeons quite uniformly recommend 
lavage as being useful in allaying the danger from subsequent anesthesia, 
when vomited material so readily gains access to the lungs. If used at 
all, lavage should be resorted to in the early stages. 
Surgical Treatment.-In all cases of obstruction in which the symptoms 
are not relieved within forty-eight hours under general and medical 
management, surgical intervention must be advised, and in many cases 
immediate operation should be recommended. Attempts to relieve 
volvulus and complete obstructions by bands and the like by means 
other than surgical operation are inadvisable, although occasional cures 
have been obtained from such treatment. In the long run, the loss of 
time and strength thus occasioned makes the subsequent operative 
measures less likely to prove successful. 
VOLVULUS OF THE OMENTUM 
Volvulus of the omentum may be considered briefly in this place on 
account of the resemblance of the symptoms to those of intestinal 
obstruction. The great omentum may become twisted in the same 
manner as a coil of intestine. This usually takes place either in a part 
of the omentum included in a hernia or in a contracted portion that 
had been contained in a hernia and afterward restored to the abdominal 
cavity. Sometimes the twisting is the result of adhesions of the omentum 
to fixed structures. Occasionally several turns are observed, and some 
of these may be manifestly of considerable duration. 
The omentum becomes swollen, oedematous, engorged with blood, 
and finally may undergo necrotic change from stasis. Hemorrhagic 
extravasations into its tissues and free exudation or extravasation into 
the abdominal cavity may take place. 
Symptoms.-These are similar to those of intestinal obstruction. 
Sudden and severe abdominal pain with nausea and vomiting are the 
initial manifestations. The appearance of an abdominal mass, more or 
less tender on pressure, or the sudden distension of a hernial sac, if the 
twisted omentum is contained within the sac, are usually met with. 
Constipation is usually present but is less obstinate than in cases of 
volvulus of the bowel. 
Treatment is purely surgical. 
INTESTINAL OBSTRUCTION DUE TO MOTOR PARALYSIS 
Partial or complete obstruction may be due to motor insufficiency 
or complete paralysis of the motor power of the bowel. Sometimes DISEASES OF THE INTESTINES 
419 
this results from direct or reflex causes without organic lesions affecting 
the bowel itself. More frequently such obstruction from paralysis is 
a concomitant of organic diseases of the bowel. 
Functional Paralysis.-A complete paralytic obstruction has occa- 
sionally been observed as the result of injuries or diseased conditions, 
such as contusion, compression, or torsion of the ovary or testicle, 
various inflammatory conditions in the inguinal region or in hernial 
sacs, after operations for hemorrhoids, or in consequence of the passage 
of renal or biliary calculi. In such cases the paralysis of the bowel is 
a result of violent irritation of the sensory nervous mechanisms. 
Cases have been observed in which the condition has followed para- 
centesis of large abdominal effusions or injuries to the abdominal cavity 
of various sorts, not involving the viscera. In a similar manner, after 
abdominal operations in which the intestines have not been involved, 
and in which infection of the peritoneum has not been discoverable, a 
paralytic condition of the bowel has developed. 
After the reduction of hernias, paralysis of the affected coils may 
occur, although the bowel presents no evidence of inflammatory or other 
organic change. In cases of intestinal obstruction involving the upper 
part of the small intestine, complete cessation of all movements indi- 
cates a secondary paralytic condition of the lower bowel. In all these 
cases there is a functional paralysis which may be explained by a direct 
or reflex stimulation of the inhibitory nerve, the splanchnic, which 
occasions cessation of peristaltic movements. 
In another group of cases the paralytic condition is probably due to 
toxic conditions affecting the intestinal walls or the nervous mechanism 
of peristalsis. In this group may be included the occasional cases of 
paralysis of the bowel occurring in the course of severe attacks of pleurisy 
or pneumonia. Mannaberg and the writer have observed instances 
of this sort. In some cases the obstruction was so severe as to call 
for operation. A similar condition occasionally attends cases of cholera, 
typhoid fever, and severe intestinal intoxications or enteritis. In all 
these instances the absorption of toxic matters acting upon the muscles 
or upon the nervous apparatus may explain the condition. 
Paralysis of the Bowel Attending Organic Disease.-Much more 
common than the preceding are the cases in which segments or a large 
part of the intestinal canal become obstructed by paralysis that is 
secondary to some form of intense organic disease. The more frequent 
and important cause of such paralysis is acute peritonitis. In cases of 
general peritonitis the bowel soon becomes quiescent; finally, all peri- 
stalsis ceases and a paralytic condition ensues. In localized peritonitis, 
such as that attending appendicitis, localized segments are involved. 
In chronic peritonitis and tuberculous peritonitis, obstruction of the 
bowel is more commonly due to adhesions or mechanical obstructions, 
although the inflammation of the bowel wall and the reflex nervous 
influences also play a part in the process. Embolism and thrombosis 
of the mesenteric vessels occasion a paralysis and consequent obstruction. 
In all those cases in which paralysis has followed organic lesions the 
cause of the motor palsy is in part the direct involvement of the wall 420 
DISEASES OF THE DIGESTIVE SYSTEM 
of the intestine in the disease process, and in part the effect of this 
condition upon the nervous apparatus. 
Occasionally paralysis is due to excessive accumulations of intestinal 
gases or of fecal matter. In cases of chronic constipation or partial 
obstruction of the bowel, or in various diseases in which a partial but 
not a complete paralysis has occurred, excessive meteorism may deter- 
mine a complete paralysis; or the gradual accumulation of fecal matter 
may so distend the bowel as to cause the complete cessation of all 
peristaltic power. 
Symptoms.-The symptoms are practically those of obstruction by 
mechanical causes. When due to violent reflex nervous stimuli, as in 
cases of injury to the ovary or testicle, or to the passage of calculi, the 
onset may be attended with sudden intense pain, vomiting, and prostra- 
tion, following which obstinate constipation and distension of the 
abdomen make their appearance. Although vomiting is usually marked, 
it less commonly becomes fecal in character than in cases of mechanical 
obstruction. Other symptoms may indicate the cause of the paralytic 
condition, and may serve to establish a-correct diagnosis; although this 
is usually difficult. The course depends upon the cause. In cases in 
which some injury has occasioned the paralysis, a return to normal 
conditions may occur after the original disease has subsided. Paresis 
of the bowel following operations, and that attending peritonitis, whether 
local or general, are exceedingly grave conditions. 
Treatment.-This must always be directed to the original cause of 
the intestinal condition. Sometimes this may be controlled by medical 
means, as in toxic or inflammatory conditions of the bowels; in other 
cases, as when an injury has been sustained, local applications or cold 
or other local measures may be employed with advantage. Surgical 
intervention is frequently necessary. Moderate paralytic conditions 
of the bowel may sometimes be corrected by hypodermic injections of 
sulphate of eserin (gr. q- to gr. ^-); by colonic douches of cool water 
or saline solution, or enemata containing stimulating remedies like 
asafetida and turpentine. External applications, such as mustard 
plasters and turpentine stupes, may also be beneficial. In cases of 
paralysis of the bowel following other abdominal diseases, surgical 
treatment of the original condition alone can be relied upon. 
INTESTINAL DIVERTICULA 
Intestinal diverticula are classified as congenital and acquired. Accord- 
ing to their anatomical peculiarities they can be divided into true and 
false diverticula. True diverticula are those composed of all the coats 
of the normal intestinal wall. False diverticula are those composed of 
only the mucosa and serosa. They are, in other words, hernial protrusions 
of the mucosa through defects in the muscularis. As most congenital 
diverticula are true and most acquired are false, the terms "congenital" 
and "true" and "acquired" and "false" have often been employed 
synonymously. Although in the majority of cases this holds good, DISEASES OF THE INTESTINES 
421 
some cases of the acquired form have apparently been true diverticula, 
so that the synonymous use of the terms "acquired" and "false" is not 
to be recommended. 
Congenital Diverticula.-Meckel's diverticulum, so called, is the 
only form of congenital diverticulum that requires description. Other 
forms are of such extreme rarity as to be of no practical significance. 
Meckel's diverticulum results from the persistence of the omphalo- 
mesenteric duct. This should be entirely obliterated by the sixth or 
seventh week of fetal life, but some remains of it are frequently found. 
It is apparently more common in males than in females. Kelynack 
found 4 cases of Meckel's diverticulum in 298 autopsies, all 4 cases 
occurring in males, while in 337 cases Rolleston found 10 instances, 9 
of which were in males. The diverticulum usually takes its origin from 
the convex side of the small intestine, about 1 meter above the ileocecal 
valve. Exceptionally it arises from the upper portion of the small 
intestine. It varies from 3 to 10 cm. in length and may be as 
long as 25 cm, The wall of the diverticulum, commonly composed 
of the same structures as the intestinal wall, and its mucosa contain 
both Lieberkuhn's glands and Peyer's patches. The lumen of the 
intestinal end of the diverticulum is large, frequently as large as that 
of the intestine itself. A valve-like fold of the mucous membrane at 
times occludes the opening of the diverticulum. Toward the free end 
of the diverticulum the lumen decreases, so that the process 'has some- 
thing of a conical form. Occasionally the end is enlarged, at times 
assuming a hammer-like form. In unusual cases the same lumen is 
maintained throughout the entire extent of the diverticulum. 
Usually the end lies free within the abdominal cavity. Occasionally, 
however, it remains attached to the umbilicus. Under these circum- 
stances the lumen of the peripheral end alone becomes obliterated, 
forming a fibrous cord, but in other cases the entire duct may remain 
patulous, thus forming a free communication between the external 
surface and the ileum, permitting the discharge of intestinal contents 
at the umbilicus. Hubbard has collected 9 such cases, in all of which 
operation resulted in a cure. The remains of the duct in the umbilicus 
may give rise to an adenomatous growth or carcinoma. 
When, as is usually the case, the peripheral portion of the lumen 
becomes obliterated, the fibrous cord resulting may remain attached 
to the umbilicus and later become the possible cause of intestinal stran- 
gulation, or this cord may atrophy, and the end of the diverticulum 
then becomes free within the abdominal cavity. Subsequently inflam- 
matory conditions may cause the free end to become adherent to any 
point within the abdominal cavity with which it may come in contact. 
This is most frequently the mesentery. Cazin and Halstead1 have 
made exhaustive analyses of the various places and structures to which 
the peripheral end of Meckel's diverticulum may attach itself, and 
Fitz2 discussed the possibilities of strangulation of portions of the intes- 
tinal tract by such adherent diverticula. 
1 Halstead, Annals of Surgery, 1902, xxxv, 471. 
2 Amer. Jour. Med. Sd., 1884, Ixxxviii, 30. 422 
DISEASES OF THE DIGESTIVE SYSTEM 
If, finally, the diverticulum assumes its most frequent form, a finger- 
like projection, the tip of which lies free within the abdominal cavity, 
it may remain an entirely harmless appendage throughout the patient's 
life. On the other hand, it may be the seat of various phenomena of 
extreme gravity. It may be the seat of a volvulus by rotating upon 
its own axis; it may be the starting-point of an intussusception by becom- 
ing inverted into the ileum; or it may become knotted about a coil of 
intestines and produce stricture. If, as is sometimes the case, the diver- 
ticulum possesses a mesentery of its own, the latter may produce a 
stricture of the ileum. Occasionally the lumen becomes occluded at 
its intestinal end, inducing cyst formation which may suppurate or by 
pressure produce obstruction of the intestines. Ulcerations of the 
mucosa of the diverticulum, sometimes perforative, may result from 
fecal accumulations or from typhoid or tuberculous infection. 
Acquired Diverticula.-These may be true or false. True acquired 
diverticula are of extreme rarity. They are usually in the form of 
minute spherical or conical traction diverticula, occurring as a result of 
adhesions due to some extra-intestinal inflammatory condition. It appears 
possible, however, to have a true acquired diverticulum which is not 
the result of traction. Such a condition appears to have been present 
in the first case reported by Mayo, Wilson, and Giffin.1 False diverticula 
are hernial protrusions of the mucous coat through the muscular coat. 
As the protrusion of the mucous coat makes its way through the muscular 
coat it naturally carries the serosa with it, so that usually the wall of 
the diverticulum is composed of mucosa and serosa. At times a few 
muscular fibres are found between the two layers. These diverticula 
may be conical, cylindrical, hemispherical, or irregularly lobulated, and 
vary in size from that of a pea to that of an apple. They may occur 
throughout the entire intestinal tract, but are more frequently found 
in the large than in the small intestine. As a rule, they are multiple, 
and at times occur in extraordinary numbers. Hansemann has recorded 
as many as 400 in a case. They differ from Meckel's diverticulum in 
that they usually arise from the concave side of the intestine close to 
the mesenteric attachment. At times they occur between the peritoneal 
coats of the mesentery. It has been claimed that the simple intra- 
intestinal pressure resulting from long-continued constipation is the 
etiological factor. Another view is that they result from the atrophy of 
some of the fibrous elements of the intestinal wall. A view that at the 
present day has many adherents is that first advanced by Klebs, namely, 
that the point of entrance of the mesenteric vessels into the intestinal 
wall forms a focus of lessened resistance through which the mucosa 
forces itself, carrying with it the overlying serosa. The primary factor 
in the production of diverticula is decreased resistance of the intestinal 
wall. This may be due to structural -weakness at the points of entrance 
of the vessels or to areas of atrophy of the fibrous or muscular tissues 
of the bowel wall. The various theories of the production of intestinal 
diverticula are thoroughly discussed by Fischer.2 
1 Transactions of the American Surgical Association, 1907, p. 240. 
2 Jour. Exper. Med., 1901, v, 333. DISEASES OF THE INTESTINES 
423 
According to Gordinier and Sampson, acquired diverticula were 
found 64 times in 8132 autopsies (Dresden Hospital); 19 times in 2600 
autopsies (Johns Hopkins Hospital); twice in 953 autopsies (Bender 
Hygienic Laboratory); once in 2382 autopsies (Boston City Hospital). 
Careful investigation of left-sided tumors will doubtless reveal more. 
Retention of fecal matter and infection may occasion inflammatory 
lesions of the mucous lining or entire wall of the diverticulum and local- 
ized peritonitis, sometimes with considerable induration, may surround 
the diverticulum and involve the adjacent portions of the bowel wall. 
Tumors of considerable size and easily palpated through the abdominal 
wall may result. In cases of inflammation confined to the mucosa, 
ulceration and perforation into the peritoneal cavity may occur, some- 
times quite acutely. In the case of the tumor-like indurations surrounding 
the diverticulum intestinal obstruction is more frequently the con- 
sequence. The term "diverticulitis" may be applied to both classes. 
A variety of diverticula requiring special mention are those occurring 
in the duodenum at the site of the papilla of Vater. They are apparently 
due to weakening of the intestinal wall at the point of entrance of the 
bile-duct. Keith claims that they occur in women from a forced viscero- 
ptosis, as the result of the pressure of corsets. The forced descent of 
the duodenum is not participated in by the bile or pancreatic ducts, on 
account of their more fibrous consistency, and a pouching of the intestinal 
wall in the neighborhood of the papilla thus results. 
Bland-Sutton1 describes a form of abscess of the epiploic appendages 
caused by the penetration of foreign bodies through the intestinal wall 
and their lodgement in the epiploic appendage. Anatomically the 
appendix epiploica is a fold of peritoneum filled with fat, the latter being 
directly continuous with the subserous fat of the intestine. Very often 
after middle life there appear in the wall of the gut, especially of the 
descending colon, small pouch-like diverticula in which small foreign 
bodies may lodge and so penetrate the intestinal wall. In thin indi- 
viduals the foreign body would probably enter the peritoneal cavity, 
while in the more obese it might enter the epiploic appendage and set 
up an inflammatory disturbance. 
In a large majority of cases acquired diverticula give no clinical 
evidence of their existence. Lately, however, those situated in the 
descending colon, and especially in the sigmoid flexure, have been shown 
to be the cause of very profound diseased conditions, and their recogni- 
tion explains some obscure phenomena having their seat in the left iliac 
fossa. Among the contributions which have shed light upon the con- 
dition are those of Mayo, Wilson, and Griffin, Brewer,2 and Beer.3 
The clinical features presented by these cases may conveniently be 
divided into the inflammatory and the obstructive. 
The inflammatory phenomena may be the result of either a virulent 
infection of the diverticulum or perforation. The symptoms may briefly 
be described as those of appendicitis on the left side. The patients are 
1 The Lancet, 1903, ii, 1148. 
2 Trans. Amer. Surg. Assoc., 1907, p. 258. 
3 Amer. Jour. Med. Sci., 1904, cxxviii, 135. 424 
DISEASES OF THE DIGESTIVE SYSTEM 
usually males over forty-five years of age, otherwise in robust health, 
and generally inclining to obesity. The direct attack may be preceded 
by left-sided pain low in the abdomen, coming in spells and associated 
with constipation. Sudden, more acute pain, general at first, later 
localized to the left iliac fossa, and more or less paroxysmal in type, 
marks the onset of definite symptoms. Vomiting is usually not marked 
unless the pain is very severe. There is more or less rigidity of the left 
rectus muscle. The previous constipation may now change to diarrhoea. 
Finally a mass is discovered developing to the left of the median line in 
the middle or lower quadrant of the abdomen. In women this mass is 
at times pelvic rather than abdominal. 
In the obstructive cases the inflammatory symptoms are much less 
marked and the general symptoms of slowly progressive obstruction 
predominate. The condition may be readily confounded with carcinoma, 
especially as both conditions occur in advanced life; the formation of 
the tumor is, however, more rapid in the former. In diverticular obstruc- 
tion there is usually a noticeable disharmony between the rather con- 
siderable size of the tumor and the lack of cachexia. Furthermore, the 
presence of blood in the stools would point strongly in favor of carcinoma. 
The treatment of all forms of diverticula is purely surgical. 
CARCINOMA OF THE INTESTINES 
Compiling the statistics of Maydl, Nothnagel, Heimann, Zemann, and 
Muller, we find that of 26,340 cases of carcinoma in general, 2255, or 
8.56 per cent., were in some portion of the intestines inclusive of the 
rectum. In determining the location of the tumor in the intestines 
there is a marked predominance of carcinoma of the colon and rectum. 
Combining the statistics of Maydl, Nothnagel, Zemann, Muller and 
Bryant, it is seen that of the 659 instances of intestinal carcinoma that 
they have collected, 6.22 per cent, were in the small intestines, 6.82 per 
cent, in the cecum and appendix, 22.76 per cent, in the various portions 
of the colon, and 64.18 per cent, in the sigmoid and rectum. Carcinoma 
of the duodenum is frequent as compared with the ileum and jejunum, 
despite the great difference in the lengths. In the combined statistics 
of Maydl, Nothnagel, and Muller, of the 26 cases of carcinoma of the 
small intestine, 13 were in the duodenum and the remaining 13 in the 
ileum and jejunum. Rolleston collected 54 cases of primary cancer of 
the duodenum and but 19 of the jejunum and ileum. 
Carcinoma of the intestine is in the vast majority of cases primary. 
Secondary involvement may occur either by metastasis or by direct 
extension. Metastatic involvement is seldom noted, and when it does 
occur it is not infrequently as a part of a general carcinomatosis. Metas- 
tatic carcinoma of the intestines is usually multiple. The nodules have 
a tendency to locate in the mesentery just at its attachment to the 
intestines, thus producing multiple stenoses without involvement of 
the mucosa. Direct extension of cancer of a neighboring organ to the 
intestines is somewhat more common and occurs especially as a result 
of carcinoma of the pancreas, gall ducts, and pelvic viscera. DISEASES OF THE INTESTINES 
425 
Sex is of little etiological significance in cancer of the intestines. 
Males are apparently somewhat more frequently affected with carcinoma 
of the rectum and sigmoid, whereas this relative susceptibility is less 
evident in carcinoma of the upper portion of the tract. Age is probably 
a less important factor in carcinoma of the intestines than in carcinoma 
of almost any other portion of the body. The majority of cases occur 
in individuals over forty years of age, but not infrequently the condition 
is found in younger individuals. According to Maydl, one-sixth of all 
cases of carcinoma of the intestines occur between thirty and forty years 
of age, and one-seventh under thirty years of age. Bernoulli has collected 
37 cases in individuals under thirty years of age, and Nothnagel mentions 
8 cases in individuals under twenty years of age. One of them was in a 
three-year-old boy, another in a boy aged three and a half years. 
Pathology.-The majority of intestinal carcinomata are cylinder- 
celled adenocarcinomata taking their origin from the intestinal glands. 
Depending upon the relative proportions of the connective tissue to 
the epithelial elements, these tumors may be simple, medullary, or 
scirrhus. Of somewhat less frequent occurrence than cylinder-celled 
adenocarcinomata are cylinder-celled solid carcinomata and round-celled 
solid carcinomata, which may be either simple, scirrhus, or medullary; 
colloid cancer may occur in the cylinder-celled or round-celled 
forms. 
The macroscopic appearances that carcinomata of the intestines may 
assume are varied. Frequently the tumor assumes a saucer-like form, 
having a necrotic ulcerated centre and elevated, indurated edges. Again, 
it is common to find the tumor extending about the entire lumen of the 
bowel in a girdle-like manner. Considerably rarer is the cauliflower-like 
mass of a papillary carcinoma. The tumors vary greatly in size. As 
the growth is dependent, to a great extent, upon the amount of epithelial 
tissue present, the larger forms are more commonly found among the 
medullary and simple carcinomata. The scirrhus forms seldom assume 
very great dimensions, and on account of their density and small size 
they rarely undergo very extensive ulceration. They have a particular 
tendency to encircle the entire lumen of the bowel, and consequently 
stenosis is one of the most constant results. Colloid cancers, which are 
relatively most common in the rectum, tend to infiltrate extensive areas 
of the intestinal wall. 
Obstruction.-Both the degree and character of the obstruction differ 
materially in the various types of carcinoma and in individual cases. 
It may result in one of three ways. The carcinoma may produce an 
actual stricture of the bow'el, as is most commonly seen in annular 
carcinoma, especially when of the scirrhous form. The same result 
may occur in the case of an annular carcinoma of a softer variety when 
in reaction to the carcinoma there is proliferation of the connective 
tissue of the bowel wall. In the second place, obstruction may result 
when the carcinoma so infiltrates the bowel wall as to materially increase 
the thickness of the intestinal wall and thus encroach upon the lumen. 
This is seen especially in colloid carcinoma, which tends to infiltrate 
the entire circumference. Lastly, obstruction may result when the 426 
DISEASES OF THE DIGESTIVE SYSTEM 
carcinoma growing from the intestinal wall projects so far into the 
lumen as to occlude it. 
Stagnation of the Intestinal Contents and Dilatation of the Intestine.- 
These are conditions which are the direct result of the obstruction 
offered by the carcinoma. Not infrequently the stagnated contents 
just above the carcinoma become inspissated and hard, so that in pal- 
pating through the abdominal wall this mass may be mistaken for the 
tumor itself. This error probably accounts for those cases in which 
a large tumor is diagnosed, but in which one of small size is found on 
operation or postmortem examination. 
Dilatation of the intestine consequent upon carcinomatous obstruction 
may be either acute or chronic. Chronic dilatation results in those 
cases of slowly progressive obstruction in which the bowel above the 
point of obstruction has time to accommodate itself in part to the 
obstruction. Acute dilatation may result in those rare cases in which 
the obstruction is of rapid formation, but is much more commonly found 
as a terminal phenomenon in chronic dilatation. Hypertrophy of the 
wall cannot go on indefinitely, and there naturally occurs a time when 
the pressure resulting from the force of the peristalsis above and the 
obstruction below overcomes the resistance of the bowel wall and it 
balloons out. Occasionally in carcinoma of the colon acute dilatation 
of the cecum is found, although the portion of the colon above the 
obstruction is not dilated. The explanation of this peculiar phenomenon 
probably lies in the fact that the cecum is subjected to the combined 
pressure of the peristalsis of the small intestines and the reverse peristalsis 
of the portion of the colon between the obstruction and the cecum. 
Rupture of the intestines in acute dilatation may occur. 
Adhesions.-In the majority of cases of carcinoma of the intestine of 
some duration, adhesions are found between the peritoneal covering 
of the area involved and some other portion of the peritoneum. They 
may bind the intestines to the abdominal wall, or coils of intestines to 
each other or to any of the abdominal or pelvic viscera with which they 
come in contact. Frequently the adhesions are not limited to the region 
of the cancer but involve areas for some distance surrounding it, and 
at times the adhesive process produces a fusing or matting together of 
the entire abdominal and pelvic contents. 
Perforation.-Perforation into the general peritoneal cavity may 
occur when the destructive processes are so rapid as to prevent the 
formation of adhesions. More common is perforation into a walled-off 
sac of the peritoneum or into one of the hollow abdominal or pelvic 
viscera. In this case there is always first a binding down of the carcin- 
omatous intestine to the portion concerned, and subsequently a per- 
foration. The rupture and the resulting fistula may be between two 
portions of the intestines, or between the intestine and the stomach, 
bladder, or uterus. Even perforation of the abdominal wall may occur. 
Peritonitis.-A generalized peritonitis may result when perforation 
occurs into the general peritoneal cavity, or a localized peritoneal abscess 
forms when perforation occurs into a walled-off portion of the peri- 
toneum. Peritonitis, either general or localized, may occur when there DISEASES OF THE INTESTINES 
427 
is no actual perforation, in all probability from increased permeability 
of the degenerated carcinomatous wall. 
Metastasis.-The commonest seats of the metastases from intestinal 
carcinoma are the lymph nodes, liver, and peritoneum. There is some 
difference of opinion as to the frequency of metastasis, especially from 
the large intestine. Muller, Hausmann, Maydl, and Hupp claim that 
metastasis to the lymph glands occurs late in carcinoma of the large 
intestines, and especially the rectum, while Hauser and others have 
found it early. 
Symptoms.-As carcinoma in the different portions of the intestinal 
tract gives rise to essentially different groups of symptoms, the clinical 
features will be dealt with according to the location of the growth. 
Carcinoma of the Duodenum.-The average age at which carcinoma of 
the duodenum occurs, according to the statistics of Rolleston based on 
53 cases, is 51.6 years. It is rather more frequent in males than in 
females. Of 54 cases, 41 were males. 
Carcinomata of the duodenum can be classified, according to their 
location, into those of the first or superior horizontal portion, those of 
the second or descending portion, and those of the third or inferior 
horizontal portion. Moreover, the symptoms usually differ materially 
according as the tumor is located in one or another of these portions. 
These differences are dependent primarily upon the seat of the tumor 
in its relation to the papilla of Vater, which is situated in the descending 
portion. On account of this relationship between the seat of the tumor 
and the symptomatology, Boas has proposed the use of the term supra- 
papillary, circumpapillary, and infrapapillary carcinoma. 
Suprapapillary carcinoma presents in a general way the symptoms 
of carcinoma of the pylorus, especially those that are due to the purely 
mechanical effects of the latter. There is dilatation of the stomach 
with vomiting of the stagnated contents. At times the vomitus contains 
blood. Since the gastric mucous membrane is not involved in the 
carcinoma, free hydrochloric acid is usually present and consequently 
lactic acid and other products of fermentation are not present as in 
carcinoma of the pylorus. According to the Fenwicks, a tumor is palpable 
in 60 per cent, of the cases. When palpable it is found to be less movable 
than carcinoma of the pylorus and is situated more to the right. Despite 
these points the diagnosis is frequently an impossible one. 
Circumpapillary carcinoma, or carcinoma of the second portion of the 
duodenum, may present somewhat different symptoms depending upon 
whether the growth involves the papilla or not. If it does not the 
symptoms are either those of carcinoma above or below the papilla. 
When, however, as is usually the case, the papilla is involved, more 
characteristic symptoms present themselves. The symptoms of pyloric 
obstruction may be present, but in addition there are the symptoms of 
obstructive jaundice. The stools are clay-colored, the tissues and 
urine deeply bile-stained, the liver enlarged, usually tender, and digestive 
and other disturbances dependent upon the obstruction to the flow of 
the bile and pancreatic juice present themselves. These symptoms are 
not constant, for with the occurrence of ulceration the obstruction may 428 
DISEASES OF THE DIGESTIVE SYSTEM 
be partially relieved and the escape of bile made possible. Subsequently 
the obstructive symptoms again present themselves, perhaps to be 
followed by another intermission. The ulceration gives access to an 
ascending infection of the biliary channels, so that a suppurative cho- 
langeitis may supervene, as indicated by an increase in the size and 
tenderness of the liver, chills, fever, and leukocytosis. 
The severity of the gastric symptoms is dependent upon the degree 
of the stenosis caused by the cancer. If the growth should extend 
toward the pylorus, and at the same time ulceration in the neighborhood 
of the papilla occur, the symptoms of suprapapillary carcinoma would 
supervene. Similarly, if the growth extended toward the third portion 
of the duodenum, and ulceration about the papilla occurred, the symp- 
toms of infrapapillary carcinoma would present themselves. In many 
of the cancers in this location, and especially in those in which obstruc- 
tive jaundice is the predominant feature, the differentiation from carcin- 
oma of the ampulla of Vater or of the lower end of the common duct 
or of the head of the pancreas is extremely difficult. The occurrence 
of intermissions in the jaundice and the development of a suppurative 
cholangeitis speak strongly for circumpapillary carcinoma. When a 
tumor is palpable it is felt as an immovable, hard mass deep in the right 
hypochondriac region near the midline. Either diarrhoea or constipation 
may be present and anemia and cachexia supervene. 
Infrapapillary carcinoma characterizes itself by the symptoms of 
gastric obstruction associated with the vomiting of bile and pancreatic 
juice. The regurgitation of these fluids into the stomach neutralizes 
the acidity of its secretion, so that, although no free acid is found, the 
combined acidity may not be greatly decreased. The presence of the 
pancreatic secretion may be determined by its lypolitic action as well 
as its proteolytic action in alkaline media. The tumor is at times 
palpable as a firm, immovable mass near the midline. 
Carcinoma of the Ileum and Jejunum.-Carcinoma of the ileum and 
jejunum presents symptoms for the most part similar to those of the 
first portion of the colon. There is constipation or alternating con- 
stipation and diarrhoea. More or less definite symptoms of obstruction 
may present themselves, but these are not so frequent or marked as in 
cancer of the colon, on account of the more fluid contents of the bowel 
in the small intestine. Pain is one of the most constant symptoms, and 
it is frequently of a colicky character. It is less definitely localized than 
is the pain of carcinoma of the large bowel. Occult blood is almost 
always present in the stools, and at times visible blood appears. Occa- 
sionally large hemorrhages occur. Although in some cases the tumor 
can be felt, this is by no means constant. When it can be felt it is char- 
acterized by its great movability unless it has been bound down by 
adhesions. On account of this, it is extremely prone to prolapse and 
is consequently not infrequently found in the lower abdomen or the 
pelvis. Cachexia and anemia sooner or later make their appearance. 
As a rule, these symptoms are more marked than in carcinoma of the 
large intestine, for, other things being equal, the nearer a carcinoma is 
to the stomach the more profound are the cachexia and anemia. DISEASES OF THE INTESTINES 
429 
Carcinoma of the Colon.-Pain is a frequent but not invariable symptom. 
Some cases run almost the entire course, even to the development of 
a palpable tumor and marked cachexia, without the occurrence of pain. 
The majority of cases, however, manifest some degree of pain. It may 
vary from a vague sense of discomfort to a symptom of great severity, 
but seldom reaches the extreme until obstruction becomes marked or 
absolute. Early in the course the patient occasionally complains of 
diffuse abdominal pain without definite localization. Frequently accom- 
panying this is a sense of pressure or dragging in the abdomen. Later 
the pain becomes more localized. Occasionally the pain is referred to 
distant parts, so that a patient with carcinoma of the cecum may 
complain of pain in the left iliac fossa, or vice versa. This is a fact 
that should constantly be borne in mind in order to avoid errors in 
localization in case operation be undertaken. Another confusing phe- 
nomenon is referred pain along the course of the anterior crural or 
sciatic nerves and due to pressure on the intra-abdominal plexuses. 
The variety of pain that is of greatest significance in the diagnosis of 
carcinoma of the intestine is colic. The attacks of colic are due to the 
progressive stenosis and the consequent distension and tonic peristaltic 
activity of the intestines above the stenosis. Not infrequently these 
paroxysms constitute the first symptom of which the patient complains. 
Generally the pain is diffuse throughout the abdomen, although occa- 
sionally the patient describes it as more or less localized. At times a 
cathartic brings on the first paroxysm of colic. The pain may be felt 
by the patient to move from one position to another until it comes to 
an abrupt termination with a violent cramp, indicating the location of 
the obstructive growth. 
A feature that practically always accompanies these attacks of colic 
is constipation. It is one of the most constant and frequently one of 
the earliest symptoms of intestinal carcinoma, and its occurrence in an 
individual past middle life should always excite one's suspicion. It is 
progressive in character, but it is occasionally interrupted by periods 
of normal activity of the bowels. These interruptions are sometimes 
due to ulceration of the tiimor reestablishing the lumen that had pre- 
viously been stenosed, and consequently such periods may be accom- 
panied by the appearance of blood, mucus, and pus in the stools. Relief 
of constipation may, however, be due also to a more fluid condition of 
the intestinal contents at certain times. Again, periods of diarrhoea 
are by no means infrequent in the course of intestinal cancer. 
Tumor.-A palpable tumor is the most reliable and most important 
symptom. Its detection is not, however, essential to the diagnosis. 
Some cases run their entire course without the development of a palpable 
tumor at any time. In the majority of cases careful and repeated exami- 
nations reveal a mass. The tumor may vary in size from that of a large 
nut to that of a child's head. In consistency it contrasts markedly 
with the surrounding abdominal contents, frequently feeling as firm as 
cartilage. It is round or irregular in form and its surface may be smooth 
or nodular. The infiltrating tumors, when they involve extensive areas 
of the bowel, give the impression to the palpating hand of a thick, solid 430 
DISEASES OF THE DIGESTIVE SYSTEM 
cord. When a tumor is very small, percussion over it elicits a note not 
differing from that of the surrounding intestines. The larger tumors 
are usually dull to percussion. Pressure usually causes more or less 
tenderness, which is proportionate to the degree of spontaneous pain. 
The movability of carcinoma of the large intestine, unless it be bound 
down by adhesions, is one of its most characteristic features. This is 
especially true of carcinoma of the transverse colon and the sigmoid, 
but almost equally so of carcinoma of other portions of the large bowel. 
A condition intimately associated with the tumor of intestinal car- 
cinoma, and prone to cause confusion with it, is the tendency to fecal 
impaction above the point of obstruction. It is not unusual for this 
mass to become so inspissated and compact as to cause the greatest 
difficulty in differentiating it from the carcinoma and lead to great 
misconceptions of the size of the growth. Usually, however, the con- 
sistency of this fecal mass is more doughy than that of the carcinoma, 
and unless the stenosis be complete, laxatives and enemata may clear 
up the question. Other phenomena that can at times be clearly observed 
are active peristalsis and distension of the portions of the bowel just 
above the carcinoma. They are both dependent upon the degree of the 
stenosis. In patients with thin abdominal walls, in whom hypertrophy 
of the intestines has occurred above the stenosed area, active peristaltic 
waves are frequently visible and at times serve as a means of localizing 
the growth. In carcinoma of the cecum the peristalsis of the small 
intestine is seen in the central and lower portions of the abdomen, while 
in carcinoma of the lower portion of the colon these movements are 
seen in the course of the large bowel. 
Gaseous distension, as a result of the stagnation of the intestinal 
contents, is at times so general that the portion involved cannot be 
determined by physical examination. In other cases, however, this 
distension is limited to the segment immediately above the carcinoma, 
and its observation is then of considerable value in the determination 
of the seat of the growth. If the distension is found to extend as far as 
the sigmoid, this would point to the latter portion being the seat of the 
involvement, whereas if only the transverse and ascending portions of 
the colon are distended, the localization would in all probability be at 
the splenic flexure. In carcinoma of the hepatic flexure the ascending 
colon would be the natural seat of the distension. 
The feces occasionally furnish valuable information of the possible 
existence of a carcinoma of the large bowel. The form of the feces is 
dependent upon the degree of the stenosis affected by the carcinoma. 
When the carcinoma is low down and the stenosis is of high degree, the 
feces are generally of small diameter and either circular or ribbon- 
shaped, or rudely rectangular in cross-section. Blood, pus, and mucus, 
either macroscopically or microscopically visible, are not of themselves 
diagnostic of carcinoma, but are indicative of an ulcerative process 
in the intestines. Blood and pus are derived from the ulcerated area 
itself, while the mucus is a product of the catarrhal inflammation of 
the neighboring mucous membrane. Blood may be present even when 
ulceration has not occurred. In such cases it proceeds from small 431 
DISEASES OF THE INTESTINES 
erosions of the mucous membrane, sometimes the result of the mechanical 
irritation of the fecal masses. Pus is always an indication that ulceration 
has occurred. The association of pus and blood is of considerable diag- 
nostic significance, for they occur together only in the most severe forms 
of intestinal ulceration. Shreds of tissue with the histological features 
of carcinoma may be present, and are of the greatest diagnostic signifi- 
cance. They are, of course, present only when ulceration has occurred. 
Cachexia and anemia are constant features of the later stages and do 
not differ from the cachexia and anemia of carcinoma in general, but 
are usually of later development in carcinoma of the large intestine 
than in carcinoma of the small intestine or stomach. 
Complications.-Acute intestinal obstruction may occur at any time 
from kinking by bands in the neighborhood of the carcinoma, or volvulus 
or intussusception induced by the growth, or from the impaction of a 
foreign body in the partially stenosed lumen, or the simple paralysis of 
the bowel above the stenosis. Peritonitis may result from rupture or 
from direct extension through the ulcerated intestinal wall. A localized 
peritoneal abscess may occur when adhesions have formed around the 
site of the peritonitis. Perforation of a carcinoma of the large intestine 
into another hollow abdominal viscus occasionally occurs. Perforation 
of a carcinoma of the transverse colon into the stomach forming a gastro- 
colic fistula can be recognized by the presence of fecal vomiting and 
diarrhoea in which the stools contain undigested food particles. Perfora- 
tion into another portion of the intestine may occur, and it is a peculiar 
fact that perforation of a carcinoma of the large intestine is more prone 
to occur into another portion of the large intestine than into the small 
intestine. Perforation into the bladder can usually be recognized by 
the discharge of fecal elements with the urine. 
Treatment.-When feasible, surgical treatment is employed, whether 
it be for removal of the growth or to overcome the results of stenosis. 
When surgical intervention cannot be resorted to, much can be done 
for the relief of the patient. The principal object is the prevention of 
fecal accumulation above the tumor. Of the means to guard against 
it the most important is the administration of such foods as contain 
a minimum of waste material, and in such form as to be most easily 
digested and absorbed. Small doses of laxatives may be frequently 
administered, and their action may be furthered by the occasional 
employment of oil enemata. 
SARCOMA AND LYMPHOSARCOMA OF THE INTESTINES 
Sarcomatous and lymphosarcomatous involvement of the intestines 
are much rarer than carcinomatous. Whereas, among the autopsies in 
the General Hospital of Vienna, from the years 1882 to 1893, 243 car- 
cinomata of the intestines were found, there were but 3 cases of sarcoma 
of the intestines and 9 cases of lymphosarcoma. In Bern 41 cases of 
carcinoma of the intestines were found to 1 of sarcoma. In contradis- 
tinction to the more frequent involvement of the large intestine as 432 
DISEASES OF THE DIGESTIVE SYSTEM 
contrasted with the small intestine by carcinoma, sarcoma and lympho- 
sarcoma involve the small intestine at least equally as frequent as 
they do the large intestine. Of 32 cases of intestinal sarcoma selected 
by Krueger, 16 were of the small intestine and 16 of the large intestine. 
In the 12 cases of sarcoma and lymphosarcoma occurring in Vienna, 
8 involved the small intestine and 4 the large intestine. 
The various portions of the small intestine are apparently involved 
with about equal frequency. In a series of cases collected by Libman, 
15 were in the duodenum, 18 in the jejunum, and 14 in the ileum. In 
the large intestine the rectum is most frequently involved, and next in 
frequency the ileocecal region. Jopson and White collected 22 cases of 
sarcoma and lymphosarcoma involving the large intestine. 
Lymphosarcoma apparently takes its origin from the lymphatic 
tissue of the intestinal wall and has a great tendency to involve extensive 
areas of the wall by a process of infiltration. Sarcomata arise from the 
connective tissue of the submucous layer of the intestinal wall. His- 
tologically, the most frequent form is the small round-celled 
sarcoma, but large round-celled, spindle-celled, and mixed forms may 
occur. These tumors also have a marked tendency to infiltrate extensive 
areas of the bowel wall, but at times they are more globular in form, 
when they may attain the size of a child's head. When they attain 
the latter proportions they frequently undergo central softening. They 
may occur at any age but are most frequent under forty years of age. 
They are commoner in males than in females. 
Symptoms.-The symptoms of sarcoma of the intestines differ materi- 
ally from those of carcinoma. In sarcoma the local symptoms remain 
in the background, and usually attract attention long after the consti- 
tutional effect is noticed. This is due primarily to the fact that there is 
not the tendency to stenosis of the bowel in sarcoma and lymphosarcoma 
that is present in carcinoma. Sarcoma and lymphosarcoma invade the 
intestinal wall and tend to extend longitudinally along the bowel or 
into the muscular coat, causing weakening and consequent dilatation 
of the bowel; in consequence of these modes of extension there is little 
tendency to intestinal stenosis. Consequently, in the majority of cases 
there is marked wasting and anemia before the symptoms point to any 
extent to the intestines. Ina minority of cases the symptoms of obstruc- 
tion may occur as a result of the growth of the tumor toward the intes- 
tinal lumen, or the destruction of the muscular elements of the wall 
may lead to paresis and consequent obstruction. Pain and diarrhoea 
are occasional symptoms. Blood, either occult or visible, may be found 
in the feces, but aside from this the examination of the stools reveals 
no characteristic features. Occasionally fever as high as 101° and 102° 
is an accompaniment of sarcoma or lymphosarcoma of the intestines. 
Local examination will, in the majority of cases, reveal a tumor. Gen- 
erally, this is in the nature of greatly thickened coils of intestines, but 
occasionally it is of a more circumscribed nature. Metastasis to the 
mesenteric lymphatic nodes may occasion greatly increased tumor 
masses. The duration contrasts with that of carcinoma of the intestines; DISEASES OF THE INTESTINES 
433 
in the majority of cases the patient dies in from four to eight months 
after the onset of symptoms. 
Treatment.-Excision of the growth offers the only possibility of cure. 
Medical treatment can be directed only to the alleviation of symptoms. 
BENIGN TUMORS OF THE INTESTINES 
Benign tumors of the intestines are of rare occurrence. In many 
cases they present no symptoms whatever, the first indication of their 
presence being their observation at autopsy. In other cases they give 
rise to various symptoms, but these are seldom characteristic. 
Adenoma.-These are the most frequent benign neoplasms of the 
intestines. The tumors take their origin from the glands of Brunner 
and Lieberkuhn, and are usually either polypoid or papillomatous, 
more frequently the former. Their size varies from that of a pea to 
that of an orange; they are firm or soft but usually vascular, and bleed 
on handling. They are usually multiple. Luschka has reported a case 
in which he counted over a thousand tumors. This condition of mul- 
tiple intestinal adenomas is termed by Hauser "polyposis intestinalis 
adenomatosa." The tumors may be diffusely distributed, but are 
usually most numerous in the colon and rectum. In children they tend 
to prolapse, and thus may become gangrenous or give rise to serious 
hemorrhages. Not infrequently polypoid adenomas give rise to carcin- 
omas; Quenu and Landal found carcinoma in 20 cases of 42 they studied. 
Multiple polypoid adenomas are most frequent in children from four to 
seven years of age. In 4 of the 13 cases reported by Post the condition 
appeared to be hereditary, and Niewack has reported cases showing 
a family predisposition. 
Lipoma.-These may be broad-based or pedunculated, and submucous 
or subserous; they may be small or as large as a child's head. When 
they assume the latter proportions they frequently produce obstruc- 
tion; somewhat smaller growths may induce intussusception. They are 
found somewhat more frequently in the large than in the small intestine. 
Of 36 cases collected by Dewis, 19 were in the large intestine. The 
subserous lipoma frequently develops from the epiploic appendages. 
When pedunculated, the pedicle may atrophy and the growth may lie 
free in the peritoneal cavity. A submucous lipoma may become detached 
and be expelled by the rectum. 
Myoma.-Myoma of the intestines is rare. It occurs oftener in the 
small than in the large intestine and may be internal or external. The 
former probably takes its origin from the muscularis mucosa, the 
latter from the external muscular coat of the intestines. Steiner, in 
his exhaustive analysis of benign tumors of the intestines, reported 19 
cases of internal and 15 of external myoma. They are more commonly 
found in the ileum and jejunum than in the duodenum and large intestine. 
These tumors may have a broad, flat base and appear more as localized 
thickenings of the intestinal wall, or they may be pedunculated, thus 
taking the form of a polyp. Occasionally there is an extensive distribution 
of fibrous tissue with the muscular tissue (fibromyoma). 
VOL. Ill-28 434 
DISEASES OF THE DIGESTIVE SYSTEM 
Hemangioma and Lymphangioma.-Hemangioma and lymphangioma 
are rare. McCallum collected 6 cases of hemangioma of the small 
intestine. They are usually cavernous as distinguished from telangiec- 
tatic hemangiomas; as a rule, they are small, flat, and multiple. 
Symptoms.-Benign tumors of the intestines may not give any indica- 
tion of their presence or they may present symptoms of a more or less 
definite character, and at times give rise to conditions of great severity. 
In multiple intestinal polyposis, hemorrhage and diarrhoea are the 
most frequent symptoms. If the lesions are located in the colon and 
rectum, tenesmus may be associated. The stools frequently contain 
large quantities of mucus. A rectal examination should never be neg- 
lected, as not infrequently the diagnosis will be made by finding numbers 
of the polyps springing from the wall of the rectum. In these cases the 
polyps are especially liable to constant irritation, and the presence of 
blood is a frequent symptom. When these adenomatous polyps undergo 
carcinomatous degeneration the symptoms of cachexia appear. 
In myoma, fibroma, and lipoma, hemorrhage and frequent stools, 
with mucus, may again be the predominant symptoms, but they occur 
much less frequently than in the multiple polypoid tumors above de- 
scribed. If the tumor is small and situated above the rectum or sigmoid, 
it usually remains undiscovered. If it is of larger size it may produce 
a slowly progressive obstruction, or, by inducing intussusception, cause 
acute obstruction. Steiner records 7 instances of intussusception in 18 
cases of large intestinal myoma. When the tumor is of considerable 
size it can frequently be palpated as a firm, nodular, rather freely 
movable mass. If it is in the lower part of the large intestine and extends 
downward it may be palpated or seen in the rectum. Angioma may 
give rise to extensive hemorrhages. It is impossible to make more than 
a presumptive diagnosis on the basis of intestinal hemorrhages in an 
individual previously healthy and in whom no other cause for the 
condition can be determined. 
Treatment.-The internal treatment of benign tumors of the intestines 
is limited to the treatment of the various symptoms. When, however, 
the symptoms are of sufficient severity or when the tumors are situated 
in the rectum and are consequently of easy access, surgical treatment is 
warranted. In case the tumor causes obstruction by occlusion of the 
lumen or by producing intussusception, operation must be undertaken. 
In case of hemorrhage of alarming severity from angioma or other benign 
tumor, operation may be employed. In those instances in which benign 
tumors are found in the rectum, even when they give rise to no symp- 
toms, they should be removed on account of their tendency to undergo 
malignant change, as well as the possibility of dangerous hemorrhage. 
EMBOLISM AND THROMBOSIS OF THE MESENTERIC ARTERIES 
Occlusion of the mesenteric arteries by embolism or thrombosis 
constitutes a condition of considerable clinical importance. In an analysis 
of 214 cases published by Jackson, Porter, and Quimby, in 1907, there DISEASES OF THE INTESTINES 
435 
were 197 instances in which an accurate study of the anatomical details 
was obtainable. Among these, 120, or 61 per cent., were cases of arterial 
obstruction, and 77, or 39 per cent., of venous obstruction. Embolism 
is considerably more frequent than thrombosis, the former condition 
having been present in 63 of 83 cases studied by Gallavardin. 
Etiology.-Endocarditis and atheromatous conditions of the aorta or 
of the trunks of the mesenteric arteries are the important conditions 
antedating embolism. Arterial thrombosis is liable to occur when 
there has been severe enteritis or infective conditions of the intestinal 
tract, as a result of which bacterial invasion into the bloodvessels takes 
place. Litten claimed that he had found thrombotic occlusion of the 
arteries as a consequence of diseased conditions of the arterial lining, 
but the correctness of his observation has been doubted. Syphilitic 
endarteritis has also been claimed as a cause of thrombosis, as has direct 
abdominal injury. Venous thrombosis may occur as the result of cirrhosis 
of the liver, thrombosis of the portal vein, and other conditions causing 
stasis in the portal circulation. 
Embolism and thrombosis of the mesenteric vessels occur much more 
frequently in men than in women. Jackson, Porter, and Quimby found 
64 per cent, in men and 36 per cent, in women. Over half their cases 
were observed between the ages of thirty and sixty years. 
Pathology.-The superior mesenteric artery is affected much more 
frequently than the inferior. The occlusion may involve the trunk of 
the vessel or one of the terminal branches. Sometimes it affects only 
the small terminals within the intestinal wall itself. In the last-named 
cases small ulcerations of the mucosa are met with. The results of 
venous thrombosis are practically indistinguishable from those of 
arterial occlusion. There may be a single occlusion of the trunk vessel, 
or multiple obstructions of small branches. In either case changes 
occur in the mesentery and bowel embraced in the distribution of the 
obstructed vessel. The mesentery and the bowel become intensely 
engorged with blood and assume a dark red and soon almost black 
color. Hemorrhagic extravasations take place into the tissues, and 
exudations of hemorrhagic fluid into the abdominal cavity and into 
the lumen of the bowel occur. The whole lesion is practically a hemor- 
rhagic infarction of the affected area. The affected tissues may undergo 
rapid necrosis or gangrene, and perforative peritonitis may ensue. In 
the majority of cases a line of demarcation is observed. 
The lesions are usually met with in the small intestine, which is 
supplied by the superior mesenteric artery. In the rare cases in which 
the inferior mesenteric vessel is involved the lesions are situated in the 
large bowel. Partial restoration, through the development of a collateral 
circulation, has been observed in a few instances. 
Symptoms.-Two groups of cases are distinguishable, an acute and a 
chronic, the majority of the cases belonging to the former. In these 
there is sudden abdominal cramp or colicky pain, followed by nausea 
and vomiting. The vomitus at first consists of the contents of the 
stomach, but very speedily becomes hemorrhagic. Very soon diarrhoea 
sets in and also becomes of hemorrhagic character. In other cases 436 
DISEASES OF THE DIGESTIVE SYSTEM 
hemorrhage does not occur, and the symptoms are practically those 
of an acute intestinal obstruction caused by the paralytic condition 
of the affected portion of the bowel. The patient's temperature usually 
falls decidedly, he breaks into profuse perspiration, and frequently sinks 
into more or less profound collapse. 
In some cases pain is wanting, and the earliest symptom may be a 
hemorrhagic diarrhoea. Pain, however, is usually a conspicuous symp- 
tom. In some instances the patient may suffer with repeated attacks 
of colicky pain, extending over a considerable period of time, without 
characteristic symptoms of vascular occlusion. In the more acute cases, 
whether of the hemorrhagic type or of the form suggesting acute intes- 
tinal obstruction, intense abdominal pain of almost continuous character, 
or recurring in paroxysms, is met with. In over half the cases the pain 
is general. In the others it is limited to one or another region of the 
abdomen. Local tenderness on pressure may develop, and sometimes 
becomes extreme when peritonitis has set in. 
Hemorrhagic diarrhoea is the most conspicuous and significant symp- 
tom, although it is not always present. The amount of blood sometimes 
becomes excessive; and usually there is rapid succession of movements 
each containing a considerable quantity of blood. When the hemorrhage 
is marked, the blood may be quickly passed and is only slightly altered. 
In other cases, black, tarry movements and a highly offensive odor 
indicate a longer retention within the bowel. Distension of the affected 
area of the bowel sometimes develops rapidly, and general abdominal 
distension occurs in the cases in which intestinal obstruction is the 
important consequence of the vascular occlusion. In some instances a 
palpable tumor has been discovered in the abdomen, the mass being 
caused by the infiltrated mesentery and bowel. 
In the more chronic cases, which include most of the instances of 
venous thrombosis, as well as some cases of arterial occlusion, the onset 
may be insidious and the symptoms of a remittent type. At times there 
are no abdominal symptoms of any sort; or, at most, vague and indefinite 
manifestations. 
The clinical course may be exceedingly rapid. Jackson, Porter, and 
Quimby found, in their analysis, that 20 per cent, of the cases of either 
arterial or venous occlusion had a duration of but twenty-four hours; 
and 18 per cent, and 22 per cent, of the venous and arterial cases, respec- 
tively, a duration of but two days. In 8 and 10 per cent., respec- 
tively, the duration was three days. Of the prolonged cases, those due 
to venous closure showed gradual and continuous progression, while the 
arterial cases were more apt to present interrupted attacks. In the 
very acute cases, after the initial pain and vomiting, rapid distension of 
the abdomen, cessation of peristalsis, and speedy death mark the course 
of the disease. 
Diagnosis.-The rules laid down by Gerhardt are still followed with 
advantage: (1) There must be a source of embolism. (2) Copious 
intestinal hemorrhage unexplained by organic disease of the bowel or 
by portal obstruction. (3) A rapid and marked faff of the temperature. 
(4) More or less severe colicky abdominal pains. (5) Distension of DISEASES OF THE INTESTINES 
437 
the abdomen and the accumulation of free abdominal fluid. (6) The 
occurrence of embolism elsewhere, before or simultaneous with obstruc- 
tion of the mesenteric vessels. (7) The discovery of a palpable mass. 
Prognosis.-With few exceptions, the disease terminates fatally. In 
the statistics before quoted there are recorded 14 cases in which the 
diagnosis seemed reasonably accurate and in which recovery ensued. 
This favorable termination can occur only when a collateral circulation 
is speedily established. 
Treatment.-This is purely surgical. Jackson, Porter, and Quimby 
refer to 47 cases in which an exploratory laparotomy was undertaken. 
The mortality in these cases was 92 per cent. Four patients recovered. 
ARTERIOSCLEROTIC INTESTINAL DISTURBANCES 
Certain painful conditions of the intestine are occasionally met with 
in the aged and arteriosclerotic, and are of some importance on account 
of their simulation of organic or inflammatory disease of the bowel. 
The onset may be abrupt, like that of acute intestinal disturbance, and 
pain may be severe. Usually there is constipation; and sometimes this 
is obstinate. Later, and especially after the use of laxatives, diarrhoea 
may set in. Localized soreness or tenderness may be discovered, but 
there is rarely marked rigidity of the muscles. The nature of these 
conditions is uncertain. In some cases, doubtless, obstructive conditions 
of the circulation play an important part. In a case under the observation 
of the writer, after a number of attacks, death occurred from a severe 
paroxysm with obstinate constipation, which was followed by the develop- 
ment of uremia. At autopsy a partial obstruction of a branch of the 
superior mesenteric artery was found; and the section of bowel supplied 
by this was intensely engorged with blood. There was not complete 
obstruction, and no actual hemorrhagic infarction. Ortner has referred 
to cases somewhat resembling this, under the title of Intermittent 
Angiosclerotic Dyspragia of the Intestines. He suggests the resemblance 
to intermittent claudication, and refers particularly to the intermittent 
character of the symptoms. 
MUCOUS COLITIS 
Definition.-The term mucous colitis is applied to a condition in 
which the patient suffers with various symptoms of disturbance of the 
stomach and bowels and with the regular or periodic discharge of masses 
of mucus or mucomembranous shreds or casts of the bowel. The terms 
membranous colitis, tubular diarrhoea, mucous colic, and mucous diarrhoea 
have been applied, and sometimes, although with insufficient justification, 
a distinction has been drawn between these as being different forms of 
disease. It is possible to distinguish cases in which mucous or mem- 
branous diarrhoea occur as an independent affection and those in which 
it is secondary to some other disease of the bowel, but there is no funda- 
mental difference between the cases in which a discharge of masses of 438 
DISEASES OF THE DIGESTIVE SYSTEM 
gelatinous mucus occurs and those in which membranes or casts of the 
bowel are met with. 
Etiology.-The disease is most common in the middle period of life- 
that is, between thirty and fifty years; but it sometimes occurs in children 
or those below thirty years, and occasionally persists after fifty years. 
It is more common in women than in men, the proportion probably 
being 5 or 10 to 1. The disease affects persons of a better station of 
life more frequently than the poor, and is commonly associated with a 
nervous temperament or with distinct nervous disease. Not rarely it 
develops in hysterical or neurasthenic women, particularly if they have 
suffered with dyspeptic symptoms and constipation. It may follow 
after other forms of intestinal disease, the secondary variety being a 
frequent accompaniment of such diseases as enteroptosis, chronic appen- 
dicitis, partial intestinal obstruction, dysentery, tumors, and long- 
standing constipation. 
The direct cause probably varies greatly. Nutritional conditions, 
such as are met with in those of reduced strength and those having 
nervous diseases, seem to play a predisposing role. Some authors 
regard the condition simply as- an intestinal neurosis with excessive 
mucus formation (myxoneurosis). Others have the contrary view that 
the nervous manifestations are entirely secondary and that the disease 
itself is essentially an inflammatory condition with excessive tendency 
to mucus formation. French authors have attempted to establish a 
connection between mucous colitis and metabolic disorders (arthritism). 
The evidence of such connection seems rather fanciful. Recently it has 
been claimed that certain bacteria play a part in the causation, among 
other organisms being the Bacillus coli communis. 
Pathology.-The characteristic feature is the formation of excessive 
quantities of mucus. This may occur as masses or balls of gelatinous 
character, which may be discharged as such or mixed with brownish 
fecal matter of liquid, semiliquid, or even solid consistency; or, more 
characteristically, the mucus may attach itself to the wall of the bowel 
in the form of more or less tenacious and laminated membranes, which 
may subsequently be discharged as skins, shreds, long tape-like bands, 
or even casts representing quite accurately a mould of the bowel. Prob- 
ably the commonest form is that in which the skins or shreds of mem- 
brane are discharged in masses or mixed with soft or liquid fecal matter. 
The shreds or casts are somewhat laminated, and may show depressions 
corresponding with the openings of the glands of the mucous membrane. 
Epithelial cells may be found clinging to the outer surface. The mucous 
membrane itself may present an inflamed appearance, but usually there 
is surprisingly little evidence of any structural disease of the bowel. 
Often an atonic dilatation of the colon is observed, but in other cases a 
firm toxic contraction of the bowel causes a narrowing of the lumen 
and an apparent thickening of the wall. 
Symptoms.-These are gastric, intestinal, nervous, and nutritional. 
Usually the patient complains of some form of indigestion or dyspepsia. 
The appetite is poor and capricious; and the patient accustoms herself 
to greater and greater restriction of diet, as the result of attempting to DISEASES OF THE INTESTINES 
439 
find a dietary that will not cause discomfort. Distension of the stomach, 
flatulence, heaviness, or pain after eating, nausea, and other gastric 
symptoms may occur. Sometimes pronounced manifestations of various 
forms of nervous dyspepsia are present. 
Among the intestinal symptoms, constipation and the discharge of 
characteristic mucus- or membrane-containing stools are most impor- 
tant. The majority of patients are constipated, and the discharge of 
mucus or membrane occurs from time to time, attended with painful 
paroxysms of varying grades of severity. In cases in which large casts 
or abundant membranous shreds are passed, an attack of abdominal 
pain of great violence may precede this, suggesting some form of intensely 
acute inflammatory trouble. After the passage of the mucus or membrane 
the painful attack ceases, but a rawness or soreness of the bowel and 
abdomen is left which may persist for some time. In the majority of 
cases such painful paroxysms are exceptional, and not rarely the passage 
of the mucus or membrane is accompanied by a relief of symptoms 
that have previously been in evidence, such as intestinal distension, 
general abdominal discomfort, depression, low spirits, etc. Occasionally, 
instead of constipation, the patient suffers with continued looseness 
of the bowels and the passage of large quantities of mucus mixed with 
fecal matter. Sometimes when shreds of membrane or casts are passed 
there may be a certain amount of blood streaking the membranes; and in 
exceptional instances a considerable quantity of blood may be discharged. 
On examination, the abdomen is distended or scaphoid. Preceding 
attacks, there may be increasing distension of the colon, which later 
gives place to a contracted or scaphoid condition; but in many instances 
distension is wanting at all times, and on direct examination the colon 
is found contracted as a hard tube. It may be possible to palpate the 
ascending and descending colon and the sigmoid flexure. The transverse 
colon is less commonly palpable. 
The patient may for a long time suffer with gastric and vague intestinal 
symptoms and constipation, and may become increasingly nervous, 
before the characteristic symptoms of mucus- or membrane-formation 
develop. In such cases the mucous colitis is probably secondary. 
The nervous manifestations are usually striking. It is difficult to 
determine to what degree these are the result of the condition, rather 
than the predisposing cause of it. Nearly all patients who suffer with 
this condition are depressed, gloomy, irritable, and of low vitality. 
Distinct hypochondriacal tendencies may be marked, and sometimes 
the patient becomes actually melancholy. Reflex nervous disturbances 
of various sorts may occur, such as weakness and irregularity of heart 
action, neuralgias, headaches, attacks of migraine, etc. 
The nutritional condition corresponds with the state of the gastro- 
intestinal tract and of the nervous system. Most of the patients are 
thin or emaciated, and many become progressively more so with its 
persistence. Sometimes, however, typical and progressive mucous 
colitis may occur in neurasthenic or hysterical subjects, who show no 
loss of weight at all commensurate with the gastric and intestinal dis- 
turbance. The patient presents an appearance of anemia which, 440 
DISEASES OF THE DIGESTIVE SYSTEM 
however, is frequently deceptive, since an examination of the blood may 
reveal a practically normal condition. 
Complications.-In some cases the passage of intestinal sand is 
observed. This presents itself as a reddish deposit, resembling brick- 
dust, or as a grayish or white powder, which consists of phosphate and 
oxalate and carbonate of calcium with magnesium and iron. A small 
amount may be passed with each movement, or sometimes large quan- 
tities may be discharged from time to time. 
In some cases intense soreness of the bowels and probably actual 
ulceration result from the separation of firm, membranous formations. 
In these cases the passage of the membrane may be preceded by painful 
paroxysms of great violence, and may be attended with the discharge 
of small or large quantities of blood. After the attack, local soreness in 
the left side or general abdominal tenderness may persist. 
Various disorders of the pelvic organs occur in women suffering with 
this disease; among others, endometritis, menstrual irregularities, 
dysmenorrhoea, and neuralgic affections localized in the pelvic region. 
Occasionally, membranous dysmenorrhoea and membranous cystitis 
have been found combined with membranous colitis. 
Diagnosis.-Examination of the stools alone enables the physician 
to diagnose the condition. Neglect of such examination may be the 
cause of regarding cases of mucous colitis as various sorts of primary 
nervous disease. Secondary mucous or membranous colitis associated 
with organic diseases of the bowel, such as chronic appendicitis, adhe- 
sions, diverticula, and tumors or strictures, may be indistinguishable from 
the primary variety. Usually, however, the organic conditions named 
serve to localize the symptoms and indicate the association. 
Prognosis.-Mucous colitis is essentially a chronic disease, which 
tends to continue and increase, although it is not often directly fatal. 
The general health may be so greatly undermined and nervous vitality 
so impaired that the patient falls a prey to other conditions. A large 
proportion of cases (perhaps 50 per cent.) eventually improve to such 
an extent that, although the health of the individual may be permanently 
impaired, the actual disease no longer manifests itself. In other cases 
the disease persists with more or less unabated intensity up to the time 
of death. Under continuous treatment some improvement is usually 
obtained, but the chronicity of the affection is such that few patients 
continue the treatment long enough to obtain the full result possible. 
Treatment.-The general hygiene and the diet are the most important 
considerations. Outdoor exercise and suitable occupation are essential. 
The majority of patients suffer from a sedentary life and a lack of suitable 
occupation. Not rarely, forced exercise may bring about decided relief, 
particularly in those cases in which general nervous depression has been 
augmented by lack of occupation. In some cases, active treatment of 
the gastric digestion may prove helpful. Increasing doses of nux vomica 
with bicarbonate of soda or the use of digestives may be beneficial. 
The dietary treatment may follow one of several rather different 
plans. Certain authors insist upon the necessity of limiting the dietary 
decidedly so as to exclude all irritating and unabsorbable matters. They, DISEASES OF THE INTESTINES 
441 
therefore, exclude vegetables containing large amounts of cellulose and 
prescribe mainly farinaceous articles with milk, eggs, and a limited 
amount of meat-all of which should be so prepared as to be rather 
semi-solid or liquid. They advise in addition a rather careful study of 
the tolerance of each patient for the different articles of diet allowed. 
On the contrary, other authors following von Noorden advise a rather 
coarse dietary containing rye bread, whole wheat bread, vegetables 
rich in cellulose, raw fruit, etc. The immediate effect of the former 
plan is undoubtedly more satisfactory in most cases and is better, though 
in some cases the coarser diet may be eventually the best. Whatever 
plan is adopted it is advisable to see that the patient has sufficient 
nourishment. 
It is important that the intestinal drainage should be maintained, 
and when constipation is marked some form of laxative is helpful. In 
many cases the occasional administration of castor oil relieves the 
patient for some time, and may have a lasting beneficial effect. In 
some, the administration of very small doses of castor oil several times 
daily, in combination with such intestinal antiseptics as salol, beta- 
naphtol, guaiacol carbonate, and calomel in fractional doses, may be 
beneficial. Now and then it is advisable to administer some form of 
saline purgative or to use medicinal waters for the same purpose. 
Paraffin oil in doses of one to two teaspoonfuls three times daily, or of 
one or two tablespoonfuls at night, often gives excellent results if con- 
tinued patiently for considerable periods. 
When the condition seems to affect the lower bowel, colonic douches 
with simple saline solution, or with water containing fluid extract of 
hamamelis, small amounts of quinine or nitrate of silver (1 to 5000), 
may have a beneficial effect. It is rarely desirable, however, to persist 
in direct colonic medication or flushing, as too long a continuance of 
this plan of treatment may cause a return of the symptoms, and even an 
aggravation of them. Some patients are helped by the gentle injection 
into the colon of ten or twelve ounces of olive or cotton-seed oil at bed- 
time, to be retained during the night. 
Local treatment of the abdomen is useful in some cases. Abdominal 
massage given by a skilful manipulator, external or intra-intestinal 
electricity, and high-frequency currents have sometimes been used- with 
advantage. Recently, Wright and others have treated patients by 
vaccination with killed cultures of the Bacillus coli. This method, 
however, rests upon no certain foundation. 
Surgical measures have been used with advantage. Occasionally 
the removal of a chronically inflamed and adherent appendix has been 
followed by remarkable improvement. Some obstinate cases have 
been treated by attaching the tip of the appendix to an abdominal 
opening and flushing out the bowel daily, or at stated intervals. In 
other cases an artificial anus has been made in the right iliac region, 
and has been used to flush the colon thoroughly. The seriousness of 
such an operation and its generally objectionable features militate against 
its frequent employment. It has also been suggested that the ileum 
be anastomosed with the rectum. CHAPTER VII 
DISEASES OF THE LIVER, GALL-BLADDER, AND 
BILIARY DUCTS 
By the Late A. O. J. KELLY, M.D. 
REVISED BY 
WILLIAM PEPPER, M.D. 
THE LIVER1 
DISORDERS OF FUNCTION 
The liver, the largest glandular organ in the body, is of complex 
structure and is endowed with a multiplicity of functions. Several of 
the structural peculiarities are mentioned in connection with the discus- 
sion of the histology of cirrhosis, and the structural changes that occur 
in different diseases are discussed under the respective headings. The 
disorders of the functions of the liver are less well understood. 
Inasmuch as health and disease each consists of a sum of variables 
that have no well-defined limits, overlap materially, and pass gradually 
the one into the other, it is not surprising that the ultimate beginnings 
of disease often escape our observation. As regards the liver specifically, 
if, as for instance in certain infections, the time of the onset of the infection 
is apparently quite obvious, in many other diseases, especially those of 
a more insidious onset and more chronic course, the time of onset cannot 
be determined, and frequently structural alterations are well advanced 
before obtrusive symptoms develop. It is difficult to believe, however, 
that normal liver cells can perform their functions otherwise than 
normally, and, conversely, abnormal function presupposes structural 
alterations-macroscopic, microscopic, or physicochemical. In some 
instances these structural alterations cannot be detected by the means 
of investigation at our command, but their existence cannot be denied, 
and we must look upon the sensible evidences of disease, the symptoms, 
as the manifestations of structural alterations already effected. As 
a rule, noteworthy symptoms are associated with more or less readily 
demonstrable structural alterations; but extreme disorder of function 
is not infrequently associated with apparently normal structure, and 
advanced structural alterations are not incompatible with long life 
1 The best work on the subject is Rolleston's Diseases of the Liver, Gall-bladder, 
and Bile Ducts, 2d edition, Macmillan & Co., 1912, a record of much personal obser- 
vation, including a thorough review of the literature, with many statistics and selected 
case-reports in brief. Another excellent book is Quincke and Hoppe-Seyler's Die 
Krankheiten der Leber, 2 Aufl., Wien u. Leipzig, Holder, 1912. 
442 DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
443 
and freedom from distress. It is essential to correlate function with 
structure, and to study diseased processes from the structural, the 
functional, and the chemical points of view. 
The functions of the liver may be said to be: (1) To detoxify poisons 
that enter the body by way of, or are elaborated within, the gastro- 
intestinal tract, or are perhaps produced elsewhere; (2) to secrete bile; 
(3) to warehouse some of the excess of fat taken as food and to release 
it when the supply from without becomes deficient; (4) to warehouse 
glycogen derived from the carbohydrates taken as food, or from the 
non-nitrogenous part of the proteins when the supply of carbohydrates 
is deficient, and to convert the glycogen into glucose and liberate it as 
it is required; and (5) to assist in the metabolism of the proteins to 
the extent, at least, of forming urea from ammonia compounds. 
Disorder of the functions of the liver may be primary or secondary 
(to structural alterations in the liver or to disease elsewhere); and it 
may be partial, involving perhaps only one function, or it may be total, 
involving presumably all the functions. The belief in a primary general 
disorder of function is exemplified in the terms torpid liver, biliousness, 
bilious headache, lithemia, etc., that have been handed down to us by 
our forefathers. Present-day opinions tend, perhaps unwisely, to 
minimize the influence of the liver in these disorders; but this seems 
an almost inevitable result of the knowledge that phenomena commonly 
attributed to a supposed torpid liver and the other affections mentioned 
may result from factors that do not involve the liver primarily, if at all, 
and that uric acid (lithemia), by no means the important factor in 
disease it was once thought, is not formed ■exclusively in the liver. The 
dyspeptic symptoms of a supposed torpid liver are usually due to a 
gastro-intestinal catarrh set up by dietetic indiscretions, excessive 
eating (especially of proteins and carbohydrates), the consumption of 
too much alcohol, etc.; the spread of this catarrh to the diverticulum 
of Vater and the common bile duct, or perhaps rarely a toxic descending 
radicular cholangitis, is answerable for the subicteric tint of the con- 
junctiva and skin. The liver usually participates only secondarily; 
perhaps toxins are produced in such amounts that the liver cannot 
neutralize them and they pass over into the circulation, or they are 
so virulent that they impair the detoxifying function of the liver cells or 
set up congestive and other alterations in the liver. In either event the 
symptoms are gastro-intestinal rather than hepatic in origin, and the 
liver, responding to excessive demands has often, for a time at least, 
increased rather than decreased functional activity. 
There is, however, another series of cases, such as the passive congestion 
of chronic cardiac and pulmonary disease, in which there is reason to 
believe that the functional activity of the liver is reduced. It is usually 
difficult, if not impossible, in these cases to differentiate the symptoms 
properly referable to disordered functions of the liver from those really 
due to the defective circulation in general with consequent congestion 
of the different organs, notably the intestines and the kidneys, and 
defective elimination. 
In another series of cases, more or less complete functional failure 444 
DISEASES OP THE DIGESTIVE SYSTEM 
of the liver ensues. These are cases of severe intoxication or infection, 
in which widespread destruction or disorganization of the hepatic par- 
enchyma occurs. The striking clinical phenomena, which may develop 
suddenly although they are sometimes preceded by minor symptoms, 
are for the most part nervous; they are variously designated hepatargia, 
acholia, cholemia, hepatic auto-intoxication, etc. Headache is a con- 
spicuous symptom, and is soon followed by mental excitement, delirium 
(which may be very active or maniacal), muscular twit chings, and 
convulsions; or mental hebetude progressing to deep coma may ensue. 
Most of these cases are associated with varying grades of jaundice and 
other phenomena that will be more fully discussed later. From time 
to time tests for determining the functional activity of the liver have 
been advanced, but few have withstood critical investigation. 
The Detoxifying Function.-Certain substances, highly poisonous 
when administered hypodermically, are much less harmful or entirely 
innocuous when administered by the mouth. In some cases, perhaps, 
this detoxification may be brought about by the gastric and the intestinal 
secretions; but in many cases the poisons are carried by the portal 
circulation to the liver, and there, probably by a process of oxidation, 
deprived of their toxicity. This obtains in the case of substances such 
as curare, nicotine, etc., and to a less extent in the case of substances 
such as morphine, strychnine, etc. The liver is believed to exert a 
similar detoxifying action on the toxins of certain bacteria, such as the 
typhoid bacillus, etc., and on the products of bacterial putrefaction in 
the intestine, such as indol and phenol. Doubtless in some cases these 
poisons are excessive in amount or in virulence, and the liver is unable 
successfully to cope with them. Disturbances in this protective or 
detoxifying function of the liver are believed by some observers to be 
the basis of the eclamptic manifestations of uremia, pregnancy, etc.; 
but the question still awaits solution. Pick1 also believes that if 
this detoxifying function is interfered with by an excess of toxin, dis- 
turbances of bile production, glycogen storage and uric acid formation 
may result and that the likelihood of cholelithiasis may be increased 
by consequent concentration of bile acids. In favor of the connection 
between disturbance of liver function and auto-intoxication is the co- 
incident appearance of gall-stone disease, gout, and glycosuria. 
There is no doubt that in disease the detoxifying function of the 
liver is more or less impaired, but there is no trustworthy method of 
determining and utilizing this as a diagnostic test clinically. The results 
of some studies by Hawk,2 suggest the wisdom of restricting the amount 
of meat in the diet in autotoxic conditions, since the use of meat appeared 
to increase the toxic phenomena. 
The Lipogenic Function.-In health the warehousing of fat in the 
liver is a function of less importance in man than in some of the lower 
animals, especially those that have little power to accumulate fat in 
the muscles and other tissues. In disease, however, the liver may store 
considerable fat, but only when the amount of stored glycogen becomes 
1 Wien. med. Wchnschr., 1912, Ixii, 3145. 
2 Am. Jour. Physiol., Boston, 1908, xxi, 259. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
445 
much decreased or disappears. Disturbances of fat metabolism may 
be attended by extremely serious consequences, notably the condition 
spoken of as acidosis, due to the presence of the acetone bodies-ace- 
tone, diacetic acid, and /3-oxybutyric acid. Although formed from the 
fats of the body in certain conditions when the oxidizing powers are 
reduced, they are directly related to deficiency of glycogen, which may 
be the consequence of insufficient intake (as in starvation) or of excess- 
ive output (as in diabetes). 
The Urea-forming Function.-The synthesis of urea from ammonia 
compounds and the availability of disturbances in this function as a 
test of hepatic insufficiency have also been much studied. A priori it 
is not unreasonable to suppose that in case the activity of the liver be 
reduced the amount of urea in the urine should be diminished and that 
of ammonia increased. This opinion has received some support from 
the experimental studies, by means of Eck fistulse on dogs, of Hahn, 
Massen, Nencki, Pawlow, and Salaskin. In jaundice from obstruction 
the output of urea is usually not affected, although the percentage of 
ammonia is increased. In cirrhosis, on the other hand, the urea is 
diminished and the ammonia is much increased-which lends support 
to the theory of disturbed urea synthesis; but this theory is more or 
less discredited by the fact that feeding ammonia salts to cirrhotic 
subjects is not followed by impairment of the formation of urea. Stadel- 
mann advanced the theory of acidosis, seeking to explain the increased 
ammonia output on the purely chemical basis of the neutralization of 
an excess of acid (as is seen in diabetes). The volatile fatty acids have 
been found increased; sarcolactic acid and diacetic acid have also been 
found, which, in connection with lessening of the alkalinity of the 
blood and increase of bases in the urine (Miinzer and Soetbeer), tends 
to confirm the theory of acid intoxication. 
The Glycogenic Function.-This has been much studied with a view 
to discovering, if possible, departures from the normal and utilizing 
these in clinical diagnosis. Stoppage of the flow of bile has been supposed 
to prevent the storing of glycogen. Glycosuria, as a matter of fact, 
has been observed in certain disorders of the liver, but as changes in 
the pancreas may also cause it, the occurrence of glycosuria does not 
prove that the trouble lies in the liver. The obvious inference has been 
combated by Naunyn, Kausch, and others. The weight of opinion is that 
alimentary glycosuria is not a trustworthy test of hepatic insufficiency.1 
A new impetus to the study of alimentary mellituria was given by 
Sachs, who found that dehepatized dogs showed a lessened tolerance 
for levulose, but not for dextrose, galactose, and arabinose. Studying 
the subject clinically, he found that healthy as well as diabetic subjects 
have a greater tolerance for levulose than for dextrose, and that the 
subjects of hepatic disease have a lessened tolerance for a like amount 
of levulose. Strauss, applying these results in a large series of cases, 
found that 90 per cent, of hepatic subjects presented levulosuria after 
the ingestion of a measured amount of levulose. His observations have 
1 Churchman, Johns Hopkins Hosp. Bull., 1912, xxiii, 10, 446 
DISEASES OF THE DIGESTIVE SYSTEM 
been confirmed by von Halasz1 and Goodman.2 Alimentary levulosuria 
thus has been suggested and utilized as a test of hepatic insufficiency. 
Although its trustworthiness has been questioned by a few observers, 
such as Landsberg, the weight of opinion is that it is of distinct value. 
It is much more satisfactory than alimentary glycosuria. Bauer3 in 1908 
suggested galactose for use in tests of liver function; Reiss and Jehn4 
have studied this test and state that it must be accepted with 
reserve. 
Of the many disorders of the liver, alimentary levulosuria seems to 
be of special diagnostic significance in cirrhosis. It has not been found 
in many non-hepatic diseases; pneumonic subjects are said to exhibit 
both spontaneous as well as alimentary levulosuria, but these are not 
likely to be confused with the subject of diseases of the liver. 
JAUNDICE 
Jaundice is a term applied to staining of the tissues with bile pigments 
which are present in the blood. It is recognized clinically by a yellowish 
or yellowish-green discoloration of the skin and visible mucous mem- 
branes and by the presence of bile pigments in the urine. It is not a 
disease sui generis, but merely a symptom of a wide variety of disorders. 
Although it indicates some disturbance in the secretion or excretion of 
bile, and is, therefore, significant of disease of the liver, it occurs also in 
disorders in which the liver is not involved primarily. 
Jaundice occurs in a variety of circumstances. In many cases it 
results from an obstruction to the free flow of bile. Often the obstruction 
is obvious and consists of: (1) An obstruction within the common bile 
duct or the hepatic duct, such as gall-stones, parasites, foreign bodies, 
etc.; (2) inflammatory, cicatricial, or neoplastic stenosis of the ducts; 
(3) compression of the ducts from without by tumors of the pancreas, 
stomach, intestine, gall-bladder, regional lymph glands, kidney, retro- 
peritoneum, mesentery, etc., inflammatory adhesions, swollen glands, 
fecal accumulations, aneurism of the aorta or of the hepatic or mesenteric 
artery; etc.; or (4) kinking or torsion of the ducts in consequence of 
gastroptosis, hepaptosis, nephroptosis, the pregnant uterus, tumors 
of the abdominal or pelvic organs, etc. In another series of cases-of 
disease of the liver unattended by gross obstruction of the extrahepatic 
biliary ducts-the hindrance to the free flow of bile is none the less 
demonstrable, if less marked and less obvious at first sight; these comprise 
cases of localized inflammatory processes (abscesses), tubercles, gummas, 
hydatid cysts, primary and secondary new-growths within the substance 
of the liver, etc. Jaundice, however, occurs under other circumstances 
in which apparently the biliary ducts are patent, as in cirrhosis and 
other diffuse diseases of the liver; in many infections, such as the different 
1 Wien. klin. Wchnschr., 1908, xxi, 44. 
2 Jour. Amer. Med. Assoc., Chicago, 1909, liii, 2054, 
3 Deutsch, med. Wchnschr., 1908, xxxiv, 1505. 
4 Deutsch. Arch. f. klin. Med., 1912, cviii, 187. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
447 
types of so-called infectious jaundice, syphilis, yellow fever, septico- 
pyemia, malaria, pneumonia, typhoid fever, etc.; in intoxications, such 
as poisoning with ptomains, phosphorus, arseniuretted hydrogen, chloro- 
form, mushrooms, toluylendiamin, pyrogallol, snake venom, coal-tar 
products, etc.; in acute yellow atrophy of the liver; in progressive perni- 
cious anemia and hemoglobinemia, and in disturbances of the circulation, 
such as passive congestion; in the new-born, etc. 
Types of Jaundice.-Different classifications of the disorder have 
been made variously based upon the supposed pathogenesis, the etiology, 
the clinical features or course, etc. It must be apparent that jaundice 
can result only from: (1) An obstruction somewhere in the course of 
the biliary tract in consequence of which the bile becomes absorbed by 
the lymphatics or the bloodvessels-jaundice from stasis of bile; or (2) 
disturbances in the functions of the liver cells, whereby the bile is diverted 
from the biliary capillaries to the lymphatics or the blood-channels- 
jaundice from parapedesis of bile. In the one case the disorder involves 
the bile after it has been formed and entered the biliary channels; in 
the other it involves the bile pigments while they are still within the 
hepatic cells. There is comparatively little discussion regarding the 
nature of the cases due to obvious obstruction of the extrahepatic or 
the intrahepatic ducts; these are commonly described as obstructive or 
mechanical jaundice. Regarding the cases of so-called non-mechanical 
or non-obstructive jaundice there are different opinions. A mistaken 
interpretation of surface phenomena led to a classification into: (1) 
Hepatogenous jaundice, that in which the liver, including the biliary 
ducts, was obviously at fault, that is, obstructed; and (2) hematogenous 
jaundice, that in which no disorder of the liver or the biliary ducts being 
apparent, the bile pigments were supposed to be formed in the blood- 
vessels in consequence of the destruction of erythrocytes and the con- 
version of the thus liberated hemoglobin into bilirubin. The work of 
Naunyn, Minkowski, Stadelmann, and others, proved that all jaundice is 
hepatogenous-in the sense that bile pigments are formed only in the 
liver. Nevertheless, the influence of increased destruction of erythro- 
cytes in providing the material (hemoglobin) from which bile pigments 
are formed in excess (polychromia) in some cases of jaundice cannot 
be gainsaid; this has led to the use of the term hemohepatogenous 
jaundice. Since this form of jaundice is found in toxic, infectious, and 
other conditions associated with destruction of erythrocytes, it is spoken 
of as toxic, infectious, or hemolytic.1 
Inasmuch as the etiological factor in many of the cases of so-called 
non-obstructive jaundice is unknown, it is quite impossible to differentiate 
them clinically or otherwise, aside from the severity of the symptoms; 
but the clinical designations, mild and severe, are often quite inappro- 
priate, since the degree of the jaundice and the severity of the other 
symptoms frequently bear no relationship whatever the one to the other. 
There can be little question that many of the cases represent only different 
stages or grades of the one process. In a simple and usually mild form, 
1 Consult Whipple and Hooper, Jour. Exp. Med., New York, 1913, xvii, 593. 448 
DISEASES OF THE DIGESTIVE SYSTEM 
jaundice is an accompaniment or sequel of gastro-intestinal catarrh; 
the direct cause of the jaundice is an extension of the catarrhal process 
to the diverticulum of Vater or the common bile duct and consequent 
obstruction to the flow of bile. Since these cases commonly pursue a 
benign course, and the few that have come to necropsy have 
revealed only catarrhal papillitis or cholangitis, the disorder is spoken 
of as simple or catarrhal jaundice (preferably catarrhal cholangitis). In 
another series of cases in addition to the jaundice there are phenomena 
of general infection, such as fever, neuromuscular pains, enlargement 
of the spleen and liver, gastrointestinal disorders, such as vomiting 
and diarrhoea, nervous manifestations, such as headache, stupor, etc., 
often leukocytosis, albuminuria, tube casts, etc.; to these cases the 
term infectious jaundice (Weil's disease) has been applied.1 The 
not uncommon epidemic occurrence of such cases warrants the use 
of the term epidemic jaundice. 
Cockayne2 states that catarrhal jaundice is the sporadic or endemic 
form of what he calls epidemic catarrhal jaundice, in the majority of 
cases. He also believes that in addition to sporadic and epidemic 
catarrhal jaundice, acute yellow atrophy is usually due to the same cause, 
a specific organism of unknown nature. In other cases the clinical 
phenomena are more severe, symptoms attributable to hepatic insuffi- 
ciency (hepatargia), to poisoning by bile acids (cholemia), or to hepatic 
auto-intoxication (acidosis), supervene, and a fatal issue usually ensues; 
the condition is spoken of as grave jaundice (icterus gravis). When, 
in addition, considerable destruction of the liver cells occurs, the term 
acute yellow atrophy of the liver is employed. No sharp line can be 
drawn between the cases; mild in the beginning (seemingly catarrhal 
jaundice), they may progress to the most severe and fatal form (acute 
yellow atrophy); the degree of jaundice bears no constant relationship 
to the demonstrable changes in the liver, nor, as already stated, to the 
severity of the other clinical phenomena; in some cases of unusual and 
widespread destruction of the hepatic parenchyma the jaundice may be 
slight, rarely even entirely absent, so that, until such time as the 
etiological factors shall have been better elucidated, we perhaps must 
rest content with the terms toxic, infectious, hemolytic, or hemohepa- 
togenous jaundice, as seems best suited to specific cases. Some of the 
cases are unquestionably examples of typhoid infection of the biliary 
tract; others are likely due to infection with Bacillus coli communis, 
Bacillus proteus, etc.; perhaps others are due to infection by unidenti- 
fied (anaerobic?) bacteria which, settling in the duodenum, multiply and 
produce an ascending cholangitis and ultimately more or less destruc- 
tion of the hepatic cells. Other cases, toxic in nature, result from the 
poisons transported to the liver by way of the portal circulation. In 
still other cases the primary action of the poison is on the erythrocytes 
(hemolysis), in consequence of which an increased amount of free 
hemoglobin is carried to the liver cells and transformed into bile 
pigments. 
1 Consult Boggs in vol. i, page 1014 of this work. .' 
2 Quart. Jour. Med., Oxford, 1912, vi, 1, DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
449 
Pathogenesis of Jaundice.-The mechanism of jaundice due to gross 
obstruction of the extrahepatic biliary ducts, or to none the less real if 
less marked obstruction of the larger intrahepatic ducts, is readily 
comprehended. On the one hand, the outflow of bile into the duodenum 
is hindered; on the other hand the hepatic cells, even after the common 
bile duct has been completely occluded, continue to secrete bile (although 
perhaps in lessened amount than normally), to convert into bile pigments 
the free hemoglobin brought thither. In consequence, then, of obstructed 
outflow and of continued production, bile accumulates within the biliary 
tract, the pressure increases, and the biliary ducts become dilated. It 
has been demonstrated by Eppinger1 that this dilatation involves not 
only the larger biliary ducts but extends to the finest biliary capillaries, 
which become enormously distended, especially at the points of com- 
munication of the capillaries of adjacent rows of liver cells. Furthermore, 
evidences of the increased pressure are seen in the intercellular biliary 
capillaries, which become lengthened in the direction of their distal end, 
dilate ampulla-like, and gradually approach and finally rupture into the 
lymph spaces between the hepatic cells and the bloodvessels; thence, 
by way of the thoracic duct, the biliary constituents reach the blood- 
vessels. That the pathway of the bile to the bloodvessels is by way of 
the lymphatics and the thoracic duct has been repeatedly demonstrated. 
The mechanism of jaundice not due to obvious or gross obstruction 
of the biliary ducts is not so well understood; it has been variously 
explained. Frerichs believed that the bile found its way directly into 
the bloodvessels in consequence of changes in the tension of the contents 
of the hepatic cells and of the bloodvessels-either an increase in the 
intercellular pressure or a decrease in the portal pressure. Leibermeister 
believed that the disordered liver cells lost their ability to retain or fix 
the bile, and that in consequence it became diffused into the bloodvessels 
or lymphatics-so-called diffusion or akathektic jaundice. Minkowski 
assumed a disturbance in the normal currents within the liver cells, 
so that the bile became diverted from the biliary capillaries to the 
bloodvessels or lymphatics-jaundice from parapedesis (paracholia of 
Pick). It is not unlikely that the toxic and infectious causes of this 
form of jaundice seriously compromise the functional integrity of the 
liver cells; but it has also been demonstrated that they provoke a 
radicular cholangitis which obstructs' the free flow of bile. Eppinger 
states that in these cases thrombi made up of coagulated bile occur in 
and obstruct the biliary capillaries; in consequence thereof, mechanical 
stasis of the bile develops in the finest biliary capillaries, and, as in cases 
of gross obstruction of the larger extrahepatic ducts, the biliary canaliculi 
dilate and ultimately rupture into the pericellular lymph spaces. The 
bile thrombi are interpreted as a manifestation of biliary inspissation, 
perhaps related to coagulation of a pathological albuminous exudate 
(to which the liver cells become pervious); but the basic cause is believed 
to be marked erythrocytolysis in consequence of which the liver is 
forced to the production of increased bile pigments. Experimentally, 
1 Ergebnisse der inneren Medizin und Kinder heilkunde, 1908, i, 107 (literature). 
vol. in-29 450 
DISEASES OF THE DIGESTIVE SYSTEM 
it has been found that in these cases there is at first an increased 
formation and excretion of bile (polycholia) and of bile pigments (poly- 
chromia); soon, however, the excretion of bile lessens, the bile that is 
excreted becomes viscid, and finally excretion may cease, which may be 
attributed to a radicular cholangitis or the biliary thrombi, or both. 
Thus, although this form of jaundice is properly called toxic, infectious, 
or hemolytic, it is at the same time hepatogenous and obstructive. The 
degree of jaundice is determined by the degree and extent of the obstruc- 
tion rather than by the amount of hemolysis: a high grade of jaundice 
may occur with comparatively little hemolysis, whereas considerable 
hemolysis may be attended with only slight jaundice. 
Icterus neonatorum is a peculiar form of jaundice that develops in 
from two-thirds to three-fourths of new-born infants on the second or 
third day of life, and usually fades within a week or ten days. The 
cutaneous discoloration is slight, and is commonly unattended by other 
symptoms. The urine is often of normal color, and usually does not 
contain soluble bile pigments, but may reveal biliary granules or crystals 
in desquamated renal epithelium. The nature of this form of jaundice 
is not well understood. It has been attributed to compression of the 
biliary capillaries by distended portal radicles; to catarrhal cholangitis 
(Virchow); and to biliary stasis in consequence of the diminutive size 
of the bile ducts and consequent obstruction (Kehrer and Cohnheim). 
Frank attributed it to absorption of bilirubin from the meconium; and 
Quincke has suggested that this bilirubin, which is not converted into 
urobilin on account of the absence of intestinal fermentation in the new- 
born, being absorbed, reaches the general circulation by way of the 
ductus venosus without traversing the liver. Stumpf1 comes to the 
conclusion that it does not depend upon an infection spreading from the 
umbilical cord. Perhaps the disorder is really due to the erythrocyto- 
lysis of the early days of life. If this be the true explanation, the patho- 
genesis is that of hemolytic jaundice. This benign form of jaundice 
must be distinguished from a more severe and often fatal form that 
may also occur in the early days of life in consequence of congenital 
syphilis, septicopyemia, congenital obliteration of the bile ducts, etc. 
Chronic splenomegalic hemolytic jaundice2 is a type which has recently 
received a good deal of attention and which has been described under 
many synonyms calling attention to its hereditary or familial character, 
though some cases seem to be purely of an acquired form. In the true 
familial type the jaundice, which is not very marked, dates usually 
from birth, or is noticed first during adolescence and occurs in several 
members of a family, often through a number of generations. The 
jaundice persists throughout the life of the patient but causes practically 
no symptoms. As Chauffard has expressed it, these patients are rather 
jaundiced than sick. The urine and stools are highly colored, the urine 
containing urobilin, and there is no evidence of biliary obstruction, the 
1 Wien. klin. Rundschau, 1910, xliv, 687 (literature). 
2 Consult Chauffard. Semaine med., 1907, xxvii, 25; 1908, xxviii, 48; Tileston and 
Griffin, Am. Jour. Med. Sci., Phila., 1910, cxxxix, 847; Thayer and Morris, Johns 
Hopkins Hosp. Bull., 1911, xxii, 85. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
451 
jaundice apparently being due to an excess of biliary pigment resulting 
from the destruction of the red-blood corpuscles. Chauffard has pointed 
out that the red-blood cells show an increased fragility when they are 
exposed to hypotonic solutions of sodium chloride according to the 
method of Vaques and Ribierre. The spleen is almost invariably enlarged, 
at times to enormous size, though the liver is usually not enlarged, or 
only slightly so. These patients have "bilious attacks" quite commonly, 
even after slight indiscretions in diet; they are apt to have gall-stones 
(in 5 out of 8 cases coming to autopsy) and pain in the region of the gall- 
bladder is common. There is moderate anemia. 
In the so-called acquired form there is not the same clean-cut disease 
picture; the patients usually show a more intense anemia and the fragility 
of the red-blood cells so characteristic of the familial cases is wanting. 
Recovery may occur after prolonged administration of iron in the 
acquired forms, but apparently cannot be expected in the hereditary 
cases. Chauffard1 has lately changed his views on the apparent absence 
of danger in the congenital cases and states that serious complications 
may arise, such as cholangitis and cholelithiasis. Splenectomy, which 
has been suggested, he feels should only be resorted to after thoroughly 
explaining to the patient the danger of the operation. As Rolleston 
puts it these patients should live a protected life. 
Effects of Jaundice.-The clinical phenomena attendant upon jaun- 
dice are due largely to the underlying causes of which the jaundice itself 
is merely a symptom. The symptoms, however, insomuch as they are 
related directly to the jaundice and not to the underlying cause, are 
due on the one hand to the presence of biliary derivatives in the cir- 
culating blood, and, on the other hand, to the absence of bile from the 
intestine. All of the tissues and organs, with the exception of the nervous, 
are stained with biliary pigments; and in some severe cases of toxic or 
infectious jaundice the nervous system also may be stained. The staining 
is due, in part, to the deposition of biliary pigments in the tissues, in 
part to the circulation of blood and lymph containing undeposited 
pigments; it is most marked in the skin, mucous membranes, serous 
membranes, the liver, kidneys, heart, transudates, exudates, etc. 
The Mucous Membranes and the Skin -Jaundice is manifested first 
by a yellowish discoloration of the conjunctivae; in mild cases the dis- 
coloration is demonstrable there only. In the other visible mucous 
membranes, except that of the hard palate, the jaundice, unless of high 
grade, becomes apparent only after the tissues, by pressure, have been 
deprived of blood; the mucosa of the hard palate, however, being normally 
pale may reveal the discoloration without this. 
The skin becomes of a characteristic lemon-yellow, orange-yellow, 
greenish-yellow, olive, or olive-bronze color. The discoloration is light 
in many cases of toxic or hemolytic jaundice, in which it is rarely 
more than moderate in grade; it is light also in mild cases of catarrhal 
cholangitis; it is darkest in cases of permanent and complete obstruction 
of the common bile duct, and it may become so dark-olive bronze or 
1 Bull, med., Par., 1912, xxvi, 1159. 452 
DISEASES OF THE DIGESTIVE SYSTEM 
greenish black-as to warrant the designation black jaundice (melan- 
icterus, icterus melas). The intensity of the jaundice in these cases is 
proportionate to the completeness of the obstruction of the common 
duct, or, in case the obstruction involve one of the larger intrahepatic 
ducts, to the size of the duct implicated. The jaundice occurs earliest 
(sometimes within several hours) in cases of obstruction to the finer 
biliary ducts and capillaries, on account of the seat of the obstruction; 
it is delayed, commonly four or five days, in obstruction of the common 
duct, because the bile accumulating gradually distends the larger ducts 
and the gall-bladder. Time is required to produce sufficient pressure in 
the biliary canaliculi to cause their rupture into the adjacent lymphatic 
spaces and consequent absorption of bile. The pigment for the most 
part is deposited in the cells of the rete Malpighii, where in great measure 
it persists, often causing an obvious discoloration until the cells have 
been desquamated. It is for this reason that the cutaneous discoloration 
commonly persists a week, perhaps several weeks, after bile pigments 
have disappeared from the urine. 
Of other cutaneous manifestations, pruritus is the most common and 
distressing. Rarely it precedes the discoloration of the skin; it is likely 
to develop in cases of jaundice of sudden onset; as a rule it is most 
marked in protracted and severe cases; but it bears no definite relationship 
to the duration or the severity of the jaundice. Urticaria, perhaps due 
to a toxemia, is not uncommon. Considerable sweating, often localized 
to the palms, etc., is sometimes observed. Local infections, such as 
boils, occasionally occur. In chronic cases, local telangiectases of the 
skin (sometimes also of the oral and other mucous membranes) tend to 
develop, and flat or nodular yellowish, chamois-leather-colored patches 
(xanthelasma, xanthoma, vitiligoidea1) may appear on the skin or mucous 
membranes. These are most common in the skin of the eyelids, and in 
the folds and creased of the joints; they tend to be symmetrical in dis- 
tribution; they have been observed on the gums, in the mucosa of the 
biliary ducts (perhaps in part answerable for the jaundice), etc. They 
are believed to be inflammatory or endothelial in origin, and to be due 
to the jaundice or an associated toxemia. 
The Blood.-Bile pigments are present in excess in the circulating 
blood, but whether they exert any deleterious effect on the blood itself 
has not been satisfactorily determined. The major toxic action of the 
bile is due to the bile acids-salts of glycocholic and taurocholic acids. 
Chauffard2 calls attention to variations in the symptoms depending 
upon the predominance of one or other of the three component elements 
of the bile (bilirubin, the bile acid salts of glycocholic and taurocholic 
acids, and cholesterin). Glycocoll and taurin result from hydrolysis 
of protein; the source of cholic acid is not definitely known. At the 
inception of jaundice these acid salts may be found in the circulating 
blood, but after jaundice is well established they usually disappear from 
the blood, being apparently produced in lessened amount,although the bile 
pigments continue to be produced in normal or almost normal amount. 
1 Consult Futcher, Amer. Jour. Med. Sci., Phila., 1905, cxxx, 939. 
2 Presse med., Par., 1913, xxi, 81. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
453 
In ordinary obstructive jaundice the amount of bile acids in the blood 
is not sufficient to produce any noteworthy hemolysis; indeed, polycy- 
themia is not uncommon. Pearce, Austin, and Musser1 have shown that 
if a splenectomized animal is injected with hemolytic serum jaundice 
does not occur; they believe that this is due in some way to the anemia 
which follows splenectomy. Indeed, jaundice is not readily produced in 
animals with low counts even if the spleen has not been removed. In 
toxic or infectious jaundice, however, hemolysis is common; usually 
it is itself the direct cause of the jaundice, but it may be increased by 
circulating bile acids. Chauffard2 believes in the possibility of differ- 
entiating hemolytic from ordinary obstructive jaundice by the fragility, 
granular appearance, and small size of the erythrocytes (those from 3 
to 6^ in diameter increasing to 15 to 18 per cent, of the total number); 
in obstructive jaundice the erythrocytes are said to be normally resistant, 
of normal size, and free from granulations. The coagulation time of 
the blood is much increased in jaundice-from the normal three to four 
minutes to ten to twelve minutes, a fact of much importance when 
surgical operations in jaundiced patients are under consideration. In 
protracted and severe cases there is a marked tendency to subcutaneous, 
submucous, and subserous hemorrhages. The alkalinity of the blood 
is but slightly changed, if at all, except perhaps in some cases of cirrhosis 
with jaundice, in which it may be somewhat reduced. Whipple and 
Hooper3 believe that in dogs, at least, hemoglobin can be rapidly changed 
into bile pigment in the circulating blood without participation of the 
liver. This they showed by injecting intravenously red cells from the 
same dog after they had been laked with distilled water. There was 
bile-pigment formation notwithstanding the fact that the dog's liver, 
spleen and intestines had been shut out of the circulation. 
The Heart and Bloodvessels.-Bradycardia is a characteristic feature 
of jaundice, especially of acute cases and those of short duration. The 
pulse rate may fall to 60, to 40, even to 21 (Frerichs) a minute, and it is 
subject to sudden fluctuations upon slight provocation. This has been 
attributed to a local inhibitory action of the bile acids on the cardiac 
muscle or ganglia; but recent investigations suggest that perhaps the 
action is on the central nervous system. In chronic cases the bile acids 
become much reduced in amount or disappear, or the cardiac muscle 
becomes accustomed to their influence, and the bradycardia usually 
lessens or disappears. 
The Urine and Other Excretions.-In jaundice a considerable portion 
of the biliary derivatives is excreted in the urine, which, in consequence, 
is discolored yellowish, yellowish red, greenish, or greenish brown, 
depending upon the relative amounts of bilirubin, biliverdin (its oxidation 
product), or urobilin (its reduction product). These bile pigments may 
be found in the urine several hours, or even several days, before there is 
any obvious discoloration of the skin or visible mucous membranes. 
The urine often contains a number of hyaline, sometimes bile stained, 
1 Jour. Exp. Med., New York, 1912, xvi, 758. 
2 Semaine med., Par., 1908, xxviii, 49. 
3 Jour. Exp. Med., New York, 1913, xvii, 593. 454 
DISEASES OF THE DIGESTIVE SYSTEM 
casts, attributable to irritation of the convoluted and Henle's tubules 
provoked by excreting the bile pigments (which are not excreted by 
the glomeruli). 
Urobilinuria1 is commonly observed in disease of the liver. Urobilin 
as well as urobilinogen are formed in the intestine by the action of 
bacteria on bilirubin; they are absorbed and carried to the liver by the 
portal circulation. They are found in the urine especially when the 
liver is disordered, and in chronic disease of the liver they are believed 
by Edsall2 to be significant of cirrhosis when there is no passive con- 
gestion, obstruction of the biliary ducts, or carcinoma. The occurrence 
of urobilinuria in cases of jaundice does not justify the designation 
"urobilin jaundice," since the cutaneous pigmentation is due to 
bilirubin and biliverdin. 
Excretions other than urine also are stained in jaundice, such as the 
sweat (staining of the personal and bed linen), serous exudates and transu- 
dates, etc. The saliva, tears, mucus, and milk are not stained, unless 
a pathological inflammatory exudate be added to them. The sputum of 
complicating croupous pneumonia is stained, but not that of bronchitis. 
The Liver.-Although it is quite impossible to study the bile during 
life, except in those cases in which biliary fistulse have been made, it is 
probable that during the persistence of the biliary obstruction bile is 
formed in lessened amount (oligocholia, hypocholia). In some cases 
bile pigments appear to be formed in normal amount; in some cases 
they seem to be lessened. French authors have described a colorless 
bile, which is said to contain bile acids and cholesterin. 
Nervous System.-Grave disturbances of the nervous system occur 
in many cases of jaundice; on the one hand, there are manifestations of 
depression, such as general neuromuscular weakness, asthenia, headache, 
vertigo, mental depression (that may progress to melancholia), insomnia, 
etc.; on the other hand, there are manifestations of irritation, such as 
severe headache, active delirium, coma, convulsions, etc. These mani- 
festations are more common in cases of acute toxic or infectious jaundice 
(associated with fever) than in the more protracted cases of obstructive 
jaundice; but they may supervene in any case of jaundice and not 
uncommonly lead to the fatal issue. They are commonly described 
under the name cholemia, but it is difficult to separate from one another 
the symptoms due to bile acidemia, to interference with the detoxifying 
function of the liver, and to the initiating toxic or infectious process. 
The condition is not cholemia in a restricted sense, that is, it is not due 
to bile acidemia, since the symptoms may occur when bile acids are not 
in excess in the blood, as well as in cases of disease of the liver (such as 
cirrhosis) unassociated with jaundice. The condition is most likely an 
acid intoxication, due to disturbances of the detoxifying function of the 
liver, which may be brought about by disorganization of the hepatic 
parenchyma such as occurs in severe forms of toxic and infectious 
jaundice, acute yellow atrophy of the liver, phosphorus poisoning, 
1 Consult Hildebrant, Ztschr. f. klin. Med., Berl., 1906, lix, 351. See also a com- 
plete discussion by Wilbur and Addis, Arch. Int. Med., 1914, xiii, 235 (literature). 
2 Univ. Penn. Med. Bull., Phila., 1904, xvi, 427. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
455 
Eek's fistula, starvation, diabetes, etc., or by an excessive formation of 
enterogenic toxins, the consequence of absence of bile from the intestine. 
Gastro-intestinal Tract.-The absence of bile from the intestinal tract 
results, as a rule, in the passage of large, pale, grayish, slate-colored or 
clay-colored, pasty, fetid, acid stools. The pale color is due, in part 
only, to the absence of bile; in part it is due to the large amount of 
imperfectly digested fats, which may be increased from the normal 7 
to 10 per cent, to as much as 80 per cent. Microscopically and chemically 
the fats are found to consist of free fatty-acid crystals and soaps (calcium 
and magnesium) of the higher fatty acids; neutral fats are present in 
very small amounts. Rarely pale or decolorized stools contain biliary 
derivatives in considerable amount-determinable by chemical exami- 
nation; this occurs especially in disease of the pancreas attended by 
obstruction to the outflow of the pancreatic juice but unassociated with 
jaundice. The pale color of the feces in these cases is due to the large 
amount of fat,1 and to the reduction of bilirubin to leuko-urobilin.2 
It is not always warrantable, therefore, to base on the color of the stools 
an opinion of the amount of bile that enters the intestine or of the degree 
of biliary stasis. The offensive odor of the stools is usually ascribed to 
the absence of bile which, when present, limits fermentation of the intes- 
tinal contents. Often, however, there is very little fermentation. Stras- 
burger has demonstrated no undue protein decomposition; and the 
odor may be described as peculiar rather than offensive, being due to 
the higher fatty acids. Rogers3 believes that the bile acts not by neutral- 
izing toxins but by hindering their formation. Constipation is perhaps 
the rule, and is due to defective motility, the result of lack of the stimu- 
lating influence of the bile. Sometimes the bowel movements are 
frequent, perhaps diarrhoeic, which may be due to large fecal masses 
resulting from imperfect digestion of fat and to the laxative action of 
the free fatty acids. There is no effect on carbohydrate metabolism and 
very little on protein metabolism. Gastric hyperacidity is the rule, 
the biliary obstruction apparently causing an increase in the secretory 
activity of the stomach. 
General Nutrition.-Man is able to withstand the effects of jaundice 
for a long time. The fatalities that ensue in the acute as well as in the 
chronic cases are due not so much to the jaundice per se as to other 
causes-the underlying cause of the jaundice, acid intoxication, etc. 
In long-standing cases, however, more or less disturbance of the general 
nutrition gradually ensues-due largely to imperfect fat absorption. 
ANOMALIES OF FORM AND POSITION 
Congenital Anomalies of Form.-The liver, in consequence of defects 
of development, is occasionally found in the thoracic cavity or 
1 Consult Gordon, Cammidge, Watkins, and Robson, Lancet, Lend., 1905, ii, 1687, 
1803, 1951; 1906, i, 57, 185, 255. 
2 Schmidt und Strasburger, Die Faeces des Menschen, 1905, 2te Aufl. 225. 
3 Lancet, 1910, i, 210. 456 
DISEASES OF THE DIGESTIVE SYSTEM 
projecting beneath the skin near the umbilicus (hepatomphalos); in 
monsters the organ may be entirely absent. Small portions of aberrant 
hepatic tissue are occasionally found in the suspensory ligament or the 
adjacent connective tissue. In partial and complete transposition of the 
viscera the liver may be as much in the left half of the body as normally 
it is in the right; in this event the left lobe is the larger. Rarely the 
normal relative size of the different lobes is changed: the left lobe may 
be unusually large or unusually small (defective blood-supply during 
intra-uterine or early extra-uterine life); the smaller lobes may be smaller 
or larger than normally, and they are sometimes more or less pedun- 
culated. Congenital linguiform lobulation of the right lobe has been 
described; it is commoner in children, and it may be mistaken clinically 
for acquired linguiform lobulation. Well-marked lobulation of the entire 
organ is occasionally encountered: sometimes, doubtless, it is a fetal 
manifestation, homologous with similar lobulation of the kidney; often, 
however, it is a postnatal acquired condition due to syphilis, perhaps 
tuberculosis, perihepatitis, etc. 
Acquired Anomalies of Form (Deformities).-The important acquired 
anomalies of form consist of: (1) The so-called corset, or constricted, 
liver; (2) linguiform lobulation; and (3) changes due to diseases of 
adjacent organs. 
The corset, or constricted, liver is the consequence of tight lacing, and 
is therefore almost wholly confined to the female sex (as much as 25 per 
cent, of female cadavers in some series); but an analogous condition is 
sometimes encountered in men, the result of the constricting influence 
of a tight belt or strap. The basis of the deformity is a pressure atrophy 
of the liver parenchyma followed by fibrosis. Sometimes there is only 
a deep circumferential furrow; usually the liver is considerably elongated 
and markedly thinned at the point of greatest constriction (most marked 
atrophy), which often corresponds with the plane of the upper pole of 
the right kidney. In some cases but little hepatic parenchyma remains 
at the point of maximum constriction, and the elongated portion of 
the right lobe, which may reach to the transverse umbilical line, is 
attached to the major portion of the organ by a fibrous hinge-like band. 
Various grades of this condition are encountered, and it gradually merges 
into that spoken of as a linguiform (or Riedel's) lobe (partial hepato- 
ptosis). Occasionally the left lobe is similarly constricted and elongated. 
The surface of the superior part of the right lobe usually exhibits furrows 
or indentations corresponding with the ribs; occasionally the posterior 
margin of the left lobe is much infolded (corresponding folds of the 
diaphragm are usually encountered). The capsule of the liver and the 
overlying peritoneum are often much thickened, 'especially at the point 
of greatest pressure and constriction. 
Linguiform lobulation is in many respects an exaggeration of the condi- 
tion previously described. Both are common in female subjects, but 
the linguiform lobe, as originally pointed out by Riedel (whence Riedel's 
lobe) is intimately related to cholelithiasis and cholecystitis, enlargement 
of the gall-bladder being found in 60 per cent, of the cases. Tight lacing, 
however, is often at least partly responsible for the condition, since it 457 
DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
doubtless leads to kinking of the cystic duct and consequent obstruction 
to the free flow of bile. These linguiform lobes are often long and much 
attenuated; frequently they are attached to the main portion of the liver 
by a thin fibrous band; and they are often extremely mobile (partial 
hepatoptosis). In consequence of long-continued congestion they not 
infrequently show the lesions of well-marked nutmeg liver with increase 
in fibrous tissue. They are comparatively commonly the seat of other 
diseases, such as gumma, abscess, tumor, etc. 
Symptoms.-The corset liver and a linguiform lobe may be entirely 
symptomless. In some cases there are symptoms of indigestion, as likely 
due to the tight lacing as to the changes in the liver. A lingual lobe is 
sometimes painful and tender, due to congestion or associated chole- 
cystitis and cholelithiasis; occasionally nausea and vomiting ensue, and 
have been attributed to interference with the functions of the pylorus 
and duodenum; occasionally pains of biliary colic occur. In other cases 
the abnormality may be mistaken for an abdominal tumor. 
Diagnosis.-This is not specially difficult when the likelihood of the 
conditions is borne in mind and the abdomen is examined carefully. 
Usually the abnormal lobe will be found to move with the liver during 
respiration, and it can be proved to be continuous with the liver, even 
when a coil of intestine courses over the most constricted part. The 
lobe may be mistaken for a dilated gall-bladder, floating kidney, hydro- 
nephrosis, tumor of the stomach, colon, pancreas, omentum, or ovary 
(solid or cystic), appendicitis, etc. 
Prognosis.-The prognosis depends upon the etiological factors and 
the advance made by the lesions. 
Treatment.-The corset liver is better prevented than cured. 
Acquired Anomalies of Position.-The liver may be displaced upward, 
downward, or laterally, or it may be rotated on its anteroposterior axis 
(anteverted or retro verted). Displacement downward results in conse- 
quence of disease above the diaphragm, such as pleuritis with exudation, 
hydrothorax, emphysema, tumors or abscesses of the lungs or medias- 
tinum, etc., as well as of disease between the diaphragm and the liver, 
subdiaphragmatic or suprahepatic abscess. Displacement upward results 
in consequence of disease of the abdominal organs, especially ascites, 
tympanites, tumors, traumatic diaphragmatic hernia, etc. Frequently 
when displaced upward the liver is also rotated posteriorly, so that the 
inferior surface presents anteriorly and upward, due to the liver being 
rather fixed posteriorly with the inferior vena cava. Occasionally the 
liver is tilted anteriorly, so that much of the upper surface of the organ 
comes in contact with the anterior abdominal wall; its anterior edge 
may fall as low as or lower than the umbilicus, whence marked enlarge- 
ment of the organ may be simulated. This may occur in large aneurism 
of the descending thoracic or upper abdominal aorta, and in tumors of 
the kidney, adrenal, retroperitoneal glands, etc. The symptoms of such 
displacement of the liver are altogether secondary to those due to the 
primary disorder. The diagnosis is usually quite obvious upon detecting 
the primary disorder; indeed, in some cases the evident displacement 
of the liver is a valuable aid in recognizing the primary disorder (such 458 
DISEASES OF THE DIGESTIVE SYSTEM 
as pleural exudation, etc.). The displacement must be differentiated 
from other diseases, causing, on the one hand, lessening of the liver dulness 
and apparent diminution in the size of the liver (acute yellow atrophy, 
portal cirrhosis, intestinal distension, etc.), and those, on the other hand, 
causing enlargement of the liver (fatty and amyloid degeneration, portal 
and biliary cirrhosis, leukemic infiltration, carcinoma, sarcoma, etc.). 
Hepatoptosis.-The important acquired anomaly of position is that 
variously spoken of as hepatoptosis, wandering liver, movable liver, 
etc., a condition in which the liver is abnormally movable and presents 
variously in the abdominal cavity. 
DISEASES OF THE HEPATIC ARTERY 
Dilatation.-This occurs when the portal vein is obstructed (throm- 
bosed or compressed), in which event the artery acts vicariously for 
the vein; this is seen especially when small branches of the portal vein 
are obstructed. The dilatation involves usually the branches of the 
hepatic artery, but it may extend to the main trunk. This compensatory 
action of the artery for the vein is never efficient. A compensatory 
enlargement of the hepatic artery is observed also in conditions of 
connective-tissue overgrowth, as in the advanced stage of cirrhosis. 
The capillaries especially are involved, but the process may extend to 
the main trunk. This is an important factor in causing the increased 
portal pressure and the consequent ascites in portal cirrhosis. 
Thrombosis.-Thrombosis of the hepatic artery in man is such a 
rarity, not more than two cases (Ledien and Lancereaux) being on record, 
and one of these being doubtful, that its results are unknown. 
Embolism.-Embolism of the hepatic artery is comparatively uncom- 
mon. Purely mechanical emboli are probably comparatively innocuous, 
on account of the free arterial anastomosis, and the part of the organ 
cut off from blood-supply by embolism of a small branch of the hepatic 
artery is doubtless speedily supplied by blood from a collateral vessel. 
Embolism of the main trunk or principal branch has resulted in anemic 
infarction and necrosis. Infectious emboli are not rare; they occur in 
sepsis, involve the smaller branches of the artery, and give rise to multiple 
abscesses. Clinically the general condition usually overshadows the 
local lesions in the liver. Sarcomatous emboli are often observed in 
melanotic sarcoma, especially that originating in the eye. 
Aneurism.-Aneurism of the hepatic artery is a rare condition. Rolland1 
in 1908 was able to collect from the literature only 40 undoubted cases. 
The condition is about three times as common in men as in women (30 
men, 9 women, Rolland). The age varies from fourteen to eighty-three 
years, the average of 36 cases being thirty-seven years; the average in 
men being thirty-five years, in women forty-five years (Rolland). 
Pathology.-The aneurism may be extrahepatic or intrahepatic. Of 
the 40 cases collected by Rolland, 24 were extrahepatic, 8 intrahepatic, 
1 Glasgow Med. Jour., 1908, Ixix, 342. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
459 
2 both extrahepatic and intrahepatic (two aneurisms in each), and 6 
were not definitely described. In Rolland's own case there were three 
aneurisms, all intrahepatic. In 16 cases the main vessel was involved; 
in 12, the right branch; in 3, the left branch; in 3, both branches; and in 
1, the cystic artery. The aneurism may be of the true or the false variety. 
Of the 40 cases collected by Rolland, 32 resulted in rupture into the 
peritoneum, the biliary passages, the portal vein, the stomach, the 
duodenum, with associated rupture of the liver in the intrahepatic forms 
in 4 cases; 6 were found unruptured; and in 2 the condition is not known. 
Symptoms.-Rolland states that the three most constant symptoms 
are pain, jaundice, and hemorrhage. Pain is rarely absent; in typical 
cases it is paroxysmal and resembles that of biliary colic, being referred 
to the right hypochondrium and epigastrium, which are usually tender. 
Pain is usually absent between attacks. The pain is attributed to 
pressure on the hepatic plexus of nerves and to stretching of Glisson's 
capsule. Jaundice occurred in 16 of the 40 cases; but in most of the 
cases there is no statement with regard to jaundice. When present it 
has usually been more or less permanent, and is due to pressure on the 
hepatic or the common bile duct. In none of the cases did the jaundice 
appear to be related to the attacks of pain. Hemorrhage into the ali- 
mentary tract occurred in 17 of the 40 cases. Usually the blood reached 
the alimentary tract by way of the biliary ducts; rarely was there direct 
hemorrhage into the stomach or the duodenum; and rarely the bleeding 
was due to pressure on the portal vein and consequent passive congestion. 
Melena is the common clinical symptom; hematemesis is less common. 
The hemorrhage may be frequently repeated. Fever (as high as 104°) 
occurred in a few cases, usually with the paroxysmal pain, and was 
sometimes accompanied by rigors. Disturbances of digestion are 
common, due to the effect of local pressure by the aneurism. 
Diagnosis.-No case has been recognized during life except at explora- 
tory laparotomy-whereby Kehr first detected the condition. Cholelithi- 
asis and duodenal ulcer are the most likely diagnoses. Hemorrhages are 
much less frequent in cholelithiasis than in aneurism of the hepatic 
artery; in aneurism hemorrhage may be the first symptom; in chole- 
lithiasis it is always a late symptom, usually due to fistula formation; 
both conditions may occur together. The association of symptoms of 
duodenal ulcer and of biliary colic might suggest the diagnosis. 
Treatment.-Should the condition be diagnosed, the hepatic artery 
or one of its branches should be ligated. This has been done success- 
fully by Kehr, and is justifiable, since a sufficient collateral circulation 
is likely to develop. Otherwise treatment is purely palliative. 
DISEASES OF THE HEPATIC VEINS 
Dilatation.-Dilatation of the hepatic veins and their branches is a 
concomitant of disease of the heart and lungs attended by failure of the 
right side of the heart. The dilatation extends to the central vein of the 
hepatic lobule, and is often associated with thickening of the vessel wall, 460 
DISEASES OF THE DIGESTIVE SYSTEM 
perivascular fibrosis, and pigmentation and atrophy of the surrounding 
hepatic parenchyma. 
Thrombosis.-Thrombosis of the hepatic veins is a rare condition 
due to: (1) Intrahepatic or extrahepatic compression of the vein or 
its branches by a tumor, cyst, enlarged glands, etc.; (2) chronic stricture, 
the consequence of adhesions (perihepatitis) near the junction of the 
inferior vena cava; (3) neoplastic invasion of the vessel wall, which may 
progress to penetration of the vessel wall; (4) acute and chronic inflam- 
matory disease of the vessel wall, syphilis, tuberculosis, etc., usually 
associated with interstitial hepatitis; (5) extension of a clot partially or 
completely occluding the inferior vena cava; and (6) occasionally it 
follows, sometimes precedes, thrombosis of the portal vein. The lesions 
are analogous to those of chronic passive congestion. Ascites and more or 
less enlargement of the spleen usually develop rapidly, but the condition 
is scarcely susceptible of clinical recognition. It may be suspected in 
cases of aggravated passive hyperemia upon the sudden onset of ascites. 
Embolism.-Embolism of the hepatic veins is uncommon, and can 
result only from reversal of the blood stream. 
Suppurative Phlebitis.-Suppurative phlebitis (thrombophlebitis) of 
the hepatic veins sometimes ensues in cases of acute infectious inflam- 
mation of the liver, suppurative cholangitis, hepatic abscess, etc., the 
infection being more prone to involve the hepatic veins than the branches 
of the portal vein, because the latter are comparatively well protected 
by a connective-tissue capsule. In the event of suppurative phlebitis 
of the hepatic veins, secondary abscesses in the lungs and general septico- 
pyemia ensue. 
Chronic Obliterating Endophlebitis.-Chronic obliterating endo- 
phlebitis of the hepatic veins, a disorder characterized by slow proliferation 
of the lining of the hepatic veins and consequent obstruction, is a com- 
paratively rare affection. Hess1 in 1905 was able to collect only 23 cases, 
but he is inclined to believe that many cases have been overlooked, since 
clinically they resemble ordinary or portal cirrhosis of the liver, and 
unless at the necropsy the hepatic portion of the inferior vena cava is 
opened and the ostia of the hepatic veins examined, the clinical diagnosis 
of cirrhosis of the liver is likely to be declared correct. 
DISEASES OF THE PORTAL VEIN 
Thrombosis.-Thrombosis of the portal vein (pylethrombosis, pyle- 
phlebitis adhesiva) is more common in males than in females. It occurs 
at all ages, the average age in men being 44.8 years, and in women 41 
years (Rolleston). The thrombosis may begin in the portal radicles 
within the liver, in the main trunk of the vein, or in the peripheral 
radicles anywhere within the area of collection of the vein; and sub- 
sequently by extension the process may become widespread. 
Thrombosis of the intrahepatic radicles of the portal vein is the commonest 
form, and is due most frequently to cirrhosis. The cirrhotic process 
1 Amer. Jour. Med. Sci., 1905, cxxx, 986. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
461 
leads to gradual obstruction and ultimate isolation of certain sections 
of the portal distribution, and the increased pressure induces endo- 
phlebitis, in consequence of which the contained blood coagulates. The 
original coagula are gradually increased in size by secondary accretions, 
until not infrequently they become widespread, extending even to the 
main trunk of the portal vein. Thrombosis within the branches of the 
portal vein in the liver is also found in conditions that impede the local 
circulation, such as failure of the general circulation by whatever cause 
induced; inflammatory disorders (cholangitis, cholelithiasis, liver abscess, 
etc.); secondary new-growths, syphilis, etc.; in these conditions, however, 
the coagula, as a rule, are recent and of little clinical interest. 
Thrombosis of the main trunk of the portal vein usually results from slow 
chronic inflammatory and degenerative processes in the wall of the vein 
(endophlebitis, phlebosclerosis, calcification), which in turn may be set 
up by a variety of processes. It may be a part of the cirrhotic process; 
it may be associated with chronic inflammatory process in its vicinity, 
that is, in the lesser omentum and peritoneum (thickening and induration, 
causing kinking and constriction of the vein), in the stomach and duo- 
denum (ulcers with surrounding inflammatory induration), in the pancreas 
(swelling and induration compressing and distorting the vein); it may 
be due also to malignant and other new-growths of the stomach, intestine, 
pancreas, etc. The primary growth or the metastasis to regional lymph 
glands (hilum of the liver, retroperitoneum, mesentery, etc.), may 
implicate the main trunk or one of the larger branches that go to form it, 
and by compression, distortion, or invasion set up thrombosis. The 
thrombus may extend and become very extensive. 
Thrombosis of the peripheral radicles that go to form the portal vein may 
be induced by inflammatory or neoplastic disease in any one of the 
organs of the gastro-intestinal tract, the spleen, the female genitalia, 
etc., that lead directly or indirectly to the portal vein. The primary 
coagula often increase in size until they reach the main trunk; or small 
portions may be detached and carried to the liver, causing embolism 
and more or less extensive secondary thrombosis. 
The most frequent causes of thrombosis in any or all parts of the portal 
vein are cirrhosis of the liver and intra-abdominal new-growths. There 
is this interesting fact in connection with these thromboses: although 
they commonly do not undergo suppuration, bacteria not infrequently 
can be cultivated from them. This suggests that bacteria of attenuated 
virulence may be concerned in their formation, although of course one 
cannot exclude the possibility of secondary infection. It is not unlikely, 
however, that in at least some cases the bacteria set up a primary low- 
grade phlebitis, whereupon thrombosis follows. 
Pathology.-The thrombus may be recent or old; not infrequently it 
is both: the one part pale, firm, fibrous, and intimately adherent to the 
wall of the vein; the other reddish, soft and readily detached. It may 
completely or only partially occlude the lumen of the vein; or in the 
same case in one place it may completely and in another partially obstruct 
the lumen; that is, it may be annular, parietal, channelled, etc. The 
portal vein is usually thickened (phlebosclerosis); it not infrequently 462 
DISEASES OF THE DIGESTIVE SYSTEM 
contains calcareous plates; and it may be represented by a firm, non- 
channelled fibrous cord (stricture or complete stenosis). Peripherally 
to the thrombus the portal vein is much dilated and tortuous, and a 
collateral circulation, analogous to that of cirrhosis of the liver, usually 
becomes established.1 The liver presents the primary condition and 
sometimes, in addition, dilatation of the hepatic artery (compensatory), 
infarction, fatty degeneration, softening, necrosis, perhaps some fibrosis, 
etc. When there is thrombosis of the main trunk of the portal vein, or 
of the splenic vein, the spleen is enlarged and may show infarction. 
When the main trunk or the mesenteric veins are thrombosed, the small 
intestine shows hemorrhages and infarction, which may proceed to 
gangrene; this is usually most marked in the middle of the jejunum, 
which has no collateral circulation. 
Symptoms.-Thrombosis of the portal vein may be entirely latent, 
that is, occurring usually in the course of other disorders; the manifes- 
tations of the primary condition usually entirely overshadow those due 
to the thrombosis. Sometimes, however, to the symptoms of the primary 
disorder others are added that may suggest the diagnosis. In about 
60 per cent, of the cases (Langdon Brown)2 the onset is acute; that is, 
although the thrombosis may be a gradual process, symptoms due to 
complete obstruction develop suddenly. The most marked consist of 
ascites, enlargement of the spleen, and various disorders of the gastro- 
intestinal tract. Ascites is present in 65.6 per cent, of the cases (Rolles- 
ton) ; it may be absent in cases that speedily terminate fatally, in those 
in which the mesenteric veins are involved chiefly or alone, and in certain 
cases of long standing in which an efficient collateral circulation has been 
established. As a rule the ascites develops rapidly, becomes extreme, 
and speedily reaccumulates after removal. The spleen is usually 
enlarged, often enormously engorged; but ascites and tympanites may 
prevent its ready recognition, and perisplenitis with adhesions may 
prevent enlargement. The spleen often decreases notably in size after 
gastro-intestinal hemorrhage. Of the gastro-intestinal symptoms, the 
most important are various dyspeptic symptoms, vomiting, hematemesis, 
and intestinal hemorrhage in 44.2 per cent, of cases (Rolleston), diarrhoea 
(serous or serosanguinolent, due to increased venous pressure), symptoms 
of intestinal obstruction (paralysis due to hemorrhagic infarction), 
hemorrhoids, etc. The abdomen may reveal dilated veins. The general 
condition is poor; the appetite, strength, and flesh fail; the urine lessens 
in amount (due to lowered blood-pressure); anemia, oedema, and finally 
cachexia supervene; and not infrequently phenomena of toxemia suggest- 
ing uremia appear, and the patient dies. 
Diagnosis.-In most cases this is impossible, but it is suggested by 
the sudden onset of marked ascites, gastro-intestinal hemorrhage, 
enlargement of the spleen, abdominal pain, and symptoms of intestinal 
obstruction. When the intrahepatic branches or the main trunk of the 
portal vein are involved the disorder can scarcely be differentiated from 
cirrhosis, with which it is often associated; but a very acute onset suggests 
1 Consult Pick, Arch. f. path. Anat, (etc.), Berl., 1909, cxcvii, 490 (literature). 
2 St. Barth. Hosp. Rep., 1901, xxxvii, 62. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
463 
the thrombosis. Unusual enlargement of the spleen and copious hema- 
temesis suggest involvement of the splenic vein; diarrhoea (serous or 
serosanguinolent) or abdominal pain, bloody stools, and symptoms of 
intestinal obstruction suggest involvement of the mesenteric veins. 
Prognosis.-Many subjects die soon after the development of the 
thrombosis; the prognosis therefore is bad. In some cases, the process 
being gradual, a more or less efficient collateral circulation is established, 
which may prolong life for some time; in this event the duration depends 
largely upon the primary disorder, but it is rarely more than two years. 
Treatment.-This is purely palliative, and resolves itself into that of 
serious hemorrhages and of ascites; the ascites usually requires repeated 
tapping. Measures to prevent thrombosis in cirrhosis and in other 
conditions in which it may supervene, or to limit it when it has developed 
(providing it can be recognized), are of theoretical interest. Operative 
intervention, with a view to promote the formation of adhesions about 
the liver, or to remove the obstruction in the portal vein, is scarcely 
feasible. Curtis1 has suggested splenectomy. 
Embolism.-Embolism of the intrahepatic branches of the portal vein 
is a rather common sequence of inflammatory, suppurative, ulcerative, 
and neoplastic processes of the organs within the area of collection of 
the portal vein. The most common antecedents of such embolism are 
appendicitis (with suppuration or ulceration and thrombosis of its veins), 
ulcerative processes of the intestine, notably dysentery, and tumors 
of the gastro-intestinal tract; but embolism occurs also in divers disorders 
in which thrombosis of the hemorrhoidal, mesenteric, gastric, or splenic 
veins develops. The emboli usually are small, and they are of significance 
largely on account of the conditions in the liver to which they may give 
rise, notably multiple liver abscesses, or secondary neoplastic deposits. 
Suppurative Pylephlebitis.-Suppurative pylephlebitis (portal pyemia) 
is more common in males than in females; it is especially common in 
early adult life, coinciding with the age incidence of appendicitis. Like 
adhesive pylephlebitis, it may begin in the portal radicles within the 
liver, in the main trunk of the vein, or in the peripheral radicles anywhere 
within the area of collection of the vein; and subsequently by extension 
the process may become more or less widespread. Usually the process 
begins in the peripheral radicles, being secondary to ulcerative and 
suppurative processes of the gastro-intestinal tract. Of these the 
most common is ulcerative or suppurative appendicitis, more particularly 
in cases neglected surgically, or in which infectious thromboses occur in 
the appendicular and the mesenteric veins. Less commonly ulcerative 
and neoplastic processes of the stomach and intestines, such as gastric 
and duodenal ulcer, typhoid, tuberculous and dysenteric ulceration of 
the intestine, gastro-intestinal carcinoma, fissures, ulcer and strictures 
of the rectum and anus, suppurative or gangrenous pancreatitis, suppura- 
tion of the mesenteric glands, suppurative disease of the female genitalia, 
abscess of the spleen, etc., constitute the starting-point of the infective 
thrombosis. Occasionally, also, the process originates in operative 
1 Proc. Roy. Soc. Med., Lond., (Path. Sect.), 1909, ii, 159. 464 
DISEASES OF THE DIGESTIVE SYSTEM 
infection of the mesenteric radicles of the portal vein (operations on the 
intestine). The thrombus occasionally begins in the main trunk of the 
vein, sometimes in consequence of operative trauma, but usually second- 
arily to a local focus of suppuration-perigastric, periduodenal, sub- 
hepatic, etc.; or to gall-stones in the common duct, with surrounding 
suppuration, etc. Suppurative pylephlebitis rather rarely begins within 
the liver, but it may be sequential to a liver abscess, suppurating hydatid 
cyst, suppurative cholangitis (with or without cholelithiasis or chole-' 
cystitis), etc. In these cases the infection is much more likely to involve 
the hepatic rather than the portal vein, since the latter is protected by 
a connective-tissue envelope; but infection of the portal vein does occur, 
doubtless by the lymphatics, although sometimes by continuity. 
Pathology.-The process may be more or less localized or quite wide- 
spread. Usually the peripheral radicles and some of the main branches 
of the vein are involved; sometimes the process involves also the main 
trunk and extends into the liver; in some cases the peripheral radicles 
and the ramifications in the liver are implicated, the main trunk being 
almost if not quite free; in this event the intrahepatic lesions are embolic. 
The vein is enlarged, swollen, softened, congested, oedematous (panphle- 
bitis); it is filled with a more or less softened (necrotic) sanguinolent- 
purulent or purulent material partially or completely obstructing the 
lumen. When not entirely liquefied the clot is more or less friable, 
occasionally free in the lumen, but usually it is more or less intimately 
attached to the intima. Not infrequently there is obvious purulent 
infiltration of the wall of the vein, and a sheath of pus or purulent material 
about the vein (perivascular lymph spaces) and in the adjacent connective 
tissue, usually on the right side. The liver is usually enlarged and 
contains foci of necrosis or multiple abscesses; the spleen is enlarged and 
softened; not infrequently there is localized or generalized purulent 
peritonitis; there may be a purulent pleuritis; and sometimes secondary 
abscesses develop in different regions of the body. 
Symptoms.-Since suppurative pylephlebitis is a secondary disorder, 
the symptoms directly attributable to it are preceded by those of the 
disease to which it owes its origin, notably appendicitis. The onset of 
the pylephlebitis is usually sudden, and is manifested by the phenomena 
of septicopyemia: irregular chills, fever, and sweats, a soft, compressible, 
rapid pulse, leukocytosis, and general prostration. To these may be 
added extension of the abdominal pain beyond the seat of original 
disease, enlargement and tenderness of the liver (about one-half of the 
cases), enlargement of the spleen (one-fourth of the cases), etc. Vomiting, 
hematemesis, and diarrhoea are sometimes observed. Symptoms referable 
to various complications (pleuritis, brain abscess, etc.) may supervene. 
Diagnosis.-This rests upon an obvious primary cause, the develop- 
ment of a septicopyemic state, and evidences of involvement of the 
liver (enlargement, tenderness, and perhaps slight jaundice). In the 
differential diagnosis one has to consider other forms of liver abscess 
and of septicopyemia, typhoid fever, etc. 
Prognosis.-The disorder is fatal in the great majority of cases, espe- 
cially when the main trunk of the vein is involved or when there are 
multiple abscesses in the liver. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
465 
Treatment.-The disease is much easier prevented than cured. Appen- 
dicitis should be promptly treated surgically, and other ulcerative 
or suppurative conditions of the gastro-intestinal tract should be 
appropriately treated, so as to prevent the formation of infectious 
emboli. When developed the treatment of pylephlebitis is that of liver 
abscess. 
Chronic Endophlebitis.-Chronic endophlebitis, a process allied to 
arteriosclerosis, apparently may be primary or secondary. The primary 
process is exceptionally rare, and its etiology is ill understood; doubtless 
some cases are due to syphilis; in splenic anemia, hyperplastic changes 
initiated in the endothelium of the blood-sinuses of the spleen may 
gradually spread to the splenic and the portal veins, and ultimately 
involve the portal radicles in the liver; to this is attributed the sequential 
cirrhosis of the liver (Banti's disease with cirrhosis of the liver). Second- 
ary endophlebitis of the portal vein is encountered in cirrhosis of the 
liver, and in advanced passive congestion. In these cases it is usually 
attributed to the increased pressure, but in many cases toxic products 
doubtless play a part. Partial or complete thrombosis may follow 
chronic endophlebitis; and calcification not uncommonly ensues. 
RETROGRESSIVE DISORDERS OF THE LIVER 
Atrophy of the Liver.-This is a term more or less generally but 
inaptly applied to conditions in which the liver becomes reduced in size. 
Most of these conditions are degenerative and not truly atrophic. 
Localized atrophy occurs under most diverse circumstances, generally 
in consequence of pressure, such as tight lacing, or belts, deformities 
of the chest and vertebree (kyphosis and scoliosis), tumors and other 
disorders of adjacent organs, etc.; it occurs also in certain diseases of 
the liver itself, such as in the vicinity of tumors and cysts, in consequence 
of the occlusion of a branch of the portal vein or hepatic artery, and in 
passive congestion, amyloid disease, cirrhosis, etc. Under these varying 
circumstances there is a more or less localized reduction in the size of 
the liver, which may be: (1) Truly atrophic with subsequent replacement 
fibrosis, as in pressure exerted by corsets or other constrictions, etc.; 
or (2) atrophic and degenerative (especially fatty degeneration and 
necrosis), as in passive congestion, amyloid disease, cirrhosis, etc. 
General atrophy may follow stenosis or occlusion of the portal vein; 
general hepatitis with thickening of the capsule; advanced cirrhosis, 
advanced passive congestion, etc.; and a reduction in the size of the 
liver, which, however, is not a true atrophy, follows many widespread 
degenerative processes, such as acute yellow atrophy, and poisoning 
by phosphorus, arsenic, chloroform, etc. A decrease in the size of the 
liver, to which the term atrophy is truly applicable, occurs in conditions 
of general wasting, as in senile atrophy inanition, certain cachexias, 
etc. The liver becomes reduced in size, because of a reduction in size 
and possibly also in number of the liver cells, without degenerative 
changes in the hepatic parenchyma or noteworthy changes in the inter- 
vol. in-30 466 
DISEASES OF THE DIGESTIVE SYSTEM 
stitial tissues. In senility the liver participates in the general atrophic 
process. Otherwise this general atrophy of the liver is due to disturb- 
ances of metabolism brought about by: (1) Deficient nourishment, or 
inability to utilize available food, as in obstruction of the oesophagus, 
etc.; or (2) excessive drain and waste attendant upon malignant 
growths, protracted suppuration, etc. 
Pathology.-The liver is reduced in size, dark in color, dense, flaccid, 
of increased specific gravity, and dry-changes attributable to dis- 
appearance of the parenchyma and relative increase of the connective 
tissue. The section surface is dry, and the acini are obviously reduced 
in size and perhaps in number. These changes, although widespread, are 
not uniform, the margins, as a rule, being relatively more affected than 
the central portion of the lobes. The liver cells are reduced in size 
and number, and often contain considerable pigment. 
Symptoms.-The symptoms are those of the primary disorder. 
Parenchymatous Degeneration.-This (cloudy swelling) is perhaps 
the commonest deviation from the normal exhibited by the liver. To 
some extent it is a physiological process and is seen when excessive 
demands are made upon the liver. Otherwise cloudy swelling results 
from the action of divers poisons, bacterial and non-bacterial. The 
process is especially common in the infectious diseases, notably typhoid 
fever, pneumonia and dysentery. The liver is enlarged, somewhat soft- 
ened, of lessened elasticity, pale, somewhat dull and opaque (as though 
cooked), and on microscopic examination reveals swelling, increased 
granulation and opacity of the liver cells, and obscuration of the nuclei. 
The condition is of secondary clinical interest, being only a part of gen- 
eral toxemic processes. Clinically some enlargement and occasionally 
tenderness of the liver may be elicited. 
Gaseous or Emphysematous Liver.-This is characterized by numer- 
ous gaseous cysts in the liver due to Bacillus aerogenes capsulatus. The 
infection is rarely primary, although the organism has been cultivated 
from the blood before death; usually it is secondary, and occurs at or 
about the agonal period or after death from other causes. The 
organism is usually found in association with other bacteria, and 
although present before death, the gas formation is a postmortem 
phenomenon. The liver is most commonly involved, but the process 
may be widespread. The infection usually occurs by way of the portal 
vein (from the intestinal tract); but it may occur by way of the general 
circulation, or directly from the intestine to the biliary ducts and the 
gall-bladder. The liver is enlarged, soft, and spongy, and is pervaded 
by numerous usually small gaseous cysts. The condition is chiefly of 
pathological interest, and is not susceptible of clinical recognition. 
Fatty Liver.-This is a comprehensive term applicable to the different 
conditions characterized by an excess of fat in the liver. On the one 
hand it includes fatty infiltration, in which there is an excessive deposit 
of fat in otherwise unaltered or slightly altered liver cells; and on the 
other hand, fatty degeneration, in which in addition to the fat there 
are greater or less degenerative changes in the hepatic parenchyma, 
perhaps the direct conversion of the liver cells into fat. Formerly the DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
467 
two conditions were differentiated; doubtless there are extreme cases of 
fatty infiltration and of fatty degeneration, but many cases partake of 
the nature of both processes, and there is considerable evidence that 
the fat in the liver under all circumstances is derived mainly from 
adipose tissue elsewhere in the body; that even in phosphorus poisoning 
the fat in the liver is not due, wholly at least, to conversion of the liver 
protein.1 It seems impracticable, therefore, to differentiate fatty infil- 
tration sharply from fatty degeneration; both processes are appropriately 
discussed as fatty liver, or fatty changes in the liver. 
Etiology.-The causes are: (1) Dietetic indiscretions and associated 
disorders of metabolism, notably the ingestion of too much food, particu- 
larly fat and carbohydrates, to which is usually added a sedentary 
life and lack of muscular exercise and of mental activity-factors that, 
combined, tend to produce obesity, of which fatty liver (mostly infiltra- 
tion) is a conspicious feature. The fatty deposit is ascribed to incomplete 
oxidation of the excessive amount of food. (2) Anemic and cachectic 
conditions, such as occur in the late stages of many chronic disorders, 
such as tuberculosis, carcinoma, etc., in which in consequence of deficient 
supply of blood there is deficient oxidation; but the influence of toxic 
substances may not be ignored. (3) Passive congestion due to a variety 
of causes that lead to failure of the heart-in which the fatty infiltration 
of the periphery of the liver lobules is in marked contrast to the congested 
centres (nutmeg liver). (4) Poisons of most diverse nature, notably 
chronic alcoholism. Alcohol seems to be a definite protoplasmic poison 
to the liver cells, and in addition to taking oxygen for its own combustion, 
gives rise to deficient oxidation of other food products. The fatty changes 
are often associated with cirrhosis (fatty cirrhosis). Other poisons 
causing fatty changes are minerals, such as phosphorus, arsenic, mercury, 
etc.; mineral acids, such as hydrochloric, nitric, sulphuric, etc.; and 
other chemicals, such as chloroform, iodoform, carbolic acid, phloridzin; 
fungi, meat poisons, etc. (5) Certain local infections of the intestinal 
tract, such as the gastro-intestinal catarrh of children, dysentery, etc., 
in which toxins are carried to the liver by the portal vein. (6) Certain 
general infections, notably streptococcic and staphylococcic and other 
pyococcic infections of long duration (prolonged suppuration), tuber- 
culosis, etc. The exact cause of the fatty liver that occurs in about 
one-third of the cases of tuberculosis is not well understood, although 
doubtless it is in some way related to deficient oxidation. 
Pathology.-Usually the liver is enlarged and may weigh 3000 to 
4000 grams; it is of lessened specific gravity (sometimes floating in 
water), and of lessened resistance; it is normal in conformation, and 
has a smooth surface and rounded edges, and is pale yellowish in color. 
The section surface is usually pale, anemic, obviously fatty; in cases 
of passive congestion the well-known appearances of nutmeg liver 
(dark centre and light periphery of the lobules) are seen; and in fatty 
cirrhosis the association of fibrosis is obvious. Histologically the cells 
at the periphery of the lobules contain fat droplets that vary much in 
1 Adami, manciples of Pathology, 1911, i, 430 and 905. 468 
DISEASES OF THE DIGESTIVE SYSTEM 
size and displace the cellular protoplasm and nuclei, which otherwise 
are not notably altered; after removal of the fat the cells may revert 
to their normal condition. Fatty degeneration may involve any part 
of the liver lobule but is most often in the central zone;1 the cells reveal 
minute droplets of fat throughout the protoplasm, which otherwise 
is markedly granular, distorted, and opaque; the nuclei, at first unaltered, 
soon undergo retrograde change; after removal of the fat the cells are 
shrunken, opaque, and evidently the seat of retrograde metamorphosis. 
Symptoms.-These are ill-defined. It is important to bear in mind that 
such symptoms as may be present are due to the initiating disease and 
the degenerative change in the liver cells rather than to the mere presence 
of fat. In general the symptoms are those of the primary disorder, 
obesity, tuberculosis, alcoholism, etc. In perhaps the majority of cases 
there are no symptoms referable directly to the liver; occasionally 
sensations of weight may be due to the mere weight of the liver, and 
ill-defined dyspeptic symptoms may be attributed to functional inactivity 
of the liver, although they are more likely to be due to associated dis- 
orders of the stomach and intestines, improper eating and drinking, etc. 
The liver is enlarged and commonly palpable two or three finger- 
breadths below the costal margin; excessive fatty deposit in the abdominal 
wall, as well as the flaccidity of the liver itself, may render the examina- 
tion unsatisfactory. In thin tuberculous subjects the enlarged liver, 
however, is usually readily palpable. In associated cirrhosis and amyloid 
disease, etc., the liver is usually firm and more readily palpable. 
In phosphorus poisoning the early symptoms are those of gastro- 
intestinal irritation (epigastric distress, nausea, and vomiting). If the 
patient does not die soon, there is commonly a period of quiescence 
that to the unwary suggests recovery and speedy cure. At the end of 
two or three days, however, vomiting and epigastric distress return, 
jaundice supervenes, the pulse becomes weak and accelerated, the heart 
dilated, hemorrhages appear and the patient usually dies within a 
week. In most cases the liver is enlarged throughout, smooth and 
tender; in some cases it decreases in size before death. 
Diagnosis.-Minor grades of fatty liver cannot be recognized with 
certainty; the more marked grades must be differentiated from other 
causes of enlargement. The fatty cirrhotic liver occasions the symp- 
toms of cirrhosis, notably hematemesis, ascites, and enlargement of the 
spleen, which do not belong to the fatty liver. The amyloid liver is 
much firmer than the fatty, has a more or less obvious cause, and is 
associated with amyloid disease elsewhere. Leukemic enlargement of 
the liver is readily recognized by the blood examination. The enlarged 
liver of passive congestion is readily determined by recognizing an 
obvious cause. A displaced liver should be recognized by a careful 
examination. The liver of phosphorus poisoning should be determined 
by the history, general phenomena, and the subsequent development of 
jaundice, which does not occur in other forms of fatty liver. 
Prognosis.-The prognosis depends upon the primary cause. 
1 McCrae and Klotz, Jour. Exp. Med., Isio, xii, 746. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
469 
Treatment.-The treatment is altogether that of the primary disorder, 
obesity, alcoholism, etc., of which, from a therapeutic point of view, 
the fatty liver usually constitutes an almost negligible associate. 
Amyloid Degeneration.-This is a process characterized by the con- 
version of the proteins of the tissues into a structureless homogeneous 
substance called lardacein. 
Etiology.-Amyloid degeneration is a disease of young male subjects 
(usually less than thirty years); but sex and age are probably only of 
significance as the common antecedents of amyloid degeneration are most 
common in young males. In the great majority of cases it follows 
prolonged suppuration, especially that due to syphilis and tuberculosis 
and involving the bones and the lungs. Less commonly it occurs 
in the absence of suppuration, as in the cachexia of tertiary syphilis, 
chronic malaria, malignant disease, and in delayed convalescence from 
infectious diseases. In most cases the direct cause seems to be the 
absorption of the toxic products of pyogenic cocci. Most of the cases 
occur in association with ill-drained cavities, from which toxic ab- 
sorption is continuous and considerable. 
Pathology.-The relative frequency of involvement of the different 
organs is shown by the combined statistics of Birch-Hirschfeld, Loomis, 
Dickinson, Goodhart, and Turner. Of 795 cases the spleen was involved 
in 585, the kidneys in 539, and the liver in 387 (Rolleston). The amyloid 
liver is enlarged, sometimes to four or five times its normal size; its 
general conformation is preserved, its edges are sharp or slightly rounded, 
and its surface smooth; it is pale in color, firmer than normal, of increased 
specific gravity and lessened elasticity. The section surface is smooth, 
pale, grayish red in color, and peculiarly translucent, glistening, or 
bacony in appearance (especially apparent at the edge of the cut surface). 
In minor grades the individual lobules are more or less obvious, but 
later they lose their identity. A fresh cut surface treated with iodine 
strikes a mahogany-brown color, which occurs in more or less ring forms 
in the mid-portion of the lobules, the remaining portions (centre and 
periphery) of the lobules being pale yellowish or yellowish brown. 
Microscopically, the amyloid material is first found in the subendothelial 
layer of the capillaries of the mid-zone of the liver lobules; later it involves 
other capillaries and arterioles and spreads to the media; still later 
similar changes occur in the small venules, and ultimately the process 
involves the adjacent connective tissue. On account of defective nutritive 
supply, and doubtless also in consequence of the direct action of toxins, 
the parenchymatous cells show cloudy swelling and fatty degeneration, 
and are ultimately removed or converted into amyloid material. 
Symptoms.-These are those of amyloid disease in general-progressive 
emaciation, anemia, and debility, usually in a person the subject of 
chronic suppuration or syphilis. The liver is enlarged (it may reach 
much below the umbilicus), painless, smooth, firm, and has sharp or 
somewhat rounded edges. The spleen is usually enlarged and firm; 
often there are evidences of amyloid degeneration of the kidneys 
(polyuria, albuminuria, waxy casts, etc.), of the intestinal tract, 
(diarrhoea), and of the cardiovascular system (weak heart, low blood- 470 
DISEASES OF THE DIGESTIVE SYSTEM 
pressure, oedema, etc.). There is no jaundice or evidence of portal 
obstruction, except in the event of complications. 
Diagnosis.-This is comparatively easy in some cases: a history of 
syphilis, or of long-standing suppuration, with enlargement of the liver 
and spleen, albuminuria, and perhaps diarrhoea, or weak heart and 
oedema, is quite unmistakable. Amyloid must be distinguished from 
other painless enlargements of the liver. The fatty liver is usually 
associated with obesity, alcoholism, etc., and the liver is softer. The 
fatty cirrhotic liver is likely to be tender, there are the antecedents of 
cirrhosis and its more common phenomena. Leukemic enlargement is 
readily recognized by a blood examination. 
Prognosis.-This is bad, although some improvement may be effected; 
occasionally the liver becomes considerably reduced in size. 
Treatment.-The essential part is to eliminate the cause; suppurative 
foci must be adequately drained and the suppuration stopped as soon 
as possible; syphilis should be appropriately treated. Attention to the 
general health is of the greatest importance, and comprises good food, 
fresh air, rest, hygienic surroundings, bitter tonics and alteratives, syrup 
of iron iodide), etc. 
Pigmentation of the Liver.-This occurs under a variety of circum- 
stances, but in itself is of comparatively little clinical importance. 
Certain extraneous pigments are sometimes found, such as coal-dust 
(anthracosis), stone-dust (silicosis), silver (after medicinal adminstra- 
tion), etc. The associated changes are usually those of slight or moderate 
fibrosis, to which perhaps the extraneous pigmentation may be etio- 
logically related. Of intrinsic pigmentation the most important are 
bile pigment and other derivatives of hemoglobin. Normally the liver 
cells usually show a varying number of fine yellowish-brown granules- 
some iron-containing (hemosiderin), some iron-free (hemofuscin); these 
are likely to be increased in atrophy of the liver cells from senility or 
other causes. Bile pigments (usually bilirubin, sometimes biliverdin) 
are found normally in the biliary passages; in cases of obstruction to the 
free flow of bile these pigments are found in excess in the biliary passages 
and also in the liver cells (particularly necrotic cells), and in the interstitial 
tissue. In malaria there occurs a deposit of fine dark-brown or brownish- 
black pigment granules, especially in the endothelial cells of the capillaries 
at the periphery of the lobules and in the perivascular connective tissue, 
and in Kupfer's star-like cells which act as phagocytes; occasionally 
there is some associated fibrosis that has been described as a malarial 
cirrhosis. A deposit of iron-containing pigment (siderosis of the liver) 
is found in and about various local lesions (abscesses, gummas, scars, 
tumors, etc.), in chronic passive congestion, cirrhosis, pernicious anemia, 
leukemia, and hemochromatosis; and a special metabolic pigmentation 
is found in melanotic sarcoma. Sprunt, Colwell and Hagan1 believe 
that iron-containing, as well as other kinds of pigments, may be formed 
during autolytic degeneration of parenchymatous cells independently of 
the hemoglobin in the blood. In the nutmeg liver of chronic passive 
1 Jour. Exper. Med., 1912, xvi, 607. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
471 
congestion, iron-free and iron-containing pigment is found in and about 
the central veins; it becomes quite conspicuous in the advanced stages 
(red atrophy), in which a large section of the central part of the lobules 
may show such pigmentation; later the iron reaction may no longer be 
obtainable. In pernicious anemia the periphery of the liver lobules 
usually contains a considerable excess of iron-containing pigment 
obviously derived from the hemoglobin of the erythrocytes; this is 
found also, but in less degree, in some cases of leukemia. 
Special interest attaches to the process described as hemochromatosis, 
in which the liberated hemoglobin is deposited as pigment granules, in 
the skin, liver, pancreas, etc. Concurrently fibrosis of the liver and 
pancreas occur (pigmented cirrhosis with diabetes or bronzed diabetes). 
Leukemic Infiltration.-The leukemic process commonly involves 
the liver: the lymphocytic variety always, the myelocytic variety 
almost always, although the disease may be quite advanced before 
noteworthy changes occur in the liver. The liver is enlarged, sometimes 
weighing 6000 grams or more, that is, three or four times its normal size; 
its surface is smooth, its edge somewhat rounded, and it is of lessened 
resistance and density. The section surface is smooth, pale, opaque, 
grayish, or sometimes yellowish in color. The individual lobules are 
usually distinguishable, and may appear to be more widely separated 
than normally (periportal leukocytic infiltration). Occasionally small 
roundish masses (lymphomatous masses), suggesting miliary tubercles, 
can be detected. Microscopically there is widespread leukocytic (lympho- 
cytic or myelotic) infiltration; this is usually most marked in the peri- 
portal spaces where large masses separating the lobules are formed, but 
it involves also the lobules, being sometimes limited to the periphery, 
the capillaries of which may be fairly choked with leukocytes. 
Symptoms.-The symptoms are those of leukemia, the enlargement 
of the liver being a part of the disease. The enlarged liver is painless, 
smooth, and has fairly sharp edges. Ascites, which is not rarely a terminal 
event in leukemia, has been variously interpreted. In many cases it is 
doubtless due to the blood dyscrasia and failing cardiovascular system, 
part of the generalized oedema or anasarca; perhaps in some cases it is 
due to peritonitis, sometimes tuberculous; but it has also been attributed 
to obstruction or thrombosis of the portal radicles. 
The diagnosis is made by an examination of the blood. The treatment 
is that of leukemia. 
Necrosis.-This may occur as a widespread or a limited process. 
The widespread process, such as occurs in thrombosis of the hepatic 
artery or the portal vein, in acute yellow atrophy of the liver, tropical 
abscess, etc., is elsewhere discussed. The limited process, so-called 
focal necrosis (Mallory1), occurs under a variety of circumstances and 
in several forms, which, however, are of pathological rather than 
clinical interest. Central, peripheral, and mid-zonal forms have been 
described;2 the underlying factors of the varying zonal distribution of 
the necroses have not been definitely determined. Most of these necroses 
1 Jour. Med. Research, 1901, vi, 264; Jour. Exper. Med., 1898, iii, 611. 
2 Opie, Jour. Med. Research, 1904, xii, 147. 472 
DISEASES OF THE DIGESTIVE SYSTEM 
are found in acute infections, such as typhoid fever, scarlet fever, diph- 
theria, pneumonia, cerebrospinal fever,' etc. In some cases, doubtless, 
they result from the direct action on the liver cells of bacterial toxins; 
in other cases they follow obstruction or occlusion or the capillaries by 
swollen, proliferated, or desquamated endothelial cells, transported 
giant (usually phagocytic) cells, fibrinoid plugs, thrombi made up of 
agglutinated erythrocytes, etc. Experimentally they may be induced 
by injection into lower animals of vegetable poisons, such as abrin and 
ricin (Flexner2), or of hemagglutinins of bacterial origin or those contained 
in certain cytolytic immune sera (Pearce3) which lead to the formation 
in the portal radicles of thrombi made up of agglutinated erythrocytes. 
These have a clinical interest in that they suggest the lesions as well as 
the mode of development of cirrhosis of the liver. 
Oertel4 has described a multiple non-inflammatory necrosis of the 
liver with jaundice, and he and Symmers5 have carefully described the 
changes that occur in these necroses in the liver. 
ACUTE YELLOW ATROPHY OF THE LIVER 
Acute yellow atrophy is an acute and widespread autolytic necrosis 
of the liver cells, characterized clinically by jaundice, reduction in the 
size of the liver, and toxic disturbances of cerebration, proceeding to a 
fatal issue. The disease is comparatively rare. The earliest record of 
a case is by Ballonius (died in 1616); Best,6 in 1903, collected 450 cases. 
The best recent study is by F. W. White.7 
Etiology.-Acute yellow atrophy is especially. frequent between the 
twentieth and the thirtieth year (50 per cent, of the cases), and in women 
(two-thirds of the cases); both of these facts are explainable largely by 
the frequent occurrence of the disease during pregnancy. Hunter's 
studies show that more than 80 per cent, of the cases occur between the 
tenth and the fortieth year; Rolleston has collected 42 cases occurring 
within the first ten years of life. The influence of pregnancy is note- 
worthy, since almost if not quite half of the cases in women, that is 
about 30 per cent, of all cases, occur about the middle or during the 
latter half of pregnancy; the disease is scarcely if ever seen during the 
first three months of pregnancy, but sometimes it occurs during the 
puerperium. The onset of the disorder in pregnant women has been 
preceded by shock, fright, mental disturbances, worry, and anxiety 
(related or not to the pregnancy and expected parturition), all of which 
are believed to exert some influence; but it is extremely unlikely that 
these can do more than depress the general resistance. The causative 
1 Consult McCrae, Jour. Path, and Bacteriol., Cambridge, 1908, xii, 279. 
2 Johns Hopkins Hosp. Rep., 1897, vi, 259. 
3 Jour. Med. Research, 1904, xii, 329; 1906, xiv, 541. Pearce and Winne, Am. Jour. 
Med. Sci., 1904, cxxviii, 669. 
4 Jour. Med. Research, 1904, xii, 75; Jour. Exper. Med., 1906, viii, 103. 
B Jour. Exper. Med., 1907, ix, 64. 
6 Thesis of the Univ, of Chicago, 1903. 
7 Boston Med. and Surg. Jour., 1908, clviii, 729 (literature). DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
473 
influence of pregnancy is much more likely akin to that exerted by the 
toxemias of pregnancy, in which we now know the liver frequently 
shows degenerative changes, and in the production of which it plays 
an important, according to some observers the important, part. The 
actual etiological factor, however, is not known, since the disorder does 
not occur more commonly than once in 28,000 pregnancies (Braun). 
Various known infections exert some etiological influence; thus 10 per 
cent, of the cases occur during secondary syphilis (in which slight jaundice 
is not very rare). Various pyogenic infections (septicopyemia, osteo- 
myelitis, etc.), typhoid fever, malaria, diphtheria, etc., have antedated 
the liver disorder. Microorganisms, especially the colon bacillus and 
pyococci, have been found in some cases, but being absent in most 
cases it is difficult to believe that they possess etiological significance; 
they are probably only secondary invaders. Etiological significance 
is also attributed to certain non-bacterial poisons, such as alcohol, 
chloroform, phosphorus, etc. Chloroform is of undoubted significance, 
being responsible for the cases of so-called delayed chloroform poisoning.1 
Opie2 by the administration of chloroform accompanied by intravenous 
inoculation with Bacillus coli produced advanced hepatic cirrhosis 
accompanied by active new formation of bile ducts. Phosphorus gives 
rise to a somewhat analogous condition, but the lesions in the liver are 
not alike in the two disorders. Similar phenomena may develop in 
the course of other diseases of the liver, such as advanced passive con- 
gestion, cirrhosis, cholangitis, etc. All of the foregoing lead to the 
conclusion that the designation acute yellow atrophy, as well as icterus 
gravis, comprises a series of diverse disorders that exhibit more or less 
superficial resemblance. We are now able to separate some of the cases 
from the main group, such as those due to syphilis, septicopyemia, puer- 
peral eclampsia, phosphorus poisoning, delayed chloroform poisoning, 
etc., but the definite etiological factor of the major group still eludes us. 
Pathology.-The liver is much reduced in size and weight, being often 
one-half or one-third that of the normal (800 to 500 grams or less). The 
reduction is usually uniform, although occasionally more marked in 
the left lobe (possible site of beginning of the process); in other cases, 
there is more or less irregularity, due to varying grades of the destructive 
process or to attempts at compensatory hyperplasia. The organ is 
flaccid and has so lost its normal elasticity and resistance that it may be 
folded or bent upon itself; the capsule is wrinkled, obviously too large 
for the reduced organ, and if not thickened shows the liver to be greenish 
yellow, sometimes dirty dark grayish in color, with scattered areas 
more reddish or reddish brown in color; often small subserous foci of 
hemorrhage are also visible. On section the liver is found to be dense and 
resistant; the section surface is mottled-yellowish or yellowish-red 
areas of varying size and configuration alternating and more or less 
gradually merging the one into the other. The yellowish coloration is 
due chiefly, if not entirely, to bilirubin rather than to fatty alterations 
(the fat content is usually not increased, and may be diminished); the 
1 Consult Wells, Arch. Int. Med., 1908, i, 589 (literature). 
2 Jour. Exper. Med., 1910, xii, 367. 474 
DISEASES OF THE DIGESTIVE SYSTEM 
reddish areas seem to be an advanced stage of the yellow, and to be more 
numerous or larger the longer the patient lives. 
Histologically the appearances vary with the stage of the disease. 
There is intense and widespread (not focal) destruction of the liver cells, 
which usually begins at the periphery and spreads to the centre of the 
lobules; early the cells are somewhat swollen and roundish in outline, 
but they soon become pale and granular, lose their outline, shrink, and 
stain poorly and diffusely, and the nuclei become obscured or dissolved. 
Usually they exhibit a yellowish color (staining with bilirubin). Ulti- 
mately the cells disappear, apparently in consequence of autolysis, and 
leave behind the supporting framework of the liver, granular debris, 
and endothelium of the capillaries (the reddish areas on macroscopic 
inspection). So extreme may be the destruction of the liver cells that 
the microscopic section can scarcely be recognized as liver tissue. 
Should the disorder be more or less protracted, a variable amount of new 
connective tissue is formed. In some specially protracted cases there 
are conspicuous evidences of attempts at regeneration (compensatory 
hyperplasia) of the liver cells.1 
All the organs are more or less bile-stained. The spleen is soft, and is 
slightly or moderately, but not extremely, enlarged in about two-thirds 
of the cases. The kidneys are enlarged, softened, pale, opaque, and 
often reveal small foci of hemorrhage, cloudy swelling, and fatty changes. 
The heart also is swollen, softened, pale, and opaque (parenchymatous 
and fatty degeneration). The gastro-intestinal tract shows the lesions 
of catarrhal inflammation. Small hemorrhages are found beneath the 
skin and the various serous and mucous membranes, and are doubtless 
attributable to toxic changes in the blood and bloodvessels. Hemorrhages 
may occur also in the brain, and degenerative changes may be seen in 
the spinal cord. The blood itself is more fluid than normally, coagu- 
lates with difficulty, and readily stains the endothelium and adjacent 
tissues. 
Studies of the chemistry of the liver by A. E. Taylor,2 Wells,3 and 
others show that not only is the fat content not increased, but that it 
may be actually diminished; this specially serves to distinguish the 
disorder from phosphorus poisoning, of which fatty changes constitute 
a conspicuous feature-30 per cent, as contrasted with 5 per cent, in 
acute yellow atrophy. In phosphorus poisoning the liver is enlarged, 
as a rule, whereas in acute yellow atrophy it is usually lessened in size. 
Pathogenesis.-There are several conspicuous features of acute yellow 
atrophy that endow it with special characteristics: the rapid and marked 
reduction in size of a large solid organ, the speedy absorption of much 
of the necrotic cellular debris (in contrast with other forms of necrosis), 
and the appearance in the urine of leucin, tyrosin, and other amino-acids, 
products of destructive protein metabolism that do not occur in health. 
These seem unquestionably to point to the activity of some poison, 
virulent in nature and possessing a special affinity for the liver, upon 
1 Consult MacCallum, Johns Hopkins Hosp. Rep., 1903, x, 375 (literature). 
2 Jour. Med. Research, Boston, 1902, iii, 424. 
3 Jour. Exper. Med., New York, 1907, ix, 627. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
475 
which it acts widely and intensely. The source, nature, and exact mode 
of action of this poison are not definitely known. F. W. White supports 
the view, originally advanced by Flexner,1 that the process is autolytic 
in nature, and that it is brought about by some poison having a specific 
action on the liver cells whose life it destroys without injuring the proteo- 
lytic ferments they contain, whence autodigestion ensues. The leucin 
and tyrosin result partly from autolysis of the liver, and partly from 
non-conversion into urea of leucin and tyrosin formed elsewhere. Other 
evidence of this autolysis is found in the albuminose and purin bodies 
(destruction of nuclein) sometimes encountered in the urine. 
The jaundice is due to obstruction of the small biliary ducts by swollen 
and desquamated epithelial cells and by pressure from without exerted 
by swollen and necrotic liver cells; it is contributed to by destruction 
of erythrocytes and the formation of bile thrombi. The presence of 
bilirubin in the blood and the urine suggests that there is no suppression 
of the bile-forming function of the liver. 
Symptoms.-The initial symptoms are those of gastro-intestinal 
catarrh, soon (one to four days) followed by jaundice; these may last 
a variable period, usually five to seven days, but sometimes several weeks. 
During this period the disorder is usually looked upon as ordinary 
catarrhal jaundice (cholangitis), and as a matter of fact there is little 
if anything to suggest the more serious disorder. The patient complains 
of malaise, perhaps fugitive neuromuscular pains, poor appetite, coated 
tongue, occasional vomiting, constipation, etc.; there is usually moderate 
jaundice and bile-pigment in the urine. Soon, however, the graver 
symptoms supervene. The jaundice deepens, becoming dark yellowish 
or bronze-like, slightly greenish (in rare, extremely rapid cases jaundice 
may be absent); severe nausea and vomiting set in and are often asso- 
ciated with hematemesis; diarrhoea may supervene; and grave nervous 
symptoms ensue-headache, photophobia, mental confusion, hebetude, 
and restlessness, soon followed by a noisy delirium, and later coma and 
perhaps convulsions. Hemorrhages (disordered nutrition of the vessel 
walls and hemolytic action of bile salts on the erythrocytes) occur 
beneath the skin and into and from divers mucous membranes (intestines, 
urinary tract, respiratory tract, genital tract, retina, and most commonly 
the stomach); absorption usually occurs in pregnant women. Soon 
the patient passes into a profound typhoid state. There may be slight 
fever (pyogenic infection?), but usually the temperature is below normal 
(until shortly before death, when there may be an agonal rise); the pulse 
becomes rapid, feeble, and of low tension; the respirations become 
accelerated and irregular; the pupils dilate (said to be important diag- 
nostically); the tongue becomes dry, furred, and tremulous; sordes 
collect on the teeth and gums; and there are fibrillary twitchings. 
The liver in some cases is found slightly or moderately enlarged in the 
early stages; this may be due to preexisting disease (as cirrhosis), but 
rarely it seems to be a part of the acute yellow atrophy itself. Soon, 
however, the liver dulness diminishes rapidly in extent, until it may be 
1 Amer. Jour. Med. Sci., 1903, cxxvi, 202. 476 
DISEASES OF THE DIGESTIVE SYSTEM 
entirely absent or constitute a small area in the axillary region; this is 
due to reduction in the size of the liver and to the fact that the small 
flabby liver falls away from the anterior abdominal wall and is replaced 
by the intestine. Death may occur before the liver lessens in size. The 
region of the liver may be tender on pressure. Slight or moderate enlarge- 
ment of the spleen may be made out in about two-thirds of the cases; 
in the event of unusual hemorrhage or diarrhoea the spleen usually 
remains small. 
The urine, as a rule, is lessened in amount, of increased specific gravity, 
of increased acidity, and highly colored (bile pigment and excess of uro- 
bilin); it usually contains a small amount of albumin, and hyaline, 
granular, fatty, and epithelial tube casts. The highly significant changes 
consist in the presence of leucin, tyrosin, and the other amino-acids 
(largely the result of autodigestion of the liver); sarcolactic, diacetic, 
and other fatty acids (lactic, acetic, butyric, and succinic); marked 
reduction in the amount of urea with an associated increase in the 
amount of ammonia and other nitrogenous substances. Sugar is rarely 
found. The amount of leucin and tyrosin is no index of the amount 
formed in the body (in the liver and elsewhere), since both substances 
are comparatively insoluble, and despite elimination, considerable of 
both substances may be found in the liver after death. 
Examination of the blood often reveals a normal or an increased 
number of erythrocytes (usually attributed to concentration of the 
blood, although Grawitz and von Jaksch found the weight of the dried 
blood to be not above the normal); a moderate leukocytosis (up to 
16,000) and a moderate reduction of the hemoglobin (60 to 80 per cent.). 
Bile pigments also may be found. 
Diagnosis.-In the early stages there is scarcely anything to distinguish 
the cases from the more innocuous catarrhal jaundice, although jaundice 
and an enlarged and tender liver in a pregnant woman are of portentous 
significance. Careful studies of the urine, especially in pregnant women, 
and in cases of mild jaundice, and the detection of significant urinary 
changes, especially the evidences of an acid intoxication, should enable 
us to recognize the antecedent conditions and perhaps ward off the 
more serious later stages. The development of nervous symptoms in 
any case of jaundice should always awaken suspicion. When fully 
developed, jaundice, vomiting, delirium (and other cerebral symptoms), 
lessening in the size of the liver, and the presence of leucin and tyrosin 
in the urine are unmistakable. The presence of leucin and tyrosin is 
not unequivocal, since both substances may be found in small amounts 
in the urine in diseases in no way related to acute yellow atrophy, such 
as afebrile jaundice with slight enlargement of the liver, leukemia, 
erysipelas, typhoid fever, etc., and lessening in the size of the liver may 
be missed in those cases with cirrhosis (with a small liver), or when 
the liver is bound to the abdominal wall by adhesions. 
Phosphorus poisoning may be excluded by the absence of a history of 
the ingestion of phosphorus (not always trustworthy), the latter develop- 
ment of jaundice (which in phosphorus poisoning usually supervenes 
after a day or two of symptoms referable to disordered stomach), decrease DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
477 
in the size of the liver (which usually remains enlarged in phosphorus 
poisoning), the more severe nervous symptoms, and the constant occur- 
rence and larger amounts of leucin and tyrosin. Biliary cirrhosis may 
be excluded by the presence of an enlarged liver with jaundice and fever, 
the absence of leucin and tyrosin from the urine, and the longer course. 
Prognosis.-The disease runs a somewhat variable course. In a 
majority of the cases death ensues before the fourteenth day; almost 
half of the cases terminate fatally in from the fifth to the tenth day; 
a few cases become chronic and may last upward of four or six to 
eight weeks; rarely, but apparently undoubtedly, recovery may ensue, 
in which event the disorder is of much protracted course. Death before 
the fifth day is uncommon, except in pregnant women. The prognosis 
is extremely unfavorable, virtually fatal, the rare recovery serving 
rather to accentuate the ordinary course of the disease than to hold out 
hope of recovery in any particular case. The prognosis is especially 
bad in pregnant women, also in all cases, the more violent in nature 
and the earlier the onset of the nervous symptoms, in the event of serious 
renal complications, such as oliguria, albuminuria, casts, decrease in 
nitrogen excretion (evidences of toxic retention or acid intoxication), 
and in cases with severe hemorrhages. Virtually the prognosis depends 
upon the severity and length of the second stage of the disease; rarely 
this lasts more than two or at the most three days; should the symptoms 
be mild or abate, hope of ultimate recovery may be entertained, but 
usually the disorder becomes chronic and the patient eventually dies. 
The possibility of recovery, however, cannot be denied. 
Treatment.-The extraordinary mortality shows the futility of thera- 
peutic endeavors, nor can we hope for improvement until time and 
research have disclosed the cause. Perhaps it is too much to expect 
that we should view every case of jaundice as likely to eventuate in 
acute atrophy; but jaundice in a pregnant woman is assuredly serious, 
and should be looked upon as a possible forerunner of acute yellow 
atrophy. It is wise in all cases of jaundice in pregnant women (as well 
as in all cases of so-called catarrhal jaundice) to study the urine for 
evidences of acid intoxication and destructive protein metabolism, and, 
should these be found, to institute the appropriate treatment. Further- 
more, in view of the similarity of the hepatic lesions in acute yellow 
atrophy, puerperal eclampsia, and delayed chloroform poisoning, 
chloroform and chloral should be used much more cautiously in 
pregnant women, especially in treating convulsions, than has been 
the custom. 
In the early stages the patient should be confined to bed. Milk is 
the best food, and should be diluted with some alkaline mineral water; 
cereals and other carbohydrates may be given in considerable amounts, 
since they are likely to prevent or limit the acid intoxication. The 
bowels should be opened freely; calomel and the saline cathartics seem 
the best. Insistence should be laid upon the drinking of large amounts 
of water; any good water will suffice, but an alkaline mineral water is 
probably preferable. Alkaline diuretics may be added to the water or 
given otherwise, and should serve to promote the diuresis and counteract 478 
DISEASES OF THE DIGESTIVE SYSTEM 
the acid intoxication; sodium bicarbonate also might prove efficacious 
in the last-mentioned particular. 
The guiding principles in the treatment of the second stage of the 
disease are similar to those of the first-to prevent or limit the formation 
and to promote the elimination of toxins. The measures mentioned 
should be continued, and free catharsis and free diuresis must be main- 
tained ; otherwise the treatment is purely symptomatic. 
CONGESTION OF THE LIVER 
The liver, being a large organ well endowed with bloodvessels, and 
interposed between the portal circulation and a large area of the systemic 
venous circulation opening almost directly into the heart, is naturally 
responsive to variations in the inflow of portal blood on the one hand, 
and the outflow of the general systemic venous blood on the other hand; 
to these must also be added its responsiveness, in common with other 
organs of the body, to the supply of arterial blood. The amount of 
blood contained within the liver, therefore, is subject to wide variations 
in health, and it varies also in disease with the factors upon which it is 
dependent. That the liver is capable of accommodating an extraordinary 
amount of blood is obvious from the great size it often attains when 
congested, and the very marked reduction in size that may follow relief 
of the factors provoking the congestion (such as gastro-intestinal hemor- 
rhage, improvement in chronic heart disease, etc.). The increased 
amount of blood may be due to increased inflow or impeded outflow of 
the blood-whence we may distinguish an active and a passive conges- 
tion, but neither can be looked upon as a disease entity. The one is 
largely toxic in nature and usually gastro-intestinal in origin; the other 
is largely mechanical in nature and usually cardiac in origin. 
Active Congestion.-Etiology.-This may result from an excess of 
blood from the portal vein or the hepatic artery; the portal vein is the 
more important factor. This active congestion develops under a variety 
of circumstances: (1) It occurs as a physiological process during diges- 
tion, when the amount of blood carried to the liver by the portal vein is 
increased, lessening and finally subsiding as digestion proceeds to its 
completion. (2) Various poisons, some endogenous, some exogenous, 
may be carried to the liver by the portal vein and provoke acute conges- 
tion. (3) Active congestion of the liver may also result from the action 
of the toxins of certain infections that may reach the liver by way of the 
general circulation, such as malaria, pyococcic infections, typhoid fever, 
yellow fever, influenza, etc. In some of these infections the poison may 
reach the liver by way of the portal and the general circulation. (4) 
There is a group of cases presumably of active congestion of the liver 
attributed by men of experience to the influence of "cold." 
It is obvious that many of the aforementioned factors are the causes 
also of inflammation and of degenerative changes in the liver, and, as 
a matter of fact, it is difficult in many cases to separate the one condition 
from the other; indeed, in some cases they are combined. Degenerative DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
479 
changes are very common in all toxemias, and are not uncommonly 
associated with congestion; and congestion itself is an early stage of 
inflammatory conditions. In many cases the changes represent grada- 
tions of the one process, which, depending upon the severity and 
virulence of the operating cause, in the one case ceases at congestion 
and subsides, and in the other progresses to inflammation. 
Pathology.-The liver presents the ordinary appearances of active 
congestion (which, however, after death are ill marked); it is enlarged, 
swollen, and contains an increased amount of blood, whence it is some- 
what dark reddish or reddish brown in color, and it drips blood on section. 
Microscopically there is dilatation of the capillaries and small vessels 
of the capsule of Glisson; often there is parenchymatous and sometimes 
fatty degeneration, occasionally pigmentation of the liver cells. Rarely 
there is oedema, congestion, and proliferation of the biliary ducts. 
Symptoms.-These are rarely unequivocal. Most of the cases follow 
or are associated with dietetic indiscretions, and the symptoms are 
largely those of disturbances of digestion, which in general partake of 
the complex popularly designated "biliousness." In consequence of an 
excess of food or too much alcohol, excessive demands are made upon 
the liver; the wheels of catabolism become clogged and the drains of 
excretion more or less plugged; the blood becomes surcharged with 
partially detoxified protein substances and effete material, and a "bil- 
ious," "lithemic," or "gouty" attack supervenes. The appetite is poor, 
temporarily lost, the sight or thought of food often exciting disgust; 
there is a bad taste in the mouth and the tongue is furred; there is epi- 
gastric distress, which sometimes amounts to actual pain and is usually 
aggravated by taking food; nausea is common and vomiting may super- 
vene; there is often discomfort and sometimes actual pain in the region 
of the liver, which rarely is referred to the right shoulder and scapula, 
increased by deep breathing, sudden movement, and lying on the side; 
usually there is constipation and the stools may be light colored, but 
there may be transitory attack of diarrhoea. The patient's general 
feelings are often distressing; there is general malaise, headache, some- 
times vertigo, a feeling of nervousness with unrefreshing sleep, irritability, 
depression, etc. Occasionally there is slight jaundice; more often there 
is a peculiar sallowness of the face and the general integument. The 
liver is found enlarged and tender, but the enlargement is not marked. 
The urine is commonly concentrated, of increased specific gravity, and 
deposits an abundant sediment of urates and uric acid; occasionally 
there is a transitory (toxic) albuminuria. Bile pigments are present in 
the event of jaundice. The disorder is usually afebrile, although now 
and then there may be a rise in temperature to 100° F. or thereabouts 
(in which event the disorder should be view'ed as having progressed to 
acute parenchymatous hepatitis). 
In another class of cases, those met with in infections, such as dysen- 
tery, etc., the constitutional symptoms are the more marked, slight or 
moderate fever is usually present (progression to acute hepatitis), and 
the local gastro-intestinal symptoms are more or less in abeyance, but 
become aggravated during digestion. The liver is enlarged and tender. 480 
DISEASES OF THE DIGESTIVE SYSTEM 
Diagnosis.-This is usually apparent from the etiological factors, the 
general disturbances of the gastro-intestinal tract, the slight jaundice, 
and enlargement and tenderness of the liver; by no means of minor 
diagnostic importance is recurrence of attacks in a person of known ill- 
chosen habits of eating and drinking. The difficulties consist in deter- 
mining whether or not to the congestion permanent damage to the liver 
tissue has been added. With recurrence of attacks, their increasing 
duration, and lessening intervals, this becomes the more likely; the less 
the enlargement of the liver and the quicker it subsides (or returns to 
the normal), the more is permanent damage unlikely. In the more 
acute cases encountered in infections aggravation of the constitutional 
symptoms, together with enlargement and tenderness of the liver, 
usually suffice for diagnosis. In these cases there are usually parenchy- 
matous changes in addition to the congestion. 
Prognosis.-The disorder rarely lasts more than three or four days; 
sometimes a week. It is not dangerous in itself, but acquires its impor- 
tance because of its etiological factors (especially alcohol) and its fre- 
quent recurrence in those who persist in the use of alcohol, in whom it 
is likely to eventuate in cirrhosis, and in those continuously exposed to 
other etiological factors, such as dysentery, etc., in the tropics. 
Treatment.-There is reason to believe that in those wTho eat and 
drink too much and lead a sedentary life, in the gouty, those of plethoric 
habit, and those formerly the subjects of chronic malaria, dysentery, 
etc., in the tropics, prophylactic measures may serve to ward off attacks, 
at least recurrences, of acute congestion of the liver; and it is by no 
means unlikely that appropriate energetic treatment undertaken early 
in cases of what cannot be called other than acute congestion would 
often prevent the later development of cirrhosis. Obviously those 
factors known to provoke an attack of acute congestion should be 
avoided, and one should cultivate abstemious habits. The food should 
be moderate in amount and easily digested; highly seasoned articles 
should be avoided; alcohol should be omitted altogether or taken only 
occasionally, as whisky in small amounts, well diluted, and with the 
meals. The body, especially the abdomen and Tack of the neck, should 
be protected from the action of "cold" by day as well as by night. Con- 
stipation should be overcome, preferably by laxative foods, an occasional 
mercurial purge, and the saline cathartics. The too common sedentary 
life should be at least partially replaced by activity. 
When the attack has developed the patient should go to bed and be 
kept there until convalescence is complete. The guiding principle 
should be to reduce the functional demands upon the liver, to eliminate 
all factors that might provoke or add to its congestion, and to reduce 
any existing intestinal catarrh. These objects are best achieved by 
dietary regulations. The diet should be minimal in amount and abso- 
lutely unirritating; in general it should consist exclusively of milk, which 
should be given at stated (rather long) intervals, and well diluted with 
lime-wTater or other alkaline water. Whey, junket, albumin water, 
strained broths (without seasoning), barley water, calf's-foot jelly, 
etc., may be given plater, and, indeed, early to those who seriously DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
481 
object to or are inconvenienced by milk. Gradually the diet may 
be augmented, at first by the addition of cereals, and then meat, etc. 
Alcohol must be absolutely interdicted. Plain or alkaline water should 
be given in large amounts throughout. The congestion of the liver and 
the intestinal catarrh are influenced by free saline purgation. 
Ammonium chloride (20 grains thrice daily) has long enjoyed a repu- 
tation in the relief of disorders of the liver. It may be given in the 
early stages, combined with the alkalis (alkaline waters, sodium 
bicarbonate, etc.), or later with nitrohydrochloric acid, nux vomica, 
or strychnine, and a bitter tonic. The distressing gastric irritability 
of the early stage of some cases may be controlled by sodium bicarbon- 
ate, bismuth subnitrate, and carbolic acid or creosote. Local measures, 
such as leeches, cold compresses, etc., sometimes relieve the local dis- 
comfort, and are believed by some observers to lessen the congestion 
of the liver. 
Those subject to recurrences of congestion of the liver are much 
benefited by treatment at some of the w'ell-known spas, such as Carlsbad, 
Marienbad, Vichy, etc. Many of the waters of our own country, such 
as Saratoga, etc., are equally efficacious, but there is little if any control 
of the patient at the resorts, and the accessories are largely wanting. 
Passive Congestion.-Etiology.-This is due to factors that impede 
the efferent circulation; these are largely mechanical in nature and cardiac 
in origin (whence the name cardiac liver). The disorder occurs: (1) In 
failure of the heart, whether acute or chronic; it is most common as well 
as most advanced in the late stages of mitral valve disease (especially 
mitral stenosis) with consecutive tricuspid insufficiency; but it is found 
also in primary tricuspid disease, in advanced aortic valve disease (with 
secondary mitral and tricuspid disorder), myocardial weakening with 
dilatation, pericardial adhesions, etc. (2) It occurs also in the advanced 
stages of such diseases of the lungs as cause increased work of the right 
side of the heart and ultimately lead to its failure, such as emphysema, 
chronic bronchitis, asthma, chronic adhesive pleuritis, and compression 
of the hmgs (by pleural exudates, mediastinal tumors, aneurisms, etc). 
(3) It may result also 'from local factors that obstruct the circulation 
about the junction of the hepatic veins and the inferior vena cava, of 
which the most important are kyphosis and scoliosis, tumors, hydatid 
cysts, gummas, etc., of the liver, inflammatory bands and adhesions, 
and kinking of the hepatic veins or the inferior vena cava by a displaced 
heart or a large pleural or peritoneal effusion. 
Pathology.-Passively congested livers may be divided into three 
classes, more or less distinct, but representing different stages of the 
same process: (1) The merely congested or engorged liver, found in 
cases of acute or recent heart failure (common in the infections, such 
as pneumonia, typhoid fever, etc.), and in chronic valvular disease with 
well-maintained compensation in which death has occurred suddenly 
or after a few days' illness only; (2) the congested nutmeg liver, found 
in cases of long-standing heart disease with dilatation of the right heart 
and tricuspid insufficiency, in which compensation, although precariously 
maintained, has been on the whole fairly satisfactory, and in which no 482 
DISEASES OF THE DIGESTIVE SYSTEM 
serious or prolonged failure has occurred until that which leads to death; 
and (3) the fibrotic nutmeg liver, found also in cases of long-standing 
heart disease with dilatation of the right heart and tricuspid insufficiency, 
in which one or more severe and prolonged attacks of failure of com- 
pensation have occurred, during which the auricle has suffered especially 
and, being perhaps totally incapacitated, has permitted the full force of 
the ventricle to be transmitted to the hepatic lobules with consequent 
rupture of the venules and capillaries, laceration and destruction of 
hepatic parenchyma, and its repair by new-grown connective tissue. 
The congested liver in the early stages is increased in size, depending 
upon the amount of contained blood: it is firmer and denser, and dark 
purplish or bluish in color. On section the liver in the early stages drips 
blood and presents a more or less uniformly congested dark bluish or 
purplish color, sometimes slightly mottled with lighter areas; in more 
advanced stages the excess of blood is less apparent, and the organ 
presents the characteristics spoken of as the congested nutmeg liver; 
the intralobular and sublobular venules being distended and overfilled 
with blood, appear as dark purplish or reddish spots (transverse section) 
or streaks (longitudinal section), which are in marked contrast to the 
pale yellowish or whitish circumferential liver cells, the seat of fatty 
infiltration and biliary pigmentation. When of still longer duration, 
the liver has decreased in size and may be less than normal; it is firmer 
and denser, but still presents the nutmeg appearance; about the dis- 
tended central veins some fine new connective tissue, often pigmented, 
reddish in color, may be obvious; the hepatic veins are dilated and their 
walls thickened and opaque; the adjacent hepatic tissue is atrophic and 
pigmented, and invading it fine fibrous connective-tissue trabeculae may 
be detected (fibrotic nutmeg liver; red atrophy of the liver). The capsule 
is sometimes thickened and opaque, especially in the event of ascites, 
and through it the distended subcapsular veins may be apparent. In 
some cases there may be a more or less universal perihepatitis, commonly 
associated with pericarditis and pleuritis (so-called multiple serositis). 
More or less extensive hemorrhage into the centre of the lobules and 
consequent destruction of the hepatic parenchyma are not uncommon. 
The hepatic cells about the central veins show a variable degree of 
atrophy-partly a pressure atrophy and partly doubtless nutritional, 
the result of insufficient oxidation or due to toxins or cytolytic ferments. 
In most cases there is a considerable accumulation of fat in the liver cells; 
usually, also, the cells about the central venules contain more or less 
pigment derived from the hemoglobin, usually hematoidin, but also 
hemosiderin. In consequence of atrophy of the liver cells the supporting 
reticulum becomes relatively increased, and it becomes absolutely 
increased in consequence of new growth (replacement fibrosis). This 
fibrosis is usually most marked about the central vein, and it gradually 
radiates therefrom, following the capillaries throughout more or less 
of the lobule. There is always more or less fibrosis about the hepatic 
veins, which, as a rule, is proportionate to the degree and duration 
of the congestion. About the portal veins also some fibrosis may now 
and then be observed, but this is always minor in grade and altogether DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
483 
disproportionate to the fibrosis observed elsewhere. The capsule is 
usually thickened, and from this new connective-tissue trabeculae usually 
invade the liver a variable distance to join the new perilobular connective 
tissue. 
The new-growth of fibrous tissue has led to its comparison with 
cirrhosis, and the term cardiac cirrhosis has been employed. But the 
lesions are in no way comparable to those of ordinary cirrhosis. The 
slight fibrosis common in the congested nutmeg liver is intimately related 
to the central and sublobular and hepatic veins; it results no doubt from 
the chronic distension of the veins; but the more marked fibrosis in the 
fibrotic nutmeg liver is doubtless in large part a replacement or scarring 
process, to repair destroyed liver parenchyma. Such periportal fibrosis 
as occasionally occurs is purely subsidiary, and may readily be accounted 
for by the fact that hepatic vein obstruction may lead to portal con- 
gestion, which in turn sets up chronic intestinal catarrh; the poisons 
thus induced may be transported by the portal vein to the liver and 
induce a mild grade of portal cirrhosis; in many cases of chronic heart 
disease, alcoholism is quite common, and may set up an ordinary cirrhosis; 
and finally, many cases of ordinary portal cirrhosis have added passive 
congestion. The phenomena should be correctly interpreted; the liver 
in passive congestion rarely presents the lesions of true cirrhosis. 
Much interest attaches to the proper interpretation of the afore- 
mentioned lesions. Of special interest is the idea advanced by Salaman1 
that the liver acts physiologically as a safety valve to the heart, and 
that the various changes in structure undergone after prolonged back- 
pressure modify that safety-valve action and seriously alter the clinical 
course of the disease. Salaman states that the structure of the liver may 
be aptly compared to that of a sponge, and that in consequence of the 
elasticity of the supporting framework as well as of the parenchyma, 
the organ is capable of considerable expansion with subsequent recovery 
of shape, hastened by the pressure of the other abdominal organs. 
The congestion of the liver in the early stages of cardiac failure is 
a compensatory process; this is especially active in acute failure, such 
as occurs in many infections and in the early stage of chronic valvular 
disease; not until the liver has been distended to and beyond its 
capacity does oedema ensue; and with the progress of the valvular 
defect and the gradual loss of the safety-valve action of the liver 
(due to the described lesions), oedema appears more and more easily. 
Symptoms.-These consist of (1) those due to the primary cardiac or 
pulmonary disease; and (2) those due more directly to the disorder of the 
liver itself, which consist of local distress and gastro-intestinal phenomena. 
The severity of the local subjective symptoms often depends more upon 
the rapidity of the development of the congestion than upon its grade; 
that is, subjective symptoms may be for some time in abeyance if the 
congestion develops slowly, although it may reach a high grade; whereas 
a less grade of congestion, developing rapidly, may occasion considerable 
distress. In one class the manifestations of cardiac failure predominate; 
in another class, phenomena referable to the liver predominate. 
1 Lancet, Lond., 1907, i, 4. 484 
DISEASES OF THE DIGESTIVE SYSTEM 
Chief among the local symptoms are pain, superficial and deep tender- 
ness, and distress or a sense of weight and heaviness in the right hypo- 
chondrium, aggravated by pressure, motion, deep inspiration, and the 
lateral posture. The congestion in the hepatic veins leads to congestion 
also in the portal tributaries, with consequent disturbances in digestion, 
poor appetite, epigastric distress, especially after eating, flatulence, 
nausea, constipation, etc. Jaundice is a common phenomenon; usually 
it is slight or moderate in grade, in which even the admixture of cyanosis 
and jaundice lends a very characteristic bluish-green or greenish-blue 
discoloration. The jaundice may be due to compression of the biliary 
capillaries and consequent interference with the flow of bile; perhaps 
more commonly to radicular cholangitis; or to the extension of the 
intestinal catarrh to the diverticulum of Vater and the common bile 
duct, in which event the obstruction is rarely complete; that is, some 
bile appears in the stools. In rare instances a terminal infection leads 
to marked increase of the jaundice (sometimes associated with mental 
symptoms, icterus gravis), doubtless due to toxic destruction of the 
hepatic cells. (Edema and ascites are common.1 The oedema is usually 
preceded for some time by enlargement of the liver, except in cases in 
which there is a sudden and severe cardiac collapse. One is warranted 
in the assumption that oedema does not supervene until the liver has 
exerted to the utmost its safety-valve action, and that the readiness 
with which oedema appears and disappears is a tolerably accurate indica- 
tion of the functional activity of the liver in this respect. The ascites 
may be part of a general dropsy and due solely to the factors provoking 
the anasarca, in which event it is likely to be small in amount, propor- 
tionate to the oedema; or it may be disproportionate, large in amount, 
and require frequent tappings; in this event it is associated with the 
fibrotic congested liver, or with chronic adhesive peritonitis (peri- 
hepatitis) or a more generalized peritonitis. An acute peritonitis may 
supervene, with audible and palpable friction. 
Examination of the liver reveals it to be enlarged; the size varies from 
time to time, depending upon the condition of the heart. The organ 
may be palpable a full handbreadth below the costal margin; it is 
uniformly smooth, has a sharp or slightly rounded edge, and is usually 
more or less tender. In advanced stages the liver becomes reduced in 
size (reduction in the amount of blood, cicatrization of connective tissue, 
atrophy of parenchyma), and may even recede beyond the costal arch, 
so as no longer to be palpable. The enlarged liver not infrequently pul- 
sates. The pulsation being usually systolic in time and truly expansile 
is more likely to be found in early stages, before new-grown fibrous tissue 
interferes with expansion of the organ. True pulsation must be dis- 
tinguished from a non-expansile pulsation transmitted to the liver by 
the contracting hypertrophied heart, by an abdominal aneurism, etc. 
Polygraphic tracings are really necessary often to detect pulsation and 
to properly time it. Mackenzie2 believes that once the liver has begun 
to pulsate, it continues to do so until death. If the pulsation is 
1 Pitt, Allbutt and Rolleston, System of Medi '' ", 1909, vi, 325. 
2 A Study of the Pulse, 1902, Edin, and London. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
485 
synchronous with the contraction of the auricle, Mackenzie has shown 
that stenosis of the tricuspid valve will frequently be found. The 
enlarged liver causes proportionate displacement and compression of 
adjacent organs; it may cause collapse of the base of the right lung, 
with dulness on percussion and feeble or absent breath sounds (which 
should not be mistaken for pleural effusion). 
The urine is concentrated, of high specific gravity and high color; it 
contains an excess of urobilin, and usually a small amount of albumin. 
The albuminuria is proportionate to the cardiac debility, and disappears 
with improvement in the cardiovascular condition. 
Diagnosis.-This is usually evident from a knowledge of the primary 
disorder, an enlarged and tender liver, and other evidences of failing 
cardiac compensation. The enlarged and congested liver may usually 
be readily distinguished by the fact that its volume changes considerably 
from time to time, which does not obtain in the case of other enlarged 
livers, and that lessening in the size of the liver is commonly associated 
with other evidences of improved cardiac tone and an increase in the 
amount of urine. Congestion may be distinguished from cirrhosis of 
the liver by evidence of the primary cardiac or pulmonary disorder, 
other evidences of failing heart, a smooth liver, the absence of dilated 
abdominal veins, and by the response to medication directed to the 
condition of the heart; but one must remember that congestion is not 
uncommon in cirrhosis of the liver, and that the marked reduction in 
the size of cirrhotic livers is often due to lessening of congestion rather 
than to atrophy of hepatic parenchyma. The smooth surface and varying 
size of the liver, responding to treatment directed to the heart, and the 
absence of cachexia will usually serve to exclude malignant disease; 
absence of the etiological factors will usually exclude amyloid disease; 
and an examination of the blood will exclude leukemia. 
Prognosis.-This depends altogether upon the primary disorder, upon 
the outlook and the response to treatment of the provoking cardiac 
disorder. To some extent, especially in acute and sudden failure of the 
heart, the congestion of the liver is doubtless a compensatory and more 
or less beneficent process. In chronic and advanced cases of heart 
disease this function becomes gradually abolished and the outlook 
correspondingly bad. Only the fibrotic nutmeg liver can be said of 
itself to influence materially the prognosis, which, from the very nature 
of the process, it renders very gloomy, presaging the fatal termination. 
Treatment.-The treatment is that of the primary cardiac or pulmonary 
disorder causative of the hepatic congestion; virtually, whatever the 
primary disease, the treatment is that of failing cardiac compensation. 
The patient must be absolutely at rest so as to reduce the work of the 
heart. The diet should be light and nutritious; fluids should be small 
in amount. Digitalis is the sovereign remedy, but it may seem desirable 
to supplement its action by such other drugs as strophanthus, caffeine, 
camphor, etc. The Addison, or Guy pill, consisting of digitalis, 
squill, and mercury (calomel or blue-mass), is valuable in many cases. 
Diuretics, such as theobromine, the potassium salts, etc., may also be 
given with hope of benefit. Bleeding is often efficacious. 486 
DISEASES OF THE DIGESTIVE SYSTEM 
The hepatic congestion is also favorably influenced by cathartics, 
especially the saline cathartics, the natural aperient waters, etc., which 
should be given in quantity sufficient to cause free watery move- 
ments. The vegetable cathartics also are useful, especially in con- 
nection with a relatively dry diet, for several days, from time to time. 
Pain in the region of the liver may be relieved by hot compresses, 
an ice-bag, etc. General nervousness and insomnia are often mark- 
edly benefited by morphine hypodermically: to yg grain usually 
suffices and is quite as efficacious as, if not more so, than larger doses. 
Bromides, chloralamide, trional, veronal, and other hypnotics may 
be tried from time to time. (Edema may require punctures and the 
use of Southey's tubes, and ascites may require repeated tappings. The 
tapping should not be too long delayed if the patient suffers much 
distress; on the other hand, it should not be performed too rapidly, nor 
too much fluid withdrawn, since the removal of the pressure sometimes 
permits the rapid absorption of toxic substances and leads to the speedy 
development of uremic manifestations. 
PERIHEPATITIS 
Acute Perihepatitis.-Etiology.-This is almost, if not quite, without 
exception a secondary disorder. Rarely it follows trauma of the right 
side (contusions, fractures of the ribs, etc., with or without contusion or 
laceration of the liver and its capsule); in the great majority of cases 
the perihepatitis is secondary to disease of the liver or adjacent viscera. 
It occurs in association with acute congestion and inflammation of the 
liver (especially in the tropics); it is not uncommon in long-standing 
passive congestion; it occurs in various forms of suppuration within the 
liver; it is associated with tubercles, gummas, and rapidly growing new 
growths of the liver that reach to or project beyond the surface; it follows 
inflammatory and ulcerative processes in adjacent organs, such as ulcers 
of the stomach, duodenum, and other parts of the intestine, cholecys- 
titis, pancreatitis, appendicitis, etc., in which circumstance the lesions 
ultimately often are those of one form of subphrenic abscess; it may 
be part of a general peritonitis; and it may follow disease of the thoracic 
viscera (pleuritis, pericarditis, etc.) through extension through the 
diaphragm. Acute perihepatitis is obviously always the result of infec- 
tion; the common infecting agents are the pyogenic cocci (staphylococci 
and streptococci), the pneumococcus, the colon bacillus, etc. 
Pathology.-The lesions may be localized or diffuse, and fibrinous, 
serofibrinous, or purulent in character. Early the peritoneum loses its 
lustre and becomes dull and opaque, the vessels become injected, and a 
small amount of serum or serofibrin is thrown out. The lesions may not 
extend beyond this: the serum becomes absorbed and the fibrinous 
exudation undergoes organization, with the ultimate formation of 
filamentous or dense adhesions. The lesions vary in situation with that 
of the primary cause: in traumatic cases, and those associated with 
various diseases of the liver itself (abscess, gummas, new growths, etc.), DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
487 
and of the thoracic organs, the lesions are most likely to be on the antero- 
superior surface of the liver, and the ultimate adhesions bind the liver 
to the diaphragm and the anterior abdominal wall; in the cases that 
follow disease of the adjacent abdominal organs the lesions are most 
likely to be at the contiguous, usually inferior, surface of the liver; in 
cases due to transport of infection from a distance (appendicitis for 
instance) the lesions are most common on the superior aspect of the 
organ; but most unlooked-for lesions sometimes occur. In other cases 
the lesions progress to suppuration. 
Symptoms.-The important clinical phenomena consist of local pain 
and audible and palpable friction, which are quite similar to the analogous 
pleuritis. The pain is often acute and lancinating; it may be located 
anywhere in the region of the liver, but it is not infrequently referred 
to the margin of the ribs and the epigastrium (fairly widespread peri- 
hepatitis), or rather high up in the axilla (more localized peritonitis), and 
it frequently radiates to the supraclavicular fossa (said by Cantlie to 
be diagnostic); it is made worse by motion, such as deep inspiration, or 
the lateral posture, or by passive motion made by the physician. The 
movements of the right lower chest are restricted or abolished. Palpation 
reveals local tenderness and not infrequently rigidity of the upper 
abdominal muscles on the right side. Auscultation may reveal friction 
which, however, is often quite localized and very fleeting; rarely it may 
be palpated. Sometimes there is slight or moderate fever; there may be 
a short, hacking, dry cough sometimes set up by manipulations of the 
liver. Hiccough (suggesting involvement of the diaphragm) is not 
uncommon and may be severe. Nausea and vomiting may occur in 
case the stomach, duodenum, or gall-bladder are implicated in the 
inflammation. Occasionally slight ascites develops-due to interference 
with drainage of the peritoneum through the diaphragm; this is quite 
independent of the marked ascites due to general peritonitis, etc. 
Diagnosis.-This is not infrequently obscured by the predominance 
of symptoms of the primary disorder; sometimes the lesions are found 
after death in cases in which no noteworthy symptoms were present 
during life. However, the diagnosis can usually be made by noting the 
symptoms of the primary disorder, and in addition local pain and tender- 
ness, audible and sometimes palpable friction, and perhaps rigidity of 
the abdominal muscles of the right upper quadrant. The condition is 
probably most commonly mistaken for right-sided pleurisy-which 
may coexist; the acute perihepatitis, however, can usually be distin- 
guished by a knowledge of the primary (usually abdominal) disorder, 
the lower situation of the local signs, and the onset of severe pain 
upon passively moving the liver forward and backward (Cantlie). 
Prognosis.-This depends upon the primary or underlying condition; 
the acute perihepatitis (unless it progresses to suppuration), although 
distressing, is not in itself dangerous to life. 
Treatment.-The treatment is that of the primary disease; but in 
some cases the phenomena of the acute perihepatitis so overshadow 
those of the primary disease as to furnish the indications for treatment. 
Pain often demands immediate attention and may be relieved by 488 
DISEASES OF THE DIGESTIVE SYSTEM 
strapping the side; this may obviate the necessity of giving opium, which 
should not be withheld should the pain continue. In some cases more 
or less relief attends the use of poultices, an ice-bag, dry cupping, leeches, 
and other forms of counterirritation, etc. The patient should be kept 
at rest and on a light diet until the acute manifestations have subsided, 
whereupon the treatment should revert to that of the primary disorder. 
Local Chronic Perihepatitis.-Etiology.-This not infrequently follows 
acute perihepatitis, particularly repeated attacks, and it is due, therefore, 
to the same causes. It is perhaps most commonly found in association 
with chronic passive congestion of the liver (long-continued expansion 
and contraction of the liver with consequent peripheral friction), pressure 
atrophy (corset liver, etc.), gummatous and tuberculous new formations, 
tumors and hydatid cysts reaching the surface of the liver, chronic 
cholecystitis, gastric and duodenal ulcers, etc. 
Pathology.-In many cases local chronic perihepatitis represents the 
process of healing of acute perihepatitis by the formation of adhesions, 
in which event the process is obsolete, non-progressive; the adhesions 
are firm, fibrous, and non-vascular; they are attached to, and virtually 
form a part of, the capsule of the liver; and they serve to bind the liver 
to adjacent structures and tissues-the diaphragm, the gall-bladder, 
the anterior abdominal wall, the stomach, duodenum, pancreas, intestine, 
omentum, etc. In some cases adhesions have not formed, the capsule 
of the liver revealing here and there more or less localized thickenings, 
much resembling the so-called milk spots of the pericardium. Rarely 
there appears to be some progression from the local to the general form 
of perihepatitis, but, as a rule, the two are quite distinct. 
Symptoms.-These are scarcely, if ever, definite; but local pain, 
tenderness, and rigidity, particularly if recurrent, may suggest the 
disorder; confirmation may rarely be obtained by eliciting audible or 
palpable friction. In some cases the diagnosis may become apparent 
by the onset of an acute exacerbation. In the majority of cases the 
diagnosis is not likely to be made-which is a matter of little or no 
moment, since the disorder is of comparatively little clinical importance. 
Treatment.-This is altogether that of the primary disorder. In 
rare instances in which the chronic perihepatitis can be diagnosed, and 
the still rarer instances in which special treatment seems indicated, 
the measures mentioned in acute perihepatitis are appropriate. 
General Chronic Perihepatitis; Chronic Hyperplastic, Hyaline, or 
Deforming Perihepatitis; Sugar-iced Liver (Zuckergussleber); Multiple 
Serositis; Polyorrhymenitis; Pericarditic Pseudocirrhosis of the Liver 
(Pick).-This is a disorder first described by Van Deen, later studied 
by Curschmann, who gave to it the name of Zuckergussleber (sugar- 
iced liver), and more recently studied by Hale White, Nichols, Rolleston, 
etc.1 
Etiology.-General chronic perihepatitis is about equally common in 
the two sexes; it occurs at all ages, but is most common in the second 
1 A review of the literature, with a collection of cases and some personal obser- 
vations, will be found in Multiple Serositis, by A. O. J. Kelly, Amer. Jour. Med.Sci., 
1903, cxxv, 116. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
489 
and the fifth decades. The exciting causes are ill understood; most 
likely they are toxic in nature, but the nature and source of the toxin 
are not known. The rather common association of the condition with 
arteriosclerosis and chronic interstitial nephritis (19 of Hale White's 
22 cases) suggests that the poison may be allied to that of uremia, but 
this supposition is somewhat negatived by the rarity of chronic peri- 
hepatitis in arteriosclerosis and chronic nephritis. It is not improbable 
that the arteriosclerosis, nephritis, and perihepatitis may be due to the 
one cause, unknown as it may be. That the etiological factor is often 
widespread is shown by the common association of disease of several 
serous membranes (peritoneum, pericardium, and pleura). The process 
is best explained upon the assumption of a bacterial toxin that finds 
in the peritoneum (or other serous membrane), reduced in vitality from 
any cause (such, for instance, as nephritis), a favorable soil for activity. 
In some cases this poison may be that of malaria, typhoid fever, or other 
infections; in other cases it may be syphilitic, although syphilis usually 
causes only a local perihepatitis; in other cases it is undoubtedly tuber- 
culous, although the lesions are not those ordinarily provoked by the 
tubercle bacillus; but in many apparently non-tuberculous cases char- 
acteristic tuberculous lesions may be detected and the tubercle bacillus 
may be recovered from the lesions. McWeeney1 suggests that the bovine 
tubercle bacillus may be the cause in some cases. In most cases, however, 
no definite etiological factor can be determined. 
Pathology.-At first sight the cases appear to be separable into two 
classes, those in which the lesions are confined to the peritoneal invest- 
ment of the liver, and those in which they involve also the serous mem- 
branes above the diaphragm (pericardium and pleura); but that this 
is an artificial division is obvious from the fact that the perihepatitis 
is often only part of a more generalized chronic peritonitis, and that the 
ultimate lesions are identical, whether they begin below or above the 
diaphragm; the condition essentially is a chronic multiple serositis. 
The lesions consist of the development of a thick encasement of 
fibrous connective tissue, whitish, glistening, and much resembling 
confectioner's icing, whence the name iced-liver or sugar-iced liver 
(Zuckergussleber). This encasement may envelop the liver completely, 
or be limited to, or most marked upon, the upper surface; it may be 
5 mm. or more in thickness; it is often of cartilaginous consistency; and 
it can usually be detached in layers, leaving what appears to be a more 
or less intact peritoneum (this is quite characteristic, and serves to 
distinguish this from other forms of perihepatitis). This new connective 
tissue exhibits a marked disposition to cicatricial contraction, so that 
considerable distortion of the liver ensues, the narrower anterior margin 
in particular being frequently distorted. The gall-bladder is commonly 
embedded in dense adhesions and may be discovered and isolated only 
with great difficulty; usually it is collapsed and contains little or no bile, 
perhaps a small amount of mucus. The lesions not uncommonly involve 
the pleura (especially the right), and the pericardium, but also other 
1 Trans. Roy. Acad. Med., Ireland, Dublin, 1906, xxiv, 402. 490 
DISEASES OF THE DIGESTIVE SYSTEM 
abdominal viscera; the spleen may be similarly encased in a thick, 
whitish envelope; the omentum may become thickened, indurated and 
rolled upon itself, forming a hard, almost unrecognizable mass; the 
mesentery may become thickened and much shortened, in consequence 
of which the intestine also becomes shortened and perhaps obstructed. 
In many cases the most widespread adhesions and distortion of the 
abdominal organs ensue, giving rise to what has been aptly described 
as deforming peritonitis. Of 110 cases collected by Picchini (50 observed 
by himself and 60 collected from the literature), the peritoneum was 
involved in all (although this was recognized clinically in only 13), 
being, therefore, the most frequent and most important lesion; pleuritis 
was present in 109 cases, in 73 of which it was bilateral; the pericardium 
was involved in 9 of 50 cases. 
In 39 cases collected by Kelly, with special reference to the association 
of chronic obliterative pericarditis and ascites, the pericardium was 
obliterated in all (more or less extensively calcified in 10); the right 
pleura was entirely obliterated in 17, and was partially obliterated or 
contained fluid in 19 (in 3 the condition of the right pleura was not stated); 
the pleura was entirely obliterated in 15, it was partially obliterated or 
contained fluid in 16, it was normal in 3 (in 5 the condition of the left 
pleura was not stated); in 28 cases there was chronic perihepatitis, and 
in 31 cases chronic perihepatitis or chronic peritonitis, or both. 
The condition of the liver is of much interest. In many cases, aside 
from distortion and compression, there are no noteworthy lesions-a 
fact of much importance in determining the pathogenesis of the lesions. 
In the 39 cases mentioned, the liver was reported as nutmeg in 14, 
cirrhotic in 8, normal aside from compression in 4, nutmeg and cirrhotic 
in 4, and in 3 there appeared to be only extension of connective tissue 
from the thickened capsule into the substance of the organ. In these 
cases (Pick's pericarditic pseudocirrhosis of the liver) the nutmeg appear- 
ance of the liver may well be attributed to a failing heart; these do not 
include the many in which the pericardium is not involved, and in which 
congestive changes in the liver are rare, unless there be a failure of the 
myocardium from other causes. In these cases, although a slight amount 
of fibrosis may extend from the thickened capsule a short distance into 
the substance of the liver, cirrhosis in an acceptable sense does not 
occur; but one must remember that thickening and adhesions of the 
capsule are not uncommon in advanced cirrhosis. The spleen, in addition 
to being incased in a thick connective-tissue envelope and adherent to 
adjacent structures, especially in association with left-side pleuritis, 
is not infrequently enlarged, especially in the cases associated with 
chronic pericarditis (23 of the 39 cases already referred to). The kidneys 
usually exhibit the lesions of chronic interstitial nephritis, more so 
perhaps in the cases in which the lesions are confined to the peritoneum. 
Microscopically the encasing is seen to consist of new-grown fibrous 
connective tissue, for the most part arranged in lamellae, and the seat 
of advanced hyaline degeneration (whence Nichols speaks of the condi- 
tion as hyaloserositis); there are very few bloodvessels, and a small 
amount of round-cell infiltration-leukocytes and mast cells. Usually DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
491 
there is a more or less sharp line of demarcation between the new tissue 
and the underlying capsule of the liver. 
As already stated the lesions may begin in any one serous membrane, 
and then remain localized thereto or gradually spread to the others. 
De Renzi believes that the peritoneum is usually involved first; then 
the right pleura, and then the pericardium. If, however, the right pleura 
should be involved first, the disease then extends to the peritoneum, 
thence to the left pleura and the pericardium. In some cases this mode 
of progression of the disease is not preserved, as sometimes a pericarditis, 
usually not to be diagnosed, develops first. The intensity of the lesions 
about the liver finds its explanation in the normal circulation in the 
peritoneal cavity, whereby fluids and foreign particles, regardless of 
the position of the patient, are carried toward the upper surface of the 
liver; the lymphatics converge toward the suspensory ligament of 
the liver and the central tendon of the diaphragm. The attempt on the 
part of the peritoneum to remove certain noxious agents may result in 
partial or complete success. In the latter instance the peritoneum may 
be completely rid of the infective agent, which being carried to the 
mediastinal lymph vessels and glands, may infect the pericardium or 
the pleura, giving rise to a primary pleuritis or pericarditis; subsequently 
the peritoneum, by a descending infection, may become involved. In 
other cases the attempt on the part of the peritoneum to remove the 
infective agent being only partially successful, the region about the 
liver and the under surface of the diaphragm succumbs, and a primary 
perihepatitis occurs. Subsequently the infective agent may travel 
through the diaphragm and infect the pericardium or the pleura, or both. 
The peculiarities of course and of distribution of the lymphatics of this 
region are also accountable for the much greater involvement of the 
upper surface of the liver, as contrasted with the lower surface, that is 
present in most cases. De Renzi states that the disease is characterized 
by the fact that it remains localized to the serous membranes; that it 
does not implicate the intra-abdominal and intrathoracic organs; that 
it pursues a remarkably slow and insidious course; that it gives rise to 
the exudation of large quantities of serofibrinous fluid; and that the 
fluid portion of the exudate tends to become absorbed, in consequence 
of which adhesions with obliteration of the serous cavities result. 
Symptoms.-The disorder often remains latent for many years, and 
may be entirely unsuspected during life; in,other cases there is often a 
more or less clear history of the past occurrence of inflammation of one 
or more serous membranes; and in still other cases it is only examination 
of the patient that discloses the serous membrane disorder. In the 
cases with manifest symptoms, the most common are sensations of 
fulness, oppression, and weight in the upper abdomen; or there may be 
apparently a sudden onset with acute pain. The abdomen increases in 
size and may attain very large dimensions-due to ascites. With 
increase in the amount of ascites, the abdominal wall becomes tense 
and the other subjective symptoms aggravated. There may be slight 
and transitory jaundice. Later, oedema of the legs may develop. 
A striking feature is the ascites, which is present whether the 492 
DISEASES OF THE DIGESTIVE SYSTEM 
pericardial and pleural changes are absent, slight, or marked. Aside 
from ascites, the clinical picture varies somewhat, depending upon the 
seat of origin of the disease. In some cases the disease is ushered in 
with acute pericarditis, pleuritis, or perihepatitis, which subsides and 
leaves the patient apparently well for a number of years. Usually, 
however the lesions of the pericardium and of the pleura are latent, and 
the first sensible evidence of the disease is ascites. In some cases of 
primary pericarditis, slight and transient oedema of the legs may be 
present early, but this is not observed in many cases, inasmuch as the 
pericarditis is usually latent. When oedema is present early it usually 
soon subsides and does not recur until the ascites has been present for 
a long time or until shortly before death; except shortly before death 
it is inconspicuous when contrasted with the excessive ascites. Asso- 
ciated with early oedema, slight swelling of the spleen and disturbances 
of the gastro-intestinal tract may develop, but these usually subside 
with the oedema, and the disease, as a rule, is characterized by the entire 
absence of such symptoms, until failure of the heart supervenes, or 
until shortly before death. The ascites is characterized by the fact that 
it is excessive, that it necessitates repeated tappings, that it recurs 
rapidly after tapping, and that it may remain stationary (not requiring 
tapping) for many years. Osler mentions a child in whom tapping wras 
done 121 times, and Rumpf mentions a case in w'hich tapping was done 
301 times. The ascitic fluid is amber in color, has a specific gravity 
above 1.015, as a rule, and contains upward of 3 per cent, of albumin- 
which suggests its inflammatory nature. After repeated tappings, it 
may be impossible to drawT off much fluid on account of the presence of 
many adhesions. The liver may or may not be palpable (depending 
upon the presence and the grade of congestion); it is usually not palpable 
in the late stages. The indurated and rolled up omentum may be palpable 
as a transverse mass; it should not be mistaken for the lower border 
of the liver. The general condition remains for a long time but little 
disturbed. The gastro-intestinal functions, as a rule, are well performed, 
and emaciation is long postponed. In some patients the urine may 
reveal the usual changes of chronic interstitial nephritis, or those of 
passive congestion. In other cases there are the obvious symptoms and 
signs of arteriosclerosis. Finally, in most cases the heart fails or death 
may be due to some intercurrent complication, such as pneumonia. 
Diagnosis.-Recurrent ascites in a person in otherwise good health, 
together with the disposition and ability to be up and about between 
tappings, should suggest the diagnosis. Of special diagnostic significance 
are a history of a previous attack of pericarditis, pleuritis or perihepatitis; 
the early occurrence and subsequent disappearance of oedema of the 
legs; marked ascites with little or no oedema of the legs; an enlarged 
liver early (this may not occur), and a small and distorted but otherwise 
smooth liver late in the course of the disease; the absence or very late 
occurrence of marked enlargement of the spleen; a tendency to the 
repeated occurrence of attacks of pain, tenderness, rigidity, and possibly 
palpable and audible friction in the right hypochondriac region-attribu- 
table to the attacks of perihepatitis; and the rapid recurrence of ascites DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
493 
after tapping. One should always endeavor to determine whether the 
lesions are confined to the region about the liver or are more widespread, 
involving the pericardium and the pleura. In these cases one must 
endeavor to dissociate the symptoms due to the serositis from those due 
to failure of the circulation induced by the pericardial part of the sero- 
sitis and its consequences. In most of these cases prime importance 
attaches to the recognition of an adherent pericardium. 
From cirrhosis of the liver the condition may be distinguished by the 
signs of adherent pericardium; the absence of the etiological factors of 
cirrhosis of the liver; the slow, insidious, protracted, and intermittent 
course; the long periods during which the ascites may remain stationary 
and the patient in good condition; the entire absence or transient presence 
of slight jaundice; the absence, in most cases, of portal congestion and 
gastro-intestinal disturbances; in some cases, the association of an 
enlarged, smooth, and firm liver with marked ascites; and the fact that 
in many cases the patient survives a large number of tappings. Syphilis 
may be suggested by the history of past infection and the other evidences 
of syphilis; but gummas may be present in the liver and be associated 
with perihepatitis and ascites without other evidences of the infection. 
The diagnosis sometimes can only be made by resort to the Wassermann 
reaction or the therapeutic test. The ordinary tuberculous peritonitis is 
suggested by less exudation, other tuberculous foci in the body, perhaps 
induration about the umbilicus, and the presence of fever. Malignant 
disease of the liver is suggested by irregular, nodular enlargement of 
the liver, evidence perhaps of primary tumor formation elsewhere in 
the body, and a more rapid course. 
Prognosis.-This is bad as to eventual recovery, but the patient may 
live for many years. In more than 70 per cent, of the cases the duration 
is two years or more; in more than 50 per cent., four years or more; and 
it may be as long as sixteen years. The general health and strength are 
maintained for a long time, and the patient may go about his business 
between tappings. Sooner or later the periods between tappings become 
less, cardiac failure supervenes, or death results from some infection. 
Treatment.-This is almost wholly symptomatic, for little can be done 
to influence the progress. Diuretics may effect the discharge of the too 
abundant fluid or a similar object may be achieved by free catharsis. 
Potassium iodide and mercury or salvarsan may be tried when there is 
a trustworthy history of syphilis, as well as in doubtful cases, since they 
hold out some hope of benefit. Tapping must be performed when nec- 
essary; usually it has to be done frequently, and although occasionally 
the fluid remains at a standstill for long periods of time, tapping usually 
has to be resorted to at gradually decreasing intervals. Permanent 
drainage subjects the patients to the danger of infection and acute 
peritonitis. Operative interference, such as the Drummond-Taima 
operation, is theoretically contra-indicated, and practically has not been 
attended by any benefit in the few cases in which it has been tried. 494 
DISEASES OF THE DIGESTIVE SYSTEM 
ACUTE HEPATITIS 
The phenomena to which the term acute hepatitis are applicable may 
be divided into the suppurative and the non-suppurative forms, both 
of which conform to rather definite clinical and pathological types. The 
suppurative form comprises the different forms of abscess, suppurative 
pylephlebitis, suppurative hepatic phlebitis, suppurative cholangitis, 
etc. The non-suppurative form comprises a series of most diverse dis- 
orders that exhibit all stages of progression, from active congestion to 
the inflammatory focal necroses of many infections (localized process) 
and the more widespread process manifested clinically as the different 
forms of icterus gravis and acute yellow atrophy of the liver. 
Acute Non-suppurative Hepatitis.-Etiology.-This may result from 
the factors that provoke active congestion and parenchymatous degen- 
eration. The most common causes are the toxins of different infectious 
diseases, exogenous poisons, such as alcohol and phosphorus, and cer- 
tain endogenous autotoxins possibly of gastro-intestinal origin, etc. The 
lesions vary with the virulence of the toxic cause, the duration or recur- 
rence of its activity, and the resistance of the liver cells. As a matter 
of fact, acute hepatitis is uncommon in temperate climates, the different 
bacterial toxins rarely producing changes surpassing parenchymatous 
degeneration or cloudy swelling, unless we view as inflammatory the 
different forms of focal necrosis common in infections that sometimes 
are surrounded by inflammatory zones. Alcohol, especially if taken in 
fairly large amounts, undiluted, and at rather frequent intervals, induces, 
as a rule, only an active congestion, sometimes also more or less paren- 
chymatous degeneration (and leads ultimately to cirrhosis). 
In the tropics a disorder described by those of experience as acute 
parenchymatous hepatitis (tropical liver) is of frequent occurrence; 
it is most commonly provoked by malaria, but also by dysentery and 
kala-azar and perhaps other infections. It occurs especially in young 
adult Europeans, and not uncommonly soon (during the first year) 
after their arrival in the tropics. Undoubtedly factors other than malaria 
and dysentery are active, although these may be the exciting causes 
acting upon a liver reduced in vitality. The influence of immoderate 
eating (especially of animal food), of drinking (especially alcohol), of 
exposure to cold and fatigue, may not be overlooked. 
Pathology.-The lesions are most diverse, and no one description 
could accurately include the manifold variations, combinations of 
congestion, cloudy swelling, focal necroses, and the vascular and other 
phenomena of inflammation. The lesions vary fro,m small focal necroses, 
small opaque areas, scarcely obvious to the unaided eye, to the more 
complete or universal involvement of the organ. In slight or moderate 
cases the appearances of the liver are those of active congestion and 
cloudy swelling; in the more severe cases they vary in grade up to those 
of acute yellow atrophy. In general one may say that the liver is enlarged, 
swollen, softened, and rather pale in color; the section surface also is 
pale and opaque, and not infrequently mottled. Microscopically, in 
addition to swelling, increased granulation and opacity of the liver cells, DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
495 
and obscuration of their nuclei, dilatation of the capillaries, arterioles, 
and venules, one encounters also fatty degeneration and pigmentation of 
the liver cells, thrombosis of certain capillaries and other small vessels, 
focal necroses, more or less round-cell infiltration, swelling and des- 
quamation of the endothelium of capillaries, and swelling, oedema, 
proliferation, and desquamation of the cells of the small biliary ducts. 
In some (protracted) cases, looked upon by many authors as a subacute 
form of acute yellow atrophy, there is more or less compensatory hyper- 
plasia of the liver cells. In most cases, other parenchymatous organs, 
especially the kidneys and the heart, exhibit similar changes. 
Symptoms.-The symptoms virtually are those of active congestion, 
of which acute hepatitis is only an advanced stage. Perhaps, although 
not necessarily, the symptoms are more aggravated in the inflammatory 
than in the merely congestive disorder; the liver pain and tenderness 
are likely to be more marked; nausea and vomiting are more common 
and usually more severe; the vomited matter partakes of the so-called 
bilious character (greenish, watery), and not infrequently contains 
blood-due usually to violent and distressing retching that provokes 
marked thirst and ultimately may induce marked prostration or collapse; 
the bowels are likely to be constipated, but the constipation may alternate 
with a foul, ill-smelling diarrhoea; and the nervous symptoms, such as 
headache, restless irritability, depression, etc., are usually more marked. 
Jaundice is scarcely more common or more marked than in active con- 
gestion; usually it does not amount to more than a subicteric tint to 
the conjunctiva or a peculiar sallowness of the general integument. 
The liver is enlarged; sometimes, especially in early cases, notably so, 
when it may reach as low as the umbilicus; it may also be markedly 
increased upward, perhaps irregularly so; it is not likely to exhibit much 
enlargement in advanced cases (due doubtless to the presence of new- 
grown connective tissue-developing cirrhosis). The spleen is enlarged 
in the cases due to malaria, but usually of normal size or only slightly 
enlarged in other cases. The urine, as a rule, is concentrated, high- 
colored, of increased specific gravity, and deposits an abundant sediment 
of urates and uric acid; occasionally there is a transitory (toxic) albumin- 
uria. Bile pigment is present in the event of jaundice. That, however, 
which distinguishes the inflammatory from the congestive disorder 
is the presence of fever. It is true that slight fever, less than 100°, 
sometimes attends what is looked upon as congestion merely; but the 
gradual progression of the one disorder to the other is obvious, not only 
in the etiological factors and the general symptomatology, but also in 
the occurrence of fever. A temperature of 100° or more may be looked 
upon as conclusive evidence of the inflammatory nature of the disorder. 
In the class of cases difficult to classify, but which exhibit various 
clinical and pathological relations and graduations to certain types of 
icterus gravis, the onset of the disorder is sometimes sudden and may 
be attended by a chill or chilliness and soon followed by fever; vomiting 
may set in, and may be succeeded by diarrhoea; slight (toxic or hemolytic) 
jaundice is rather common; the liver becomes enlarged, sometimes 
irregularly so; and the constitutional symptoms are usually severe. 496 
DISEASES OF THE DIGESTIVE SYSTEM 
Diagnosis.-This is usually apparent from the etiological factors and 
the general symptoms, as narrated. The difficulties are in excluding 
other disorders, such as the different forms of suppurative hepatitis, 
and in the presence of jaundice, the different forms of toxic jaundice 
and acute yellow atrophy. In the early stages it may and frequently is 
quite impossible to differentiate between suppurative and non-suppura- 
tive hepatitis; in some cases time alone gives the diagnosis. In some 
cases the one is a later stage of the other, and the suppuration may not 
be susceptible of recognition until the development of the general phe- 
nomena of the condition-irregular chills, fever, sweats, etc. In acute 
yellow atrophy the constitutional and nervous symptoms are more 
severe, the liver, at first enlarged, becomes small, the duration is less, 
and the outcome usually death. Phosphorus poisoning is suggested 
by the etiology, the enlarged liver, gastro-intestinal hemorrhages, severe 
constitutional and nervous symptoms, etc. 
Prognosis.-The first attack of acute non-suppurative hepatitis, 
especially as observed in the tropics, usually lasts about a week or ten 
days, and results in recovery; in some cases, however, suppuration 
ensues. One attack predisposes to subsequent attacks, and with each 
recurrence the course and termination are less favorable; the liver may 
remain more or less enlarged and gradually become cirrhotic, or, as in 
some primary attacks, the process may go on to suppuration. 
Treatment.-The prophylaxis and treatment are as in active congestion 
of the liver. In addition, in those cases due to malaria, quinine should 
be administered in good doses; its use is often followed by a notable and 
rapid diminution in the size of the liver. In the event of recurring 
attacks the patient should remove from the tropics to a more temperate 
or cooler climate. Much benefit may be obtained by a course of treatment 
at some one of the well-known spas, Carlsbad, Marienbad, etc. 
Suppurative Hepatitis.-Suppurative hepatitis, or abscess of the liver, 
occurs under a variety of circumstances and in several forms. There is 
some justification for the common division into two classes-the large, 
single, so-called tropical abscess, and the small, multiple, non-tropical 
abscesses; but the processes are not altogether different, since the tropical 
abscess may be double instead of single, and even when single, by infect- 
ing adjacent liver tissue may give rise to the development of many 
secondary abscesses, and a number of small abscesses by peripheral 
extension may coalesce and give rise to a large single abscess. It seems 
wise, therefore, to discuss suppurative hepatitis as a single process. 
Etiology.-Abscess of the liver is always the consequence of infection; 
the agents are various, and reach the liver by one of several pathways. 
The common causative organisms are the ordinary staphylococci and 
streptococci, Amoeba coli (Entamoeba histolytica), Bacillus coli communis, 
Bacillus pyogenes foetidus, Bacillus typhosus, Bacillus dysenterice, Bacillus 
pyocyaneus, Diplococcus pneumonioe, Proteus vulgaris, Actinomyces bovis, 
etc. The infecting agent or agents may reach the liver directly, as when 
in consequence (1) of traumatism bacteria are introduced directly into 
the liver, or (2) when they reach the liver by extension of disease of 
adjacent organs; or the infection may be carried from afar by the blood- DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
497 
stream, that is, (3) by the portal vein, (4) by the hepatic artery, (5) by 
the hepatic veins, (6) by the biliary ducts, or (7) by the lymphatics. 
The abscesses that result from traumatism or the extension of disease 
of adjacent organs are sometimes spoken of as primary, whereas those 
that result from the transport of infection from distant parts are called 
secondary abscesses; this distinction, however, is of little or no practical 
importance and cannot always be maintained. 
1. Traumatism occasionally gives rise to abscess of the liver. The 
resulting abscess is usually single and small or moderate in size. 
2. Diseases of adjacent organs rarely give rise to abscess of the liver, 
but occasionally an ulcerative or suppurative (usually calculous) chole- 
cystitis may perforate into the adjacent hepatic tissue and set up suppu- 
ration; or after the formation of adhesions, a gastric or duodenal ulcer 
or an ulcerating gastric carcinoma may invade the liver tissue and 
induce suppuration therein. The abscess is usually single and small, 
but sometimes it attains considerable size. 
3. Infection by way of the portal vein is the commonest cause. In the 
great majority of cases dysentery, especially amoebic dysentery, is an 
antecedent condition, and the resulting abscess in the liver is spoken 
of as the single, tropical, or amoebic abscess. This form, whether or 
not it is accompanied by pylephlebitis, is characterized usually by the 
development of small multiple abscesses; occasionally, however, a single 
large abscess is produced, or it results later from the coalescence of 
several smaller abscesses. 
The most common cause of this form of liver suppuration in tem- 
perate climates is appendicitis. In this the portal vein and its branches 
may or may not reveal thrombophlebitis, and the infection of the liver 
may result from extension of the thrombophlebitis, from metastases 
by way of the portal vein from the local disease in and about the appendix 
(the most common mode), or from transit of the infection through the 
retrocecal tissues to the liver. Other gastro-intestinal disorders also 
occasionally engender abscess of the liver, such as gastric and duodenal 
ulcers (transport of infection by the portal vein in the absence of adhe- 
sions), pyococcic, typhoid, tuberculous, actinomycotic, and neoplastic 
ulcers of the small and large intestine and the rectum, suppurative 
lesions of the pelvic organs (male and female), hemorrhoids, and infected 
thrombi following operations upon the intestine, rectum, anus, etc. 
A solitary abscess of the liver may be a hydatid cyst, in which secondary 
infection has occurred. 
4. Infection by way of the hepatic artery is rather uncommon and gives 
rise to small multiple so-called septicopyemic abscesses. These occur 
in pyococcic infections, especially infective endocarditis, purulent and 
fetid bronchitis, bronchiectasis, abscess and gangrene of the lungs, 
purulent pleuritis, suppurative periostitis, suppurative otitis media, 
infected operative or non-operative wounds, etc. 
5. Infection by way of the hepatic veins may occur under exceptional 
circumstances, in which emboli may drop from the superior vena cava 
through the right auricle into the inferior vena cava and the hepatic 
veins. Perhaps it occurs also in other cases in which pyogenic bacteria 498 
DISEASES OF THE DIGESTIVE SYSTEM 
from a suppurative focus in the pelvis or lower extremities, coming up 
the ascending vena cava, are forced into the hepatic veins by some 
violent motion and by a retrograde process infect the liver. This is 
most likely to occur with myocardial weakness and venous congestion. 
6. Infection by way of the biliary ducts gives rise to abscess formation 
in the liver and in one of three ways: (1) By direct transport of the 
infection by way of the biliary passages themselves, such as may occur 
in infectious or suppurative cholangitis and pericholangitis, with extension 
to the adjacent interlobular tissues and the formation of multiple small 
abscesses; (2) by the extension of the infection in the biliary passages 
through the biliary mucosa to the subjacent vessels, thence to the portal 
vein (into which they empty), and the production of suppurative pyle- 
phlebitis, in which event the process is analogous to that described in 
connection with infection by way of the portal vein; and (3) by direct 
extension of ulcerative and suppurative processes in the biliary tract 
(usually calculous cholecystitis) to the adjacent liver tissue. 
7. Infection by way of the lymphatics may cause abscess of the liver 
under circumstances analogous to those that occasion infection byway of 
the portal circulation. In some cases, doubtless, the portal vein becomes 
involved after the infection has first gained the regional lymphatics; 
in other cases in which liver abscess, especially suprahepatic abscess, 
follows peritoneal disorders, the infection has followed the pathway of 
the lymphatics which converge from the peritoneum to the upper surface 
of the liver; in some cases of amoebic abscess of the liver the amoebae 
probably reach the liver by traversing the peritoneum. 
Pathology.-Abscesses the result of traumatism and of ulcerative and 
suppurative processes in adjacent organs are usually single and small or 
moderate in size, although those due to disease of adjacent organs some- 
times attain considerable, usually superficial, extent. Inasmuch as 
these abscesses usually are situated near and involve some one of the 
surfaces of the liver, there is commonly a more or less extensive peri- 
hepatitis, adhesions binding the liver to the diaphragm or the adjacent 
organs. In some cases the collection of pus is on rather than within the 
liver, and merits the designation suprahepatic or infrahepatic abscess. 
In the small multiple metastatic abscesses that are not uncommon in 
general arterial pyemia (hepatic artery infection) or portal pyemia 
(portal vein pyemia), and sometimes occur in retrograde emboli (hepatic 
vein infection), or follow suppurative cholangitis, the liver is usually 
enlarged, swollen, and opaque, and presents the ordinary evidences of 
parenchymatous degeneration or cloudy swelling. 
Symptoms.-Attempts are sometimes made to distinguish acute, 
subacute, and chronic abscesses; the distinction, however, is quite 
artificial, since although acute, subacute, and chronic abscesses do occur, 
a chronic abscess may remain latent for a long time and reveal itself 
acutely in consequence of some accidental disorder, such as trauma, 
intercurrent disease, etc., and suppuration that began acutely may sub- 
side and become virtually a chronic abscess. The symptoms of suppu- 
rative hepatitis vary with the nature and seat of the antecedent disorder, 
the pathway of infection, and the nature and virulence of the infectious DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
499 
agent. Many cases, especially of so-called tropical abscess, are entirely 
latent; often they are not detected until they have lasted some time; 
not uncommonly they constitute an unexpected finding at the 
necropsy. 
Traumatic abscess as well as abscess due to spread of disease from 
adjacent structures, usually manifests itself by pain in the region of 
the liver, aggravated by motion and pressure, and referred to the right 
shoulder; palpable and audible friction (attributable to local perihepat- 
itis); perhaps jaundice due to compression of the biliary ducts; chills, 
fever, sweats, and leukocytosis; enlargement of the liver, usually irregular; 
and perhaps a fluctuating tumor. The sequence of these phenomena 
upon an obvious trauma, especially if the skin and subcutaneous tissues 
have been lacerated, gives to them peculiar diagnostic significance that 
can scarcely be misinterpreted; to these are sometimes added the dis- 
charge of pus through the wound, whereupon one has only to decide 
whether the abscess is about or involves the liver tissue. The detection 
of hepatic cells in the pus or in scrapings from the base of the abscess 
cavity settles the diagnosis, which, however, is usually a matter of 
academic interest, since the treatment cannot be other than surgical. 
Multiple septicopyemic abscesses, whether due to portal vein, hepatic 
artery, hepatic vein, or biliary duct infection, often are not diagnosed; 
in perhaps the majority of cases their existence can be suspected only; 
that is, the symptoms of the primary disorder overshadow those due 
to the infection of the liver. In the one case the symptoms are those 
of a primary suppurative process in the heart (ulcerative endocarditis, 
purulent pericarditis), in another case in the lungs (abscess of lung or 
empyema); again, in the abdominal or pelvic viscera or in the extremi- 
ties. The primary local process may be more or less obvious, and the 
general symptoms, chills, fever, sweats, and leukocytosis, are usually 
referred thereto; pain in the region of the liver may be inconspicuous or 
misinterpreted; the liver may not be noticeably enlarged (since death 
usually ensues early); pain in the shoulder may be interpreted as due 
to arthritis. In many cases the diagnosis of the liver involvement is 
of academic rather than of practical importance, since the condition is 
one of general septicopyemia, of which the hepatic involvement may be 
only a minor part; and its detection would not notably influence either 
the diagnosis or the treatment, although it might add materially to the 
seriousness of the prognosis. In some cases, however, particularly of 
so-called portal pyemia, but also of general arterial pyemia, or of spread 
of infection to the liver from suppurative cholangeitis, the diagnosis is 
possible from a knowledge of the primary disorder and the development 
of local symptoms referable to the liver, the onset of which may be 
manifest by an aggravation of the general symptoms, especially the 
fever, sweating, and leukocytosis (or the marked decrease of a previous 
well-marked leukocytosis, significant of lessening general resistance). 
The significant local symptoms consist of pain in the region of the liver 
referred to the right shoulder, tenderness about the liver, perhaps a 
mild grade of jaundice, and enlargement of the liver. The enlargement 
may be quite regular, but the organ is likely to be softer rather than 500 
DISEASES OF THE DIGESTIVE SYSTEM 
harder than normal; sometimes the enlargement is irregular and nodular, 
and the nodules may be soft or semifluctuating; in this event audible 
or palpable friction (perihepatitis) may be detected. 
The so-called tropical abscesses and other liver abscesses of intestinal 
origin and slow (or comparatively slow) development are, as a rule, 
much more readily diagnosed; but some are so indefinite in their mani- 
festations as to escape detection. Generally the onset is slow and 
insidious; sometimes for weeks or months the patient may complain of 
general ill-health; malaise, or gradually increasing weakness-which 
are especially significant if they constitute part of the poor health or 
delayed convalescence from dysentery and other intestinal disorders 
attended by suppuration or ulceration (such as appendicitis, etc.). In 
some cases the onset is sudden, attended by a chill or chilliness, and 
follows directly upon these intestinal diseases; in other cases, although 
the noteworthy symptoms develop acutely, the antecedent disorder 
was present at some more or less remote time, and the abscess, doubtless 
previously latent, has been awakened into activity by some accidental 
cause. In another series of cases there have been one or several, some- 
times recurring, attacks of what one may interpret as acute congestion 
of the liver, or acute hepatitis, especially in the tropics. 
Suppuration of the liver is sometimes first suggested by pain, but 
one must remember that even a very large abscess may be altogether 
unattended by pain. In some cases early in the disease the pain is like 
that already mentioned in connection with active congestion or acute 
non-suppurative inflammation of the liver (due to tension of the capsule), 
which in reality usually precede the abscess formation. Pain when 
present varies with the situation of the abscess; when situated deep within 
the liver there may be no pain whatever, since the liver parenchyma 
is insensible to pain; the nearer the surface and the more marked the 
involvement of the liver capsule the more marked the pain; it may be 
acute, or merely a sense of weight or discomfort that may be increased 
by motion. With the progress of the abscess formation deep within the 
liver substance, the initial pain, that due to tension on the liver capsule, 
may entirely disappear (often occasioning an unwarranted sense of 
satisfaction); and it reappears when the abscess has reached the surface 
and provoked a perihepatitis, in which event the pain may be quite 
like that of pleuritis. The pain is not infrequently referred to the right 
shoulder, especially below the acromion process of the scapula, where 
it is usually dull and aching; this is said to be most common when the 
abscess is in the right lobe of the liver (the great majority of cases); 
occasionally it is referred to the left shoulder (abscess in the left lobe, 
in some cases at least); rarely it is bilateral. This pain also is due to the 
perihepatitis, which irritates the phrenic nerve which communicates 
with the superficial cervical plexus; the pain, therefore, is not significant 
of suppuration as such. 
Jaundice is present in about 16 per cent, of the cases (58 of 375 
cases, Thierfelder); usually it is slight, rarely marked. It is due to 
pressure of the abscess on adjacent biliary ducts or to intrahepatic 
cholangeitis. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
501 
Constitutional symptoms, especially chills, fever, and sweating, signifi- 
cant of suppuration under all circumstances, are of importance. A chill 
is not uncommon at the onset of the suppuration, and a chill or chilliness, 
especially toward evening with a rise in the temperature, is rather 
frequent; but in some cases that develop slowly and become well encap- 
sulated a chill may be missed-entirely or until late in the course. Fever 
is an extremely important symptom, and probably essential to the 
diagnosis. It varies much in different cases. In perhaps the majority 
the elevation is in the evening; but the fever may be more or less con- 
tinuous (especially early in the disease), remittent, or intermittent; 
sometimes the diurnal fluctuations are quite marked-96° to 104° or 
105° F. In chronic and well-encapsulated cases the fever range may 
be slight; sometimes there is apparently no fever at all or only slight and 
transitory attacks; rarely the temperature is subnormal. Sweating is 
a common, almost a constant symptom; it is usually most marked at 
night, but may occur irregularly during the day, especially if the patient 
sleeps. Often the sweats are very profuse, and give rise to great debility. 
The skin in many cases is frequently moist and clammy, especially upon 
the slightest exertion. Other manifestations of the general toxemia 
are seen in arthritic pains, and sometimes swelling of the joints (toxic 
synovitis and arthritis), and in certain nervous symptoms, such as 
headache, nervousness, insomnia, irritability, depression, etc. 
Examination often discloses a general and facial aspect, the hepatic 
facies, readily recognized and of much diagnostic significance. The 
patient obviously is sick; the facial aspect is one of anxiety, distress, 
and more or less suffering; the complexion is muddy or sallow, or slightly 
icteric; the general integument is now hot and dry, now cold and moist; 
loss of flesh is progressive and is more marked the more severe and the 
longer the duration of the disease. 
The liver is usually enlarged, although in some cases when the abscess 
is deeply seated and small, and sometimes even when it is quite large, 
no very noteworthy enlargement may be detected. The situation and 
direction of the enlargement depend upon the situation and direction 
of the abscess; since this is usually in the right lobe, the enlargement 
is usually in the right hypochondrium. In the early stages, when the 
abscess is still within the substance of the liver the enlargement is usually 
tolerably uniform; but as the abscess increases in size it commonly 
causes disproportionate enlargement of the liver upward and a corre- 
sponding change in the hepatic dulness; this often assumes a characteristic 
dome shape; that is, the upper limit of hepatic dulness rises near the 
mammillary line, reaches its highest point near the midaxillary line 
(where it may be on a level with the fourth or the third rib), and then 
descends, so that in the midscapular line it may be as low as the angle 
of the scapula. A decline of the upper limit of hepatic dulness near the 
vertebrae is quite characteristic of liver abscess. In some cases these 
changes are not present, as when the abscess occupies the left lobe, or 
when the enlargement of the liver is lateral rather than upwardly, or 
downwardly and anteriorly; in the last mentioned event there may be 
bulging beneath the margin of the ribs or in the epigastrium, where on 502 
DISEASES OF THE DIGESTIVE SYSTEM 
palpation one may detect a rounded or globular, smooth, and tense or 
semifluctuating tumor (depending upon whether the abscess actually 
projects beyond the surface or is still within the substance of the liver). 
In some cases definite fluctuation may be elicited. When enlargement 
cannot be made out by the usual methods, recourse may be had to the 
arrays, which will readily disclose any irregular enlargement as well as 
the usual limitation of the movement of the diaphragm. 
As the abscess approaches or reaches the surface of the liver peri- 
hepatitis is set up and friction may be detected; this suggests the point 
of election in the event of resorting to exploratory puncture. The muscles 
of the right upper quadrant of the abdomen become tense and unyield- 
ing, and there is usually considerable local tenderness. In some 
cases also there is local oedema, confined to one or two intercostal 
spaces or involving almost if not quite all the surface projection of the 
liver. 
The urine is concentrated, of high color, increased specific gravity, 
and deposits an abundant sediment of urates and uric acid; as a rule, 
the amount of urea is diminished, but this is quite variable, although 
it is likely to be lessened if there is much destruction of the liver tissue; 
indican, a small amount of albumin and albumose are sometimes present. 
Examination of the blood may reveal leukocytosis-a total count of 
25,000 or more-and a relative increase of the polynuclear neutrophiles; 
unfortunately leukocytosis is not always found; it is likely to be absent 
in slow-growing, chronic, and well-encapsulated abscesses. 
There are a number of other signs and symptoms that occur in varying 
combinations in different cases and are due to variable conditions. 
Thus, certain gastro-intestinal symptoms may develop, such as nausea 
and vomiting, which are most common when the left lobe is involved 
(local adhesions or pressure on the pylorus or duodenum); the appetite 
is usually poor, and the tongue coated in the centre, or smooth, red, and 
fissured; there may be constipation (usually when the abscess is latent) 
or diarrhoea (when there is marked congestion of the liver or the acute 
hepatitis of the tropics); sometimes an obsolete dysentery is reactivated; 
and large amounts of pus may appear in the stools if the abscess ruptures 
into the bowel. Amoebse may be found in the stools, especially if there 
is diarrhoea; when there is constipation they may be found in the mucus 
that often coats the feces. The growth of the abscess upward, together 
with restricted movement of the base of the right chest and of the dia- 
phragm, cause more or less congestion and compression of the base of 
the right lung, and lead to cough, dyspnoea, impaired percussion reson- 
ance, feeble or bronchovesicular breath sounds, and fine rales; later, 
pneumonia may develop. In some cases a short, hacking, spasmodic 
cough ensues; it is usually referable to irritation of the diaphragm or an 
actual pleuritis, which in turn may have been due to transport of infec- 
tion through the diaphragm or to rupture of the liver abscess into the 
pleura. The cardiac action may be embarrassed by the pressure of a 
large abscess, and the pulse rapid and irregular. The spleen usually is 
not enlarged and not palpable. Ascites does not occur unless there is 
some causative complication. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
503 
Spontaneous rupture is a common event in the course of large, especially 
tropical, abscesses of the liver. In Cyr's1 series of 563 cases, rupture 
occurred in 159 (28.2 per cent.), as follows: Into the lung in 59, the 
pleura in 31, the pericardium in 1, the peritoneum in 39, the intestines 
in 13, the stomach in 8, the kidney in 2, etc. In Thierfelder's2 collection 
of 170 cases perforation occurred into the lung in 74, the pleura in 26, 
the pericardium in 4, the intestines in 32, the peritoneum in 23, the 
stomach in 13, the kidney in 1, etc. 
In a majority of the cases rupture occurs upward through the dia- 
phragm (57 per cent, of Cyr's cases, 59 per cent, of Thierfelder's cases). 
In some cases purulent pleuritis results and gives rise to the usual signs 
thereof; in other cases (hepatopulmonary abscess) the pus finds its way 
into the lung either directly, in consequence of the early formation of 
adhesions (which is the rule), or indirectly, following a purulent pleuritis. 
When rupture occurs into the lung and the process finally involves and 
perforates a bronchus, a large amount of pus (perhaps mixed with blood) 
may be suddenly coughed up, or it may come up with very little effort, 
being evidently discharged in consequence of the release of the tension 
of the abscess; so great may be the amount of pus thus released that the 
patient's lungs may be inundated and sudden death may ensue. In 
other cases smaller amounts of pus are coughed up from time to time, 
but the total amount in the twenty-four hours may be considerable- 
ten to twelve ounces or more. The expectorated pus may exhibit ordinary 
purulent characteristics and contain necrotic liver tissue; usually, 
however, in the early stages at least, there is more or less blood mixed 
with the pus. Amoebae may be found in it, should they be the exciting 
cause. Should the condition progress favorably, which it does in many 
cases, the amount of pus expectorated gradually diminishes and ulti- 
mately ceases, and the patient recovers. In other cases the expectoration 
lessens or ceases, but the patient's general condition becomes worse, 
and chills, fever, and sweats recur; evidently drainage has become 
insufficient and pus accumulates. Again, a large amount of pus may be 
discharged, and again the expectoration may cease; such variation in 
the phenomena (alternate emptying and refilling) may recur for some 
time until recovery eventually ensues or the patient dies. A second 
unruptured abscess should be suspected in the event of persistence of 
the septic phenomena, despite evident free drainage. 
Rupture into the stomach or the duodenum is usually followed by 
epigastric distress, nausea, vomiting of considerable pus, diminution 
in the size of the liver, and perhaps relief of the local symptoms referable 
to the liver. Rupture into the intestine is followed by diarrhoea and pus 
in the stools; the pus frequently is overlooked, especially when the 
rupture occurs into the small intestine. Perforation into the peritoneum 
may occur into preformed adhesions, whence a localized extrahepatic 
abscess may ensue, or into the general peritoneal cavity, in which event 
a generalized peritonitis may be set up; but sometimes, in view of the 
1 Traite pratique des maladies du foie, 1887. 
2 Cyclopaedia of the Practice of Medicine, v. Ziemssen, 1880, ix, 138. 504 
DISEASES OF THE DIGESTIVE SYSTEM 
fact that the abscess may be sterile, peritonitis may not immediately 
ensue and the patient, if operated upon, may recover. 
Diagnosis.-This is often attended with considerable difficulty. The 
most suggestive signs are the etiological factors, which vary with the 
source of infection, but which should be carefully studied; pain in the 
region of the liver, perhaps referred to the right shoulder; progressive 
enlargement and tenderness of the liver; slight jaundice, and chills, fever, 
sweats, and leukocytosis. These symptoms, however, are not always 
outspoken; the leukocytosis, for instance, may be slight, and the so-called 
tropical abscess may be latent for a long time, and when somewhat 
active may give rise to quite indefinite symptoms. 
Manson1 states: "Golden rules in tropical practice are to think of 
hepatic abscess in all cases of progressive deterioration of health; and 
to suspect liver abscess in all obscure abdominal cases associated with 
evening rise of temperature, and this particularly if there be enlargement 
of or pain in the liver, leukocytosis, and a history of dysentery-not 
necessarily recent dysentery. If doubt exists, there should be no hesita- 
tion in having early recourse to the aspirator to clear up the diagnosis." 
"The most common mistakes in diagnosis are: (1) Failure to recognize 
the presence of disease of any description, even when an enormous 
abscess may occupy the liver. (2) Misinterpretation of the significance 
and nature of a basic pneumonia-a condition so often accompanying 
suppurative hepatitis. (3) Attributing the fever symptomatic of liver 
abscess to malaria. (4) Mistaking other diseases for abscess of the 
liver, and vice versa-for example, hepatitis of a non-suppurative nature; 
suppurative hepatitis before the formation of abscesses; syphilitic disease 
of the liver-softening gummata which are often attended with fever 
of hectic type; pylephlebitis; suppurating hydatid; gall-stone and inflam- 
mation of the gall-bladder, subphrenic abscess; abscess of the abdominal 
or thoracic wall; pleurisy; encysted empyema; pyelitis of the right 
kidney; pernicious anemia; leukemia; scurvy and similar blood diseases 
associated with enlargement of the liver; ulcerative endocarditis; kala- 
azar; Malta fever; trypanosomiasis. Any of these may be attended 
with fever of hectic type, increased area of hepatic percussion dulness, 
and pain in and about the liver." 
Malaria may be excluded by an evening rise in temperature (that of 
malaria being more common during the day); disproportionate enlarge- 
ment of the liver as compared with the spleen (the reverse being the 
case in malaria); absence of malarial parasites in the blood; polynuclear 
leukocytosis; and the non-response to quinine. Cholelithiasis and 
Charcot's biliary intermittent fever may be excluded by the absence of 
a history of cholecystitis, cholelithiasis, and biliary infection; the absence 
of attacks of fever, etc., separated by longer or shorter periods of apyrexia; 
non-occurrence of increase in the jaundice after each attack; and the 
absence of serious impairment of the general health. 
Prognosis.-The small multiple abscesses of the liver, whatever their 
etiology, are almost invariably fatal, death usually resulting within one 
1 Tropical Diseases, 1907, 4th edit., 510. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
505 
to three weeks. Many of the large single so-called tropical abscesses 
eventuate in recovery; their duration, however, is uncertain, since it 
is not possible always to say when they began; they are often latent for 
a long time. The mortality in unoperated cases has varied up to 80 
per cent., but Cantlie states that now the figures "have fallen to between 
20 and 30 per cent., and there is no doubt that with earlier operations 
the mortality will be still further reduced." The outlook after rupture 
into the lung and evacuation through a bronchus (hepatopulmonary 
abscess) is rather favorable (75 per cent, of recoveries, De Castro), 
although the condition may last for months; rupture into the hollow 
abdominal viscera or externally may also be followed by recovery; 
but rupture into the peritoneum, the pericardium, etc., is usually fatal. 
Recurrence of the abscess may follow apparent recovery. 
Treatment.-This is essentially surgical in such forms as are amenable 
to treatment. The treatment of the multiple septicopyemic abscesses 
is that of septicopyemia in general; the liver condition neither modifies 
nor influences appreciably the treatment, which should be stimulating 
and supporting, with such drainage or other surgical treatment of the 
original focus of disease as may be possible. Rogers1 has claimed remark- 
able results in amoebic abscess by the use of emetin hydrochloride or 
hydrobromide in | to | of a grain doses injected subcutaneously. He 
also believes emetin to be of distinct diagnostic value on account of the 
rapid improvement seen after its use in amoebic cases. 
The diagnosis of the large single abscess furnishes the indication for 
its evacuation; and even when the diagnosis of a single abscess cannot 
be made positively, although hepatic suppuration is obviously present, 
resort should be had to operation. Manson, Cantlie, and others of much 
experience advocate evacuating the abscess by means of a trocar and 
cannula.2 In the event of perforation of the abscess, immediate operation 
is indicated; operation is indicated also in the event of perforation into 
the lung, hollow abdominal viscera, etc., but it need not be undertaken 
immediately, since in many of these cases spontaneous recovery ensues; 
signs warranting delay consist of good general condition of the patient, 
minor septic or toxic phenomena, free discharge of pus, by the bowel or 
by expectoration, improvement in the local conditions, etc. 
CHRONIC INTERSTITIAL HEPATITIS: THE CIRRHOSES OF THE 
LIVER 
Chronic interstitial hepatitis, comprising the so-called cirrhoses of 
the liver, has been much and variously classified-etiologically, anatomi- 
cally, and clinically.3 The disorder was first described by Vesalius, 
but the term cirrhosis was first employed by Laennec to describe the 
yellowish "hobnails," which he regarded as new growth. 
1 Brit. Med. Jour., 1912, ii, 405. 
2 The details of the procedure may be found in Manson, loc. cit., and Cantlie, 
Internal. Clin., Phila., 1904, 14th series, ii, 93. 
3 Consult Edwards, Internal. Clin., Phila., 1902, 12th series, ii, 92. 506 
DISEASES OF THE DIGESTIVE SYSTEM 
Eliminating from consideration cases of: (1) So-called capsular cirrhosis 
(more properly called perihepatitis or hepatic capsulitis), in which the 
liver tissue may be not at all affected, except perhaps secondarily in 
consequence of compression or by slight ingrowth of new connective 
tissue from the capsule; (2) so-called cardiac cirrhosis or cardiac liver, 
which develops in consequence of long-standing passive congestion; 
(3) syphilis of the liver, in which the lesions are specific and peculiar 
to that infection; and (4) circumscribed or focal fibroses which follow 
limited inflammatory and degenerative processes, focal necroses, chronic 
obstruction of the biliary ducts (pericholangitis), etc., there are two 
types of chronic diffuse disorder of the liver, attended by fibrosis, to 
which the term cirrhosis may be limited. One of these disorders is 
very common; it is usually due to the misuse of alcohol; it is character- 
ized by moderate enlargement of the liver (which in advanced stages 
may become reduced in size), by phenomena of portal obstruction 
(notably hematemesis and ascites), and by the absence or unimportance 
of jaundice; and after the development of symptoms it usually runs a 
comparatively short course (Laennec's portal, alcoholic, atrophic, or 
multilobular cirrhosis). The second of these disorders is rare; it is of 
unknown etiology; it is characterized by marked and persistent enlarge- 
ment of the liver and spleen, by chronic jaundice, by periodic attacks 
of abdominal pain and fever, and by the absence of manifestations of 
portal obstruction (notably ascites); and it runs a comparatively long 
course (Hanot's, biliary, hypertrophic, or monolobular cirrhosis). 
There can be no serious objection to the use of the terms Laennec's 
and Hanot's cirrhosis, aside from that inherent in eponymic terms. 
Alcoholic cirrhosis accurately describes most, but not all, cases of 
Laennec's cirrhosis; but alcohol perhaps sometimes gives rise also to 
Hanot's cirrhosis, although this is a disputed point, and the study of 
the etiological factors is important from many points of view, particularly 
the therapeutic. The terms atrophic and hypertrophic, to designate, 
respectively, a small and a large liver, are most ill-advised and have led 
to confusion and misapprehension. There has been much discussion 
as to whether or not there is a so-called hypertrophic stage of atrophic 
or Laennec's cirrhosis, and this so-called hypertrophic stage has been 
confounded with what is spoken of as hypertrophic or Hanot's cirrhosis. 
Aside from notable variations in size that may occur within a com- 
paratively short time in a liver the seat of Laennec's cirrhosis, a small 
or so-called atrophic liver is often hyperplastic to a considerable degree, 
and a large or so-called hypertrophic liver always exhibits considerable 
atrophy of the hepatic parenchyma; and many cases of Laennec's 
cirrhosis result fatally while the liver is still larger than normally; that 
is, in many cases the so-called atrophic liver does not become atrophic 
(smaller than normally), but remains to the end, as it were, hypertrophic. 
The terms assuredly are inadequate to describe the conditions, and 
should be discontinued. 
The preferable terms for the two main types of cirrhosis, of which 
there are subtypes, are portal and biliary; portal, because the etiological 
factor is perhaps always transmitted by the portal circulation, the new- DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
507 
formed connective tissue is specially conspicuous in and about the 
portal spaces in the liver, and the obtrusive symptoms are those of 
portal obstruction; biliary cirrhosis, because the essential lesion is a 
radicular cholangeitis and the conspicuous clinical feature is jaundice, 
due to obstruction to the free flow of bile. 
Two subtypes of biliary cirrhosis are sometimes differentiated: (1) 
The hypertrophic biliary cirrhosis of Hanot; and (2) an obstructive 
biliary cirrhosis-by which is meant a condition of pericholangeitic 
fibrosis spreading to the adjacent liver lobules in obstruction of the 
extrahepatic biliary ducts. The disorder was first described by Wickham 
Legg, and later by Charcot and Gombault, Gilbert and Sourmont, 
Chauffard, Ford,1 Weber,2 etc. There is no doubt that fibrosis does 
occur in the liver in some cases of chronic obstruction of the extrahepatic 
biliary ducts; but the fibrosis is usually minor in grade, develops about 
the intrahepatic biliary ducts (pericholangeitis), seldom implicates the 
liver lobules to a noteworthy degree, and of itself does not give rise to 
noteworthy symptoms; the symptoms remain those of the obstruction 
(especially chronic jaundice and acholic stools), to which subsequently 
may be added, as in any disorder of the liver, phenomena attributable 
to disorganization of the hepatic parenchyma. Compression of the 
common bile duct, with complete interruption to the flow of bile, as 
occurs in carcinoma of the head of the pancreas, is often attended by 
serious consequences, such as dilatation of the intrahepatic ducts with 
rupture of the biliary capillaries leading to degeneration and necrosis 
in the centre of the lobule,3 or to compression atrophy, degeneration, 
and pigmentation of the liver cells; in some cases also some replacement 
fibrosis occurs, but in degree it is by no means comparable to that of 
cirrhosis in the ordinary sense. The inference is that in most cases of 
considerable fibrosis of the liver in chronic obstruction of the biliary 
ducts, factors other than the obstruction are the real cause of the fibrosis. 
In some cases this is doubtless infection of the biliary tract, with connec- 
tive cholangeitis and pericholangeitis, as occurs in some cases of cholelithi- 
asis, with more or less incomplete obstruction; in other cases, the common 
causes of portal cirrhosis, such as alcoholism, disorders of the intestine 
(due in part perhaps to absence of bile), etc. The proper interpretation 
of the phenomena is of more importance and interest than attaches to 
academic discussions; those that interpret localized fibrosis as cirrhosis 
will continue to speak of the condition as obstructive biliary cirrhosis; 
but it is not beyond the facts to assert that biliary obstruction of itself 
does not give rise to cirrhosis in an acceptable sense, that the fibrosis 
that does occur is not of constant type, is almost negligible anatomic- 
ally, and is assuredly negligible clinically, and that when a noteworthy 
cirrhosis occurs in association with obstruction to the biliary ducts it 
is probably due to the ordinary causes of cirrhosis rather than to the 
obstruction. 
1 Amer. Jour. Med. Sc., 1901, cxxi, 60. 
2 Trans. Path. Soc., Lond., 1903, liv, 103. 
3 Consult Ogata, Beilr. z. path. Anat. u. z. allg. Path., Jena, 1913, Iv, 236. 508 
DISEASES OF THE DIGESTIVE SYSTEM 
Portal Cirrhosis. - Portal cirrhosis is a chronic degenerative and 
inflammatory disease of the liver characterized by recurring degen- 
eration and regeneration of the hepatic parenchyma and by con- 
comitant and consecutive fibrosis in and about the interlobular or 
portal spaces, all of which leads ultimately to obstruction of the portal 
circulation. 
Etiology.-Portal cirrhosis is peculiarly a disease of adult life; it is 
most common during the fifth decade, the majority of the subjects 
succumbing before the fiftieth year, forty-eight and seven-tenths years 
being the average age of 121 males, and forty-seven years of 44 females, 
(Rolleston). It is, however, by no means rare at the extremes of 
life. A notable number of cases occur in young children, in whom it is 
often fatal before the sixth year. It is a little more than twice as com- 
mon in men as in women; and it is also more commonly latent in men. 
Occupation is of significance only as it concerns other factors, notably 
alcoholism. 
Portal cirrhosis is undoubtedly the expression of the activity of some 
poison or poisons; these are various in nature, and may reach the liver 
by way of the portal vein, the hepatic artery, or both. In the great 
majority of cases the portal vein is unquestionably the pathway. From 
time immemorial major importance has been attributed to alcohol, and 
assuredly with reason; but during recent years attempts have been 
made to minimize its influence, and its action is probably indirect rather 
than direct. Alcohol is especially active when taken in the form of 
distilled liquors, but cirrhosis occurs also in those addicted to the use 
of wine, beer, ale, porter, etc., and it is more common among those who 
drink constantly a small amount than among those who occasionally 
drink a considerable amount. The stronger liquors are the more active 
probably because they are often taken on an empty stomach and con- 
sequently reach the liver in concentrated form. How the alcohol acts 
is not definitely known, but it is likely that it acts: (1) As a direct 
irritant or poison to the liver cells (of which there is sufficient experi- 
mental proof), causing parenchymatous and fatty degeneration, even 
necrosis, or disturbing the functions of the liver cells and rendering them 
unduly susceptible to the influence of other causative factors (autogenic 
poisons, bacterial toxins, etc.), as well as irritating the connective tissue 
of the organ; and (2) by causing gastro-intestinal catarrh and thus 
favoring the formation of divers autotoxins inseparable from that con- 
dition which, transported by the portal vein, may be the active factor 
in provoking cirrhosis in a liver otherwise rendered vulnerable. It has 
been suggested that ethyl alcohol is not the active factor in setting up 
the cirrhosis, but rather adulterants, such as amyl alcohol, the aldehydes, 
aromatic substances, etc.; but as yet this is pure hypothesis. Certainly, 
however, cirrhosis occurs in the absence of alcoholism, and not all 
alcoholics become cirrhotic. In cases in which alcohol seems to be, or 
is, the only obviously active factor, it is not unlikely that there is also 
a concealed hereditary or a postnatal acquired lowered vitality on the 
part of the liver that renders it especially susceptible; and this is doubtless DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
509 
true also in respect to other etiological factors.1 That hereditary influence 
is sometimes operative is suggested by the occasional occurrence of 
several cases of cirrhosis in the one family; but in these cases one cannot 
overlook the likelihood of familial addiction to alcoholism, as well as 
hereditary syphilis. 
There is reason to believe that poisons, particularly the fatty acids 
(lactic, butyric, acetic, valerianic, etc.) and other ill-understood entero- 
genic toxins associated with different forms of indigestion may be causa- 
tive factors, especially in non-alcoholic subjects who give a history of 
long-continued indigestion, following or associated with overindulgence 
in highly seasoned foods, spices, etc. (dyspeptic cirrhosis, Budd's non- 
alcoholic cirrhosis). The fatty acids and other toxins rarely may be 
ingested preformed with the food; but they are much more likely to be 
manufactured in the intestinal tract in cases of gastro-intestinal catarrh 
(fermentative dyspepsia); experimentally lesions resembling those of 
cirrhosis have been produced by injecting fatty acids into lower animals. 
To the influence of enterogenic toxins, spices, etc., may also be attributed 
the cirrhosis occurring among the Hindus, Egyptians, etc., who, avoiding 
alcohol, nevertheless often eat food that is not above reproach and are 
quite partial to condiments and spices, such as ginger, pepper, etc., often 
in decoctions. It is also likely that a poison elaborated in the spleen 
may cause cirrhosis (Banti's disease). 
Infections of various kinds may be followed by cirrhosis, but the 
relationship of the one to the other has not yet been definitely determined. 
In most of these cases the infection is carried to the liver by the general 
as well as by the portal circulation. Many acute infections are known 
to cause pathological changes in the liver (degeneration, focal necroses, 
inflammation, etc.), and some of these are followed by fibrosis-usually 
localized and minor or moderate in grade; but this scarcely constitutes 
cirrhosis in an acceptable sense. McCrae and Klotz2 believe that the 
focal necroses occurring at times in typhoid fever are caused by toxins 
and that they do not contain bacteria. These changes may perhaps 
lead later to cirrhosis. A malarial cirrhosis has been widely commented 
upon, but it is probably not as common as many observers believe: both 
diseases may occur concurrently. Tuberculosis is sometimes associated 
with cirrhosis, especially fatty cirrhosis, and some observers believe 
that the tubercle bacillus or the tubercle toxin absorbed from the intes- 
tinal tract or the peritoneum may set up the lesions of cirrhosis.3 The 
lesions in the liver caused by syphilis are not those of cirrhosis (in a 
restricted sense), but antecedent syphilis may render a liver unusually 
susceptible to the ordinary causes of cirrhosis. A form of cirrhosis 
occurring in Egypt and elsewhere has been attributed to a toxin 
1 Consult Kern's article on changes in the liver in chronic alcoholism (Zeitschr. f. 
Hyg. u. Infectionskrank., Leipz., 1912, Ixxiii, 143) and Mathias Thiesen on Atrophic 
(Laennec's) Cirrhosis of the Liver (Dissert., Strassburg, 1912). Both these articles 
contain interesting statistics gathered from a wealth of autopsy material upon the 
subject of the influence of alcohol on the liver. 
2 Jour. Path, and Bacterial., Cambridge, 1908, xii, 279. 
3 Consult Jagie, Wien. klin. Wchnschr., 1907, xx, 849; Stoerk, ibid., 1907, xx, 1011, 
1048; and Isaac, Frankf. Zeitschr. f. Path., Wiesbaden, 1908, ii, 125. 510 
DISEASES OF THE DIGESTIVE SYSTEM 
elaborated by Uncinaria duodenalis and Bilharzia hcematobia, with which 
these subjects are infected. Rogers1 has described a peculiar form of 
intralobular cirrhosis produced by the protozoal parasite of kala-azar. 
Adami's observations relating to a so-called diplococcic form of the 
colon bacillus in cirrhosis in man and in infective cirrhosis in cattle is 
of interest, not so much as suggesting an etiological relationship of the 
bacterium to cirrhosis, but as illustrating the bactericidal properties of 
the liver cells. It is not improbable that bacteria may be indirectly 
the cause of cirrhosis in setting up catarrhal and fermentative processes 
in the intestine, the toxic concomitants of which, being transported to 
the liver, may act as the direct irritant factor. 
Other sorts of irritants sometimes appear to give rise to cirrhosis. Thus 
in hemochromatosis, in consequence of hemolysis, blood pigment is set 
free and infiltrates the tissues, and the liver and the pancreas become 
fibrotic. Cirrhosis of the liver has been found in association with pneu- 
monokoniosis, and with poisoning with lead, silver, arsenic, etc. 
Experimentally,2 so-called cirrhosis, but usually minor and circum- 
scribed fibrosis, has been produced by injecting certain bacteria, alcohol, 
and other irritants, such as chemicals, vegetable alkaloids, etc., into the 
portal circulation, the general circulation, and the intestine. Much more 
significant and of more importance are Pearce's3 studies regarding the 
effects of hemolytic and hemagglutinative sera: the early necrotic lesions 
in the liver are followed by reparative processes that constitute a chronic 
interstitial hepatitis; these are of special interest, since they demonstrate 
that cirrhosis may follow widespread destruction of necrotic lesions in 
the liver, and explain the histogenesis of cirrhosis and other reparative 
processes in the liver. Opie4 has demonstrated that cirrhosis of the 
liver can be experimentally produced by administering chloroform by 
mouth and injecting bacteria into the blood. 
Pathology.-The liver varies much in size in different cases, and in 
the same case at different times. At the necropsy it may be very small, 
weighing only 970 grams or less; or it may be very large, weighing as 
much as 4000 grams or more; but in the majority of cases at autopsy 
it weighs more than normally. Rolleston states that the average weight 
of the liver in 155 consecutive necropsies on cirrhotic subjects at St. 
George's Hospital was 63.6 ounces (1978 grams); the average weight 
of the liver in 100 cases collected by Hawkins was 52 ounces (1617 grams), 
the minimum being 32 ounces (995 grams), and the maximum 74 ounces 
(2300 grams); the average weight in 93 cases collected by Kelynack 
was 53 ounces (1648 grams); and the average weight in 34 cases at the 
German Hospital, Philadelphia, was 1875 grams, the minimum being 
980 grams and the maximum 2760 grams. In fatal cases in young subjects 
the liver is relatively and often absolutely larger than in older subjects. 
Variations in the size may be due to different factors. It is essential 
to bear in mind that in the usual course of events the liver may be 
1 Ann. Trop. Med. and Parasitol., Liverpool, July, 1908. 
2 Consult Fischler, Deutsch. Arch. f. klin. Med., Leipz., 1908, xciii, 427. 
3 Jour. Exper. Med., 1906, viii, 64; Jour. Med. Research, 1906, xv, 99 (literature). 
4 Jour. Exper. Med., 1910, xii, 367. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
511 
enlarged from the beginning to the end of the disease. It is often said 
that the liver is enlarged in the early stages and small in the later stages 
-in consequence of contraction of the newly formed fibrous tissue. 
This change in size is sometimes observed, but it is incorrect to assume 
that the decrease in size is due always or solely to contraction of the 
new fibrous tissue. Marked variations in size often occur rapidly, within 
several days or weeks, and are due solely to changes in the vascular 
supply. The writer saw a liver a handbreadth below the costal margin 
in the nipple line lessen so rapidly in size that at operation, two weeks 
later, it had receded well above the costal margin and presented the 
typical appearances of portal cirrhosis. A liver small at one clinical 
examination may be much enlarged subsequently. The large liver 
may be due to vascular engorgement, hyperplasia of the liver cells, 
disproportionate fibrosis that is likely to be diffuse, as in the so-called 
monolobular type, and fatty infiltration and degeneration of the liver 
cells (fatty cirrhosis). 
As a rule, the liver is of increased density (increased specific gravity), 
so that a small liver may weigh more than a liver of normal size; it is of 
increased consistency and lessened elasticity. The capsule is often 
opaque, sometimes considerably thickened, and not infrequently adherent 
to the under surface of the diaphragm. Adhesions, when present, are 
usually old, fibrous, and circumscribed rather than widespread; occa- 
sionally, however, they are almost if not quite universal and may extend 
to adjacent organs-the gall-bladder, stomach, intestine, omentum, 
through the diaphragm to the pleura, lung, etc. In other cases more or 
less recent, acute, fibrinous adhesions are encountered. 
The surface of the liver is distinctly granular, the small livers more 
so than the larger ones: grayish-white opaque depressions alternate 
with pale, yellowish-brown, sometimes reddish-brown, roundish or ovoid 
elevations-the so-called granular or "hobnail" liver. The hobnails 
vary considerably in size, from those scarcely larger than a pinhead 
(under which circumstances the surface of the liver is comparatively 
smooth) to others 1 to 2 cm. in diameter; usually they average from 2 
to 4 mm. in diameter. Sometimes many-ten or more-hobnails appear 
specially surrounded by an unusually wide band of connective tissue 
that isolates them from adjacent tissue and causes a more marked pro- 
jection from the general surface of the organ. These lesions usually 
are distributed uniformly throughout, but occasionally one lobe is more 
involved than the others; the left lobe especially may be very small 
(lessened resistance?); rarely the caudate, quadrate, or Spigelian lobe 
may be disproportionately affected. 
On section the liver cuts with increased resistance, being much denser, 
firmer, and tougher than normally. The cut surface reveals interlacing 
bands of whitish or grayish-white fibrous connective tissue that vary 
somewhat in thickness, pervade the entire organ, and are continuous 
with the grayish opaque depressions on the surface. These bands, which 
obviously take their origin in the periportal spaces, form a network 
that encloses or surrounds islets of liver tissue that vary in size from 
that of a pin-point to others 1 cm. or more in diameter; the larger islets 512 
DISEASES OF THE DIGESTIVE SYSTEM 
are made up of several, often eight, ten, or more, liver lobules (or remains 
of liver lobules), and are pervaded by more delicate bands of connective 
tissue (so-called multilobular cirrhosis). In many, but not all, cases 
the islets of liver cells appear to be under some tension, since on section 
they project somewhat; it is not improbable that this is due to the 
elastic tissue of which in part the newly formed connective tissue consists. 
The liver tissue is usually pale yellowish in color or yellowish brown; 
occasionally it is greenish (from staining with bile), or reddish or brownish, 
especially in the centres of the lobules (from staining with blood or blood 
pigment). The islets of liver tissue are sometimes very large, hyper- 
plastic, evidently the result of active proliferation, a condition sometimes 
spoken of as nodular cirrhosis, or cirrhosis with multiple adenoma. 
This process, doubtless at first compensatory, sometimes becomes 
unrestrained and results in the production of carcinoma (cirrhosis with 
carcinoma). Occasionally the islets of liver tissue are very pale (fatty 
degeneration) and at first sight resemble new-growth; in some cases 
the centres of some of the nodules are quite soft and necrotic. 
The bloodvessels show more or less well-marked changes. The hepatic 
artery and its smaller branches are often distended-doubtless related 
to the necessity of supplying with blood the increased fibrous tissue; 
in some cases the vessels exhibit the ordinary lesions of endarteritis, 
especially in the cirrhosis of hemochromatosis and of syphilis. The 
hepatic veins may show the lesions of obliterating endophlebitis, as has 
been pointed out by Hess.1 The smaller intrahepatic branches of 
the portal vein, especially those between the liver lobules, are often 
compressed and not infrequently thrombosed; the larger intrahepatic 
branches, the main trunk, and the gastro-intestinal branches that go to 
form the main trunk are usually dilated; the wall of the vein is often 
thickened-periphlebitis and endophlebitis; and thrombosis of the main 
trunk may occur (more common in cirrhosis than in any other condition). 
Communications between the portal vein and the systemic circulation 
constitute a part of the cirrhotic process. For the most part these 
consist of dilatations of normally existing anastomoses. They subserve 
the useful purpose of diverting to the superior and the inferior venae 
cavae the venous blood in the portal tributaries flowing against the 
obstruction in the portal distribution in the liver, and thus they relieve 
the portal congestion. Although usually present, they are not always 
observed; they are sometimes absent in fatal cases of cirrhosis in which 
death has resulted from other causes.2 Through increased pressure in 
the portal circulation various anastomoses become dilated, thus giving 
passage to the venous blood obstructed by the cirrhotic liver. Various 
compensatory anastomoses occur. Rolleston considers them under the 
heading of (1) general and (2) local. 
1. General communications between the retroperitoneal veins opening 
into The lumbar and azygos veins, and the veins of the peritoneum and 
of the intestines. Also branches of the portal vein anastomosing with 
1 Am. Jour. Med. Sc., 1905, cxxx, 986. 
2 For an excellent study with a review of the literature consult also Gilbert and 
Villaret, Rev. de med., Par., 1907, xxvii, 305. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
513 
the inferior vena cava, as described by Retzius, producing at times an 
intense injection of a large part of the parietal peritoneum. The Talma 
operation, frequently tried in cases of cirrhosis, attempts surgically to 
produce a similar collateral circulation. 
2. Local.-Internal portocaval anastomoses developing in the lobules 
of the liver between branches of the portal vein and the intralobular 
vein. Communications may develop between the veins in the substance 
and capsule of the liver and the phrenic and intercostal veins, where 
the liver and diaphragm are uncovered by peritoneum. In addition a 
large vein running to the umbilicus in the falciform ligament may com- 
municate with the veins of the abdominal wall, thus connecting the 
portal vein with the deep epigastric and external iliac veins, producing 
a "Caput Medusae" most marked around the umbilicus. The veins 
of the oesophagus, which open into the azygos veins, communicate at 
the cardiac orifice with the gastric veins and so with the portal vein. 
In this way oesophageal varices are formed from which hemorrhages 
may occur. In cases of ascites with obstruction of the inferior vena cava 
a "Caput Medusae" also occurs, due to enlargement of the veins of the 
skin connecting with the superior and inferior epigastric veins. Here 
the dilated veins run from the middle of the groins to the costal arches 
and avoid the umbilicus. 
These anastomoses serve both a useful and an evil purpose. On the 
one hand, as long as the collateral circulation is efficient, obstructive 
symptoms are in abeyance and the liver is enabled better to perform 
its functions, perhaps enabled to regenerate, whence in some cases the 
disease remains or becomes latent, even apparently cured; on the other 
hand (a) the dilated veins are likely to rupture, either spontaneously 
or in consequence of trauma, and lead to more or less severe hemorrhage 
(hematemesis, hematoma of the abdominal wall about the round liga- 
ment) ; and (6) much of the blood from the gastro-intestinal tract being 
thus diverted from the liver to the general circulation, conditions some- 
what analogous to those induced by the establishment of an Eck 
fistula supervene, much of the product of digestion is not brought 
under the influence of the liver, is not detoxified, and toxemia ensues. 
The gall-bladder and the biliary ducts are usually normal; occa- 
sionally there is some thickening of the wall of the gall-bladder from 
chronic cholecystitis. Calculi are sometimes encountered in the gall- 
bladder or the ducts: in 21 (15.4 per cent.) of 136 fatal cases (Rolleston); 
in 18 (8.6 per cent.) of 209 men, and in 7 (17 per cent.) of 41 women 
(Klopstock); in 8 (22.2 per cent.) of 36 cases at the German Hospital, 
Philadelphia. 
Histology.1-A clear conception of the cirrhotic process is best attained 
by bearing in mind that, as emphasized by Kretz,2 the liver is not made 
up of acini in an acceptable sense. While the physiological unit is that 
1 This is largely an abstract of an article by A. 0. J. Kelly, entitled The Nature and 
the Lesions of Cirrhosis of the Liver, with Special Reference to the Regeneration 
and Rearrangement of the Liver Parenchyma, Am. Jour. Med. Sc., 1905, cxxx, 951. 
2 Ueber Lebercirrhose, Wien. klin. Wchnschr., 1900, xiii, 271; Verhandl. d. deutsch. 
path. Gesellsch., Berl., 1904, viii, 54; Internal. Clin., Phila., 1905, iii, 289. 514 
DISEASES OF THE DIGESTIVE SYSTEM 
collection of cells drained by a radicle of the bile duct, this unit is scarcely 
delimitable anatomically; nor are the so-called acini, or lobules, cross- 
sections of which, surrounded by connective tissues, form such a conspicu- 
ous feature of microscopic sections, of such simple structure as at first 
appears. Study of the liver in serial sections and its reconstruction 
show that the liver parenchyma does not form isolated acini, or lobules, 
everywhere surrounded by connective tissue, but that what appear to 
be acini are merely cross-sections of liver cells arranged as a mantle 
about the numerous dendritic ramifications of the hepatic vein, and 
that this mantle is nowhere discontinuous, forming, on the contrary, a 
continuous whole, everywhere connected, particularly at the points of 
junction of the sublobular, lobular, and lobar veins. The intimate 
relationship that the liver cells structurally bear to the hepatic vein is 
further shown by the radial disposition of the cells about the branches 
of this vein-the so-called central veins. 
As distinguished from most other organs, the liver has two sources 
of I blood-supply-the portal vein and the hepatic artery-which com- 
mingling form a plexiform capillary network, in the meshes of which the 
liver cells are arranged. Ultimately, the capillaries unite again to form 
the radicles of the hepatic vein-the rectilinear veins of Sabourin which 
empty into the so-called central veins. The circulation within the liver, 
which is of much importance in connection with certain features of 
cirrhosis, has been studied attentively by Opie.1 It has long been known, 
and Opie especially has directed attention to the fact that one of the 
important characteristics of the liver is its susceptibility to variations 
in blood-pressure, saying: "The portal vein, hepatic artery, and hepatic 
vein are in such free communication that the entire lobule can be injected 
from any one of these vessels. Hence artificial injections do not define 
the intralobular distribution of the portal and arterial blood, for doubtless 
differences of venous and arterial pressure have a part in determining 
peculiarities of the circulation within the lobule." Opie's experimental 
studies led him to the conclusion "that both the hepatic artery and 
portal vein pour their blood into the periphery of the lobule, and here the 
influence of the arterial blood-pressure is most strongly felt. When 
foreign material reaches the liver by the portal vein it is washed from the 
peripheral zone by the arterial blood, and tends to be deposited in a middle 
zone, where the influence of the opposing circulation is less strongly felt. 
Hence it is not improbable that toxic substances capable of causing 
necrosis of the hepatic cells, brought to the liver by the portal vein, 
might first exert their effect upon cells within a midlobular zone. The 
periphery of the lobule, moreover, is supplied with arterial blood, and 
is perhaps for this reason less susceptible to injurious agencies." 
If the parenchyma of the liver in a moderately advanced or well- 
advanced case of cirrhosis is studied attentively, certain noteworthy 
deviations from the normal become apparent-changes in the size, shape, 
and configuration of the lobules, and in the arrangement of the liver 
1 Jour. Med. Research., 1904, xii, 147. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
515 
cells; degenerative, atrophic, and hyperplastic changes in the liver cells; 
changes in the vascular arrangement and supply. 
The size of the lobules or "hobnails" in cirrhosis has been studied by 
Kretz,1 MacCallum,2 etc. Kretz has shown that the normal lobules 
are roundish polygonal in shape, with their long axes in the direction of 
the central vein, and (as is well known) that their greatest diameter is 
usually a little more than 1.5 mm., and may reach 2.5 mm., whereas 
the short diameter is about 1 mm., and that in cirrhosis these figures 
are surpassed, some lobules being much larger, and other collections 
of cells much smaller. MacCallum found that while the average radius 
of a lobule (that is, the thickness of the mantle of cells about the central 
vein) in a number of normal livers is about 0.66 mm., in advanced cirrhosis 
lobules are encountered that measure, from central vein to periphery, 1 
mm. or more, the small diameter, therefore, being more than 2 mm. 
There is a notable departure from the normal shape and configuration 
of the lobules; many of them are no longer rounded, but quite irregular 
in transverse section; many of the cell mantles no longer surround the 
central veins equally on all sides, but very unequally, so that many central 
veins are situated eccentrically in a more or less misshapen lobule; many 
so-called lobules have no central vein at all (and are not tangential 
sections of otherwise normally arranged lobules); certain lobules (or 
so-called lobules, usually remains of several) have two, three, four, or 
more central veins; and often the central vein may be seen in the adjacent 
interlobular connective tissue. Thus the mantle of cells covering a 
central vein varies much in thickness in different regions (transverse 
planes), sometimes exposing, sometimes covering, the vein to a greater 
or less extent; and although isolated collections of liver cells (that is, 
collections devoid of central veins) do occur, some supposedly isolated 
collections are merely sections of more or less irregularly proliferating 
dendritic branches of what may be called the parent stem, or mantle 
covering a single central vein. 
Furthermore, although the normal radial arrangement of the liver 
cells about the central vein is preserved to some extent, in many places 
it is totally wanting; the architecture of the lobule has become altered 
so that the cells are arranged irregularly in parallel rows, etc. This 
is quite as well-marked in many of the lobules that have a central vein 
as in those collections of cells entirely devoid of central veins. 
The parenchymatous cells show various degenerative changes. In 
the early stages many cells become degenerated, necrotic, and are 
removed, but from the nature and the stage of the process at which 
this occurs, it is rarely observed, except in cases that run a rapid course 
and in certain cases of pigmented cirrhosis. In some cases there is 
considerable or widespread fatty infiltration (so-called fatty cirrhosis). 
In advanced cases considerable atrophy of the liver cells may be observed. 
Evidences of hyperplasia of the liver cells are readily found in almost 
every cirrhotic liver, even in far-advanced cases. Mitoses are rarely 
encountered in advanced cases-largely in consequence of the nature 
1 Loc, cit. 
2 Jour. Am, Med, Assn., 1904, xliii, 649, 516 
DISEASES OF THE DIGESTIVE SYSTEM 
of the process, the advanced stage at which the examination is generally 
undertaken, and the length of time after death that the liver is obtained, 
time sufficient for the completion of any mitoses present at death. That 
many of the liver cells are newly formed is quite apparent from their 
large, clear, and plump appearance, their rounded (rather than polyg- 
onal) outline, the presence of two or more nuclei, and the absence of 
fat and of pigment from their protoplasm. These cells, sometimes small 
collections of them, are situated amidst other liver cells normal in size 
and outline, provided with only a single nucleus each (though sometimes 
with two nuclei, which is quite normal), and the protoplasm of which 
is normally pigmented and contains fat. These newly formed cells 
are usually found at the periphery of a lobule; sometimes they make 
up a larger or smaller sector of a lobule; sometimes they seem to have 
compressed the older cells in their immediate vicinity; and sometimes 
small collections of them are found completely surrounded by wide bands 
of connective tissue. It is, however, probable that liver cells always 
regenerate from preexisting liver cells. Necrotic and hyperplastic changes 
may be found in the one lobule. 
A characteristic feature of almost all cases, more conspicuous in some 
cases than in others, is the bile-ducts or so-called pseudobiliary canaliculi, 
the nature and origin of which has occasioned much discussion. Doubt- 
less the great increase of these structures in cirrhosis, as contrasted with 
the normal liver, is relative only, and due in part, but only in small part, 
to mutual approximation of already existing bile ducts occurring in 
consequence of loss of the liver tissue; but that most of them are newly 
formed is generally conceded, and is quite apparent from their excessive 
number and the evidences of active proliferation (mitosis) that they 
commonly exhibit. Their origin has not been determined definitely for 
all cases. It seems quite certain that some of them, at least, result from 
proliferation of previously existing bile ducts; on the other hand, since 
they are found in a wide variety of disorders, such as all forms of cirrhosis, 
acute yellow atrophy, in the neighborhood of hydatid cysts, tubercles, 
gummas, etc., in other words, in diseases alike only in that they destroy 
liver tissue; since they differ from normal bile ducts in the absence or 
relative paucity of encircling elastic tissue; since they have been found 
by Ackermann and others to be directly continuous with liver cells; 
and since in cases in which the liver cells have been much destroyed 
they are found in large numbers in what may be interpreted as the 
remains of the skeleton of the lobule, we are quite warranted in the 
opinion that they may result from proliferation of the liver cells them- 
selves, constituting in this event a reversion to a less highly specialized 
type of structure. The important fact to point out is the histogenetic 
equivalence of the liver cells and the epithelium of the bile ducts, and 
the fact that proliferative changes of the liver parenchyma are a con- 
spicuous feature of common cirrhosis. 
The changes in the connective tissue vary with the stage and activity 
of the process. Early there is more or less round-cell infiltration in and 
about the portal spaces; later there is considerable increase in the 
amount of connective tissue-in part the result of organization of the DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
517 
inflammatory exudate, in part a replacement fibrosis to fill up potential 
lacunae left by destroyed liver parenchyma. This newly formed connec- 
tive tissue commonly encloses rather than invades the liver lobules; some- 
times only one lobule is enclosed in a wide band of connective tissue, 
sometimes many lobules-whence the designation multilobular cirrhosis. 
A conspicuous change is the great increase in the elastic tissue- 
probably more or less intimately related to the great increase in the 
capillaries derived from arterioles; this elastic tissue not only makes 
up a large part of the fibrous bands between the lobules, but it is also 
found to some extent within the lobules, and occasionally a very small 
amount of it is found about or in the immediate neighborhood of the 
central veins.1 A not inconsiderable part of the fibrosis is made up of 
reticulum-not only the reticulum normally between the lobules, but 
the intralobular reticulum-that remaining after the liver cells have 
degenerated and been removed. 
Lesions in other Organs.-The spleen is enlarged in at least 80 per 
cent, of the cases (198 of 250 cases, Klopstock;2) it is probably enlarged 
some time during the course of all cases, but variations in size are due 
to different factors. There is no constant relationship between the size 
of the liver and of the spleen. At the necropsy the average weight of 
the spleen is about 400 grams; the average weight of 32 cases at the 
German Hospital, Philadelphia, was 400 grams, the minimum 110 grams, 
and the maximum 1320 grams. In the early stages, in consequence of 
increased vascularity, proliferation of the splenic pulp, and hyperplasia 
of the endothelial cells of the sinuses, the organ is about normal in 
consistency; later it becomes firmer and harder, in consequence of increase 
of the trabeculae and consecutive atrophy of the lymphoid elements, 
particularly the Malpighian bodies. Considerable diminution in the 
size of the spleen may follow gastro-intestinal hemorrhage, severe 
diarrhoea, etc. Chronic perisplenitis occurs in about one-third of the 
cases; it may be localized or generalized. 
The enlargement of the spleen is usually thought to be due to two 
factors: (1) Toxemia, bacterial or other toxins brought to the organ 
by the general circulation-which is especially operative during the 
early stages, since enlargement is not frequently observed early, before 
there is any evidence of portal obstruction; and (2) passive congestion- 
which is especially operative, although not the sole factor, in the later 
stages; undoubtedly it distends the blood spaces, and, obstructing the 
return circulation, it serves to retain irritating poisons in the organ. 
Hartwich3 believes the hypertrophy to be compensatory 
The gastro-intestinal tract shows lesions due in part to the cause of the 
cirrhosis (alcoholism especially), in part to portal obstruction. The 
oesophagus shows general congestion, thickening of the mucosa, and in 
80 per cent, of cases, dilated and tortuous veins, especially toward the 
lower end; these not infrequently rupture and cause severe and even 
1 Consult Milne, Jour. Path, and Bacteriol., Cambridge, 1909, xiii, 362. 
2 Arch.f. path. Anat, (etc.), Berl., 1907, clxxxvii, 111. 
3 Deutsch, med. Wchnschr., 1912, xxxviii, 1087. 518 
DISEASES OF THE DIGESTIVE SYSTEM 
fatal hemorrhage. The stomach is the seat of chronic gastritis, often 
associated with small superficial ulcers or abrasions; pigmentary infil- 
tration, especially toward the pylorus; and dilated veins, especially 
toward the cardia; these also frequently rupture. The intestines reveal 
the ordinary lesions of chronic passive congestion and chronic enteritis 
with pigmentation. The rectum is often congested and the seat of small 
superficial ulcers and of dilated veins (hemorrhoids), both of which may 
lead to more or less severe hemorrhage. The peritoneum usually shows 
dilatation of the bloodvessels; often it is inflamed and chronically thick- 
ened, participating, on the one hand, in causing the ascites, and on the 
other hand, leading to thickening and distortion of the omentum and 
the mesentery with consecutive thickening and shortening of the small 
intestine (a reduction of eight to ten feet in length may occur). Tuber- 
culous infection of the peritoneum is common, occurring in 9 per cent, 
of the fatal cases (Rolleston), and being more common in cirrhotic males 
than in other male subjects. It is often responsible for the fatal issue. 
It is sometimes latent and found only at the necropsy; in other cases it 
dominates the clinical picture. Roque and Cordier1 maintain that every 
case of ascites occurring in portal cirrhosis is of tuberculous nature. The 
pancreas2 is enlarged, swollen, and fibrotic, but there is no constant 
relationship between the size and the degree of fibrosis of the pancreas 
and of the liver; the parenchymatous cells show fatty degeneration and 
pigmentation; the islands of Langerhans are intact, except in the cirrhosis 
of hemochromatosis, in which they become destroyed. 
The kidneys show deviations from the normal in about half of 
the cases. In most of these cases they are simply enlarged-doubtless 
the result of overwork (excessive drinking on the part of the patient, and 
efforts to remove toxic substances circulating in the blood); or they 
exhibit the lesions of chronic passive congestion (failure of the heart). 
In some cases, and usually early, albuminuria is encountered; later, 
distinct fibrosis occurs in 25 per cent, of the cases (110 of 440 cases 
collected by Rolleston). Few of these cases are due to the cirrhosis per 
se; both are usually due to a common cause (alcoholism), and both, as 
well as arteriosclerosis, occur at the same period of life and predominantly 
in the male sex. There is no constant relationship between the degree 
of fibrosis and the size of the kidneys and the liver. 
The heart is often fibroid and fatty (alcoholism, arteriosclerosis), and 
consequently dilated. Endocarditis may occur as an accidental com- 
plication and the pericardium may contain a considerable excess of 
fluid (partly inflammatory, partly transudation). Arteriosclerosis is 
common, occurring in more than 60 per cent, of cirrhotic subjects; but 
it is not due to the cirrhosis (the blood-pressure is low in cirrhosis); both 
are more likely due to common causes-alcoholism, etc. 
The lungs exhibit no characteristic lesions; but with the peritoneum 
they constitute the most frequent seat of tuberculosis in cirrhotic subjects. 
The tuberculosis maybe acute or chronic, latent or obvious; and it leads 
directly to death in from 12 to 15 per cent, of the cases of cirrhosis 
1 Rev. de med., Par., 1912, xxxii, 761. 
2 Consult Lando, Ztschr. f. Heilk., 1906, xxvii, 1. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
519 
(Rolleston). Right-sided pleuritis, due to transport of inflammation 
through the diaphragm from a perihepatitis, occurs in about 10 per cent. 
Pathogenesis.-In portal cirrhosis, in consequence of the activity of 
some poison, larger or smaller areas of the liver tissue, that is, of the cell 
mantles about the central veins, become necrotic and are removed- 
whereby the central veins become more or less uncovered, thus on cross- 
section appearing eccentrically situated in more or less misshapen lobules; 
in some cases in which the destruction of liver cells has been through 
the entire radius of the cell mantle, the central vein may be entirely 
exposed and may even be found in the interlobular connective tissue, 
in which event it is very likely to be mistaken for a branch of the portal 
vein. The cells destroyed are those about the periphery of the lobules- 
in the area of portal distribution, conforming to the fact that the etio- 
logical factor is usually carried by the portal vein. Following the 
primary destruction of certain liver cells, the intact cells, exhibiting a 
remarkable regenerative capacity, attempt to replace the lost cells and 
sometimes succeed in restoring more or less completely the volume of 
the cell mantles. The cells that regenerate are those in the immediate 
vicinity of those that have become necrotic, that is, in the ordinary case 
in which the destruction is not widespread, cells toward or at the periph- 
ery of the lobule-which thus are not only most exposed to Rhe dele- 
terious influence of poisons carried by the circulation, but in consequence 
of being better supplied by arterial blood are also better adapted for 
repair. Kelly was inclined to believe, in view of Opie's researches, that 
the primary destructive action may be exerted, at least sometimes, in 
the so-called midlobular zone-at all events, not immediately at the 
periphery; that the peripheral cells, being better supplied with arterial 
blood, survive when others nearer the centre of the lobule succumb, and 
that these peripheral cells also serve as a focus of regeneration, although, 
of course, the cells nearer the centre of the lobule also regenerate. 
The continuing activity of the etiological factor leads to a continuous 
or recrudescing death of certain old as well as newly formed liver cells, 
which in turn is followed by renewed regeneration. This continuous 
degeneration and regeneration ultimately lead to complete transformation 
of the architecture of the liver; certain lobules are entirely destroyed, 
others are partly or completely rearranged, some are markedly hyper- 
plastic although tolerably well arranged, some show dendritic and other 
irregular proliferation, new islets of liver tissue entirely devoid of 
central veins appear, and, what is especially important, new circulatory 
conditions-capillary and venous-arise. 
Concurrent with the degeneration of the liver cells, the framework of 
the lobules collapses and participates in the formation of the fibrosis. 
This ultinfttely contracts, and on the one hand causes atrophic changes 
in the liver cells, and on the other obstruction and obliteration of some 
of the interlobular and intralobular branches of the portal vein; this 
latter, although it contributes to, is not the sole cause of, the ascites- 
other important factors being the new circulatory conditions, especially 
certain changes in the hepatic arterial supply. Ultimately the poten- 
tiality for regeneration possessed by the liver cells lessens, and is finally 520 
DISEASES OF THE DIGESTIVE SYSTEM 
lost, the general functional capacity of the cells being meanwhile com- 
promised by the contracting connective tissue; the degenerative changes 
predominate over the regenerative, and the patient dies, if he has not 
succumbed earlier to an accidental infection. 
Symptoms.-Cirrhosis of the liver may remain for many years entirely 
latent; indeed, in most cases the lesions in the liver are well advanced 
before the onset of noteworthy symptoms, and the disease not infre- 
quently constitutes an unexpected finding at the necropsy table. Symp- 
tomatically the disease has been divided into the pre-ascitic and the 
ascitic stage; and the symptoms are described as being (1) obstructive 
and (2) toxic. As long as the collateral circulation is efficient obstructive 
symptoms are in abeyance. 
In a few cases, during the early stages, phenomena attributed to an 
ill-defined, so-called, active hyperemia of the liver are encountered; 
that is, the patient complains of ill-defined or vague gastric symptoms, 
a sense of weight in the right hypochondrium, perhaps short transitory 
attacks of slight fever, slight jaundice, and actual pain in the region of 
the liver, which on examination is found enlarged and tender. Such 
attacks may last several days, disappear, and recur at intervals. 
In most cases the early symptoms are an expression of gastro-intestinal 
catarrh-due partly to portal congestion, and partly, in many cases at 
least, to chronic alcoholism with acute exacerbations. The patient 
complains of coated tongue, irregular appetite, flatulence, epigastric 
distress, especially after eating, sometimes of nausea and vomiting (often 
in the morning and usually referable to alcoholism), irregular action of 
the bowels (alternating attacks of diarrhoea and constipation), or habitual 
constipation, hemorrhoids, etc. The increasing portal obstruction leads 
to increasing congestion of the gastro-intestinal tract and the spleen, 
the congestion being doubtless favored by the absence of valves in the 
portal tributaries. This congestion reduces the functional capacity of 
the stomach and intestines, limiting the digestive juices and the intestinal 
secretions (although sometimes increasing the mucus), reducing the 
absorbing power of the intestines, and often inhibiting peristalsis. Con- 
stipation increases and tympanites not infrequently ensues, and both 
may become of high grade and distressing; occasional relief is sometimes 
afforded by attacks of diarrhoea which relieve the engorged vessels. 
These phenomena, while not diagnostic, are highly suggestive of the 
disease, especially with a history of alcoholism. 
With the progress of the disease the foregoing evidences of derangement 
of the gastro-intestinal tract become more marked, and the general 
health becomes impaired; but the first obtrusive manifestation is not 
infrequently hematemesis or ascites. * 
liematemesis is an initial symptom in some cases, and it is a common 
event some time in most cases. Usually it occurs early-while the liver 
is large; when not the initial symptom, it is often the first evidence of 
serious disease (33 per cent, of the cases); but it may occur late, that 
is, after the development of ascites and when the liver may have become 
small. The vomiting of blood may come on without warning, especially 
when the bleeding occurs from oesophageal varices and the blood does DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
521 
not enter the stomach; in some cases it is preceded by distress or pain 
and faintness, particularly when it comes from the stomach; severe 
collapse is uncommon; an immediately fatal result is unusual, but it 
does occur: in one-third of 60 fatal cases collected by Preble1 the first 
hemorrhage was fatal. The hemorrhage, as a rule, is large and consists 
usually of dark, partially clotted blood. A second or a third hemorrhage 
may occur at short intervals, and perhaps lead directly ,to death; or 
repeated hemorrhages may occur for years, eleven years being the maxi- 
mum (Preble). The hemorrhage may be derived from: (1) Rupture 
of varicose veins in the oesophagus. These were present in 80 per cent, 
of the cases collected by Preble; in more than half of these the point of 
rupture was obvious to the naked eye, but in only 60 per cent, of the 
cases with oesophageal varices were there the typical signs and symptoms 
of cirrhosis. (2) Rupture of varicose veins of the stomach, which usually 
are situated near the cardiac end; the bleeding is sometimes profuse and 
may lead to a fatal termination. (3) Gastritis, in which event the 
hemorrhage is due to oozing from distended capillaries and venules. (4) 
Abrasion of the gastric mucosa, which may proceed to definite ulceration, 
and is often associated with gastritis. If the hemorrhage does not soon 
lead to death, it is an important factor in the development of anemia. 
With the hematemesis there is usually blood in the stools; but blood 
may occur in the stools without the vomiting of blood, especially when 
the bleeding into the stomach is slow, and also when the source of the 
blood is the intestine, the rectum or hemorrhoids. 
Hemorrhage from or into other parts of the body is very common. 
The tendency of cirrhotic subjects to bleed independently of stasis and 
the presence of jaundice is well known, and is justly attributed to toxemia 
with disturbed nutrition, the result of functional insufficiency of the liver. 
Whipple2 has demonstrated that there is a low fibrinogen content of 
the blood. This is doubtless the underlying factor in some of the gastro- 
intestinal hemorrhages and in much of the other hemorrhages. Epistaxis 
and bleeding from the gums are very common. Sometimes the amount 
of blood lost is large; it may occasion a well-marked anemia, and has 
proved fatal. Not infrequently the blood is carried to the fauces or 
pharynx, and, being then spat out, may simulate hemoptysis. The 
larynx occasionally exhibits varices (usually associated with oesophageal 
varices) which rupturing may lead to severe hemorrhage or a fatal issue. 
Bleeding from the lungs is not uncommon. Menorrhagia and metror- 
rhagia occur particularly in the early stages. Hemorrhages, usually 
petechial, into or beneath the skin, the mucous membranes and the 
serous membranes (pleura, pericardium, peritoneum) are not rare, 
although not so common as in biliary cirrhosis. 
Jaundice is not a part of portal cirrhosis, but it occurs as a complication 
some time during the course of from 15 to 20 per cent, of the cases. A 
faint subicteric hue to the conjunctiva and the skin is not uncommon; 
it may come and go repeatedly, and last a longer or shorter time; it is 
usually due to a radicular cholangitis, and has been attentively studied 
1 Am. Jour. Med. Sc., 1900, cxix, 263. 
2 Arch. Int. Med., 1912, ix, 390. 522 
DISEASES OF THE DIGESTIVE SYSTEM 
by Naunyn.1 More marked grades of jaundice attributable to catarrhal 
inflammation of the biliary ducts are occasionally observed. In the 
terminal stages more or less marked jaundice may result from associated 
catarrh of the biliary ducts, duodenal catarrh, compression or kinking 
of the ducts, or degenerative changes in the liver cells, and the changes of 
acute yellow atrophy. 
Toxic symptoms may develop at any time during the course. They 
are much less common early than late, but are occasionally observed 
early in cases that for some time pursue a latent course. Minor symp- 
toms consist of restlessness, weakness, headache, and itching; the itching 
may precede or be unassociated with jaundice. More severe toxic symp- 
toms comprise: (1) Apathy, stupor, and coma; (2) an active noisy 
delirium; and (3) convulsions, paralyses, contractures, one of which 
may alternate with the others. These phenomena much resemble and 
are often mistaken for those due to uremia; in fact, they are not infre- 
quently related to renal insufficiency. 
Cirrhosis of the liver may be afebrile throughout its course; during 
the terminal stage the temperature may be subnormal; but attacks of 
fever (100° to 102.5°) are not uncommon. Sometimes these seem to be 
part of the disease, especially when it advances rapidly; sometimes they 
are due to attacks of perihepatitis; sometimes they are due to com- 
plications. The more continuous fever, which is common late in the 
disease, is usually due to tuberculosis-of the peritoneum, lungs, etc. 
Physical Signs.-The general aspect is often quite characteristic and 
may suggest the diagnosis. In the early stages there is pallor and sallow- 
ness; the face is peculiarly muddy or subicteroid. Later, the patient 
becomes thin and emaciated; the musculature is soft and flabby; the 
general integument is dry, harsh, and wrinkled; the face is drawn, occa- 
sionally bloated; the eyes are sunken; the conjunctivae are muddy or 
subicteric; the cheeks and temples are hollow; the lips are dry and 
fissured; the tongue is flabby and coated; the gums are spongy and bleed 
readily; the breath is foul; the skin of the face and cheeks reveals many 
distended venules that are prone to bleed; naevi consisting of localized 
stellate varices and so-called mat naevi ("areas of skin of a reddish or 
purplish color due to the uniform distension of small venules," Osler) 
may occur on the face, neck, and back; and small capillary, subcutaneous 
hemorrhages are prone to develop, especially in regions exposed to 
traumatism. The abdomen is more or less markedly, sometimes enor- 
mously, distended, and is in notable contrast to the emaciated face and 
extremities. The umbilicus becomes everted and has been known to 
rupture. The abdominal wall reveals enlarged and varicose veins due 
to the establishment of a collateral circulation. The very obvious 
communication sometimes established between the superficial epigastric 
veins and the long thoracic and the mammary veins is due not to the 
portal obstruction but to interference with the circulation in the inferior 
vena cava, the consequence of increased intra-abdominal pressure 
caused, as a rule, by the ascites. The collateral circulation, although 
1 Internal. Beitr. z. inner. Med., Berl., 1902, i, 457. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
523 
often marked, is rarely ample or efficient; sometimes it is apparently 
for a time, at least, since an extensive collateral circulation occasionally 
relieves more or less permanently a previous ascites, but under these 
circumstances one cannot ignore the likelihood of the liver having become 
more pervious to the passage of the portal blood. 
Examination shows the liver to be enlarged in most cases, but the size 
varies considerably in different cases and in the same case at different 
times. Foxwell has well said that the liver is " enlarged at all stages of 
the disease, and that whether enlarged or contracted the clinical symp- 
toms and course are much the same," a statement that has been especially 
emphasized by Dreschfeld, Rolleston, etc. Usually before the onset of 
the ascites, and often during the prevalence of the ascites, the lower 
border of the liver is palpable one, two, or three fingerbreadths below 
the margin of the ribs in the right nipple line. The liver is often tender, 
its edge sharp, and its surface irregular; in some emaciated subjects the 
hobnail surface can be readily appreciated by the palpating hand, but 
one must be careful not to confuse therewith irregular areas of fat and 
fibrous tissue in the abdominal wall. In some cases late in the course 
of the disease percussion and palpation show the liver to be considerably 
reduced in size, but in many cases in which the liver appears to be small 
it is of normal or increased size and elevated, being pushed up by ascites 
or drawn up by a paretic diaphragm (due to perihepatitis, etc.); in other 
cases emphysema may decrease the extent of liver dulness, or adhesions 
may prevent the descent of the organ on deep inspiration. In any event, 
whether small or only elevated, the organ can often but not always be 
palpated by firm pressure upward under the ribs. The left lobe is often 
disproportionately small and not at all palpable in the epigastrium- 
which is quite significant of cirrhosis. Notable variations in the size of 
the liver occur from time to time, and often rather rapidly; the common 
change consists of the reduction in size of a large liver, but the reverse 
is not unknown, although it may be temporary. 
The spleen is usually palpable two or three fingerbreadths below the 
left costal margin; but as also in the case of the liver, tympanites and 
ascites often interfere with satisfactory examination. Early the spleen 
is sometimes not notably increased in consistency; later it is usually 
firm, and it is often tender. It is often much reduced in size by copious 
gastro-intestinal hemorrhage, severe diarrhoea, the recurrence of ascites 
after tapping, etc. On the contrary, an unusual enlargement is some- 
times a forerunner of hemorrhage, which may be prevented by a prompt 
resort to free purgation. 
Ascites is often the first obtrusive manifestation that leads the patient 
to seek medical advice. Sometimes it is attributed to a definite exciting 
cause, such as exposure, cold, trauma, etc.; but, as a rule, the onset is 
gradual and without definite cause, and the accumulation is slow. Occa- 
sionally the fluid accumulates with marked rapidity, in which event it is 
attributable to thrombosis of the portal vein. Ascites is to be looked 
upon as a late event, although it is not improbable that congestion and 
transudation of a small amount of fluid into the peritoneum occurs 
comparatively early, in some cases at least; but this is more or less readily 524 
DISEASES OF THE DIGESTIVE SYSTEM 
absorbed. It is present in almost if not quite all subjects dying of 
cirrhosis per se, but in scarcely more than 50 per cent, of cirrhotic subjects 
at the necropsy table. Klopstock found ascites in 172 of 250 cases of 
cirrhosis that came to necropsy. There is no direct relationship between 
the size of the liver and the onset or the degree of ascites; in most cases 
the liver is larger than normal at the time of development of the ascites; 
but a large liver may be present without ascites; a small liver is rarely 
found without ascites. It is believed by many observers, such as Hale 
White, Rolleston, etc., that ascites is really a terminal event, and that 
if, in a case presumed to be cirrhosis of the liver, the patient lives to 
require a second tapping, the cirrhosis is complicated with chronic 
peritonitis (perihepatitis), or the diagnosis is incorrect. 
Some patients require repeated tappings. Casati reports one in whom 
tapping was done 111 times, and Rumpf a case in which it was done 301 
times; but these are most unusual. Usually the tapping is of temporary 
benefit, relieving the patient's distress for a short time only; the fluid 
soon reaccumulates, slowly, as a rule, occasionally rapidly. In unusual 
cases more or less permanent benefit seems to result, doubtless in 
consequence of the formation of adhesions. Cheadle reports a case in 
which a man was tapped 19 times and lived eight years after the last 
tapping; and MacDonald reports two cases in which disappearance of 
the ascites ensued upon 31 and 60 tappings, respectively. 
The ascitic fluid varies in amount-in the average case from 4 to 8 or 
10 liters, but it may be as much as 20 liters, with consequent enormous 
distension. The fluid is usually pale amber in color, clear, somewhat 
opalescent, and alkaline; it has a specific gravity of 1.008 to 1.015, and 
it contains 0.5 to 1 per cent, of albumin, and occasionally also traces of 
urea, urobilin, purin bodies, sugar, etc. Sometimes it is turbid from 
associated peritonitis, in which event it is of higher specific gravity and 
contains more albumin; rarely it is chylous, chyliform, or hemorrhagic- 
the last mentioned usually the consequence of traumatism, or petechial 
hemorrhages in the serosa, etc. Bacteriological examination shows the 
fluid to be sterile, unless there has been secondary infection. Cytological 
studies show the cellular constituents to be few and to consist of lympho- 
cytes and endothelial cells, with a few erythrocytes and leukocytes. 
Cryoscopy reveals the freezing-point to vary with the amount of 
albumin. 
Varying with the amount of fluid there is more or less displacement 
and compression of the abdominal and thoracic organs. The liver and 
the diaphragm are pushed upward and cause embarrassment of the 
respiration and the heart action, and not infrequently compression and 
consequent congestion and collapse, and perhaps bronchopneumonia, 
in the bases of lungs, particularly the right. 
The ascites is doubtless due to different factors: portal obstruction, 
peritonitis (or perihepatitis), and toxemia-which are variously operative 
in different cases. Portal obstruction is an important, but by no means 
the sole, factor. Ascites seems a natural consequence of the other 
manifestations of portal obstruction (hematemesis, collateral circulation, 
etc.), and it is the conspicuous result of complete portal obstruction, 525 
DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
such as occurs in portal thrombosis. The cause of the increased portal 
pressure in cirrhosis is not immediately patent, and probably it is not 
always the same. In some cases thrombosis of at least some of the 
portal radicles is found upon histological examination-which serves 
to explain, in part at least, the increased portal pressure, in some but 
probably few cases. Usually the increased portal pressure is attributed 
to obstruction of the portal vessels by the newly formed connective 
tissue, but doubt has been thrown upon this by Kretz and by Herrick,1 
who believes that an important factor in this increased portal pressure 
is the communication of the arterial pressure to the portal circulation. 
Lessening of the portal area is probably also of some significance in 
increasing the portal pressure. That increased portal pressure is not 
the sole factor in causing ascites is apparent from the fact that it is not 
always present when the portal pressure is undoubtedly high, as at the 
time of (or just before) severe gastro-intestinal hemorrhages; in these 
cases, however, the hemorrhage is often due to factors other than the 
increased portal pressure, such as inflammation and erosion of vessels; 
and frequently the peritoneal lymphatics are still active and able to 
carry away a considerable amount of fluid. Usually the fluid is not 
inflammatory in nature, but sometimes it is, supporting the view that the 
ascites is sometimes due in part at least to peritonitis (perihepatitis). In 
part the ascites may be toxic, an unknown toxin acting as a lymphagogue 
on the peritoneum; but this is pure hypothesis. 
(Edema is common late in the disease, that is, it comes on after the 
ascites. It is most marked in the feet and legs, but often involves the 
trunk, especially the dependent portions; rarely anasarca ensues. The 
oedema of the lower extremities is referable to interference with the 
venous flow in the inferior vena cava. (Edema of the anterior abdominal 
wall is sometimes related etiologically to increased pressure in the dilated 
and tortuous regional veins. Occasionally oedema precedes the develop- 
ment of the ascites, in which event it may be due to one of several factors: 
it may be toxic, in nature analogous to some of the ascites (hypothesis); 
it is sometimes due to anemia or to chronic renal or heart disease with 
dilatation; occasionally it may result from thrombosis of the iliac veins 
or the inferior vena cava; or it may be due to alcoholic neuritis. 
The action of the heart is often impeded by the upward pressure 
exerted by the ascites. The blood-pressure is usually low, the pulse 
small and frequently rapid, and the breathing labored. The myocardium 
is often weak, due to fibroid alterations the consequence of alcoholism, 
malnutrition, and cachexia. A systolic murmur and other evidences of 
dilatation may develop. A venous murmur is sometimes audible in the 
epigastrium (dilated veins in the falciform ligament), and sometimes 
over the spleen. Evidences of cardiac failure are sometimes so marked 
as to obscure the cirrhosis. 
The blood shows the changes of secondary anemia. There is no leuko- 
cytosis unless there is some associated infection. Late in the disease 
evidences of considerable toxic disorganization of the blood become 
1 Jour. Exper. Med., 1907, ix, 93. 526 
DISEASES OE THE DIGESTIVE SYSTEM 
apparent-hydremia, oedema, submucous and subcutaneous hemor- 
rhages, and the blood-findings may simulate those of pernicious 
anemia. 
The urine is usually diminished in amount, in consequence of deficient 
absorption of fluid, the large amount of fluid in the peritoneum, pressure 
exerted on the kidneys, and decreased blood-pressure; the specific gravity 
and the color are high; sometimes the urine is reddish in color (urobilin, 
urates); it is highly acid; sometimes it contains albumin (congestion due 
to failing heart, parenchymatous changes, nephritis); sugar is rarely 
present; the chlorides are diminished; the urea is reduced; the ammonia 
is increased (effort to neutralize acid intoxication); indican, albumoses, 
leucin, tyrosin, and increased volatile fatty acids may be found. Ali- 
mentary levulosuria may be detected, and may prove a serviceable sign 
of hepatic insufficiency; which is true also of urobilinuria and phenoluria. 
In so-called bronzed diabetes (hemochromatosis) sugar is present in the 
urine, but it is due not to the associated cirrhosis of the liver, but to 
fibrotic and other changes in the pancreas. 
Complications.-The cirrhotic subject is peculiarly susceptible to 
infections of diverse sorts, both acute and chronic. Tuberculosis is the 
most common (more common in adults than in children) and shows a 
special predilection for the lungs and the peritoneum. The complication 
is often overlooked, because unthought of and unsought; it should always 
be suspected when there is fever otherwise unaccounted for. In some 
cases the lung involvement is altogether latent; in other cases it gives 
rise to physical signs sufficient for diagnosis, but no obtrusive symptoms; 
in a few cases it dominates the clinical picture. Tuberculous peritonitis 
is very common, and not infrequently determines the fatal issue. It is 
often overlooked, the ascites naturally being attributed to the cirrhosis; 
it is suggested by the presence of fever, tenderness and rigidity of the 
abdominal wall, perhaps increase in the amount of ascites previously 
stationary (the fluid sometimes becomes hemorrhagic), more rapid 
course, and more speedy death. The ascites seems to predispose to 
tuberculous infection, which otherwise is uncommon in adult males. 
The cirrhosis is undoubtedly the primary disorder in the great majority 
of cases, but some observers believe that in some cases the tuberculosis 
of the peritoneum is the primary, the cirrhosis the secondary. 
Tuberculous pleuritis is not rare, but non-tuberculous pleuritis also 
occurs. The pleuritis may be primary or secondary to disease of the 
lungs or the peritoneum; in the latter case the infection doubtless travels 
through the diaphragm. The pleuritis is usually right-sided, but it may 
be left-sided or bilateral. Some care is required in diagnosing right-sided 
pleuritis, since compression of the lung by a large liver or ascites may 
occasion dulness and other signs simulating pleural effusion; or a localized 
bronchitis or bronchopneumonia may develop. 
Evidences of involvement of the kidneys occur in about half of 
the cases. In some cases there is only a slight albuminuria, attributable 
to toxic degeneration of the renal epithelium or passive congestion; in 
other cases in addition to the albuminuria, which is more marked, there 
are signs significant of parenchymatous nephritis; in most cases (almost DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
527 
one-fourth of all cases of cirrhosis) the common manifestations of inter- 
stitial nephritis occur. 
Peripheral alcoholic neuritis (neuromuscular pains and tenderness, 
muscular cramps, cutaneous hyperesthesia, lost knee-jerks, etc.) occurs 
in a considerable proportion of cases, and is often overlooked or the 
symptoms are misinterpreted. A.number of acute infections, especially 
pyococcic infections (local and general), endocarditis, croupous pneu- 
monia, etc., are not uncommon, and may determine the fatal issue. 
Diagnosis.-This is not always an easy matter in the early stages, 
but it should be made more frequently than it is. In an alcoholic subject 
with dyspepsia, an enlarged and tender liver suggests the diagnosis; 
and this is virtually confirmed if to these there be added an enlarged 
spleen, perhaps recurring attacks of pain in the region of the liver with 
slight fever or slight jaundice, and urobilinuria. If the diagnosis were 
made upon these symptoms and the patient treated accordingly, many 
subjects doubtless w'ould not later exhibit the typical phenomena of 
advanced cirrhosis; in some perhaps the diagnosis would be incorrect, 
but in many the disease would be arrested-of the possibility of which 
the lesions in the hepatic parenchyma afford abundant testimony. 
Later, when hematemesis, ascites, the hepatic facies, etc., have appeared, 
the diagnosis can be no longer in doubt. 
Little difficulty is likely to be experienced in differentiating biliary 
cirrhosis, which, aside from its rarity, occurs in younger, usually non- 
alcoholic subjects, and is characterized by persistent jaundice, an enlarged, 
smooth liver, much enlarged spleen, the absence of all signs of obstruction 
of the portal circulation, and a very chronic course. 
When the liver is enlarged and there is no ascites, one must exclude 
other causes of enlargement of the liver, such as passive congestion 
(chronic cardiac or pulmonary disease, cyanosis, usually marked enlarge- 
ment and tenderness of the liver, some jaundice, urinary signs of con- 
gestion of the kidneys, etc.); fatty liver (rather soft and smooth liver, 
causes of fatty disease of the liver, such as tuberculosis, etc.); amyloid 
disease (causes of amyloid disease, involvement of other organs, spleen, 
kidneys, etc.); leukemia (examination of the blood, etc.); malaria (history 
of chronic malaria or repeated acute attacks, plasmodia or pigment in 
the blood, disproportionate enlargement of the spleen, irregular fever, 
cachexia, anemia, response to quinine, and perhaps absence of a history 
of alcoholism). Syphilis is suggested by a history or other evidences of 
syphilitic infection, more local distress and pain due to the more marked 
perihepatitis, irregular enlargement of the liver especially of the left 
lobe, and more common jaundice; in some cases the diagnosis is impos- 
sible and recourse should be had to antisyphilitic treatment. 
The occurrence of hematemesis and other gastro-intestinal hemorrhages 
necessitates differentiation from gastric and duodenal ulcer. This is 
often difficult, but cirrhosis is suggested by a history of alcoholism, 
enlarged and tender liver, an enlarged spleen, absence of marked evidence 
of hyperchlorhydria (hyperchlorhydria may occur in cirrhosis), absence 
of localized epigastric tenderness, etc. In some cases of cirrhosis the 
hemorrhage is due to associated gastric or intestinal ulceration, which, 
however, is commonly not of the peptic variety. Hematemesis, especially 528 
DISEASES OF THE DIGESTIVE SYSTEM 
if small in amount, may also suggest carcinoma of the stomach; but in 
cirrhosis there are no signs of pyloric obstruction or the evidence of 
carcinoma afforded by the gastric contents and a tumor is not palpable; 
indeed, in cirrhosis there is more likely a void in the epigastrium rather 
than a sense of increased resistance. In the event of gastric carcinoma 
signs of involvement of the liver are likely to supervene sooner or later, 
so that ultimately the differential diagnosis has to be made between 
cirrhosis and secondary carcinoma of the liver; alcoholism, long-continued 
dyspepsia, and enlargement of the spleen are much in favor of cirrhosis. 
Should the primary growth be elsewhere than in the stomach, there may 
be localizing signs or symptoms, and perhaps metastases elsewhere, as 
in supraclavicular or other glands, etc. Splenic anemia, or Banti's 
disease, may be excluded by the primary enlargement of the spleen, the 
early anemia, the later development of signs of portal obstruction, and 
the comparative youth of the subjects-twentieth to the fortieth year. 
When ascites has developed one must exclude other causes of ascites, 
especially chronic peritonitis and perihepatitis (multiple serositis), 
thrombosis of the portal vein, tumors of the peritoneum and the abdomi- 
nal organs, chronic cardiac disease, and cachectic states. As already 
stated, the ascites in many cases of cirrhosis is due, in part at least, to 
peritonitis or perihepatitis, but in other cases it may be due solely to 
perihepatitis, occurring alone or as part of multiple serositis, or in tuber- 
culous peritonitis. Tuberculous peritonitis is suggested by the absence 
of a history of alcoholism and of evidences of portal obstruction, and 
by the presence of fever, tenderness and rigidity of the abdominal 
muscles; should the tuberculous peritonitis be secondary to cirrhosis 
with ascites, there may be rather sudden increase in a previously station- 
ary ascites, a more rapid course, and speedy death. 
Thrombosis of the portal vein occurs in one-third of the cases of cirrhosis, 
and is suggested by sudden development of ascites (or sudden increase 
in the ascites, if already present), rapid enlargement of the spleen, severe 
(perhaps repeated) hematemesis, and rapid recurrence of the ascites 
after removal; the sudden onset of these symptoms in the absence of a 
history of alcoholism suggests primary thrombosis of the portal vein, 
but in many cases of supposed primary thrombosis there has been a latent 
cirrhosis until this event. 
In the ascites of tumors of the peritoneum or the abdominal viscera, 
the seat of the primary growth may be more or less obvious, metastases 
may be found in the supraclavicular fossa, in glands, about the umbilicus, 
along the course of the falciform ligament of the liver, etc.; emaciation 
and cachexia are more marked than in cirrhosis, and signs of portal 
obstruction are wanting; should the liver or biliary ducts be involved, 
there is also deep jaundice and nodular and progressive enlargement of 
the liver. The ascites of chronic cardiac disease is recognized by detect- 
ing the disorder of the heart or an antecedent pulmonary disorder with 
consecutive hypertrophy and dilatation of the heart; the oedema of heart 
disease begins usually in the legs and other dependent portions of the 
body (only exceptionally giving rise to primary ascites); and the oedema 
and ascites, as well as the size of the liver, vary with the functional 
activity of the heart, responding, therefore, to cardiac tonics. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
529 
The ascites of cachectic states, such as advanced nephritis, amyloid 
disease, leukemia, various anemic conditions, convalescence from typhoid 
and other infections, is usually slight in grade, often only part of the 
general anasarca, and is associated with readily recognizable disorders; 
only when there is associated cardiac or hepatic disease does the ascites 
become at all marked. 
In some cases of ascites the liver is small-in which event the disorder 
may be syphilis of the liver, advanced passive congestion (red atrophy), 
chronic deforming peritonitis and perihepatitis, thrombosis of the portal 
vein, etc. Each of these should be readily differentiated. The small 
size of the liver may also be due to acute yellow atrophy superadded to 
cirrhosis of the liver-which also should be readily recognized. 
Examination of the fluid removed by tapping (or otherwise) aids in 
the differential diagnosis. The transudate of cachectic states is clear, 
pale-amber colored, and limpid; it has a specific gravity of 1.010 or less, 
and contains less than 1 per cent, of albumin; its cellular content is slight 
and consists of a few lymphocytes and endothelial'cells, and perhaps an 
occasional erythrocyte. The transudate due to mechanical obstruction 
is clear-amber colored; it has a specific gravity of 1.008 to 1.014, and 
contains from 1 to 3 per cent, of albumin; its cellular content consists of 
a few lymphocytes and endothelial cells, a few erythrocytes, and an 
occasional polynuclear leukocyte. The inflammatory exudates may be 
serous, serofibrinous, purulent, or hemorrhagic in character; even the 
serous exudates are usually slightly turbid; they have a specific gravity of 
1.015 or more, and they contain from 3 to 6 per cent, or more of albumin; 
their cellular content consists of lymphocytes, polynuclear leukocytes, 
endothelial cells, and erythrocytes in varying proportion, depending 
upon the nature of the infection; lymphocytes in large numbers (upward 
of 90 per cent.) indicating tuberculous infection, disproportionate 
polynuclear leukocytosis indicating pyococcic infection. In tuberculous 
peritonitis and in malignant disease of the peritoneum the fluid is often 
quite obviously hemorrhagic. The tuberculous nature of the process 
may be further demonstrated by culture methods, animal inoculations 
and resort to tuberculin reactions. That the fluid is due to malignant 
disease may be proved by finding cells with asymmetrical karyokinetic 
figures. Occasionally the fluid is chylous (admixture with chyle) or 
chyliform (fatty degeneration of the endothelial and other cells). These 
figures relating to the specific gravity and the percentage of albumin of 
the ascitic fluid are often modified by the occurrence in the one patient 
of two or more conditions that give rise to ascites. 
Special Types.-Certain special types of portal cirrhosis may be 
differentiated, of which the following are the more important: (1) 
Cirrhosis of hemochromatosis; (2) malarial cirrhosis; (3) anthracotic 
cirrhosis; and (4) cirrhosis in children. 
Cirrhosis of Hemochromatosis (or Bronzed Diabetes).-This is 
a rare disease. Futcher,1 in 1907, was able to find references to only 35 
undoubted cases, and Potter and Milne2 in 1912 collected 51 cases. The 
1 Am. Jour. Med. Sc., 1907, cxxxiii, 78. 
2 Ibid., 1912, cxliii, 46. 530 
DISEASES OF THE DIGESTIVE SYSTEM 
disorder is most common in men (33 of 35 cases) between the ages of thirty 
and sixty-one years, but it is most common during the fifth decade. Its 
characteristics are pigmentation of the viscera and usually also of the 
skin, cirrhosis of the liver, and fibrosis of the pancreas with involve- 
ment of the islands of Langerhans and consequent diabetes. The 
pigments become deposited in the tissues; the visceral pigmentation 
antedates that of the skin. The liver, as a rule, is most markedly 
affected. Mallory1 believes that the liver cells containing the pig- 
ment become necrotic and that leukocytes take up the pigment and 
damage the connective tissues mechanically by collecting in the lymph- 
atics, thus leading to proliferation of the fibroblasts. In the liver and 
the pancreas, especially, fibrotic changes develop with the pigmentation 
and degenerative changes in the parenchyma; in advanced cases these 
reach a high grade, and in the pancreas ultimately involve the islands 
of Langerhans and lead to diabetes (but death may ensue before this 
happens). The sequence of events may be described as hemolysis, 
chronic interstitial hepatitis and pancreatitis, and diabetes. The liver 
is usually enlarged and presents the common appearances of portal 
cirrhosis; it is, however, manifestly pigmented, reddish, resembling 
brick dust or iron rust. The spleen is enlarged, firm, and pigmented. 
The symptoms are those of cirrhosis in its early stage, especially the 
dyspeptic symptoms, and pain in the right hypochondrium; usually 
also there is progressive weakness. Occasionally the onset may be 
sudden. The noteworthy signs consist of general cutaneous pigmentation 
(suggesting Addison's disease), enlargement of the liver and the spleen 
(quite like that of ordinary portal cirrhosis), and the ultimate develop- 
ment of diabetes. Ascites may be slight or absent; hemorrhages may 
or may not occur, but death may result from rupture of oesophageal 
varices, or there may be purpuric attacks. Diabetes when it supervenes 
is severe; acidosis is common and usually leads to coma. 
The diagnosis is apparent from the cutaneous pigmentation, enlarge- 
ment of the liver and the spleen, and diabetes. The cutaneous pigmenta- 
tion must be differentiated from that of argyria; of chronic jaundice 
(in which the sclerse are involved); of Addison's disease (in which there 
is no enlargement of the liver and spleen and no diabetes); and of 
ochronosis (alkaptonuria). 
The prognosis is bad, although life may be prolonged for many years. 
Death may occur suddenly from rupture of oesophageal varices, etc.; 
usually it occurs within a year after the appearance of glycosuria. 
The treatment in the early stages is that of cirrhosis; in the later stages, 
that of diabetes. 
Malarial Cirrhosis.-Many observers doubt that malaria ever causes 
cirrhosis, preferring to believe that the cases of so-called malarial cirrhosis 
are due to the operation of the ordinary causes of cirrhosis in a malarial 
subject. It has been suggested that conditions formerly thought to be 
malarial cirrhosis are the results of the organism of kala-azar. Malarial 
cirrhosis unquestionably is rare in temperate climates; but in view of the 
1 Johns Hopkins Hosp. Bull., 1911, xxii, 71. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
531 
very marked lesions produced in the liver by acute and chronic malaria, 
especially severe attacks, there can be no well-founded reasons for 
doubting that malaria may cause cirrhosis. 
Antiiracotic cirrhosis is a rare disorder of the liver, described by 
Welch, and associated with the presence of carbon dust (analogous to 
coabminer's lung). Adami has described a similar condition. 
Cirrhosis in children is by no means rare.1 Usually it is of the com- 
mon or portal type; it may be of the biliary type; in congenital syphilis 
there is a so-called pericellular cirrhosis; and fibrotic lesions sometimes 
designated cirrhosis are found associated with congenital obliteration of 
the biliary ducts. 
The portal cirrhosis of children is due to the usual causes, such as 
alcohol, intestinal intoxication, infections, etc. It is not uncommon 
in several members of the same family, which doubtless is referable to 
familial habits as regards alcohol, etc., and to the influence of hereditary 
syphilis (pericellular cirrhosis of the liver), which although cured may 
leave the liver quite susceptible to the common causes of portal cirrhosis. 
The symptoms in general conform to those in the adult. Hematemesis 
is less common (greater distensibility of the spleen in children), diarrhoea 
and slight jaundice are more common; the liver and the spleen are dis- 
proportionately larger than in adults (relative greater volume and more 
ability for repair in children); tuberculous peritonitis is common and 
perhaps accounts for most of the ascites and the not uncommon fever. 
Prognosis.-On the whole, the outlook in portal cirrhosis is not 
encouraging. There is much evidence that the liver cells early in the 
disease and often for a long time undergo considerable hyperplasia in 
an effort to compensate for the damage, and the collateral circulation 
is additional evidence of efforts in the same direction; there is reason to 
believe, therefore, that if early recognized and properly treated the 
disease could often be brought to a standstill, perhaps cured. As a 
matter of fact, when recognized early, marked benefit is often obtained. 
The size of the liver is of comparatively little prognostic significance, 
although a very small liver is indicative of the later stages; as already 
stated, however, the liver may be enlarged from the beginning to the 
end. The occurrence of hematemesis does not make the outlook hopeless, 
since it is sometimes an early symptom and may lead the patient to mend 
his ways. With the onset of ascites the prognosis becomes distinctly 
bad, since ascites must be looked upon as a terminal event in the ordinary 
course of the disease; sometimes, however, the ascites becomes stationary 
or subsides, in consequence of the establishment of an efficient collateral 
circulation, and the patient may live for many years. The prognosis 
is also bad in the event of anasarca, emaciation, cholemia, failure of the 
heart or the kidneys, and any of the many complications and secondary 
infections. Ordinarily the disease runs a fatal course within three years 
from the onset of symptoms; but sometimes arrest ensues and the patient 
may live for a number of years-eight or ten. Occasionally the course 
is rapid, six or eight months, especially in young subjects much addicted 
1 Consult Jones, Brit. Jour. Children's Diseases, Lond., 1907, iv, 1, 43; and Pexa, 
Wien. klin. Rundschau, 1908, xxii, 33, 50, 68, 83, 117. 532 
DISEASES OF THE DIGESTIVE SYSTEM 
to alcohol; in these cases to the cirrhosis is often superadded serious 
degenerative changes in the hepatic parenchyma, and a form of severe 
jaundice may ensue and lead to the fatal issue. 
Treatment.-This to be effective must be instituted during the forma- 
tive stage; little beneficial effect can be expected after the destruction 
of much hepatic parenchyma and the overgrowth of much fibrous tissue. 
The only trustworthy treatment is based upon our conception of the 
etiological factors, and consists essentially in the avoidance of all causes 
known or suspected to lead to the disease. Of these, the most important 
are alcohol, stimulating and highly seasoned foods, foods likely to undergo 
fermentation in the intestinal tract, etc., all of which must be strictly 
prohibited. In the early stages, when the hope of marked benefit, if 
not cure, may be reasonably entertained, alcohol in all forms (including 
medicinal agents, tinctures, etc.) must be absolutely interdicted; there 
can be no question that the likelihood of improvement or arrest of the 
disease depends more upon the non-use of alcohol than upon any or all 
other factors. But when the disease is well advanced and cure or notable 
improvement is manifestly impossible, it is not always necessary or 
wise to discontinue alcohol entirely: the question must be decided for 
each individual patient. Although it may be quite obvious that the 
patient's deplorable condition is the consequence of the misuse of alcohol, 
it does not follow as a corollary that the disuse of alcohol will result in 
improvement; he may have become so accustomed to the effects of 
alcohol and so dependent upon it that its withdrawal will be attended 
by more ill consequences to the general economy than by good results 
to the liver. In these cases the alcohol should be reduced to the smallest 
amount consistent with general well-being; and this amount should be 
given well diluted with the meals. Nux vomica or strychnine is often an 
excellent substitute for alcohol, and is otherwise beneficial; in some 
cases, after its use for a time, the alcohol may be entirely withdrawn. 
The diet is of the utmost importance. On the one hand, it must be 
sufficiently nourishing; on the other hand, it must be absolutely non- 
irritating to and not overtax the functional capabilities of the liver, 
and it must be readily assimilable and not likely to undergo fermentation 
in the intestine, which, if it occurs, may give rise to the production of 
harmful toxins. Milk is unquestionably the best diet; it is sufficiently 
nourishing, readily digested and assimilated, its protein is easier utilized 
by the liver than that of meat; it leaves little residue, and it is somewhat 
diuretic. In almost all cases it should form the only diet, for a time at 
least-four to six weeks, depending upon the improvement. Two to 
three quarts should be given during the twenty-four hours. Sodium 
bicarbonate or some one of the natural alkaline waters, such as Vichy, 
Apollinaris, etc., may be added to the milk with advantage; or it may 
be flavored with vanilla, tea, coffee, chocolate, cocoa, etc. If the milk 
seems to disagree, skimmed milk, buttermilk, or koumyss (less desirable 
on account of the contained alcohol) may be tried; in exceptional cases 
it may be necessary to peptonize the milk. At the end of from four to 
six weeks in ordinary cases, if improvement has occurred, the diet may 
be increased by the addition of eggs, gruels, cercais, and stewed fruits, DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DVCTS 
533 
and from time to time some fish or green vegetables may be permitted. 
After a month or more, depending upon the condition, the absolute milk 
diet should be again resorted to for several weeks; thus alternating, the 
diet should be continued indefinitely. In general, meat, all highly 
seasoned and stimulating foods, spices, tea and coffee, etc., should be 
prohibited, because of their irritating effect upon a damaged liver; the 
use of carbohydrate foods and of fats also should be carefully supervised, 
since carbohydrates not uncommonly undergo fermentation and lead 
to the production of toxic substances, and the fats may lead to the 
formation of fatty acids--all of which may provoke or increase the 
lesions in the liver. One must individualize, however: in some cases 
occasional dietetic relaxations are attended by mental as well as 
bodily satisfaction, a more hopeful outlook, and more or less im- 
provement. 
Comparatively little can be done to influence directly the lesions in 
the liver, but it is always well to try the effect of potassium (or other) 
iodide, in the hope that it may do good, and with the knowledge that 
should the lesions be syphilitic benefit assuredly will follow. Minute 
doses of mercuric bichloride (gr. to thrice daily), perhaps com- 
bined with the iodide, or ammonium chloride, or nitrohydrochloric acid, 
also seem to do good in some cases. Rolleston warns against the use of 
arsenic (which has been recommended to stimulate the hepatic cells to 
compensatory hyperplasia), believing that it may cause cirrhosis. The 
use of the alkaline waters or ammonium chloride perhaps retards the 
development of the terminal acidosis. The use of organic preparations 
of liver has proved of no value whatever. 
Special attention must be paid to the gastro-intestinal tract: indiges- 
tion, nausea, vomiting, constipation, diarrhoea, etc., must be prevented 
as far as possible, and when present should be efficiently treated. In 
the early stages much benefit may follow a course of treatment at some 
one of the well-known spas, such as Carlsbad, Vichy, etc. The purgative 
waters have a good influence in lessening the intestinal catarrh and the 
portal congestion, and in ridding the system of toxins; their good effect 
may be as well obtained at home as abroad; or one may give, with 
the same object in view, sodium sulphate or phosphate, magnesium 
sulphate, etc., as well as an occasional dose of blue mass or calomel. 
The good effect of free catharsis is often seen in diminution in the size 
of the liver and spleen following copious movements. In some cases in 
which unusual enlargement of the spleen suggests the imminence 
of hematemesis or other gastro-intestinal hemorrhage, this may be 
warded off by free catharsis; in other cases ascites may be thus in 
part absorbed. 
The indigestion, nausea, and vomiting are to be treated on general 
principles; often the disuse of alcohol is followed by immediate improve- 
ment in these symptoms; in other cases the additional use of the purgative 
waters, or saline aperients, is all that is required to secure the desired 
relief. In other cases, however, medication is required. In one class 
of cases, sedatives, such as the different preparations of bismuth, creosote, 
carbolic acid, dilute hydrocyanic acid, silver nitrate, and hyoscyamus 534 
DISEASES OF THE DIGESTIVE SYSTEM 
or belladonna, etc., may be desirable; in another class of cases (subacidity) 
diluted hydrochloric acid, mix vomica, strychnine, and the bitter infusions 
may lead to the desired result; in still other cases excessive flatulence 
suggests the use of bismuth, salol, creosote, carbolic acid, and other 
antifermentatives. Diarrhoea should not be indiscriminately checked, 
since it may serve a useful purpose of elimination; but when severe and 
obviously exhausting, it should be met by regulation of the diet and the 
use of astringents and perhaps small amounts of opium. Pain and 
distress in the region of the liver may be relieved by hot fomentations 
or a cold compress locally, abdominal massage, the administration of 
ammonium chloride, and depletive measures. 
Ilematemesis calls for treatment similar to that of bleeding in gastric 
ulcer. The patient should remain in bed absolutely at rest, and tran- 
quillity should be promoted by a hypodermic injection of morphine; 
an ice-bag may be lightly applied to the epigastrium (supported, if 
necessary); all food and drink should be withheld; to relieve the dryness 
and thirst the mouth and lips should be moistened, or small bits of 
ice may be given to the patient to suck, but the water should not be 
swallowed. Usually in consequence of the quiet and rest thus induced, 
and of the relief to the congestion afforded by the bleeding, the hemor- 
rhage ceases of itself. If there is much shock and collapse, stimulants 
and saline infusions should be resorted to. For several days after the 
hemorrhage no food should be given by the mouth; if deemed necessary 
rectal enemas may be administered: thirst if distressing, may be relieved 
by water by the bowel. The subsequent feeding and after-treatment are 
analogous to those of gastric ulcer. 
The onset of severe nervous symptoms (cholemia, acidosis) calls for 
treatment required in uremia-free purgation, sweating, and diuresis 
(hot applications to the loins, large amounts of water, alkaline diuretics, 
digitalis, etc.), and saline infusions. Should diacetic or other acids be 
present in the urine, large amounts of sodium bicarbonate may be given 
internally and added to the saline infusion. 
Ascites may sometimes be favorably influenced by the use of purgatives 
and diuretics, such as the alkaline diuretics, caffeine, sparteine, theo- 
bromine, etc. In the majority of cases medicinal measures are of little 
if any value in ascites, especially if the amount of fluid be large; resort, 
therefore, must be had to tapping. This is indicated when the fluid 
causes local discomfort, dyspnoea, pulmonary congestion, oliguria, etc. 
There is no advantage in delaying tapping when it has become indicated; 
indeed, the resort to tapping as often as it may be indicated may lead 
to the development of adhesions which may augment the already formed 
collateral circulation. When done under aseptic precautions, the danger 
of infection may be disregarded; when the fluid is withdrawn slowly there 
is little likelihood of collapse. The tapping may be done with a trocar 
and cannula in the median line midway between the umbilicus and 
the pubes (after preliminary catheterization of the bladder). Continuous 
drainage is sometimes practised, but does not commend itself. Recently 
it has been recommended that the fluid removed by aspiration should be DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
535 
utilized for the purpose of auto-serotherapy, injecting it subcutaneously 
in small amounts every other day. A small amount of adrenalin has 
been injected into the abdomen at the completion of a tapping with 
beneficial results at times. 
Operative relief of the ascites and of the conditions upon which it 
depends is sometimes undertaken. The procedure, which is known as the 
Taima-Morison operation1 (omentopexy, epiplopexy, Roberts), has for 
its object relief of the portal circulation, the diversion of the portal 
blood to the general systemic circulation through the medium of adhesions 
(and consequent increased vascularity) set up between the liver, the 
omentum, the parietal peritoneum, etc. How the operation does good 
has been much discussed. Rolleston points out that the beneficial results 
cannot be due solely to diversion of the portal blood to the general 
systemic circulation, since this, imitating an Eck fistula, should tend 
to provoke or increase toxemia. He suggests that the benefit attained 
may be due to: (1) Diminution in the flow of blood through the liver, 
in consequence of which it is enabled to deal more satisfactorily with 
the blood that does pass through it, and thus reduces the toxemia which 
is probably an important factor in inducing the ascites; and (2) relief 
of the venous engorgement and a consequent freer supply of arterial 
blood consequent upon the vascular adhesions over the surface of the 
liver, as a result of which the nutrition of the liver cells is improved and 
they undergo compensatory hyperplasia and become enabled better to 
perform their function. Of 227 cases collected by Sinclair White, 84 
(37 per cent.) resulted in cure and 29 (13 per cent.) in improvement; 
34 (15 per cent.) were failures, and death ensued in 75 (33 per cent.). 
The operation should be done early, while there is hope that sufficient 
hepatic tissue still remains to discharge reasonable functional demands. 
The patients submitted to the operation should be carefully selected; 
associated cardiac, pulmonary, or renal disease, repeated tappings, jaun- 
dice, toxemia, and emaciation should be considered contra-indications. 
Rosenstein2 has performed the operation known as "Eek's fistula," an 
artificially formed anatomosis between the portal vein and the inferior 
vena cava, for the relief of a case of cirrhosis with marked ascites. He 
reports that the anticipated result was not attained, but that the accumu- 
lation of fluid was less rapid than before the operation. 
Billiary Cirrhosis.-Biliary cirrhosis is a chronic disorder of the liver, 
probably infectious in origin, characterized anatomically by radicular 
cholangitis and connective-tissue hyperplasia, and clinically by chronic 
jaundice and enlargement of the liver and spleen. It is commonly 
spoken of as Hanot's cirrhosis, hypertrophic biliary cirrhosis with 
chronic jaundice, in contradistinction to Laennec's, or portal, 
cirrhosis. 
1 Consult Drummond and Morison, Brit. Med. Jour., 1896, ii, 728; White, Ibid., 
1906, ii, 1287 (227 cases); Jones, Tr. Med. Soc. Lond., 1907, xxx, 238; Omi, Beitr. z. 
klin. Chir., Tubing., 1907, liii, 446 (literature); Lieblein, Mitth. a. d. Grenzgeb. d. Med. 
u. Chir., Jena, 1908, xviii, 794; Koch, 2me Cong, de la soc. internal, de Chir., Brussels, 
September 21-25, 1908, and Grant, Interstate Med. Jour., St. Louis, 1913, xix, 487. 
2 Archiv. f. klin. Chir., Berl., 1912, xcviii, 843. 536 
DISEASES OF THE DIGESTIVE SYSTEM 
Etiology.-Biliary cirrhosis is especially common during adolescence 
and early adult life; most cases occur between the twentieth and the 
thirtieth year; it is rare after the fortieth year, but it is quite common in 
children (juvenile type), especially in India. In adults about 85 per 
cent, of the cases (22 of Schachmann's 26 cases) occur in males; in children 
it is equally common in the two sexes. A seeming hereditary influence 
is not uncommon; it is mentioned by Osler, Dreschfeld, Finlayson, 
Rolleston, and others, and it is especially in evidence in the disorder as 
it occurs in India. Boix, Boinet, and others have pointed out that the 
disorder may occur in more than one generation of the same family, and 
that the spleen may be enlarged in certain members of the family who 
show no evidence of disease of the liver. 
The exact nature of the disease is not known. Some, but not all, 
subjects are alcoholic, and it seems that alcohol plays at most a minor 
etiological role. In the cases so common in children in India it is not 
in any way an etiological factor. There is some rather inconclusive 
evidence that the disorder may be the consequence of infection that 
provokes a radicular cholangeitis; but no definite etiological agent has 
been discovered, nor are the pathways of infection known. That the 
disorder is an infection is suggested by its sometimes developing after 
infectious diseases, by the common occurrence of attacks of fever and 
leukocytosis, and the not rare occurrence of general glandular enlarge- 
ment. Organisms have been isolated from the blood, liver, and spleen 
during life in several cases, but the evidence is by no means conclusive 
that they are related etiolpgically. The postulated infectious agent is 
believed by some observers to reach the liver by the general circulation, 
there being a hemic infection or intoxication of a chronic nature, whence 
the disease is conceived to be a descending cholangeitis; by others the 
infection is believed to be an ascending infection from the duodenum. 
The concurrent, sometimes antecedent, enlargement of the spleen and 
the occasional occurrence of general enlargement of the lymphatic glands 
are looked upon as evidence of the widespread activity of some infection; 
the absence or paucity of dyspeptic phenomena and of catarrhal altera- 
tions of the duodenum and of the pancreatic duct at necropsy is in 
favor of the view that the infection does not occur by way of the common 
bile duct from the duodenum, but by the general circulation. Such 
evidence as is at hand favors the view that the disease is a radicular 
cholangeitis, the consequence of a general blood infection. It seems likely 
that the poison does not reach the liver by the portal circulation, since 
portal toxemia probably always gives rise to the common or portal 
cirrhosis; but should the postulated microorganisms of biliary cirrhosis 
produce a poison in the spleen, which is not improbable, this being con- 
veyed to the liver might induce the lesions of portal cirrhosis, which 
being added to those of biliary cirrhosis might account for some of the 
cases of so-called mixed types. 
Pathology.-The liver is enlarged and weighs from 2000 to 4000 
grams; its shape is maintained, its consistency increased, and its elasticity 
diminished. The surface is smooth and exhibits very fine granulations 
(in marked contrast to the coarse granulations of portal cirrhosis); DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
537 
adhesions sometimes occur, but are not very common. The liver is 
usually dark olive green in color. The cut surface is dark greenish or 
yellowish green in color, smooth, or very slightly granular in advanced 
cases; usually the liver lobules are more or less obvious, sometimes 
apparently enlarged, and always separated by widened trabeculae of 
connective tissue. The gall-bladder and biliary ducts, the hepatic artery 
and veins, and the portal vein show no abnormalities, as a rule; gall-stones 
are rarely found, not more frequently than in non-hepatic subjects, 
which is worth comment in view of the common catarrhal cholangeitis 
which might lead one to expect the formation of bilirubin-calcium calculi. 
Microscopically the obtrusive feature consists of an overgrowth of 
fibrous connective tissue; but the basic and essential process seems to be 
the radicular cholangeitis-which is disclosed by proliferation and des- 
quamation of the epithelium of the small biliary ducts. These lead to 
obstruction of the lumina of the small ducts, with consequent dilatation of 
the biliary canaliculi, which in turn are found distended with inspissated 
bile and bile thrombi (perhaps related to an exudation of inflammatory 
albuminous fluid). Branching columns of cells, so-called pseudobiliary 
canaliculi, in and about the periphery of the liver lobules, constitute a 
conspicuous feature of the lesions. Some of these formations result 
from proliferation of preexisting bile ducts; but some of them undoubtedly 
are derived from proliferation of the liver cells themselves. The liver 
cells otherwise exhibit comparatively inconsequential changes. The 
retrograde alterations so common in portal cirrhosis are rare. Apparently 
for a long time, much longer than in portal cirrhosis, the liver cells are 
enabled to maintain their structural integrity. Acute necrotic or auto- 
lytic changes, however, may occur at any time and determine the fatal 
issue. The new connective tissue occurs in delicate fibrillar bands that 
not only course between the lobules but also invade the lobules to a 
greater or less extent (so-called monolobular, unilobular, or intralobular 
cirrhosis). In some advanced cases the arrangement of the connective 
tissue is not so regular, so that it imitates the so-called multilobular or 
portal cirrhosis. The new connective tissue consists in part of elastic 
tissue, but proportionately less than in portal cirrhosis. 
All the organs of the body are bile-stained. The spleen is enlarged, 
and commonly weighs from 600 to 1000 to 1500 grams or more; in 
children it may be as large as or larger than the enlarged liver. It is 
firmer and denser than normally, and often adherent to the adjacent 
tissues (perisplenitis). Microscopically it reveals lymphoid and endothe- 
lial hyperplasia, and fibrosis with consecutive atrophy of the parenchyma. 
The pancreas usually shows no noteworthy lesions; occasionally a slight 
periductal fibrosis has been observed. The gastro-intestinal tract shows 
no noteworthy lesions, in particular no congestive or catarrhal lesions 
of the duodenum and the diverticulum of Vater. The lymphatic glands 
in the portal fissure and usually the adjacent glands are enlarged, oedema- 
tous, and congested, but they exert no pressure on the biliary ducts. 
Symptoms.-The onset is insidious. For a long time there may be 
ill-defined complaint of poor health, general malaise, weakness, loss of 
flesh, etc.; or there may be a sense of weight or distress, perhaps actual 538 
DISEASES OF' THE DIGESTIVE SYSTEM 
pain, in the right hypochondrium; rarely there is some dyspepsia, coated 
tongue, poor appetite, perhaps nausea, diarrhoea, etc.; in a few cases 
the patient's attention may be first directed to increase in the size of 
the abdomen. 
In the great majority of cases the obtrusive symptom is jaundice, 
which is slight at first. The jaundice varies in degree from time to time, 
but on the whole it tends to increase and eventually it may become 
extreme, usually greenish; sometimes the markedly bronzed color 
suggests or is mistaken for that of Addison's disease. The usual con- 
comitants of protracted jaundice are seen. There is often intense itching, 
sometimes xanthelasma, etc. Bleeding from the nose or the gums or 
other mucous membranes may occur from time to time for a long period, 
or there may be recurring attacks of purpura; the urine shows the presence 
of bile pigment. The feces also contain bile pigments and may be very 
dark (in contrast to the clay-colored stools of obstructive jaundice). 
In addition, the disease is characterized by periodic attacks of more 
or less severe abdominal pain, especially in the region of the liver, some- 
times attended by nausea and vomiting, and associated with fever, 
leukocytosis, and increase of the jaundice. These attacks occur without 
regularity and without demonstrable cause, and they last variable 
periods-several days to several weeks. Usually the fever does not go 
above 102°; in some cases there is slight fever for long periods. Occa- 
sionally these exacerbations are attended by the nervous and other 
phenomena of icterus gravis, and with high fever, delirium, coma, etc., 
the patient may die. 
The other manifestations are not characteristic. There may be 
dyspnoea from impeded action of the diaphragm and pressure upon the 
lungs and the heart by the enlarged liver and spleen. The myocardium 
may become disorganized, so that dilatation ensues; the pulse is rarely 
slowed. Diarrhoea is the rule rather than the exception. 
Examination usually reveals an obvious bulging of the lower right 
costal arch and the upper part of the abdomen, which is found to be 
due to a much and uniformly enlarged liver; it may reach, in the right 
nipple line, from the fourth rib, or higher, to near or below the transverse 
umbilical line; it occupies a proportionate area in the epigastrium; and 
it extends well into the left hypochondrium. It presents a smooth 
surface; rarely it may be slightly irregular from fine granulations on the 
surface (which, however, are scarcely appreciable by palpation) or from 
adhesions. The organ is firmer than normal, and its edge is sharp and 
well defined. Usually the enlargement is progressive, although the size 
of the organ may vary somewhat from time to time. Rarely toward the 
end some decrease in size may become apparent (usually more apparent 
than real), attributed to contraction of the newly formed connective 
tissue or secondary portal cirrhosis. The liver may be moderately but 
often is not at all tender. The gall-bladder is not enlarged, except in 
the event of some complication. 
The spleen is markedly enlarged, much more so than in portal cirrhosis; 
it is hard and presents a sharp and well-defined edge. Some writers 
believe that the enlargement of the spleen may antedate that of the DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
539 
liver. In children the spleen may be actually larger and heavier than 
the enlarged liver-the juvenile type of biliary cirrhosis (cirrhose biliaire 
splenomegalique of Gilbert and Fournier). On auscultation one may 
sometimes hear a soft murmur or friction (perisplenitis). 
The blood reveals oligocythemia, leukocytosis during the periodic 
exacerbations, diminished coagulability, etc. The urine, usually increased 
in amount in addition to containing bile pigments, is highly colored and 
of increased specific gravity; albumin and sugar are usually absent. 
Rarely a bulbous enlargement of the terminal phalanges of the fingers 
(Hippocratic fingers) and of the toes occurs; it is due to thickening of 
soft tissues (ar-ray examination shows no bony overgrowth), and although 
it resembles the hypertrophic pulmonary osteo-arthropathy of Marie, it 
cannot be correlated with any disease of the lungs; presumably, however, 
it is due to some unknown toxin, which is not peculiar to biliary cirrhosis, 
since it may be found in other types of protracted jaundice. In children 
growth is stunted, the condition spoken of as infantilism develops, and 
the onset of puberty is delayed. 
Types of Biliary Cirrhosis.-The varying relations between the size of 
the liver and of the spleen and the time of the onset of these enlargements 
have led certain French authors, especially Gilbert, Chauffard, Fournier, 
to postulate different types of the hypertrophic biliary cirrhosis, 
depending on the priority of involvement of the liver or spleen and also 
on relative amount of enlargement of these two organs. The differen- 
tiations are of minor clinical significance, although they suggest that 
all cases of biliary cirrhosis are not of the same nature and genesis. 
Diagnosis.-This, as a rule, presents no unusual difficulties, although 
it is made more frequently than the rarity of the disease warrants. The 
important diagnostic features consist of the occurrence in a young, 
usually non-alcoholic, subject of chronic progressive jaundice, with 
considerable and persistent enlargement of the liver and spleen, and 
periodic attacks of abdominal pain, fever, and leukocytosis, with sub- 
sequent increase in the jaundice, and no signs of cholelithiasis or portal 
obstruction. 
There should be no difficulty in differentiating the more common or 
portal cirrhosis, which occurs, as a rule, in older and alcoholic subjects 
and is attended by more marked dyspeptic symptoms and by evidences 
of portal obstruction. In portal cirrhosis hemorrhages, especially hema- 
temesis, often occur early and are commonly profuse; whereas in biliary 
cirrhosis hemorrhages are usually a late manifestation and small; they are 
most common from the oral and nasal mucous membrane and into the skin, 
and hematemesis is rare. Jaundice sometimes occurs in portal cirrhosis, 
but it is a complication and catarrhal in nature; in biliary cirrhosis it is 
the conspicuous feature, and, although permanent, it is not associated 
with absence of bile from the feces. Constipation is common in portal 
cirrhosis, diarrhoea in biliary cirrhosis. Portal cirrhosis usually runs 
a fatal course within three years or less; biliary cirrhosis not uncommonly 
lasts from five to ten years or more. 
The clinical phenomena of biliary and of portal cirrhosis are some- 
times combined; that is, jaundice supervenes in a case of portal cirrhosis 540 
DISEASES OF THE DIGESTIVE SYSTEM 
with enlarged liver and ascites, or ascites develops in a case of supposed 
biliary cirrhosis with enlarged liver and jaundice. This has led some 
authors to believe that biliary cirrhosis is not a disease entity; others 
postulate mixed forms, or the superaddition of portal cirrhosis to the 
final stages of biliary cirrhosis. The diagnostic difficulties are much 
simplified by bearing in mind that biliary cirrhosis is a rare disease; 
that, although jaundice is not an essential part of portal cirrhosis, it 
occurs in from 15 to 20 per cent, of the cases, being due to a complicating 
radicular cholangeitis; and that inasmuch as the liver is usually enlarged 
in portal cirrhosis (although it may become small), an enlarged liver 
with ascites and jaundice does not necessarily mean a mixed form of 
cirrhosis, but is quite consistent with the natural history of portal or 
the common type of cirrhosis. On the other hand, the very rare cases 
in which ascites supervenes after the long continuance of biliary cirrhosis 
may be variously interpreted: in some cases the ascites may be due to 
disease of the peritoneum (perihepatitis, peritonitis, etc.); in other cases 
it may be due to gross obstruction of the portal vein, or if terminal to 
cachectic states; in other cases perhaps the lesions of portal cirrhosis 
are added to those of the primary biliary cirrhosis. 
When the jaundice is slight and perhaps readily overlooked, other 
forms of enlargement of the liver, such as passive congestion, fatty 
liver, amyloid liver, leukemia, tuberculosis, syphilis, and hemochroma- 
tosis must be differentiated. Other causes of chronic jaundice also must 
be excluded, such as cholelithiasis and carcinoma. 
Prognosis.-The outlook as to cure is hopeless. The disease usually 
runs a protracted course, averaging four or five years, but not uncom- 
monly continuing for ten years or more. The periods of remission are 
often of long duration and the general health may be well maintained; 
but the exacerbations may be severe and seriously undermine the general 
resistance, and they may lead to a severe form of jaundice and death. 
The prognosis is especially bad in the event of severe jaundice with 
nervous symptoms (fever, delirium, coma, etc.), recurrent hemorrhages, 
marked general weakness, intercurrent complications, etc. 
Treatment.-The treatment is largely symptomatic, and in general 
does not differ materially from that advised in portal cirrhosis. The 
hygienic conditions should be the best obtainable, and should comprise 
much fresh air, non-exposure to cold and damp, moderate and carefully 
regulated exercise, etc. The diet may be more generous than in portal 
cirrhosis, but with a view not to provoke gastro-intestinal derangements; 
the patient should avoid dietetic indiscretions, alcohol, etc. Constipation 
should be overcome by the use of calomel, blue mass, and the salines. 
The probable infectious nature of the disorder suggests the use of 
antiseptics, such as hexamethylenamine and the salicylates, which are 
eliminated with the bile. Their use has been followed by some apparent 
improvement. Good results also are reported to have followed drainage 
of the gall-bladder and biliary ducts; but the diagnosis in some of the 
cases is open to question: undoubtedly they may have been cases of 
infection of the biliary tract, but probably not of biliary cirrhosis. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
541 
TUBERCULOSIS, SYPHILIS, AND ACTINOMYCOSIS 
These diseases are discussed elsewhere. 
CARCINOMA OF THE LIVER 
Etiology.-Carcinoma of the liver may be primary or secondary. 
Primary carcinoma of the liver is a rare disease. Among 11,500 necropsies 
Hale White1 found only 11 cases. Secondary carcinoma is more common, 
the ratio of the primary to the secondary being 1 to 25 (Hale White) or 
1 to 40 (Hansemann2). Among 4200 necropsies, Hale White found 136 
examples of secondary deposits in the liver, of which at least 126 were 
carcinomatous. 
Pathology.-Primary carcinoma of the liver appears under three 
forms: (1) Nodular or multiple carcinoma. This is the most common 
form, occurring in 65 per cent. (Eggel3). (2) Massive carcinoma is the 
type occurring in 23 per cent. (Eggel). It appears as a whitish or grayish- 
white opaque mass, often occupying almost if not quite an entire lobe 
(usually the right). It is sharply defined from the surrounding hepatic 
tissue, which is compressed and atrophic, and sometimes contains smaller 
secondary nodules. (3) Infiltrating or diffuse carcinoma is the type 
occurring in 12 per cent. (Eggel). One or both of the major lobes of the 
organ become pervaded by new-grow'th, and often the seat of considerable 
new fibrous-tissue formation, so that the macroscopic appearances are 
similar to and are commonly mistaken for portal cirrhosis (the cirrhosis 
with multiple adenoma, or with carcinoma, of Hanot and Gilbert, and 
other French authors). Microscopically the cells in carcinoma of the 
liver are usually polyhedral in type, and are believed to be derived from 
the hepatic cells; rarely they are columnar in type, and are then referred 
to proliferation of the epithelium of bile ducts. Transitional types also 
occur, which suggests the histogenetic equivalence of the liver cells and 
the cells of the biliary ducts. In some cases the sequence of events is 
represented by hyperplasia, adenoma, carcinoma. It is doubtful, how- 
ever, whether the designation carcinoma with cirrhosis is as widely 
applicable as maintained by French authors-who believe that this 
represents one-third of the cases of primary carcinoma of the liver. In 
perhaps the majority of the cases the condition is merely cirrhosis with 
considerable hyperplasia of the liver cells (nodular cirrhosis); appearances 
suggesting carcinoma are sometimes due to softening of some of the 
so-called "hobnails," with rupture into the hepatic or the portal veins, 
and to thrombosis-either of which may be the antecedent condition. 
Secondary carcinoma appears usually as multiple, whitish, grayish- 
white, or yellowish-white nodules scattered through the organ, most 
commonly at the periphery, where they often occasion perihepatitis. 
1 Allbutt's System of Medicine, 1900, iv, 204. 
2 Berl. klin. Woch., 1890, xxvii, 353. 
3 Beitr. z. path. Anat. u. Physiol., Jena, 1901, xxx, 506 (literature). 542 
DISEASES OF THE DIGESTIVE SYSTEM 
Often they become umbilicated and softened or hemorrhagic. The 
adjacent liver tissue is compressed, atrophic, and degenerated. 
Symptoms.-These are not notably different whether the growth be 
primary or secondary, although variations occur and, in perhaps one- 
half of the cases of secondary carcinoma, symptoms referable to the 
primary growth are not apparent. Usually the onset is insidious; the 
patient may complain of general ill health, languor, anemia, emaciation, 
etc., for a long time before the true nature of the disorder is disclosed; 
in many cases, certainly in at least one-third of the cases of secondary 
carcinoma, the actual conditions are recognized only at autopsy. In 
some cases symptoms referable to the primary growth precede, for a 
variable time, symptoms significant of involvement of the liver; but in 
a considerable number of cases carcinoma of the stomach, rectum, etc., 
may be for a long time latent; or the symptoms are not obtrusive, and 
the first noteworthy manifestations may be referable to the liver. In a 
small percentage of cases the primary growth remains insignificant; the 
lesions are most marked in the liver, and the symptoms almost if not 
exclusively hepatic, consisting of local pain and distress, jaundice, 
ascites, and enlargement of the liver. 
Local discomfort is quite common, but even with large carcinoma there 
may be no actual pain. The sense of discomfort and weight is usually 
proportionate to the size and rapidity of growth of the carcinoma; it is 
often increased by the left lateral posture, which increases the tension 
on the ligaments. Actual pain sometimes occurs, and may be quite 
severe, in which event it is attributable to a concomitant perihepatitis; 
it often radiates to the right shoulder, and may be increased by motion. 
Sometimes there is more or less local tenderness, especially on deep 
palpation and occasionally there is severe colicky pain. 
Jaundice is present in more than half of the cases; it is variable 
in degree, at first, at least, depending upon its cause, but it tends to 
increase and become permanent. It may be due to a variety of causes 
that are often difficult to differentiate. Thus, it is not infrequently due 
to compression of the common bile duct by a primary growth in the head 
of the pancreas, or to secondary nodules in the lymphatic glands; it 
may be due to primary carcinoma of the biliary ducts; or it may be due 
to pressure on the intrahepatic ducts by sufficiently large nodules, to 
extension along the lumen of the biliary ducts, or to more widespread 
obstruction, such as may occur in massive carcinoma. In the last- 
mentioned instance, if jaundice occurs, which is unusual, it is slight in 
grade and not associated with clay-colored stools. In the other cases 
the jaundice is obstructive in origin; it increases in intensity until it 
becomes of the most severe grade; it is permanent, although for a time, 
at least, it may vary in intensity; and the stools are clay-colored. 
Ascites is somewhat less common than jaundice; it occurs in almost 
if not quite half of the cases; both occur together in about 20 per 
cent., in which event the ascitic fluid is bile-stained; otherwise the fluid 
is pale, of low specific gravity, and contains a small amount of albumin; 
occasionally it is hemorrhagic or chylrform. It varies considerably in 
amount, but is usually moderate and often for a considerable time DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
543 
stationary; it rarely requires tapping. Perhaps in some cases the ascites 
is due to portal obstruction, but this is unusual, since other evidences 
of portal obstruction are usually absent or in abeyance. In most cases 
the ascites is due to perihepatitis or peritonitis; in some cases to car- 
cinomatous involvement of the peritoneum. 
Progressive enlargement of the liver is the phenomenon that determines 
the diagnosis. The enlargement may be moderate or very great. Usually 
it involves the right lobe more than the left, but the percussion dulness 
is increased in all directions. The liver may be observed to increase 
notably in size under observation. The edge is usually firm and hard, 
and it, as well as the palpable surface, is quite irregular-nodular. The 
nodules vary considerably in size; usually they are firm, especially when 
small, but as they grow they often soften in the centre and hence become 
depressed or umbilicated; sometimes this umbilication can be made out 
by palpation, which is quite diagnostic of carcinoma; in other cases they 
may seem semifluctuating. Sometimes they suddenly increase in size 
from hemorrhage; occasionally as they degenerate they become smaller. 
In the massive carcinoma this nodular formation, of course, does not 
occur, but one can often make out marked distortion due to a very large 
new-growth. The gall-bladder can sometimes be palpated as an enlarged 
pear-shaped tumor at the lower edge of the liver. In a few cases secondary 
nodules develop along the falciform ligament, and become palpable at or 
through the linea alba, at the umbilicus; these are conclusive evidence 
of the real nature of the disorder, but in some cases a microscopic exami- 
nation of an excised nodule may be required to eliminate tuberculosis. 
In many cases the base of the right lung becomes compressed, with 
dulness and feeble or bronchovesicular breath sounds, etc. In other 
cases the growth in the liver forms an attachment to and finally pene- 
trates the diaphragm, and sets up pleuritis that may become purulent. 
In rare cases a nodule in the liver penetrates a branch of the hepatic 
vein, and the carcinomatous cells, being carried to the lung, set up wide- 
spread metastasis. Any of these conditions may be responsible for a 
harsh, dry cough, but in some cases no abnormalities can be detected 
to account for the cough, which must be attributed to irritation of the 
diaphragm (perihepatitis) or the pleura, etc. The liver sometimes 
merely by reason of its weight, and in other cases by causing kinking, 
impedes the circulation in the inferior vena cava, and gives rise to dilata- 
tion of the superficial veins of the abdomen (but leaves the region of the 
umbilicus free-which is a point of distinction from the dilatation due to 
portal obstruction); in other cases oedema of the feet and legs results 
from this cause, but, especially in advanced cases, this may be due also 
to anemia, cardiac weakness, thrombosis of the femoral veins or the 
ascending vena cava, etc. Albuminuria is occasionally observed late 
in the course and is attributable to anemia and toxic degeneration of the 
renal epithelium (hepatogenous albuminuria, Tessier); indicanuria and 
increase of the nitrogenous extractives also may be observed. Hydro- 
nephrosis may ensue from pressure on the ureter or renal pelvis. Gastro- 
intestinal symptoms are often present, apart from the cases of primary 
carcinoma of the stomach; vomiting may result from pyloric obstruction 544 
DISEASES OF THE DIGESTIVE SYSTEM 
(pressure or kinking). The spleen may become enlarged, especially in 
the event of pylethrombosis or carcinoma with cirrhosis. 
In the course of time the patient loses strength and emaciates (rarely, 
when the liver increases rapidly in size and attains huge dimensions, 
the weight may remain stationary or actually increase); he becomes 
anemic and cachectic, and phenomena attributed to hepatic insufficiency 
(cholemia) develop. 
Diagnosis.-This is not always possible, especially in the cases of 
secondary growth in which the deposits are few in number, small in 
size, and deep within the substance of the liver. In another series of 
cases, in which a primary growth is obvious or found on examination, 
and in which there is a persisting severe jaundice, cachexia, and a 
rapidly enlarging and nodular liver, the diagnosis can often be made 
on inspection alone, especially if the patient be made to take a deep 
inspiration (whereupon the irregular nodular liver, covered only by a 
thin layer of skin, will be seen to descend). Between these extremes 
lie the majority of cases, in which the diagnosis is often difficult. Should 
the liver seem to be the seat of disease, one must determine (1) whether 
a new growth is present; (2) whether, if present, it involves the liver, 
and (3) if so, whether it is primary in the liver. 
Difficulty is sometimes experienced in determining whether a new- 
growth is present, since it may be imitated by fecal accumulation in 
the colon, and by inflammatory thickenings about the gall-bladder and 
the biliary ducts. Feces, however, may be indented and pushed about; 
they change their position spontaneously from time to time, and they 
may be removed altogether by cathartics and enemas. In inflammatory 
thickenings about the gall-bladder there is usually a history of past 
cholecystitis or cholelithiasis; the mass is in the region of the gall-bladder 
and is single (that is, there are no other nodules on the surface of the 
liver); the liver may not be enlarged at all, and if so, the enlargement 
is slight or moderate and uniform; jaundice, if present, varies from time 
to time, and may clear up altogether (which is practically unknown in 
carcinoma); and the patient's general health is not so seriously 
involved. 
One must avoid the error of mistaking tumors of adjacent organs for 
a new growth of the liver. This can usually be done by attention to 
the symptomatology, a careful physical examination, and by a study of 
the gastric contents, urine, etc. Tumors of other organs, which are 
near the liver, may have respiratory movement, but such movement 
is less common in renal and other retroperitoneal growths, which in 
addition fill out the loin, are covered in front by the intestine, and do 
not project so high toward the thorax as hepatic tumors. Tumors of 
the stomach have a significant symptomatology, often cause dilatation 
of the stomach, characteristically change the gastric contents, and can 
usually be found quite separate from the liver. New growths of the 
omentum, or the thickened indurated omentum of tuberculous or other 
chronic process, usually has a peculiar elongated or irregular shape and 
is separated from the liver by a zone of tympany, and the free edge of 
the liver can usually be felt free and uninvolved. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
545 
Should the disorder be definitely located in the liver, one has to 
eliminate other causes of enlargement, especially cirrhosis, syphilis, 
abscess, hydatid disease, obstruction of the common duct, as well as 
other less common disorders, such as passive congestion, constricted 
liver, leukemia, amyloid disease, fatty liver, etc. 
In portal cirrhosis there is a history of alcoholism; evidences of portal 
obstruction are common; the liver usually is uniformly enlarged, although 
as the disease advances it may grow smaller (in new-growths it continues 
to increase); the palpable nodules are small, not umbilicated, and not 
surrounded by intervening areas of smooth liver. Biliary cirrhosis 
occurs, as a rule, earlier in life than carcinoma; the jaundice is early, 
moderate in grade, and yellowish; since some bile always reaches the 
intestine, the stools are bile-stained; the liver is uniformly enlarged 
and smooth; the spleen is enlarged; and the course is less rapid. 
In syphilis of the liver the pain is often more marked; the liver does 
not increase so rapidly in size and lessens under the influence of anti- 
syphilitic treatment; and there is a history or there are signs of syphilis 
elsewhere. Abscess which is sometimes simulated by those cases in 
which the carcinomatous nodules soften and become semifluctuating, 
and in which the fever of cachexia, anemia, or terminal infection ensues, 
may be differentiated by the antecedent disorder, by the absence of 
cachexia, by the less common occurrence of jaundice and ascites, and 
by the more common fever, etc. 
Hydatid disease is much rarer than carcinoma; it develops, as a rule, 
earlier in life, and is of slower course. The enlargement of the liver is 
usually single (perhaps double, rarely multiple), smooth, and not 
tender; the spleen is enlarged; there is seldom jaundice and rarely if 
ever ascites; and cachexia does not ensue until the disease has lasted 
a long time. 
Having determined the liver to be the seat of carcinoma, it is often 
difficult, sometimes impossible, to say whether the new growth is primary 
or secondary. In at least one-third of the cases (in 50 per cent, according 
to Leube) the primary growth is latent; but in some cases in which it is 
apparently latent it may be detected upon careful study. Attempts to 
find it should always be made, since, as already said, secondary growths 
of the liver are from 25 to 40 times as common as primary growths. 
The presence of a growth in the liver is presumptive evidence of its 
secondary nature; this is rendered more likely by the presence of many 
nodules (which, however, do not exclude a primary liver growth with 
secondary circumferential nodules); by more marked emaciation; and 
by the less rapid course and less rapid enlargement of the liver. Primary 
growths usually are single and cause uniform enlargement of a part of 
the liver; they less frequently cause jaundice and ascites; and they grow 
more rapidly and hence lead to less emaciation, but to earlier death. 
Prognosis.-The diagnosis, of course, brings with it the prognosis: 
the outlook is hopeless. Hale White gives the duration of life as four 
months from the development of symptoms in primary carcinoma, and 
seven months after the development of symptoms referable to the liver 
in secondary carcinoma. 546 
DISEASES OF THE DIGESTIVE SYSTEM 
Treatment.-This is purely palliative, and has for its object promotion 
of the comfort of the patient and relief of his distress. Rare cases have 
been reported in which a single growth has been removed by operation. 
SARCOMA OF THE LIVER 
Sarcoma of the liver may be primary or secondary, but it is very rare.1 
Primary sarcoma may occur as a nodular or a diffuse growth, and may 
originate from any of the connective tissues of the liver or from the 
endothelium of the bloodvessels or the lymphatics (angiosarcoma, 
endothelioma, perithelioma). Secondary sarcoma may follow a primary 
growth anywhere else in the body, but it is especially common after 
sarcomas of the bones, adrenal, mediastinum, and uveal tract; the last 
mentioned are likely to be pigmented. Several years may elapse after 
enucleation of an eye on account of melanotic sarcoma before recurrence 
in the liver occurs. Clinically sarcoma cannot be distinguished from 
carcinoma, except perhaps in the cases that occur in infants,2 in whom a 
tumor is more likely to be sarcomatous than carcinomatous. Sarcoma 
of the liver runs a rapid course, and soon terminates fatally. 
BENIGN TUMORS OF THE LIVER 
Benign tumors, such as adenoma, angioma, so-called fibroma, lipoma, 
etc., are occasionally observed, but are chiefly of pathological interest. 
Adenomas3 may be single or multiple, and may develop from the hepatic 
cells or from the biliary ducts. The biliary-duct adenoma may become 
the seat of cystic dilatation (cystadenoma or adenocystoma). Another 
tumor, often described as an adenoma, arises not from liver tissue but 
from aberrant adrenal in the liver. Multiple adenomas are encountered 
chiefly in association with cirrhosis (so-called nodular cirrhosis); the 
adenomatous formations are really localized compensatory hyperplasias 
of the liver cells. It is difficult, if not impossible, to distinguish between 
hyperplasia and adenoma: there is no sharp line of demarcation, and 
both may progress to carcinoma. The single adenoma is not susceptible 
of clinical recognition unless it becomes very large, when it presents 
more or less outspokenly the symptoms of carcinoma of the liver. 
The symptoms of multiple adenoma are those of the basic condition 
-cirrhosis. 
Angioma is a rare tumor, although it is quite as common in the liver 
as anywhere in the body. They may be congenital or develop in advanced 
life; they may be single or multiple, and small or very large. They cannot 
be recognized clinically. Most of the so-called fibromas and lipomas 
are not true tumors, and one may well doubt whether such tumors occur 
in the liver. 
1 Consult Marz, Centralbl. f. allg. Path. u. path. Anat., Jena, 1904, xv, 433 (litera- 
ture). 
2 Consult Pepper, Am. Jour. Med. Sc., 1901, cxxi, 287. 
3 Watzold, Beitr. z. path. Anat. u. Physiol., Jena, 1906, xxxix, 456 (literature). DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
547 
CYSTS OF THE LIVER 
Cysts may be parasitic or non-parasitic. The parasitic cysts are due 
to infection with Echinococcus granulosus. Non-parasitic cysts may 
occur alone or in association with cystic disease of the kidneys or con- 
genital anomalies elsewhere. There may be one or many cysts. Accord- 
ing to Moschcowitz the cysts, as a rule, are multiple and most abundant 
in the zone of the liver just beneath the capsule. They vary in size from 
those that are microscopic to those that occupy nearly the entire liver. 
They are equally common in the two sexes, and occur at all ages. They 
are believed to originate in aberrant bile ducts, in consequence of inflam- 
matory hyperplasia or of retention of fluid the result of congenital 
obstruction. The diagnosis may be hazarded from the association of 
an enlarged liver with tumors in the loins (cystic kidneys) or symptoms 
of chronic interstitial nephritis. 
THE GALL-BLADDER AND BILIARY DUCTS 
ANOMALIES OF FORM AND POSITION 
Rarely the gall-bladder may be absent, misplaced, or misshapen. 
When the gall-bladder is absent, the common bile duct not infrequently 
presents a circumscribed dilatation (analogue to the gall-bladder); a 
similar dilatation occasionally develops after operative removal of the 
gall-bladder. Rarely there is a double gall-bladder with two cystic 
ducts. Furthermore, the gall-bladder may be misplaced-to the left 
of the transverse fissure; or it may be embedded more or less deeply in 
the substance of the liver, and more or less completely surrounded by 
liver tissue; or the fundus may penetrate the liver substance and present 
on the anterosuperior surface of the liver. Sometimes it exhibits an 
hour-glass constriction, aside from the consequences of inflammatory 
changes. The biliary ducts vary in length. There may be little if any 
common hepatic duct, due to the unusual length of the right and the 
left hepatic ducts. The cystic duct may not join the common hepatic 
duct until close to the insertion into the duodenum. The common bile 
duct and the pancreatic duct may enter the duodenum separately; some- 
times the common bile duct enters with the duct of Santorini. Finally 
the biliary ducts may be congenitally obliterated. 
Congenital Obliteration of the Biliary Ducts.-This is a disorder 
characterized anatomically by obliteration or atresia of the biliary ducts 
and biliary cirrhosis of the liver, and clinically by persistent jaundice 
and so-called cholemia which proceed to a fatal issue. The disorder 
was first prominently brought to the attention of the profession by John 
Thomson,1 who, in 1892, collected fifty cases; Lavenson,2 in 1908, collected 
sixty-two cases. The nature of the disorder has not been definitely 
1 Congenital Obliteration of the Bile Ducts, 1892. 
2 Jour, Med, Research, 1908, xviii, 61 (literature) 548 
DISEASES OF THE DIGESTIVE SYSTEM 
determined, at least for all cases. It is likely, as stated by Rolleston,1 
that several different conditions may give rise to obstruction or oblitera- 
tion of the large bile ducts in the new-born, such as peritoneal adhesions 
set up by fetal peritonitis, syphilis, or a mixed form of hepatic cirrhosis 
with descending and obliterative cholangeitis (the disease usually called 
congenital obliteration of the bile ducts). Lavenson supported the view 
that in most instances the obliteration is due to an anomaly of develop- 
ment, and atresia of the ducts, and that the associated cirrhosis is the 
result of the ensuing biliary stasis. 
Clinically the disorder is characterized by jaundice, which is present 
at or develops soon after birth, although rarely it may be delayed for 
several months; it becomes persistent and intense. The stools become 
acholic, if not acholic from birth; the urine contains bile pigments; 
the liver and the spleen are enlarged; vomiting often ensues; and hemor- 
rhages occur from the umbilical cord and into the subcutaneous and the 
submucous tissues. Gradually the'infant emaciates; stupor, coma, or 
convulsions (cholemia) develop, and death ensues. The course is rarely 
less than a week; usually it lasts for several weeks or several months. 
The more benign icterus neonatorum may be distinguished usually by 
the presence of bile in the feces and by the less-marked jaundice which 
soon fades. Syphilis may be excluded by the absence of a history of 
syphilis in a parent, the absence of other evidences of it, non-response 
to antisyphilitic treatment and by a negative Wassermann reaction. 
Rarely a congenital jaundice persists into adolescence or adult life. 
This type of disorder was first studied attentively by Minkowski,2 and 
later by Chauffard3 who, separating it from the aforementioned types, 
believes the essential change to be, not a radicular cholangeitis, but a 
splenohemolysis-an anomaly in the destruction of the blood influenced 
by a primary disorder of the spleen. 
INFECTIONS OF THE BILIARY TRACT 
The biliary tract is particularly susceptible to, and frequently the 
seat of, infections. The result of these varies with the virulence of the 
infecting microorganism and the resistance offered by the subject: they 
may be insidious or frank in onset, acute, subacute, or chronic in course, 
and slight or extremely severe in character; or they may be entirely 
latent. The frank acute cholangeitis and cholecystitis are usually so 
obtrusive as scarcely to escape recognition; when, however, the infection 
is more insidious in onset and subacute or chronic, and the infecting 
microorganisms of low virulence, the resulting lesions are of such nature 
and the symptoms so slight, or altogether absent, that they are often 
ill understood, misinterpreted, and referred to other organs. 
The introduction of microorganisms of low virulence into the biliary 
tract may be unattended by pathological lesions; this is the more likely 
if the ducts are patent and the flow of bile unobstructed. Comparatively 
1 Brit. Med. Jour., Lond., 1907, ii, 947. 
2 Verhandl. d. XVIII Cong.f. innere Med., Wiesb., 1900, p. 316. 
3 Semaine med., Par., 1907, xxvii, 25, DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
549 
virulent microorganisms also may be disposed of if the biliary drainage 
is free and unimpeded, but usually serious and even fatal forms of 
disease are thus provoked-suppurative cholangeitis and suppurative 
and gangrenous cholecystitis. Between the extremes of mild and more or 
less innocuous lesions and the severe lesions that lead to quick and early 
disaster lie the great majority of cases of biliary infection. 
The immediate results of moderate or low-grade infection of the biliary 
tract is the production of a catarrh with the usual inflammatory phe- 
nomena-oedema and congestion of the mucous membrane, increased 
production of mucus, and desquamation of epithelium. If the biliary 
circulation is free, the results of this catarrh are washed away for the 
most part, but on account of special local conditions (largely dynamic) 
they are likely to accumulate, to become accentuated, and to persist in 
the gall-bladder; in the event of obstruction to the free flow of bile, 
these are all the more certain to occur. In many cases the lesions thus 
provoked are entirely latent or without noteworthy symptoms; they 
may pursue a short course or continue for years; and they constitute 
the important factor in the etiology of gall-stones. 
The inflammatory disorders of the biliary tract, cholangeitis, chole- 
cystitis, and cholelithiasis, thus represent varying manifestations of 
infection; etiologically, anatomically, and clinically they have much 
in common; and they occur in varying relationships the one to the 
others-singly or combined. It is important to bear in mind that the 
one infectious agent, the typhoid bacillus, for instance, may give rise to 
cholangeitis, cholecystitis, and cholelithiasis concurrently or sequentially; 
that one of these disorders, cholecystitis, for instance, having developed, 
may lead to another (cholelithiasis), and that the secondary condition 
serves to maintain the first; that acute catarrhal cholangeitis may become 
chronic and is usually associated with gallstones, and that the one 
or other of these conditions may lead to suppuration within the biliary 
tract; that it is often difficult clinically to differentiate these disorders; 
and that the diagnosis must often comprise more than one of them. 
The Infectious Agents.-Although considerable interest attaches to 
postmortem studies of the bacteriology of infections of the biliary tract, 
the results are frequently vitiated by more or less obvious factors, and 
they cannot be relied upon implicitly unless the examinations are under- 
taken within a very short time after death. The conditions at operation 
are quite different and the results much more trustworthy-although 
in subsiding or long-standing infections the primary infective agent 
may not be recovered, since it may have died out or have become over- 
grown by secondary invaders. At the German Hospital, Philadelphia, 
Kelly studied the bacterial cause of the infection of the biliary tract in 
240 of the patients operated upon by John B. Deaver: 
Cases. 
Per cent. 
Bacillus coli communis was found in 
68 
28.33 
Bacillus typhosus was found in 
27 
11.25 
Staphylococcus pyogenes aureus was found in 
7 
2.92 
Streptococcus pyogenes was found in 
1 
.42 
Staphylococcus pyogenes albus was found in . 
2 
.83 
Bacillus coli and Staphylococcus aureus were found in 
2 
.83 
Unidentified bacilli were found in 
6 
2.50 
The cultures remained sterile in . .... 
127 
52.92 550 
DISEASES OF THE DIGESTIVE SYSTEM 
In general these results do not differ materially from those obtained 
by other observers. Other bacteria, however, have been isolated from 
the biliary tract, such as the cholera bacillus, Bacillus subtilis, Bacillus 
capsulatus aerogenes, leptothrix, etc. Biliary infections complicating 
pneumonia and influenza suggest the possibility of the pneumococcus 
and the influenza bacillus respectively being the etiological agent. 
Some etiological importance attaches to anaerobic bacteria-which 
abound in the intestine. A most suggestive study of this entire question 
has been published by Lippmann.1 
The Pathways of Infection.-These are: (1) The diverticulum of Vater 
and the common bile duct; (2) the portal circulation; (3) the systemic 
circulation; (4) the lymphatic circulation; and (5) directly through the 
wall of the gall-bladder or the biliary ducts from the peritoneum. 
1. Infection from the duodenum by way of the diverticulum of Vater and 
the common bile duct has long been looked upon as at once the most likely 
and the most common source of biliary infections, but whether with good 
reason remains to be decided. Although the frequency of Bacillus coli 
communis and of Bacillus typhosus in infections of the biliary tract 
suggests an intestinal source, these bacteria find a direct pathway from 
the intestine to the liver by the portal circulation. Furthermore, whereas 
the jejunum and the ileum always contain many bacteria, the duodenum 
when free from food is often bacteria-free; certainly, in health its bacterial 
content is small and it does not contain the bacteria often found in 
cholangeitis, cholecystitis, etc. It is quite conceivable, however, indeed 
it is quite likely, that in conditions of disease of the upper intestine, when 
bacteria are present in the duodenum, the biliary tract may become 
infected by way of the diverticulum of Vater; doubtless many of the 
cases of so-called catarrhal jaundice following gastroduodenitis arise 
in this fashion. But there are at least two important factors opposing 
a ready ascending infection of the biliary tract: the one, the action of 
the sphincter of the diverticulum, which has been estimated by Oggi2 
as exerting a force equal to a pressure within the common bile duct of 
700 mm. of water; the second, the influence of the free flow' of bile. 
Indeed, it is doubtful w-hether infection of the biliary tract ever takes 
place by way of the diverticulum of Vater in the absence of stasis of 
the bile. One of the most important factors in preventing such infection 
is the free flow, that is, the regular periodic expulsion, of the bile-the 
free flow of the bile rather than the bile itself, since the bile is a quite 
favorable medium for the growth of bacteria. 
2. Infection by way of the portal circulation is a common source of 
biliary infection. Definite experimental proof that the bile may become 
infected from the circulation w'as furnished years ago by Blachstein3 
and Welch,4 and their results have been amply confirmed and amplified, 
so that there is no doubt that bacteria transported to the liver by the 
portal circulation may be found in the bile. Under normal circumstances 
bacteria carried to the liver by the portal circulation are there destroyed 
1 Le microbisme biliaire normal el pathologique, Paris, 1904. 
2 Quoted by Naunyn, Mitth. a. d. Grenzgeb. d. Med. u. Chir., Jena, 1905, xiv, 537. 
3 Johns Hopkins Hosp. Bull., 1891, ii, 96. 4 Ibid., 121. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
551 
by the bactericidal properties of the liver cells; but there is a limit 
which when overcome permits the entrance of bacteria into the biliary 
passages. Adami having shown that under apparently normal conditions 
bacteria may be found in the deeper layers of the intestine, in the portal 
circulation, and in the liver, suggests that they invade the portal circu- 
lation through the aid of the leukocytes-which are especially active 
during digestion, carrying foodstuffs, foreign matters, bacteria, etc., 
between the epithelial cells to the lymphatic radicles and the portal 
venules. Ordinarily most of the bacteria are destroyed; sometimes, 
however, they pass through the liver and appear in the bile; in other 
cases they invade the general circulation. This is the latent infection 
of Adami and certain French and German writers. 
3. Infection by way of the systemic circulation is probably not an exceed- 
ingly common source of infection of the biliary tract. Its importance 
has been enhanced since we have ascertained the frequency of bacteremia 
in the great majority of infectious processes. Doerr found that micro- 
organisms injected into the general circulation of rabbits appear in the 
gall-bladder within a few hours, and that typhoid bacilli and colon 
bacilli multiply in the gall-bladder and may be recovered therefrom in 
pure culture even after four months. The occurrence of cholecystitis 
and cholangeitis as a complication of general infections, such as influenza, 
pneumonia, etc., also suggests the likelihood of the infection occurring 
by way of the general circulation; but one must concede the possibility 
of the local biliary infection being due to organisms other than those 
occasioning the primary infection, and that the complicating infection 
may occur by way of the portal circulation or the diverticulum of Vater. 
Infection by the hepatic artery is a descending infection and operates 
as does infection carried by the portal circulation-since both circulations 
commingle at the periphery of the liver lobules; but infected blood carried 
by the cystic artery may, although probably rarely, lead directly to 
infection of the gall-bladder without the intermediation of infected bile. 
4. Infection by way of the lymphatic circulation is probably a most 
infrequent source of infection. 
5. Direct infection through the wall of the gall-bladder or of the ducts 
from the peritoneum has been suggested as a possibility; but excluding 
cases of general peritonitis in which the gall-bladder may participate 
secondarily and in which the mechanism of the local infection may be 
quite obvious, it is doubtful if infection of the biliary tract directly from 
the peritoneum can occur in the absence of adhesions-in which event 
it is probably an infection by way of the lymphatic circulation. 
The pathways of biliary infection vary with the infecting agent. 
Bacillus coli infections, which must be looked upon as the most common, 
doubtless occur most frequently by way of the portal circulation. In 
most cases the liver in full functional activity is enabled to destroy 
or render innocuous such colon bacilli as may pass the barrier of the 
intestinal mucosa and be transported to it; but should the physiological 
activity of the liver become impaired, or should the colon bacilli become 
of heightened virulence, bacilli of attenuated virulence may pass over 
into the biliary circulation and, being excreted with the bile, set up a 552 
DISEASES OF THE DIGESTIVE SYSTEM 
low-grade biliary catarrh. This commonly passes unnoticed but it is 
one of the most important factors in the etiology of gall-stones, as it is 
also the most important factor in the complications of gall-stones. We 
must admit that in the event of gastroduodenitis colon bacilli may 
infect the biliary passages by way of the diverticulum of Vater and the 
common duct; in this event, the lesions are likely to be more abrupt in 
onset and more manifest clinically. 
ACUTE CATARRHAL CHOLANGEITIS (CATARRHAL JAUNDICE) 
Etiology.-Acute catarrhal cholangeitis,more commonly called catarrhal 
jaundice, is a common disorder in young adults, although it occurs at 
all ages; it is more common in men than in women, largely because of 
men being more under the influence of the exciting causes. The disorder 
usually follows in the wake of gastro-intestinal catarrh. Perhaps most 
cases follow some dietetic indiscretion or overindulgence in alcohol. These 
set up gastro-intestinal catarrh, which spreads to the biliary papilla 
and causes swelling of the mucosa and obstruction to the free flow of 
bile. 
Jaundice is an occasional accompaniment of certain infectious diseases, 
such as typhoid fever, pneumonia, etc. In some cases it results from 
spread to the biliary papilla of gastro-intestinal catarrh, that is, the 
jaundice is obstructive. It seems impossible to distinguish clinically 
between all cases of mild jaundice; some are catarrhal, some toxic, 
whereas in others, catarrhal in the beginning, the infection may travel 
up the ducts and involve the finer intrahepatic radicles. Catarrhal 
jaundice may be due also to passive congestion of the duodenum and 
swelling of the mucosa; thus it occurs in portal cirrhosis, in advanced 
stages of cardiac disease, etc.; but the jaundice of portal cirrhosis may 
also be due to radicular cholangeitis, and that occurring in advanced 
heart disease to pressure exerted on the biliary radicles. Catarrhal 
jaundice also may complicate organic diseases of the liver, but the 
jaundice that occurs in syphilis, carcinoma, hydatid cyst, etc., is more 
commonly due to pressure on the ducts from without than to catarrh. 
In some cases of supposed catarrhal jaundice no adequate cause can be 
determined. 
Pathology.-The lesions consist of congestion, swelling, oedema, and 
increased production of mucus at the lower end of the common bile 
duct and of the duodenal mucosa adjacent to the diverticulum of Vater. 
In some cases the swelling itself is sufficient to obstruct the flow of bile, 
but in other cases a plug of inspissated tenacious mucus effectually 
blocks the diverticulum of Vater. The swelling and congestion often 
subside after death, so that their absence at the necropsy is not trust- 
worthy evidence of their absence during life. All the tissues are bile- 
stained; rarely the liver may be swollen; the bilary ducts and perhaps 
the gall-bladder may be distended from the accumulation of bile. 
Opportunities to study the lesions in catarrhal jaundice are rarely 
afforded, since the disease in itself is not fatal. There are many reasons, DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
553 
however, for believing that the cases interpreted as catarrhal jaundice 
are not all of one type. In many cases, doubtless, the lesions are as 
described; in others, perhaps, the lower end of the common bile duct, 
itself not diseased, is obstructed from without by catarrhal changes in the 
surrounding duodenal mucosa; in other cases the swelling and consequent 
obstruction occur perhaps higher up in the common bile duct, or in the 
hepatic duct, or involve the finer intrahepatic branches. It is not unlikely 
that many cases are as that described by Eppinger,1 who studied the 
lesions in a case of catarrhal jaundice in which death occurred from 
accident on the eighth day. The significant lesion was hyperplasia of 
the lymphoid tissue of the mucosa of that part of the common biliary 
duct that runs in the wall of the intestine; this led to complete occlusion 
of the common duct and dilatation of the rest of the biliary system. 
Eppinger suggests that this lymphoid tissue is analogous to that of the 
tonsil, and is provided at the end of the biliary ducts as a means of 
defense against infection from the intestine; that it is subject to attacks 
analogous to tonsillitis; that epidemics of catarrhal jaundice may be 
analogous to epidemics of tonsillitis; and that some attacks of jaundice 
in young persons developing without obvious cause may be due to a 
so-called lymphatic constitution. 
Symptoms.-In most cases the early symptoms are those of the 
provoking gastro-intestinal catarrh: loss of appetite, bad taste in the 
mouth, coated tongue, foul breath, epigastric distress especially after 
eating flatulence, nausea, and perhaps vomiting; there may be constipa- 
tion, or perhaps diarrhoea from extension of the intestinal catarrh; and 
the patient complains of headache, vertigo, mental depression, general 
malaise, etc. Rarely there is an acute onset, jaundice being the first 
symptom noticed; but in most cases after the mentioned symptoms have 
lasted for a few days to a week, the patient notices, or his attention is 
directed to the fact, that he is slightly jaundiced. The jaundice is of 
slow and insidious onset, and gradually increases. It is first and best 
seen in the sclerotic coats of the eyes; soon the integument of the face 
becomes discolored, and then that of the rest of the body and the visible 
mucous membranes. With the appearance of the jaundice, sometimes 
before there is any obvious jaundice, the stools become pale in color 
and soon are devoid of bile pigment; the urine becomes scanty, dark in 
color, deposits an abundant sediment, and shows the presence of bile 
pigments. Usually the bile pigments can be detected in the urine before 
the appearance of the jaundice in the sclerotics. 
When the disorder is fully developed, that is, at the end of four or five 
days, the discoloration of the skin and mucous membranes is usually 
well marked, but even when highly developed the color is distinctly 
yellow, the dark olive-greenish discoloration of malignant disease never 
developing. Pruritus is often marked; sometimes it even precedes the 
development of the jaundice. The itching is sometimes so extreme as 
to induce severe eczema in consequence of uncontrollable scratching. 
The pulse usually is slowed, 60 or less per minute, and may reveal the 
1 Wien. klin. Wchnschr., 1908, xxi, 480. 554 
DISEASES OF THE DIGESTIVE SYSTEM 
dicrotism of low vascular tension; sometimes this is obvious as a well- 
marked capillary pulsation. The patient usually is irritable or melan- 
cholic, often sleepy, and loses flesh and strength. 
In most cases neither the liver nor the gall-bladder is palpably enlarged 
or tender; sometimes, however, the liver can be felt below the costal 
margin. In cases in which the liver or gall-bladder is much enlarged 
one should suspect a complicating cholecystitis or inflammation of the 
intrahepatic ducts. The spleen may be enlarged. Fever (101°) is occa- 
sionally present, but it is rarely due directly to the cholangeitis, except 
in the epidemic infectious cases; that which sometimes occurs at the 
beginning of the attack and lasts a day or two is probably due to the 
gastro-enteritis; when conspicuous or when it lasts more than several 
days, it suggests some one of the types of toxic or infectious jaundice 
(of which, in reality, it may be a mild manifestation). Often late in the 
disorder the temperature is subnormal. 
At the end of about a week, sometimes not until later, the evidences 
of gastro-intestinal irritation subside, the bad taste in the mouth and 
the coated tongue disappear, and the appetite returns; in some cases, 
however, nausea and vomiting persist for ten days or more; and in most 
cases constipation continues as long as the feces are clay-colored. Grad- 
ually the evidences of biliary obstruction lessen, bile pigments appear 
in the feces, and disappear, first from the urine and then from the skin, 
where, however, traces may be found for several months. Restoration 
of the general health is often much delayed; and may not occur until 
the bile pigments begin to be removed from the tissues. Ordinarily 
an attack lasts three or four weeks, but sometimes six weeks or more. 
Diagnosis -In most cases the diagnosis is readily made from the 
youth of the patient, an antecedent gastro-intestinal catarrh provoked 
by some more or less obvious cause, and the absence of local pain and of 
serious involvement of the general health (emaciation, etc.); the diagnosis 
is further confirmed by the benign and favorable course, which in many 
cases definitely determines the diagnosis. Doubt regarding its catarrhal 
nature should always be awakened by the occurrence of jaundice in a 
middle-aged or elderly person, if it becomes deep or olive-tinted, and 
if it lasts more than six weeks. Jaundice in a middle-aged or elderly 
person is much more likely to be due to impaction of a gall-stone, or to 
carcinoma compressing the common duct. In gall-stones there is usually 
a history of past infection of the biliary tract, or of definite attacks of 
cholelithiasis, and the jaundice is commonly preceded by pain; in impac- 
tion of the calculus in the common duct there are usually periodic attacks 
of chills, fever, and sweats, and variation in the degree of the jaundice; 
occasionally, however, in protracted catarrhal jaundice, fluctuations in 
the intensity of the jaundice occur, but these relapsing cases are usually 
referable to repeated dietetic or other indiscretions. Mild grades of 
so-called toxic or infectious jaundice may be mistaken for catarrhal 
jaundice-perhaps often they are only different grades of the same 
process; but in infectious jaundice there is usually an acute onset with 
fever, and signs of general infection are more prominent-enlarged spleen 
and liver, albuminuria, etc. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DVCTS 
555 
Prognosis.-As a rule, the prognosis is good; the disease of itself does 
not endanger life, and recovery is usually complete and lasting. Most 
cases last from three to four weeks, but sometimes longer; cases lasting 
five months and followed by recovery have been reported, but protracted 
as well as relapsing cases of jaundice are usually due to causes other than 
catarrh. So-called abortive cases of slight grade and short duration 
may subside entirely within two weeks or less. In cases that begin with 
much fever the prognosis at the beginning should be guarded, since 
they may be the early stage of, and progress to, serious and fatal forms 
of jaundice. Protracted cases in middle-aged and elderly persons are 
sometimes of serious import-in consequence of impairment of the general 
nutrition and the tendency to hemorrhage. Usually complete recovery 
ensues, but sequels are not unknown; recurrences are not uncommon, 
especially in those who repeat dietetic and other indiscretions. In some 
cases a mild grade of chronic catarrh persists, which, involving the 
gall-bladder and the intrahepatic ducts, may lead to hydrops of the 
gall-bladder, a mild chronic cholecystitis, cholelithiasis, etc., and perhaps 
also to some cases of Hanot's biliary cirrhosis; and from progress of the 
infection, to infection and chronic inflammation of the pancreas. 
Treatment.-The treatment is essentially that of the gastro-intestinal 
catarrh, commonly provocative of the cholangeitis. The patient should 
go to bed; for several days at least the diet should be reduced to a 
minimum, and should consist of a moderate amount of milk, preferably 
skimmed milk, or broth. The common distaste for food is a good indica- 
tion to give no food whatever for a day or two, and to be content to 
relieve the thirst with copious draughts of water, which are usually 
relished and well borne. The natural alkaline waters are especially 
serviceable; but alkalis, especially sodium bicarbonate, may be added 
to ordinary water. Nausea and vomiting, if they persist after with- 
drawal of the food, may be relieved by lavage with hot alkaline water, 
the drinking of hot alkaline water, or the administration of bismuth 
subnitrate or subcarbonate, carbolic acid, etc.; or by warm applications 
to the epigastrium. The bowels should be opened freely. Custom 
sanctions the use of calomel, which may be given in a single large dose 
or in repeated small doses (a blue pill is equally efficacious); it should 
be followed by a saline aperient. These are much more efficacious if 
taken hot (or in hot water), in which event they exert an increased 
beneficial action on the gastro-intestinal catarrh. They should be given 
in sufficient dose to cause one or two free evacuations daily; more are 
undesirable. The diarrhoea sometimes present in the early days of the 
attack rarely demands treatment. Occasionally it may be necessary 
to administer astringents and antifermentatives, but preparations of 
opium should be avoided. 
After the lapse of several days, when the gastro-intestinal catarrh 
begins to subside, the tongue to clear, and the appetite to return, addi- 
tions may be made to the diet, but for some days still, only milk diluted 
with lime-water or Vichy-water, thin or strained soups, milk toast or 
dry toast, fish, etc., should be allowed. Later one may add chicken, 
chops, rice and other carbohydrates, the finer green vegetables, etc.; 556 
DISEASES OF THE DIGESTIVE SYSTEM 
but for some time all highly seasoned food and food likely to undergo 
fermentation must be avoided. The indication of progress toward 
recovery and of permissible liberality in diet is found not in the degree 
of jaundice but in the return of bile pigment to the feces and its diminu- 
tion in the urine. The use of the alkaline aperients should be continued. 
Injections into the rectum of cold water are sometimes very efficacious 
in stimulating intestinal, and perhaps also gall-bladder, peristalsis. As 
the biliary stasis begins to subside, diluted nitrohydrochloric acid and 
bitter tonics render excellent service. Excessive flatulence is sometimes 
distressing; it may be relieved by the use of bismuth salicylate, soda-mint, 
aromatic spirit of ammonia, chloroform water, and antifermentatives. 
The pruritus is best relieved by the measures that tend to relieve the 
biliary catarrh and thus promote the removal of bile pigments from the 
tissues. Temporary relief may also be obtained by the use of cold spong- 
ing, or of a carbolic acid lotion (1 to 40 to 60), or the internal use of the 
bromides or other nerve sedatives. The general health requires attention 
for some time, often months, after an attack of catarrhal cholangeitis. 
SUPPURATIVE CHOLANGEITIS 
Etiology.-Suppurative cholangeitis results from virulent bacterial 
infection of the biliary ducts. The common infectious agents are 
Bacillus coli communis, staphylococci, streptococci, pneumococci, 
Bacillus typhosus, the comma bacillus, Bacillus aerogenes capsulatus, 
etc. Bacillus coli communis is sometimes found alone, but it is not 
improbable that in some of the cases it is a secondary invader, or 
has been present in association with and has outgrown the other or 
primary infectious agents. Bacillus aerogenes capsulatus usually invades 
the tissues only during or just prior to death, but occasionally it is the 
primary agent and may be found during life. 
The infection may occur by way of the portal or the general systemic 
circulation (descending infection), or by way of the duodenum and the 
diverticulum of Vater (ascending infection). Infection sometimes 
occurs in certain general infections, but it is rendered much easier of 
accomplishment by local disease of the biliary tract; indeed, in the 
absence of very virulent infection it is doubtful if infection of the biliary 
tract ever occurs in the absence of local biliary disease, since the free 
flow of bile usually is an effective preventive of biliary infection. Suppu- 
rative cholangitis, however, is occasionally observed in association with 
general infections. The provoking microorganism, aside from the 
typhoid bacillus, is often not that of the primary infection, but the colon 
bacillus or the pyogenic cocci. This cholangeitis rarely occurs without 
concomitant cholecystitis. 
In the great majority of cases suppurative cholangeitis is definitely 
related to local disease of the biliary tract. The local disease acts as the 
necessary predisposing agent; this comprises all disorders that interfere 
with the free and unimpeded circulation of the bile and reduce the re- 
sistance of the biliary ducts. The commonest antecedents of suppurative DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
557 
cholangeitis are gall-stones and tumors obstructing the ducts. Gall- 
stones themselves are a consequence of low-grade biliary infection and 
catarrh, and by the obstruction to the flow of bile that they induce, as 
well as because of the consequent reduction in the resistance of the 
biliary mucosa, they participate in the formation of a vicious circle. 
Suppurative cholangeitis thus may supervene upon long-standing chronic 
catarrhal cholangeitis with or without cholelithiasis, upon acute impaction 
of a gall-stone in the ducts, and upon chronic infective cholangeitis with 
a gall-stone in the common duct (intermittent hepatic fever). Tumors 
of the biliary ducts or of the adjacent tissues that may obstruct the ducts 
also favor the development of suppurative cholangeitis by obstructing 
the flow of bile and causing secondary dilatation and reduction in the 
resistance of the ducts, and, in the event of the growths becoming 
ulcerated, by affording a means of ready access for bacteria. 
Pathology.-Although the process may be more or less limited it is 
usually widespread. The biliary ducts are dilated (in advanced cases 
often enormously dilated) and filled with purulent material, commonly 
stained with bile. The walls of the ducts are much thickened, softened, 
and obviously the seat of purulent infiltration; the mucosa is congested, 
oedematous, and covered with a layer of mucopus, and in fairly well- 
advanced cases irregularly ulcerated. Usually analogous changes are 
found in the gall-bladder. About the terminal branches of the biliary 
ducts there are usually small abscesses; these may be very small and 
very numerous, but in advanced cases some at least have attained con- 
siderable size, in consequence of confluence of several or many small 
abscesses. The liver is enlarged, swollen, softened, and opaque; the 
surface usually is irregular, in consequence of the projection of many 
small abscesses. The cut surface is quite characteristic: more or less, 
sometimes enormously, dilated biliary ducts, filled with pus (multiple 
abscesses), with the intervening liver tissue, the seat of marked peri- 
ductal congestion, parenchymatous degeneration, and necrosis. The 
abscesses on the surface of the liver may extend to the adjacent peri- 
toneum and set up perihepatitis or more widespread peritonitis, and 
perhaps extend to the pleura and the lungs or the adjacent intestine; 
or the process may involve the portal vein, or the hepatic artery; or the 
suppuration may extend along Wirsung's duct and induce suppurative 
pancreatitis and abscess in the lesser omentum. The adjacent lymphatic 
glands, especially those in the portal fissure, are congested, swollen, 
softened and sometimes necrotic. 
Symptoms.-The symptoms are not always distinctive; sometimes 
not even suggestive. Usually there is a history of antecedent cholelithiasis 
or vague symptoms that may be interpreted as due to gall-stones; in 
other cases there is some impairment of the general health, which, in the 
light of subsequent events, may be ascribed to malignant disease; in 
still other cases the patient suffers from, or has recently suffered from, 
some general infection, such as typhoid fever, etc. The onset is often 
insidious; occasionally the first noteworthy symptom is slight jaundice, 
but in perhaps most cases, especially in cases in which there has been 
antecedent jaundice due to other causes, the onset is announced by 558 
DISEASES OF THE DIGESTIVE SYSTEM 
constitutional phenomena, such as chills, fever, and sweats. These are 
usually severe, more or less frequently repeated at irregular intervals, 
and soon lead to considerable impairment of the general nutrition, 
emaciation, loss of appetite, nausea, perhaps vomiting, diarrhoea, etc.; 
variable afebrile periods, however, are not uncommon. Jaundice is 
almost always present, but it is variable in degree; usually it is slight or 
moderate only, except in cases in which the cholangeitis is associated 
with other conditions that cause intense jaundice. Rare cases of 
suppurative cholangeitis without jaundice have been described. 
Sometimes there is no pain in the region of the liver. Usually there 
is at least dull aching or discomfort (tension of the liver capsule); now 
and then there is more severe pain due to acute cholecystitis, chole- 
lithiasis, obstruction of the ducts, perihepatitis, peritonitis, etc. The 
liver is enlarged and usually continues to enlarge. It presents a smooth 
surface, except in the event of an unusually large abscess presenting 
on the palpable surface, and it is tender; perhaps, also, there may be a 
tender spot posteriorly on the right side on a level with and 2 to 3 cm. 
from the twelfth thoracic vertebra (Boas). Usually the gall-bladder is 
enlarged and tender (acute cholecystitis). The spleen also may be 
enlarged. Examination of the blood reveals polynuclear leukocytosis, 
more marked during and just after the febrile periods; sometimes it is 
absent during the afebrile periods. 
Extension of the lesions locally may lead to the ordinary signs of local 
or general peritonitis, pleuritis, etc., with perhaps evacuation of pus 
through a bronchus. Absorption of toxins may induce severe headache, 
joint pains, swelling, and tenderness, and their excretion may be attended 
by albuminuria and casts. Involvement of the hepatic vein may lead to 
multiple abscesses in the lungs, infectious endocarditis, general septico- 
pyemia, etc. Sometimes a single abscess ensues, and may establish 
communication with the intestine or pleura and lung. 
Diagnosis.-This is usually apparent from a history of antecedent 
gall-stones or other disorder of the biliary tract, or of typhoid^fever or 
other infection, and the development of chills, fever, and sweats, and 
jaundice, local pain, progressive enlargement of the liver, perhaps also 
of the gall-bladder and spleen, and leukocytosis. In the absence of a 
history of antecedent disease of the biliary tract, the other symptoms 
mentioned, if at all outspoken, suffice for the diagnosis; but in many 
cases the symptoms are added so insidiously to those of the antecedent 
disease, or they are, in the beginning at least, so mild and evanescent, 
that it is difficult if not impossible to say just when the suppurative 
process began or how severe it is. A slight and temporarily increased 
obstruction to the flow of bile may lead to increased absorption of toxins 
from a chronically infected biliary tract and increase of the general and 
local symptoms; release of the obstruction may permit of the free dis- 
charge of pus from the biliary tract with subsidence of the symptoms. 
Thus in some cases recurrences and remissions of the symptoms 
occur, for instance in the discharge of an impacting gall-stone, drain- 
age may become very free and lead to temporary subsidence of the 
symptoms. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
559 
Difficulty may be experienced in differentiating suppurative pyle- 
phlebitis, other forms of abscess (especially solitary or tropical abscess), 
malaria, etc. Jaundice is not an essential symptom, but it is suggestive 
of and occurs earlier in suppurative cholangeitis than in pylephlebitis or 
single abscess of the liver. Enlargement of the spleen, while it occurs 
in suppurative cholangeitis and pylephlebitis, is more common in pyle- 
phlebitis; but cholangeitis and pylephlebitis may coexist. In abscess 
there is usually a history of antecedent dysentery. Malaria may be 
excluded by the absence of periodicity of the chills, fever, and sweats, 
the absence of plasmodia from the blood, and the presence of leukocytosis. 
Prognosis.-This is decidedly unfavorable, but it is modified by a 
number of attending phenomena and the treatment. In view of the 
difficulty of determining accurately the time of onset, it is difficult to 
say how long it lasts; but the acute cases which pursue a progressive 
course seldom continue more than three weeks. In less severe cases, 
in which the infection is less virulent and becomes subacute or chronic, 
or in which the lesions gradually subside and perhaps become localized 
to the gall-bladder, or in which a fistulous communication is established 
with the hollow abdominal viscera or the thoracic viscera, and the pus 
is discharged, etc., the duration may be much longer and recovery may 
ensue. The prognosis is materially improved by the spontaneous or 
operative removal of the source of obstruction (gall-stones, etc.) and 
the consequent free drainage. 
Treatment.-Prevention is much more readily effected than cure. 
Even minor grades of biliary infection, such as the acute and more 
chronic catarrhal cholangeitis (jaundice), gall-stones, etc., should be 
carefully and persistently treated. This, especially in the event of 
gall-stones, comprises surgical intervention-which not only is curative 
of the gall-stones and the accompanying catarrh, but preventive of the 
more serious suppurative cholangeitis. When suppurative cholangeitis 
has developed, the treatment is essentially surgical, and consists in the 
establishment of free drainage. Medical treatment may be used in 
conjunction with surgical, and consists in the use of salicylates, hexa- 
methylenamine, and other remedies to disinfect the biliary tract and 
promote the free flow of bile. Otherwise, medical treatment is purely 
palliative and analogous to that laid down for acute catarrhal jaundice. 
CHRONIC CATARRHAL CHOLANGEITIS 
Etiology.-Chronic catarrhal cholangeitis may involve only the larger, 
especially the extrahepatic, ducts, or more or less of the entire biliary 
tract, or it may be confined to the finer intrahepatic ducts (radicular 
cholangeitis or angiocholitis). Usually the lesions are widespread, involv- 
ing the larger extrahepatic ducts, more or less of the larger intrahepatic 
ducts, and the gall-bladder. This form of the disease is due to the 
factors that provoke acute catarrhal cholangeitis, and may result from 
repeated attacks of acute catarrhal cholangeitis or from chronic low-grade 
infections. It is most commonly found in association with gall-stones, 560 
DISEASES OF THE DIGESTIVE SYSTEM 
with which its etiology and pathogenesis are so intimately associated 
that it will be discussed therewith; but chronic non-calculous cholangeitis 
also occurs, being found in association with chronic gastroduodenal 
catarrh, after certain infections, in association with chronic obstruction, 
and in association with certain chronic disorders of the liver, such as 
hydatid cysts, chronic abscesses, etc. Chronic catarrhal radicular 
cholangeitis or angiocholitis is rarely an independent affection. 
Pathology.-The lesions consist of congestion and swelling of the 
mucosa, increased production of mucus, round-cell infiltration, and 
proliferation of the submucosa and muscularis, with the production of 
new fibrous connective tissue; these lead to thickening and induration 
of the walls of the ducts and to pericholangeitis. There may be partial 
or complete obstruction of the ducts. In the event of complete obstruc- 
tion, the ducts become enormously dilated (up to the size of a thumb 
or larger); the gall-bladder and some of the intrahepatic ducts also 
become dilated. The biliary tract usually contains a clear, almost 
colorless, often sterile mucus; when the mucus is sterile, the mucosa 
of the biliary tract is usually quite smooth. In the event of incomplete 
obstruction the ducts and especially the gall-bladder are less dilated, 
the contents are usually turbid and often contain bacteria, and the 
mucosa may be more or less ulcerated. 
Symptoms.-The symptoms are those of chronic relapsing jaundice. 
Rarely this may represent a direct continuation of an acute catarrhal 
jaundice, being more insidious in onset, and subject to exacerbations 
and remissions. The attending phenomena are those of acute catarrhal 
cholangeitis-prolonged. In the cases of complete obstruction, the 
contents of the biliary tract being sterile, there is usually no fever, and 
remissions in the jaundice are slight. In the cases of incomplete obstruc- 
tion, remissions in the jaundice are more marked, and the contents of 
the biliary tract being infected, attacks of chill, fever, and sweats are 
common. These attacks by no means warrant a diagnosis of suppuration 
of the biliary tract, although they are evidences of infection. This 
chronic catarrhal cholangeitis may lead to suppurative cholangeitis (of 
which it is often only a minor manifestation), acute infectious jaundice, 
acute yellow atrophy of the liver, etc. 
Diagnosis.-In cases of persisting jaundice that begin seemingly as 
acute catarrhal cholangeitis, one must attempt to eliminate cholelithiasis 
and malignant disease obstructing the ducts. Often it is quite impossible 
to differentiate non-calculous from calculous cholangeitis with a gall-stone 
in the common duct. A history of antecedent gall-stone colic is suggestive 
but by no means conclusive. Hypertrophic biliary cirrhosis may be 
eliminated by the absence of marked enlargement of the liver and spleen. 
Prognosis.-This is dependent upon the associated lesions. 
Treatment.-The treatment is essentially that of acute catarrhal 
cholangeitis. In protracted cases operation should be undertaken with 
a view to drain the biliary ducts; this is the more demanded in view 
of the impossibility of excluding obstruction due to a gall-stone. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
561 
ACUTE CHOLECYSTITIS 
Etiology.-It is largely artifice that leads to a distinction between 
cholangeitis and cholecystitis; the one like the other is an expression of 
infection of the biliary tract. In some cases the infection may remain 
confined to the ducts or the gall-bladder. In other cases, developing 
in the one or the other, the process may extend to that not primarily 
involved; and it may persist in the gall-bladder and subside in the 
ducts, or vice versa. A separate discussion of the two conditions seems 
warranted, however, because cholecystitis is characterized by certain 
definite features that develop largely because the gall-bladder is a closed 
sac with a small and readily obstructed exit, and because a common 
sequence of cholecystitis is cholelithiasis, which serves to keep active 
or readily induces cholecystitis. 
Like cholangeitis, cholecystitis results from bacterial infection, which 
is facilitated by any cause that reduces the resisting power of the gall- 
bladder or interferes with the free flow of bile. Mixed infections are not 
uncommon; and in some cases one organism having set up the lesions 
may die out spontaneously or be overgrown by another, whence in some 
cases the gall-bladder contents are sterile or the primary infectious agent 
eludes detection. The infectious agents reach the gall-bladder usually 
by way of the portal circulation or the general systemic circulation, 
although, of course, they may reach it by way of the diverticulum of 
Vater and the common bile duct. When cholecystitis or cholangeitis 
complicates typhoid fever, pyococcic infections, etc., a natural inference 
is that the microbrganismal cause of the general or primary infection 
is the cause of the local complication in the biliary tract-an inference 
usually but not always borne out by the fact. A biliary infection com- 
plicating or occurring sequentially to pneumonia, influenza, etc., may 
be due not to the specific cause of the general infection, but to pyogenic 
cocci or the colon bacillus, the original infectious agent or its toxin 
perhaps having prepared the way for the secondary invader. Certain 
zooparasites also (especially round-worms, bilharzia) may invade the 
biliary tract, and reaching the gall-bladder may set up cholecystitis and 
subsequently cholelithiasis; in some cases, however, the zooparasites act 
only as the carrier of other infectious agents. 
Typhoid Infections.-Major importance and interest attaches to typhoid 
infections of the biliary tract.1 It is now definitely known: (1) That 
the typhoid bacillus is regularly present in the gall-bladder, and commonly 
in pure culture, in practically all cases of typhoid fever; (2) that the 
typhoid bacillus may persist in the gall-bladder, as well as within gall- 
stones, years after the patient has recovered from an attack of typhoid 
fever; (3) that cholangeitis and cholecystitis are by no means infrequent 
complications of typhoid fever; and (4) that a history of antecedent 
typhoid fever may be obtained in many patients with cholecystitis and 
cholelithiasis. The manifestations are various: 
1 Consult Infections of the Biliary Tract, by A. O. J. Kelly, Am. Jour. Med. Sc., 
1906, cxxxii, 446, 744. 
vol. hi-36 562 
DISEASES OF THE DIGESTIVE SYSTEM 
1. Acute cholecystitis occurring during the course of or after typhoid 
fever does not vary materially from acute cholecystitis due to other 
bacterial causes, although less likely to become suppurative. 
2. The development of gall-stones. 
3. Primary typhoid cholecystitis, often associated with cholangeitis; 
that is, an infection of the biliary tract with Bacillus typhosus without 
other evidence of past or present typhoid infection. The resemblance 
that many cases of infectious jaundice, Weil's disease, etc., bear to 
typhoid fever has been frequently commented upon, and it has, in fact, 
been suggested that Weil's disease is a modified form of typhoid fever. 
Possibly in many cases it is only typhoid (or paratyphoid) infection 
of the biliary tract. 
4. Chronic Carriers.-In many cases the typhoid bacillus may be 
recovered from the gall-bladder years after an attack of typhoid fever. 
Although bacterial infection is the essential factor in provoking acute 
cholecystitis, other factors are of contributing or predisposing importance; 
these are such as (1) reduce the vitality and resisting power of the gall- 
bladder and biliary ducts, and (2) interfere with the free flow of bile. 
Among the first mentioned are: trauma, such as blows and other injuries 
in the region of the gall-bladder, which rarely may reduce the resistance 
of the gall-bladder, and render it vulnerable to bacteria already present 
or that may be brought thither; a previous attack of cholecystitis and 
gall-stones, which favor infection; local diseases of the intestinal tract 
which may act as the source of the bacteria; and general disorders, such 
as Bright's disease, in which complicating or terminal infections are 
common. Among the conditions that act as predisposing causes by 
interfering with the free and unimpeded flow of bile are gall-stones, 
usually associated with chronic cholangeitis, tumors or foreign bodies 
(worms, etc.) within the ducts, tumors without the ducts, kinks or 
cicatrices compressing the ducts, etc. 
Pathology.-Various types of acute cholecystitis may be differentiated 
-catarrhal, suppurative, phlegmonous, gangrenous, and membranous. 
Properly interpreted these are varying manifestations of the one process 
(an infection) which result from variations in the virulence of the infecting 
agent, in the local and general resistance and in the freedom of the 
circulation of the bile; they differ in degree rather than in nature, and 
pass sometimes almost imperceptibly the one into the others. In the 
mild grade of inflammation, so-called acute catarrhal cholecystitis, the 
gall-bladder is distended and tense; the wall is swollen, oedema tons, 
and softened, and the mucosa is congested and covered with a layer 
of mucus. In many cases the inflammatory phenomena invade also the 
peritoneal covering, which then is covered with a thin layer of fibrin 
which may unite the gall-bladder to adjacent structures. The cystic 
duct usually is partially obstructed from swelling of the mucosa; some- 
times it is completely obstructed, but usually only in the event of recur- 
rent attacks of inflammation or of cicatrization of ulcerations. The 
contents of the gall-bladder usually consist of turbid bile; usually this 
is in excess and much thickened, inspissated, and tar-like; sometimes 
the contents consist of turbid, bile-stained, serous, or serofibrinous fluid; DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
563 
rarely it may be stained with blood, in which event there is likely to 
be some erosion or superficial ulceration of the mucosa. Gall-stones 
may be encountered, especially in recurrent attacks; usually not in 
cases of less than four to six months' duration. 
In the more severe, or suppurative cholecystitis, or acute empyema, 
the gall-bladder varies in size depending upon antecedent conditions. 
Should it have been previously normal or only slightly diseased and 
non-adherent, it may become considerably, sometimes very much, 
enlarged; but if previously the seat of cicatrization from chronic inflam- 
mation, no enlargement may occur; in this case it is usually united to 
adjacent tissues and organs by adhesions. The wall of the gall-bladder 
is softened, swollen, cedematous, congested, and usually very dark 
reddish, greenish, or blackish in color. The mucosa is congested and 
desquamated, and covered with a fibrinopurulent, sometimes also 
hemorrhagic, exudation. In many cases there is more or less ulceration, 
especially toward the fundus, in consequence of the relatively poorer 
vascular supply of the fundus and the gravitation of gall-stones. The 
ulceration may proceed through the wall and lead to perforation. 
The cystic duct is usually occluded even in the absence of gall-stones. 
The contents consist of turbid, bile-stained, fibrinopurulent, sometimes 
sanguinolent fluid; gall-stones are present in about 80 per cent. 
In some cases the phenomena are less acute; the congestion and 
softening of the wall are less marked or entirely absent, the wall then 
being thickened and indurated; there is little if any pericholecystitic 
fibrinous exudation, although the gall-bladder may be firmly united to 
adjacent organs; the mucosa of the gall-bladder is more or less ulcerated 
and the contents are more or less purulent-cases of so-called chronic 
empyema of the gall-bladder or chronic ulcerative cholecystitis. On the other 
hand rarely the lesions may be more acute than in the more common 
cases of acute suppurative cholecystitis; the cedematous, hemorrhagic, 
and purulent infiltration of the gall-bladder is widespread, and may 
lead to extensive dissection of the different coats, the separation, for 
instance, of the mucosa from the underlying coats, or extensive sloughing 
with or without perforation-so-called phlegmonous cholecystitis. A 
further or more advanced and rare stage is spoken of as gangrenous 
cholecystitis, a term very inconsiderately employed. The small foci of 
necrosis that occur in suppurative cholecystitis, for instance, are some- 
times spoken of as localized gangrene-ulcerative cholecystitis being a 
more preferable term. When, however, a large section of the gall- 
bladder becomes necrotic the term gangrenous cholecystitis is not 
inaptly applied. This results from very virulent infection, or interference 
with the blood-supply due to a gall-stone impacted in the neck of the 
gall-bladder or in the cystic duct, or to infectious thrombosis of the 
nutrient artery. The lesions resemble those of advanced suppurative 
or phlegmonous cholecystitis, with the addition of complete necrosis 
or gangrene of a variable portion of the gall-bladder; the gangrene usually 
begins at or near the fundus (where the blood-supply is poorest) and 
spreads toward the neck; in some cases it begins about a gall-stone more 
or less firmly embedded in the wall of the gall-bladder. Membranous, 564 
DISEASES OF THE DIGESTIVE SYSTEM 
cholecystitis is a rare condition characterized by the formation of a 
membranous or fibrinous coat of the interior of the gall-bladder, and 
perhaps of the biliary ducts. It is usually associated with gall-stones, 
and with mucous enteritis or colitis. 
Symptoms.-Acute cholecystitis is extremely variable in its symptoma- 
tology. In many cases it is altogether latent; in other cases, although 
it occasions obvious symptoms, the true nature of these is often masked, 
and they escape correct interpretation, being commonly regarded as 
evidences of disordered stomach. Thus, for instance, during typhoid 
fever, but also in other circumstances, there are: (1) Cases in which a 
noteworthy enlargement of the gall-bladder occurs; but the biliary ducts 
being patent, the drainage sufficient, and the patient's sensibilities 
somewhat obtunded, there is no complaint and the disorder escapes 
recognition, unless systematic examinations of the gall-bladder region 
are undertaken; in this event a more or less enlarged and tender gall- 
bladder may be encountered. It is surprising how frequently this 
condition occurs and how frequently it goes undetected. (2) There 
are cases in which a little epigastric discomfort, perhaps slight nausea, 
in some cases actual pain, is complained of, and examination reveals 
an enlarged and tender gall-bladder. (3) Cases in which, announced 
by the ordinary symptoms, acute cholecystitis or cholangeitis develops. 
Initial nausea and vomiting, fever, pain, and tenderness in the region 
of the gall-bladder, rigidity of the overlying abdominal muscles, and 
an enlarged and tender gall-bladder constitute the important clinical 
manifestations of acute cholecystitis. These may be of sudden or rather 
insidious onset. The nausea and vomiting are usually moderate and 
soon subside, except in the event of pericholecystitic or more general 
peritonitis and concomitant paresis of the intestine. In catarrhal 
cholecystitis the fever is slight and lasts only a short time; in the cases 
complicating some general infection there may be little if any added 
fever, but if occurring, for instance, during convalescence from typhoid 
fever, the onset of the cholecystitis is usually announced by fever, which 
may be high. The pain usually occurs first in the epigastrium, sometimes 
directly in the midline, and later becomes more localized to the right 
hypochondrium; it varies much in character. In some cases it is dull 
and aching; in other cases it is sharper and more severe, and while con- 
tinuous is subject to acute exacerbations; in perhaps the majority it 
is severe and paroxysmal and resembles or is identical with the pain of 
so-called gall-stone colic. The complaint of pain is much influenced by 
the mental state of the patient: in acute infections attended by mental 
torpor due to toxemia there may be little or no complaint of pain, but 
there may be considerable local tenderness. The pain may be referred 
to the region of the right scapula, as in gall-stone colic, or to the right* 
shoulder when the peritoneum is involved, or downward to the right 
lower abdominal quadrant, and suggest appendicitis; as a matter of 
fact, the two conditions cholecystitis and appendicitis may be con- 
current. 
There is more or less tenderness in the right upper abdominal quadrant. 
At first this may be diffuse, but usually it soon becomes localized to the DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
565 
region of the gall-bladder. The overlying muscles are rigid, and in 
consequence sometimes simulate a tumor of the gall-bladder. In most 
cases, however, by careful palpation one can feel an enlarged and tender 
gall-bladder; in many cases it is also visible. The degree of enlargement 
varies considerably in recent cases in which the gall-bladder is non- 
adherent and there is little pericholecystic exudation. The tumor, 
corresponding with the enlargement of the gall-bladder, is pear-shaped, 
tense or semifluctuating, moves with respiration, and is displaceable 
by palpation, although both of these may be inhibited by the attendant 
pain; in older or recurrent cases, in cases in which there are old adhesions, 
and in cases in which there is considerable pericholecystitic serofibrinous 
and other exudation, and perhaps also involvement of adjacent tissues 
(with intestinal paralysis, tympanites, abscess formation, etc.), the 
tumor mass is likely to be more globular or irregular, or ill-defined, and 
it may not move at all on respiration or be displaceable on palpation. 
Usually the mass is in the region of the gall-bladder, and as it increases 
in size it advances toward the umbilicus; but in a considerable number 
of cases it descends in the flank; sometimes it is found so low as to suggest 
periappendicular suppuration. With the progress of the disease the 
tumor often can be observed gradually to increase in size. As the inflam- 
matory phenomena subside and the cystic duct again becomes patulous, 
the tumor decreases in size and may ultimately disappear. Some local 
tenderness especially on deep palpation, however, usually remains for 
some days or weeks. Bahrdt1 has called attention to certain cases 
masquerading as bronchitis, in which the only symptoms point to the 
lungs and bronchi. Slight dulness with rales accompanied by fever and 
later slight jaundice characterize the attacks which may be numerous. 
Jaundice is not a part of uncomplicated cholecystitis; its development 
signifies extension of the inflammation of the ducts (cholangeitis), spasm 
of ducts, or some complication such as gall-stones obstructing or com- 
pressing the hepatic or the common duct. The liver is not enlarged 
unless there is cholangeitis. The pulse may be normal or slightly accele- 
rated. Usually there is a moderate leukocytosis (12,000 to 15,000). 
The consequences of acute cholecystitis are many and various, and of 
much clinical importance. In the majority of cases, especially in those 
occurring during general infections, such as typhoid fever, the clinical 
manifestations subside at the end of four or five to ten or fourteen days; 
perhaps in some of these cases the lesions also subside and the gall- 
bladder returns to its previously normal condition. In the great majority 
of cases the lesions become chronic, the infection becomes latent for a 
time and of minor grade: the usual consequence of this is gall-stone 
formation; but chronic cholecystitis may ensue without gall-stone forma- 
tion. In many cases after the formation of the gall-stones the infection 
gradually dies out, and the gall-stones may remain latent, perhaps 
throughout life, although the gall-bladder in such circumstances is 
disposed to ready reinfection. Sometimes, especially if the infection 
was slight in grade and soon died out, and if a gall-stone obstructed the 
1 Munch, med. Wchenschr., 1912, lix, 2326. 566 
DISEASES OF THE DIGESTIVE SYSTEM 
cystic duct or the exit of the inflammatory exudation was otherwise 
prevented, the contents of the gall-bladder soon take on a serous or 
mucous character, and a condition of cystic distension or hydrops of 
the gall-bladder results. In other cases the gall-bladder remains con- 
tinuously infected; in other cases the patient may suffer from minor 
phenomena due to chronic cholecystitis (with or without gall-stones), 
and in addition become subject to repeated recurring attacks of acute 
cholecystitis (reinfections or exacerbations of a chronic infection); in 
either case the lesions are likely to become suppurative or ulcerative- 
so-called chronic empyema of the gall-bladder. Again, although the 
lesions of the gall-bladder subside, adhesions have developed between 
the gall-bladder and adjacent organs, which often engender serious 
consequences. In some cases of acute cholecystitis the lesions do not 
subside; they progress to the more serious forms of the disease-suppura- 
tive, phlegmonous, or gangrenous cholecystitis; but suppurative phleg- 
monous and gangrenous cholecystitis may also develop suddenly, as a 
primary manifestation of an infection; in about 80 per cent, of the cases, 
however, they occur in connection with gall-stones, therefore in chronic 
infections or reinfections. The clinical manifestations consist of an 
aggravation of the symptoms of acute cholecystitis. The evidences of 
local inflammation, peritonitis, are more severe; in some cases persistent 
nausea, vomiting, widespread abdominal pain and tenderness, tympan- 
ites, constipation, etc., suggest infection of the general peritoneal cavity. 
Occasionally the manifestations are those of acute rapidly developing 
general peritonitis without localizing symptoms. The gall-bladder, as 
a rule, is palpable-near the tip of the ninth costal cartilage in case it is 
incapable of little if any distension, or near the umbilicus, in the flank, 
or in the right inguinal region in case it has become much distended. 
In many cases it is quite low, being associated with cholelithiasis and 
linguiform lobulation (Riedel's lobe), and may simulate appendicitis. 
Jaundice is not a necessary symptom, but it occurs more frequently 
in the severer than in the milder form of acute cholecystitis, because of 
the associated lesions, such as gall-stones and tumors obstructing the 
ducts, and the more common occurrence of eholangeitis. The temperature 
is usually high (103° to 104°), and commonly accompanied by chills 
and sweats; but in some cases of severe infection, with minor resistance 
on the part of the patient, the temperature may be lower. The pulse 
is accelerated, 120 or more-which is a better indication of the seriousness 
of the patient's condition than the temperature. Usually there is a 
polynuclear leukocytosis of from 15,000 to 35,000 or more. 
Perforation of the gall-bladder may occur: into preformed adhesions, 
and lead to the development of a localized abscess, which, if the adhesions 
involve the abdominal wall, may become manifest by local oedema and 
other signs of inflammation; into the liver, and lead to a liver abscess; 
into the general peritoneum, and lead to widespread purulent peritonitis; 
into the hollow abdominal viscera, and lead to fistula?, etc. Sometimes 
the onset of the perforation is announced by sudden increase of the local 
pain, more or less collapse, increased pulse rate, and progression of the 
local abdominal and the general symptoms; but, as in appendicitis, the DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
567 
symptoms often only steadily increase, and no time can be set as that 
of the occurrence of perforation. 
Diagnosis.--The diagnosis of acute cholecystitis presents no serious 
difficulties in the great majority of cases: nausea and vomiting, pain 
and tenderness in the region of the gall-bladder, rigidity of the overlying 
abdominal muscles, and an enlarged and tender gall-bladder constitute 
a complex of symptoms that can scarcely be attributed to anything else. 
In some cases the symptoms are not obtrusive, and the enlarged and 
tender gall-bladder must be sought, but even these cases present no 
diagnostic difficulties. The phenomena of gall-stone colic also are prop- 
erly attributable to an acute (perhaps acute exacerbation of a chronic)* 
cholecystitis, and the local pain and tenderness and rigidity of the over- 
lying muscles, if sought, will usually be found. ^The more serious forms/ 
of cholecystitis are to be distinguished from me milder or catarrhal 
form, usually by their more abrupt onset, or abrupt increase in severity, 
and by the more marked local and general symptoms, that is, more 
evident and perhaps widespread peritonitis and more serious toxemia, 
and by the fact that iojuost cases there is a history of antecedent chole- 
cystitis or cholelithiasisAThe onset of perforation or gangrene can rarely 
be diagnosed with certainty, except perhaps by a sudden increase in 
abdominal pain, with collapse, increased pulse rate, and spreading 
peritonitis; it should be suspected in the event of sudden fulminating 
peritonitis occurring in a chronic cholecystitic or cholelithitic subject, 
especially if the lesions began in or remain limited to the upper abdomen. 
In this event one must exclude other causes of peritonitis, in which a 
study of the patient's past history is of the utmost importance. 
Difficulty may be experienced in differentiating acute appendicitis, 
particularly in those cases in which the enlarged gall-bladder is unusually 
low and perhaps projects into or is situated in the right iliac fossa; but 
cholecystitis is suggested by previous attacks of so-called dyspepsia or 
of more obtrusive symptoms of cholelithiasis or cholecystitis, especially 
if associated with jaundice, by relationship of the attacks to dietetic 
indiscretions, by limitation of the pain to the epigastrium or the right 
hypochondrium and radiation to the right shoulder (the pain is rarely 
as diffuse as is often the case in early appendicitis), by the presence of 
a zone of cutaneous hyperalgesia (Head) about the upper right half 
of the abdomen, by the fact that the mass (enlarged gall-bladder) often 
moves with the liver during the phases of respiration, etc. 
Prognosis.-In the majority of cases the prognosis in acute 
cholecystitis is good, the process tending to subside, under appropriate 
treatment, within ten days or a fortnight; the mildest cases may subside 
within four or five days or a week; the inflammatory and retained secre- 
tions are discharged through the cystic duct and the gall-bladder reverts 
to its normal size. Sequels, especially gall-stones and adhesions, however, 
are almost certain to occur, so that the subsequent outlook is not the 
best; in other cases a low-grade infection may persist and the patient 
become a subject of chronic infection and recurring attacks of chole- 
cystitis. In the more severe forms, suppurative, phlegmonous, and 
gangrenous cholecystitis, the tendency toward spontaneous cure is slight. 568 
DISEASES OF THE DIGESTIVE SYSTEM 
In this event the prognosis is grave, since not only are the lesions serious 
in themselves but a localized excess or general peritonitis may ensue 
and a fatal issue result, unless recourse is had to surgical intervention. 
Occasionally in these serious cases the obstruction of the cystic duct 
may be due only to swelling of the mucosa; in this event it may lessen, 
and part, at least, of the contents of the gall-bladder may be discharged; 
but if the acute inflammatory lesions subside, chronic empyema is likely 
to ensue. In some cases the infection is so virulent that extensive 
phlegmonous inflammation or gangrene develops before limiting adhe- 
sions can form. The prognosis in these cases is extremely grave, death 
usually resulting unless the patient is operated upon. 
Treatment.-This in general is that recommended for gall-stone colic, 
which virtually is an attack of more or less acute cholecystitis. The 
diet should be reduced to a minimum; perhaps withheld altogether for 
a day or two, if the patient's general condition permits. Until the acute 
phenomena subside the diet should be bland and easily digested: milk 
and Vichy or lime-water, broth, cereals, etc. The bowels should be 
opened by enemas of hot water for the first day or two, whereupon 
Carlsbad salts or sodium phosphate or similar salts in hot water should 
be given, yt is wise to withhold morphine, which, unless required 
to mitigate acute suffering, tends to mask symptoms, to promote a 
false security, and is otherwise objectionable.! Relief from pain usually 
follows hot fomentations to the region of the bladder, lavage of the 
stomach with hot alkaline water, a full hot bath, etc.; if not, a small 
dose of morphine (TV to grain) may be tried; a very small dose is 
often extremely efficacious. Nausea and vomiting depend upon the 
same factors as the pain, and they usually subside with the pain. Follow- 
ing subsidence of the acute phenomena the treatment recommended 
for cholelithiasis should be instituted. 
Happily most cases of acute cholecystitis gradually subside; occa- 
sionally the local symptoms increase, evidences of more or less extensive 
peritoneal irritation or actual peritonitis supervene, the temperature, 
leukocytosis, and other manifestations of infection increase; the local 
lesions have progressed to suppuration, necrosis, or gangrene. In this 
event the necessity of operative intervention must be considered. 
CHRONIC CHOLECYSTITIS 
Etiology.-Chronic cholecystitis may be the residual manifestation 
of an acute cholecystitis, or the process may be chronic from the begin- 
ning. Its etiology is that of acute cholecystitis, the chronicity of the 
process being a manifestation of lingering infection, or the consequence 
of very low-grade infection with almost but not quite sufficient biliary 
drainage. In the great majority of cases the condition is associated with 
gall-stones, the one process sustaining the other; that is, most cases are 
calculous cholecystitis; in a few cases the lesions extend throughout the 
biliary tract; that is, cholangeitis and cholecystitis are associated. 
Pathology.-The process may or may not be associated with gall-stones. 
In absence of gall-stones the lesions may be catarrhal, that is virtually DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
569 
confined to the mucosa, which shows more or less congestion, swelling, 
desquamation, and increased formation of mucus; the gall-bladder 
usually is distended and filled with thick tenacious bile or bile and 
mucus. In some cases the mucosa is thinned and atrophic, especially 
in spots, evidently the consequence of past erosion or ulceration. In 
many cases of long standing the gall-bladder becomes reduced in size, 
very small, and sclerotic; it may be represented by a mass of thickened 
contracted connective tissue, perhaps tightly enclosing one or more 
gall-stones, but sometimes not. When thus small and shrivelled, the 
gall-bladder, whether containing gall-stones or not, often makes up 
part of a mass of firm adhesions that bind together the adjacent tissues; 
in many cases the gall-bladder can scarcely be identified as such. The 
cystic duct is often, perhaps usually, patulous, but it may be partially 
or completely obstructed. In some cases the tissue adjacent to the 
gallstones, or, in their absence, that lining the still-persisting lumen, 
is made up largely of cicatrizing granulation tissue, and may reveal no 
vestige of mucosa; in other cases the lining epithelium has invaded the 
deeper layers of the walls and is clearly hyperplastic and irregularly 
proliferated (beginning carcinoma). The musculature is usually atrophic, 
and replaced by fibrous connective tissue. 
Symptoms.-These are of cholelithiasis-which is the important 
concomitant of chronic cholecystitis. A clinical differentiation between 
cholecystitis with and without cholelithiasis may be attempted, but 
those with most experience find it increasingly difficult to determine 
whether or not gall-stones are present in individual cases. 
Diagnosis.-It is practically impossible in most cases to say definitely 
whether or not gall-stones are present. The likelihood of their being 
present is enhanced by repeated attacks of severe colic followed by 
jaundice, but colicky pains are present in many cases (70.6 per cent.) 
without gall-stones, and jaundice may occur in 35.3 per cent, of cases 
without gall-stones. The detection of faceted gall-stones in the stools 
suggests the presence of others in the gall-bladder. The absence of 
gall-stones in a case of chronic cholecystitis can scarcely be postulated 
with the knowledge at hand. 
The prognosis and treatment are the same as in cholelithiasis. 
CHOLELITHIASIS1 
Etiology.-Cholelithiasis is an exceedingly common condition, being 
found at autopsy in from 5 to 10 per cent, of subjects dead from all 
1 The literature of cholelithiasis is extensive. The more important monographs 
comprise: Naunyn, A Treatise on Cholelithiasis, 1896; Kehr, Gall-stone Disease, 1901; 
Mayo Robson, Diseases of the Gall-bladder and Bile Ducts, third edition, 1904; Moyni- 
han, Gall-stones and their Surgical Treatment, second edition, 1905; Bland-Sutton, 
Gall-stones and Diseases of the Bile Ducts, 1907; Aschoff and Bacmeister, Cholelithiasis, 
1909. Virtual monographs are contained also in Nothnagel's Encyclopedia of Prac- 
tical Medicine, article by Hoppe-Seyler, and in Rolleston's Diseases of the Liver, Gall- 
bladder, and Bile Ducts (literature). Valuable articles by Ewald, Musser, Brewer, 
Herter, Mayo, and Kehr are contained in the Tr. Cong. Am. Phys, and Surg., 1903, vi. 
The results of considerable personal experience will be found in the following articles: 
Deaver, Am. Jour. Med. Sc., 1908, cxxxv, 137, cxxxvi, 625; Mayo, Ann. Surg., 1906, 
xliv, 209; Richardson, Boston Med. and Surg. Jour., 1906, civ, 329; 1907, clvi, 687; and 
Kehr, 2me Cong, de la Soc. internal, de Chir., Brussels, September 21-25, 1908. 
Moynihan, Brit. Med. Jour., 1908, ii, 1598; 1913, i, 8. 570 
DISEASES OF THE DIGESTIVE SYSTEM 
causes. It is specially prevalent in the temperate zones, being quite 
uncommon in the tropics. It occurs at all ages, but the incidence increases 
progressively with advancing years: 75 per cent, or more of the cases 
are found in persons over forty years of age, and less than 1 per cent, 
in those under twenty years; but this age incidence does not correctly 
represent the time of the formation of gall-stones, since in many cases, 
having formed, they remain latent for years and are found only when 
the subject dies at a more advanced age. Doubtless many if not most 
gall-stones are formed in early adult life, before the fortieth year, corre- 
sponding with the period of greatest frequency of typhoid and other 
infections, etc. Rarely the disorder is encountered in infancy or child- 
hood. The majority of cases in infancy are doubtless due to intra-uterine 
infection, the process perhaps being analogous to that which in other 
circumstances induces congenital obliteration of the bile ducts; the 
cases found in older children also may have originated during fetal life 
and remained latent for a number of years, but it is not always possible 
to exclude postnatal typhoid and other infections. Gall-stones are more 
common in women than in men, the ratio being variously stated as 5 
to 1 (Schroeder) to 4 to 3 (Rolleston). 
The one necessary factor is a low-grade catarrhal inflammation of the 
biliary tract; the second requisite seems to be some obstruction to the 
free flow of bile. The one without the other factor is not sufficient; 
whether a third factor is of significance remains to be determined. The 
catarrhal inflammation of the biliary tract is set up especially by typhoid 
and colon bacilli; but also apparently by attenuated streptococci, 
staphylococci, and other microorganisms that may cause acute chole- 
cystitis; perhaps also by anaerobic bacteria. It is essential that the 
antecedent catarrh be mild in grade, sihce in severe infections the mucosa 
of the gall-bladder is likely to be more or less destroyed and its choles- 
terin-producing function abolished. The infective agents usually reach 
the gall-bladder by the portal circulation; variations in the source and 
pathways of infection are similar to those mentioned in connection with 
acute cholecystitis. Kuru1 has studied by means of Weigert's fibrin 
stain sections of gall-stones and calls attention to the importance of 
fibrin in their production, i 
Apart from infection of the biliary tract, a secondary requisite seems 
to be some obstruction to the free flow of bile. This occurs in circum- 
stances similar to those mentioned in connection with acute cholecystitis; 
but there are also a number of additional contributing factors. .Thus 
gall-stones are especially common in those who lead a sedentary life as 
contrasted with laborers and others who work much outdoors, in women 
as contrasted with men, etc.; as part of the general muscular inactivity, 
the abdominal muscles and the diaphragm, contract relatively feebly 
and the bile, inefficiently expelled, stagnates in the gall-bladder. 
In women a number of factors contribute. In addition to a more 
sedentary life, they are more often the subject of hepatoptosis or nephro- 
ptosis, that occasion more or less marked and continuous distension of 
1 Arch.f. path. Anat, (etc.), Berl., 1912, ccx, 433. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
571 
the abdomen and interfere with the movements of the diaphragm. In 
consequence of the prolapse of the liver, the gall-bladder becomes depend- 
ent and the cystic or the common bile duct kinked, or perhaps has 
considerable traction brought to bear upon it and becomes obstructed, 
so that the gall-bladder is less easily emptied than in health and is more 
disposed to infection. Tight lacing may act in a similar manner. The 
frequency of pelvic infections may be of some etiological significance, 
either by serving as the source of the infection or leading to the formation 
of adhesions. The association of cholelithiasis with pregnancy is undeni- 
able, but its importance is difficult to estimate, since the great majority 
of middle-aged women, whether or not they suffer from gall-stones, 
have been pregnant; there is some evidence, however, that gall-stones 
are more common in those who have been pregnant, especially repeatedly 
pregnant, than in those who were never pregnant. Perhaps in some cases 
puerperal infections are the cause of the gall-stones; sometimes the biliary 
infection, although often misinterpreted, can be definitely determined to 
have been acquired during the puerperium. Cholelithiasis is sometimes 
found with appendicitis; when the appendicitis precedes, the chole- 
lithiasis and cholecystitis may have resulted from the transport of 
infection by the portal circulation; when the cholecystitis precedes, the 
appendicitis may perhaps result from the lodgement of infection in an 
unusually vulnerable organ. 
Gall-stones show a relatively increased incidence in certain forms of 
heart disease, especially mitral and aortic valvular disease. This is 
doubtless due to several factors: the more sedentary mode of life incum- 
bent upon chronic cardiac subjects, and the chronic congestive processes 
obstruct the flow and perhaps cause inspissation of the bile, reduce the 
resistance of the biliary tract, and favor infection. Similar factors 
account for the relative increase in the incidence of gall-stones in certain 
chronic pulmonary diseases. 
Diet, disorders of the gastro-intestinal tract, and disorders of metab- 
olism have long been credited with more or less etiological significance, 
but their exact influence is difficult to determine. Disorders of the 
gastro-intestinal tract associated with catarrh doubtless are of signifi- 
cance, since they may lead to extension of congestive processes to the 
biliary tract, provide bacteria that may induce catarrhal disorders in 
the bile ducts, and are a fruitful source of many toxic products that exert 
a deleterious influence on the biliary passages. Dietetic and other 
indiscretions that lead to gastro-intestinal catarrh are of at least indirect 
influence in causing gall-stones; and a vicious circle is formed in that 
cholelithiasis' and the antecedent cholecystitis not only are frequently 
manifested by misinterpreted symptoms of so-called dyspepsia or 
indigestion, but lead directly to gastro-intestinal catarrh, and in virtue 
of the commonly associated precholecystic adhesions induce much more 
serious disturbances of the stomach and intestines. Constipation, an 
expression of or associated with dietetic indiscretions, sedentary habits, 
etc., is probably of some etiological significance in itself, largely on 
account of the attendant sluggishness of the intestinal circulation. 
Whether diet as such is of real etiological significance is difficult to 572 
DISEASES OF THE DIGESTIVE SYSTEM 
determine. Heavy eating and the excessive use of alcohol are doubtless 
of importance, especially by virtue of the gastro-intestinal catarrh and 
the chronic congestion of the portal system that they lead to; whether 
they are of additional significance, by virtue of disturbances of metab- 
olism, is not definitely known, although it is widely and has Jong been 
believed in. Perhaps an excessive amount of food is of more significance 
than its character, although it is said that a carbohydrate or fatty diet 
disposes to, and a protein diet disposes against, the formation of gall- 
stones. The matter is largely speculation. Since it has been definitely 
determined that the precipitation of cholesterin is due to catarrh of the 
biliary tract, the supposition that a carbohydrate diet leads to such 
precipitation by reducing the bile acids, the solvents of cholesterin, has 
lost much of its supposed importance, and this has been totally destroyed 
by Naunyn's statement that even in diseased conditions the bile scarcely 
if ever contains so much cholesterin that it cannot take more in solution. 
Miyake1 found gall-stones in but 3.05 per cent, of 8406 autopsies in 
Japan. The sexes were nearly equally affected. Japanese women do 
not wear corsets and Miyake believes this reduces the incidence in the 
female sex. 
Pathology.-Gall-stones may be single or multiple; there may be one 
or thousands (7802 in a case of Otto's). In most cases the number varies 
between a dozen and a hundred; most of those in excess of a hundred 
are small and inconsequential, and are spoken of as biliary sand or 
gravel. The stones vary much in size-from the smallest particle to 
those larger than a normal gall-bladder. Merkel found a gall-stone 
measuring 15 cm. in length and 12 cm. in circumference; and Frerichs 
reports one that weighed 120 grams, and Ritter one that weighed 135 
grams. When there are many stones, most of them are usually small; 
when there are few, there may be several rather large stones; when there 
is only one, it may be small, moderate in size, or very large, even com- 
pletely filling a distended gall-bladder. Gall-stones vary also in shape. 
The large single stones, or several stones that fit together (obviously 
resulting from fracture of a single large stone), conform to the shape of 
the interior of the gall-bladder, and are therefore ovoid or somewhat 
pear-shaped. Small single stones are usually ovoid or spheroidal. 
Multiple stones are usually cuboid or polyhedral, and exhibit variously 
shaped surfaces (facets), triangular, quadrangular, polygonal, etc., 
which being opposed to one another are usually smooth and polished, 
although it is doubtful if this results, as is supposed, in consequence of 
mutual attrition; the edges of these stones are rounded rather than 
sharp. Stones within the intrahepatic ducts conform to the ducts in 
shape, and are ovoid or cylindrical; occasionally they are branched, as 
are the ducts. Although usually smooth, the surface of gall-stones may 
be rough, irregular, or nodular (mulberry calculus). In consistency 
gall-stones vary, depending upon the age and the chemical composition, 
the recently formed and the cholesterin stones being the softest; older 
stones may be hard and crumble readily, especially after being dried. 
1 Archiv f. klin. Chir., 1913, ci, 54. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
573 
The following varieties of gall-stones are distinguished by Naunyn: 
(1) Pure cholesterin stones, which consist of nearly pure cholesterin 
and are uncommon. They vary in size from that of a cherry to that of 
a pigeon's egg, are hard, oval, or roughly spherical, seldom faceted, have 
a smooth or nodular surface, and are pure white or yellowish and trans- 
lucent, or rarely brown, greenish, of brownish black on the surface. 
On section they are white and crystalline throughout, or show brown 
deposits between the crystals; they are not stratified. (2) Laminated 
cholesterin stones, which consist of about 90 per cent, of cholesterin, 
together with bilirubin calcium, biliverdin calcium, and calcium carbon- 
ate. In general appearance they resemble the pure cholesterin calculi, 
but they may be brittle and friable, and they are often faceted. On 
section they are more or less distinctly laminated, layers of almost pure 
white alternating with others that are yellow, brown, green, or red. 
The centre may be crystalline, but the external layers are usually vitreous 
or earthy. (3) The common (or mixed cholesterin) stones, which vary 
much in size, although they seldom equal a large cherry; they may be 
small and very numerous, and are usually faceted. The surface is 
usually yellow, but often brown or white. When fresh they are often 
soft and greasy; when dried they undergo shrinkage and become harder. 
On section the centre is often soft and may contain a cavity. (4) Mixed 
bilirubin-calcium stones, which may consist roughly of 75 per cent, of 
bilirubin calcium, and about 25 per cent, of cholesterin. They are as 
large as a cherry or larger, and may occur singly or in groups of three or 
four in the gall-bladder or larger ducts. Their shape depends upon their 
situation; when multiple they may be faceted. They consist of concentric 
layers of reddish-brown or dark-brown material, which is seldom quite 
hard, and contracts on drying often with the formation of fissures or 
cracks. (5) Pure bilirubin-calcium stones, which vary in size from that 
of a grain of sand to that of a pea. There are two types: small, solid, 
brownish-black concretions, with rough irregular surfaces and wax-like 
consistency, and exhibiting a disposition to become welded; and harder, 
smooth concretions of a grayish-black metallic lustre and an internal 
spongy structure. (6) Parer stones, such as amorphous and incompletely 
crystalline cholesterin gravel (resembling pearls); calcareous stones; 
concretions with included bodies and conglomerate stones; and casts 
of the bile ducts. 
Gall-stones may be found in any part of the biliary tract. Of 216 
patients operated upon for infections of the biliary tract by John B. 
Deaver at the German Hospital, Philadelphia, 182 (84.2 per cent.) had 
gall-stones and 34 (15.8 per cent.) had no gall-stones. Of the 182 that 
had gall-stones, 101 (55.5 per cent.) had stones in the gall-bladder alone; 
23 (12.5 per cent.) had stones in the gall-bladder and cystic duct; 19 
(10.5 per cent.) had stones in the gall-bladder and common duct; 12 
(6.6 per cent.) had stones in the common duct alone; 11 (6 per cent.) 
had stones in the cystic duct alone; 5 (2.8 per cent.) had stones in the 
gall-bladder, cystic, hepatic, and common ducts; 4 (2.2 per cent.) had 
stones in the gall-bladder, cystic, and common ducts; 2 (1.1 per cent.) 
had stones in the adhesions (not otherwise specified); and 4 (2.2 per cent.) 574 
DISEASES OF THE DIGESTIVE SYSTEM 
had stones in regions not definitely specified. Of the 216 patients, 58 
had no stones in the gall-bladder, and of these, 23 had stones in the 
ducts; 41 had stones in the common duct, and of these, 12 had stones 
nowhere else; 9 had stones in the hepatic ducts (as well as elsewhere). 
Pathogenesis.-In consequence of bacterial infection of the biliary 
tract a low-grade catarrhal inflammation is set up; this, on the one hand 
leads to obstruction to the free flow of bile from swelling of the mucous 
membrane, and the products of this inflammation contain the essential 
constituents of gall-stones. In the gall-bladder the catarrhal inflammation 
leads to desquamation of the lining epithelium, an albuminous exudation, 
and an increased formation of mucus and of cholesterin; and in the 
gall-bladder dynamic factors frequently favor the stagnation of bile. 
The increased cholesterin is not derived from the bile; it results from 
catarrhal disintegration of the mucous cells lining the wall of the gall- 
bladder. The second important constituent of the gall-stones, bilirubin- 
calcium, is derived from the bile, being precipitated by bacterial growth 
or by the albuminous exudation of the inflammatory process-a phe- 
nomenon that can be imitated experimentally by adding egg-albumen to 
normal bile. Bacmeister1 and Exner and Heyrovsky2 have shown that 
bacteria, notably the typhoid and the colon bacillus (but not strepto- 
cocci), may effect directly a decomposition of the bile with the precipita- 
tion of cholesterin. Exner and Heyrovsky attribute this to decomposition 
of the bile-acid salts (the solvent menstruum), in consequence of which 
the normal amount of cholesterin is no longer held in solution. Stagna- 
tion and inspissation of the bile do not give rise to the increased formation 
of cholesterin nor to the precipitation of bilirubin-calcium-whence they 
are contributing factors only. Bilirubin-calcium is believed by Naunyn 
to act as a cement substance, binding together the cholesterin, desqua- 
mated epithelium, etc., the whole forming the nucleus of the gall-stone. 
The exact significance of foreign bodies and of chemical substances 
apart from bacterial products has not yet been definitely determined. 
There being no cholesterin-bearing mucous membrane in the smaller 
bile ducts, cholesterin gall-stones are not formed within the intrahepatic 
ducts, although by a retrograde movement they may be transported 
thither; bilirubin-calcium stones only are formed in the intrahepatic 
ducts; but both varieties are formed within the gall-bladder. 
Associated Lesions.-The lesions of cholecystitis and cholangitis 
are common concomitants-so-called calculous cholecystitis and cholan- 
gitis. The gall-stones may be free in the gall-bladder or the ducts, 
although usually more or less confined by the associated chronic inflam- 
matory processes; in some cases the stones may be quite adherent to 
the mucosa, especially in the gall-bladder; in other cases there is more 
or less incrustation of the wall, a deposition in the wall of cholesterin. 
The consequences of gall-stone activity may be mechanical or inflam- 
matory or both. The mechanical consequences follow what may be 
designated wandering of the stone into and through the biliary passages. 
Probably the most important and serious effects comprise permanent and 
1 Munchen, med. Wchnschr., 1908, Iv, 211, 283, 339. 
2 Wien. klin. Wchnschr., 1908, xxi, 214. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
575 
complete obstruction of the common bile duct. Of only less importance 
are the dragging sensations and discomfort attendant upon the weight 
of many gall-stones in a distended gall-bladder; the gradual production 
of a Riedel or a linguiform lobe of the liver; the effects of pressure on 
adjacent organs; complete obstruction of the cystic duct, which, as a 
rule, leads at first to some distension of the gall-bladder, but soon to 
absorption of the bile and its replacement by mucus (hydrops) and 
gradual shrinkage of the gall-bladder, etc. These acquire their major 
importance from the opportunity that they afford for bacterial infection. 
This infection of the biliary tract is of the utmost significance, and 
forms an integral part of so-called calculous cholecystitis and cholangeitis. 
The ensuing lesions are of the greatest diversity. The concomitant 
inflammatory phenomena may be of varying grades-from the mildest 
catarrhal lesions to widespread phlegmonous and ulcerative processes; 
gall-stones, if present, may be quiescent or active; they may cause an 
acute or chronic, partial or complete, temporary or permanent, obstruc- 
tion of the cystic, the.hepatic, or the common bile ducts, and, on the 
other hand, such obstruction may occur in the absence of gall-stones 
(being due to swelling of the mucous membrane, kinking of the ducts, 
or obstruction from without), and in the presence of gall-stones the 
ducts may be partially or completely patulous; the gall-bladder may 
be distended or contracted, its walls thinned or much thickened, and 
its lumen ultimately may become almost if not quite obliterated; it 
may contain bile, mucus, blood, or pus, or combinations of these, in 
addition to or in the absence of gall-stones; adhesions may form between 
the gall-bladder and adjacent structures, and by way of the adhesions 
the gallstones may rupture into the gastro-intestinal tract and sometimes 
cause intestinal obstruction; or purulent pericholecystitis and peri- 
cholangeitis, localized or generalized peritonitis, pylephlebitis, pericho- 
langitic abscesses of the liver, fistula?, acute and chronic pancreatitis, 
etc., may ensue; and finally, in some cases, a general bacterial, often 
pyococcic infection, with or without multiple abscesses, may develop. 
Symptoms.-The symptomatology of gall-stones is extremely variable, 
and one may perhaps speak of the immediate and the remote conse- 
quences, but in many cases differentiation is quite impossible. One may 
also speak of the mechanical and the infectious phenomena, the aseptic 
and the septic phenomena of the French writers; this in many respects 
is a serviceable classification, but the one set of phenomena by no means 
can always be differentiated from the other, and the one frequently 
follows the other or they occur together. The symptomatology is 
further complicated by the fact that in different cases the symptoms may 
be due to the gall-stones themselves, or to the associated infectious 
cholecystitis or cholangeitis, pericholecystic adhesions, disease of related 
or adjacent organs, etc. One may, however, differentiate (1) a general 
symptomatology, and (2) certain special phenomena due to obstruction 
of the cystic duct, or (3) of the common duct, and (4) certain complications 
and sequels. 
General Symptomatology.-The characteristic and significant symptoms 
are; (1) Chronic, long-continued, or recurring indigestion, called by 576 
DISEASES OF THE DIGESTIVE SYSTEM 
Moynihan "inaugural symptoms," and (2) the phenomena designated 
gall-stone colic. The symptoms of chronic long-continued or recurring 
indigestion are of the utmost importance and are commonly misinter- 
preted. This stands in relationship with the facts-that gall-stones are 
present in very many subjects and are commonly believed not to cause 
noteworthy symptoms; that symptoms, having once occurred, are 
exceedingly likely to recur; and that the symptoms are often paroxysmal 
and very severe. 
It is often said and widely believed that gall-stones are usually latent, 
and that only a very small percentage of gall-stone subjects (commonly 
estimated at 5 per cent.) manifest noteworthy symptoms thereof. Gall- 
stones are sometimes latent, particularly in elderly subjects in whom 
the original infection has died out, and in whom more or less atrophy, 
especially of the muscular coat of the gall-bladder and biliary ducts, 
has occurred; but it is now well known to surgeons, although less widely 
acknowledged by general practitioners, that the symptoms commonly 
denominated "stomach trouble," "indigestion," "dyspepsia," etc., 
are due in many cases to disease of and about the biliary tract. In a 
number of cases in which gallstones are an accidental finding at the 
necropsy, investigation of the past history reveals many and often 
long-continued attacks of "indigestion;" the stomach is often found 
normal-in which event the gall-stones, cholecystitis, or precholecystic 
adhesions, rather than being accidental, serve to explain the clinical 
symptoms. Moynihan1 thus describes his so-called "inaugural symp- 
toms." "The patient complains of a fullness, weight and distension or 
oppression in the epigastrium coming on soon after meals, within half 
or three-quarters of an hour, relieved by belching and dismissed almost 
on the instant by vomiting, elicited with remarkable constancy by 
certain articles of diet, especially those of a 'greasy' nature and depend- 
ing rather upon the quality than on the quantity of the food. There is 
a sensation of great tightness which if unrelieved may become acute 
pain from which the patient obtains ease by bending the body forward, 
by flexing the right thigh on the abdomen, or by loosening all garments 
which fit tightly to the waist. There is frequently great complaint of 
'acidity' or heartburn, and in the act of belching there may be sour 
or acid regurgitation. While the discomfort lasts the patient may notice 
a 'catch' in his breath and he finds, perhaps, that it is impossible to 
breathe deeply without feeling an acute stabbing pain at the right costal 
margin. There may be a feeling of faintness and nausea, and, rarely, 
vomiting may occur spontaneously. After a more than usually severe 
attack of ' indigestion' the body and side may feel stiff for several days. 
A frequent and characteristic early symptom is the occurrence, during 
an attack of indigestion, of a slight sensation of chilliness, especially in 
the evenings after a meal. The sensation of 'goose-flesh' is often 
experienced." 
Gall-stone colic usually develops suddenly with severe, often agonizing, 
pain in the right hypochondrium or the epigastrium, radiating around 
1 Brit. Med. Jour., Lond., 1913, i, 8. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
577 
the chest or to the right scapular region; with nausea, vomiting, and 
prostration-weak, pulse, rapid heart action, profuse perspiration, etc. 
Sometimes the attack is preceded by less acute, local pain or dis- 
comfort, chilliness, fever, etc.; more commonly (60 per cent, or more of 
the cases) chilliness and fever accompany and follow the pain. In some 
cases the severe pain lasts for a few moments only; usually it lasts for 
from tw'o to twelve hours; in unusual cases it may last much longer, 
but in these circumstances the phenomena are more correctly interpreted 
as a succession of paroxysms. Often the pain ceases as suddenly as it 
began, but, usually following the agonizing pain, more or less dull aching 
continues for a variable period. The sudden cessation of the severe 
pain may be interpreted as a sudden relief of tension to which the gall- 
bladder has been subjected, due to opening of the cystic duct by the 
dropping of an obstructing gall-stone into the gall-bladder or the passage 
of the stone from the common duct into the intestine; in this event the 
calculus may subsequently be found in the stools. The stools should 
always be searched for calculi by softening them in water or a carbolic 
acid solution, and passing them through a sieve. 
In the great majority if not in all cases local examination reveals 
tenderness, abdominal rigidity, and the other local phenomena of acute 
cholecystitis. The colic may recur at varying intervals-days, weeks, 
months, or years; occasionally there is only one attack; usually there are 
many; with succeeding attacks the likelihood of other attacks increases. 
The pains of cholelithiasis may be colicky or non-colicky. Although 
there is some discussion as to the cause of the colicky pain, there is 
little or no objection to attributing the non-colicky pain to inflammatory 
phenomena provoked by infection, inflammation of and about the 
gall-bladder and biliary ducts. The dull, aching pains are with excellent 
reason ascribed to inflammatory changes in the gall-bladder, with the 
exudation of inflammatory products and consequent distension. The 
more acute pains, associated with muscular rigidity, tenderness, etc., 
are due to infection of the regional peritoneum, which as it subsides 
occasions peritoneal adhesions, a contributing factor in the dull, aching 
pains, and of other significance. Some considerable distension of the 
gall-bladder is possible without provoking noteworthy pain, provided 
the cystic and the common ducts are patulous. It is to efficient drainage 
that the comparatively symptomless course of some cases of chole- 
lithiasis is to be attributed, although the absence of inflammatory phe- 
nomena in the wall of the gall-bladder and the ducts, and the absence 
of adhesions, are also of significance. As regards the referred pains, 
although the sympathetic nerve is of significance, the demonstration 
that filaments of the pneumogastric nerve are distributed to the gall- 
bladder serves to explain the common association of gastric and cardiac 
symptoms with disease of the biliary tract; and the frequent occurrence 
of pain, sometimes of actual colic, three or four hours after a meal, 
suggests a causal relationship to the normal physiological contraction of 
the gall-bladder induced by the entrance of the chyme into the intestine. 
As regards the colicky pains, there is no doubt that heretofore we have 
been too much concerned with interpreting them as evidence of the 
vol. in-37 578 
DISEASES OF THE DIGESTIVE SYSTEM 
passage of a gall-stone through the biliary ducts; pains of like character 
may doubtless be due to different factors, which have been described 
by Riedel, who gives the following as the causes of gall-stone colic: (1) 
Adhesions of a gall-bladder no longer containing ijtouas: (2) adhesions 
"when large stones are present in the gall-bladder and the cystic duct 
is patent: (3) inflammatory processes in a gall-bladder distended by 
fluid or stones, when the cystic^duct is occluded by inflammation or by 
the presence of a stone in the neck of the gall-bladder; (4) the transit 
of a stone through the bile passages; and (5) the inflammation of a 
dilated common duct or its tributaries without impaction of the 
stone. 
There can be little doubt that in a number of cases the spasmodic 
efforts of the gall-bladder and the common duct to expel their contents 
by vigorous contraction of their muscular coats are the cause of the 
peculiar gall-stone colic. This pain occurs in its greatest intensity during 
the transit of a stone through the ducts, and it ceases as the stone is 
discharged into the intestine or drops back into the gall-bladder-thus 
freeing the cystic duct. But there also can be little doubt that attacks 
of pain indistinguishable from those provoked by the transit of a stone 
may be due to other factors-those mentioned above; although in some 
instances the attacks of pain may not be so severe as those of a so-called 
true gall-stone colic. If the obstruction be incomplete, hypertrophy of 
the muscular coat results, and later often lessening of the size of the 
cavity; whereas, if the obstruction be complete, paresis of the muscular 
coat soon occurs, dilatation ensues, and the pain subsides. But, as 
exemplified by the 216 patients already mentioned, gall-stones are absent 
in 15.5 per cent, of the patients who have colicky pains, and they are 
present in -77.7 per cent, of the patients who have only non-colicky pains. 
Furthermore, as is well known, gall-stones may be passed by the bowel; 
that is, they may ulcerate into the bowel, forming a fistula, without 
colicky pains having ever been experienced by the patient. As regards 
the cause of the colic, although mechanical factors, such as traumatism, 
joltings, etc., may sometimes be the immediately provoking factor, it 
results in the great majority of cases from infection and consequent 
inflammation; that is, cholecystitis provokes activity by giving rise to 
an inflammatory exudation that distends the gall-bladder, which, 
becoming tense, contracts upon its contents in an effort to expel them, 
and, should a stone be present, drives it into the neck of the gall-bladder 
and perhaps into the cystic duct. 
Cases of protracted colic may be looked upon as due to long-sustained 
efforts of the gall-bladder to overcome the obstruction to the egress of 
its contents, or to slow progress of a calculus along the ducts, the conse- 
quence of the large size of the stone or the spiral arrangement of the 
Heisterian valve which retards progress. Gall-stone colic, therefore, 
although it is often due to the passage of a gall-stone along the ducts, 
should be interpreted rather as evidence of acute cholecystitis (qlacute 
exacerbation oi chronic cholecystitis): an interpretation sustained by 
■'the concontlWfl'Coccurrerice of {'nlftt^ement and tenderness of the gall- 
bladder, fever, chilliness, leukocytosis, etc.-the ordinary signs of acute 579 
DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
cholecystitis. Furthermore, as the inflammation subsides the stones 
become quiescent and the symptoms subside. 
Jaundice is a common but not a necessary symptom of cholelithiasis, 
and when it occurs, may come on a variable time after the pain-a few 
hours or several days; that is, when the obstruction has reached the 
common duct. It varies in degree and duration with the local conditions. 
If the obstruction results from the traumatism and consequent catarrh 
due to the passage of a stone it may be moderate in grade and pass off 
within a week or thereabouts-as the catarrhal swelling subsides and 
the duct becomes again patulous. Should the obstruction be more 
complete and the stone not be discharged, the jaundice may become 
quite extreme and lasting; but a very large stone may be in the 
common duct without causing jaundice. 
The jaundice of cholelithiasis is mechanical or obstructive and may 
be due to (1) gall-stones in the hepatic or the common bile duct; (2) 
spasm of the musculature or inflammatory swelling of the mucosa of 
the biliary ducts; and (3) compression of the common duct or of the 
extrahepatic part of the hepatic duct by a large stone in the cystic duct, 
swollen lymph glands, regional tumors, inflammatory exudations, 
adhesions, kinking of the ducts, etc. We may, therefore, speak of a 
lithogenous jaundice, an inflammatory or infectious jaundice, and a 
compression jaundice-ill-advised as these terms may be on some occa- 
sions. The practical deductions to be drawn from the known facts are: 
(1) That in some cases of cholelithiasis jaundice is not due to obstruction 
of the ducts by a stone but rather to infection, inflammatory swelling 
of the ducts, and (2) that in many cases of cholelithiasis jaundice does 
not occur at all, although other important and distressing symptoms 
may be quite obtrusive. Of 216 patients, 74 (34.2 per cent.) never had 
jaundice; 141 (65.3 per cent.) had no jaundice at the time of operation; 
whereas 121 (56 per cent.) gave a history of attacks of jaundice prior 
to the time of operation. These attacks, in some cases, antedated the 
operation many years; in some cases long periods of freedom from 
jaundice followed; in some cases there were no subsequent attacks of 
jaundice whatever. Moynihan finds that 25 per cent, of the patients 
from whose common ducts stones are removed have never been jaundiced. 
The gall-bladder may or may not be enlarged and palpable. Thus, of 
216 patients, in 88 (40.7 per cent.) the gall-bladder was enlarged; in 9 
(4.1 per cent.) the gall-bladder was normal in size; in 32 (15 per cent.) 
the gall-bladder was small and atrophic; and in 87 (40.2 per cent.) the 
size of the gall-bladder is not known. 
Special consideration has been given to the diagnostic importance 
of the size of the gall-bladder since a knowledge of what is known as 
Courvoisier's law has become general. Courvoisier, basing his opinion 
upon an analysis of 187 cases, stated that in cases of chronic jaundice 
contraction of the gall-bladder is suggestive of gall-stones, and that 
dilatation of the gall-bladder is suggestive of biliary obstruction caused 
by factors other than gall-stones-that is, pressure from without, most 
often carcinoma of the head of the pancreas. This so-called law serves 
well in the majority of cases, although as Courvoisier himself admitted 580 
DISEASES OF THE DIGESTIVE SYSTEM 
there are some notable exceptions. It is of some interest to know that 
in at least 40.5 per cent, of 116 patients who had gall-stones and jaundice 
the gall-bladder was enlarged. In somewhat more than one-half of 
these cases, however, the gall-stones were present in the gall-bladder 
alone, and the associated jaundice was doubtless due to inflammatory 
swelling, pressure from without, etc. Courvoisier's explanation of the 
shrinkage of the gall-bladder in these cases is correct; that is, it is due 
to inflammatory thickening and cicatrization, the consequence of repeated 
infection. This process requires time-whence the condition of the 
gall-bladder varies early and late in the disease. That such cicatrization 
does occur is suggested by its presence in a number of cases in which 
gall-stones were present without jaundice. It is manifestly impossible 
that such a thickened and cicatrized gall-bladder should dilate, no matter 
what the obstruction in the common duct. One can conceive, however, 
of an acute cholecystitis or empyema of the gall-bladder (with distension) 
and an acute impaction of a stone in the common duct (with jaundice); 
or of hydrops or empyema of the gall-bladder (with distension) and a 
large stone in the cystic duct compressing the common duct (with 
jaundice); or of the association of a stone in the common duct and car- 
cinoma of the head of the pancreas, in which event the gall-bladder 
might be dilated, or small, thickened, and atrophic or sclerosed. 
Sometimes when the gall-bladder contains several stones and its 
walls are not too tense, gall-stone crepitus may be elicited by palpation. 
This is valuable diagnostically when the symptoms are not frank. 
As already stated, fever is common in cholelithiasis. Of 216 patients, 
143 (66.2 per cent.) had fever some time during the course of the disease; 
65 (30.1 per cent.) had no fever while under observation; and in 8 (3.7 
per cent.) there is no note of the presence or absence of fever. This fever 
should be correctly interpreted; it is a manifestation of infection, and 
is not due merely to reflex causes, nervous perturbations, etc., as was 
at one time thought. In many cases, concurrently with the development 
of the gall-stone colic, there is a sudden elevation of the temperature, 
followed sometimes by an equally sudden fall; the onset of this fever may 
or may not be associated with chilliness or a definite chill; in other cases 
the fever is of somewhat longer duration, and is more or less obviously 
due to an acute cholecystitis or an acute exacerbation of chronic chole- 
cystitis; in other cases the fever is slight and not detected unless diligently 
searched for, perhaps it is sometimes absent-evidently cases of chronic 
low-grade infection; in other cases, especially cases of calculus in the 
common bile duct, the fever is that known as Charcot's intermittent 
hepatic fever-periodic attacks of chill, fever (103° to 104°), and sweats, 
accompanied by pain, recurrence or increase of jaundice, and perhaps 
nausea and vomiting. This fever is only an aggravation of the types 
previously mentioned; all are due to biliary infections. 
Obstruction of the Cystic Duct.-The calculus is usually lodged in the 
beginning of the duct or in the termination of the neck of the gall-bladder. 
The following conditions may ensue: (1) Acute cholecystitis (catarrhal, 
suppurative, phlegmonous, or gangrenous). (2) Chronic dilatation of 
the gall-bladder, a condition that follows complete obstruction to the DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
581 
entrance of bile into the gall-bladder, which soon becomes distended 
with mucus, at first bile-stained, but ultimately quite clear. The gall- 
bladder content is perhaps partly inflammatory, in the beginning at 
least, but in many cases the infection gradually subsides, whereas in 
others it becomes relighted or a new infection and acute cholecystitis 
ensue. (3) Chronic fibrous or atrophic cholecystitis-the usual sequel 
of hydrops when the obstruction is not complete and the infection dies 
out. The gall-bladder gradually becomes reduced in size and may 
ultimately be reduced to a mass of fibrous tissue, which usually tightly 
encircles a calculus. When the gall-bladder becomes small and con- 
tracted, symptoms may be in abeyance, or they may be those of chronic 
cholecystitis with or without acute exacerbations, or those of adhesions. 
Often there is incrustation of the wall with cholesterin; there may be 
diverticula which usually contain calculi. 
Obstruction of the Common Bile Duct.-There may be one or many 
obstructing calculi; in the majority of cases there is only one, and this 
is usually in the lower end of the common duct or the diverticulum of 
Vater, but it may be in any part of the duct; when there are many calculi 
they may extend throughout the common duct into the hepatic duct 
and its branches and into the cystic duct and the gall-bladder. The 
obstruction may be complete or incomplete, and may or may not be 
associated with cholangeitis. When the obstruction is complete a stone 
is usually tightly impacted in the common duct; when the obstruction 
is incomplete the stone may be more or less fixed, but permits the flow 
of bile around it, or it may circulate in the common duct and imitate 
the conditions in a ball valve. A calculus originally tightly impacted 
in the common duct often, in the course of time, becomes more or less 
free, in consequence of atrophy or ulceration of the wall of the duct 
about the stone, or of dilatation of the duct above the stone. Dilatation 
of the ducts is a common event; it is usually cylindrical, the common 
duct not infrequently becoming as large or larger than one's finger; 
occasionally the dilatation is saccular, the common duct attaining the 
size of an orange; small saccular dilatations may also occur on the surface 
of the liver, especially the left lobe. The liver at first is usually somewhat 
enlarged from accumulation of bile; later atrophy of the hepatic cells 
ensues, and in consequence of biliary infection, inflammatory phenomena 
spread from the bile ducts to the adjacent tissue-cholangeitis and peri- 
cholangeitis. This gives rise to some new connective tissue, and the 
atrophy of the hepatic parenchyma causes a relative increase in the 
preexisting connective tissue, so that a condition resembling cirrhosis 
is induced; but although a form of chronic hepatitis, this is not cirrhosis 
and it is at best doubtful if biliary stasis can lead to true cirrhosis. 
The clinical manifestations of a stone in the common duct vary, 
depending whether the obstruction is complete or incomplete and whether 
or not it is associated with infection of the ducts. In the event of com- 
plete obstruction without infection, permanent and lasting jaundice is 
produced, unattended by fever and other signs of local infection. In 
the event of incomplete obstruction suggestive symptoms are sometimes 
absent, as a large stone may be present for years without jaundice. 582 
DISEASES OF THE DIGESTIVE SYSTEM 
Usually, jaundice is present; it lasts a long time, and, varying with the 
degree of biliary obstruction, is subject to more or less fluctuation, which 
is very characteristic; and there is fever, periodic, intermittent, remittent, 
or more or less continuous, indicative of the concomitant biliary infection. 
This biliary infection is present in practically all cases of incomplete 
obstruction; it may continue for years without the advent of suppuration, 
but suppurative cholangeitis and cholecystitis may ensue. 
Naunyn gives the following as the characteristic signs of a calculus 
in the common bile duct: "The continuous or occasional presence of 
bile in the feces; distinct variations in the intensity of the jaundice; 
normal size or only slight enlargement of the liver; absence of distension 
of the gall-bladder; enlargement of the spleen; absence of ascites; presence 
of febrile disturbances, and duration of the jaundice for more than a 
year." Osler has emphasized the importance of the following signs in 
the diagnosis of a ball-valve calculus in the diverticulum of Vater (where 
it occurs most frequently), or in the common bile duct: "(a) Ague-like 
paroxysms of chill, fever, and sweating-the hepatic intermittent fever 
of Charcot; (6) jaundice of varying intensity, which persists for months 
or even years, and deepens after each paroxysm; and (c) at the time of 
the paroxysm, pain in the region of the liver with gastric disturbance. 
. . . Pain, which is sometimes severe and colicky, does not always 
occur. There may be vomiting and nausea. As a rule, there is no 
progressive deterioration of health. In the intervals between the attacks 
the temperature is normal." 
When the calculus is situated in the diverticulum of Vater it may 
obstruct the duct of Wirsung, and should the duct of Santorini be unable, 
on account of non-communication, to divert the pancreatic juice into 
the duodenum, accumulation of the juice and dilatation of the ducts 
ensue; furthermore, the common infection present in these cases grad- 
ually spreads to the pancreatic ducts, producing pancreatitis, with early 
enlargement of the organ, especially the head, which may become so 
hard as to suggest carcinoma; later the organ becomes contracted and 
fibrosed; in some cases pancreatic lithiasis also ensues. Mayo1 states 
that in 2200 operations upon the gall-bladder and biliary ducts the 
pancreas was found coincidently affected 141 times (6.1 per cent.); 
since the total number of operations undertaken for disease of the 
pancreas was only 168, it was found that 81 per cent, of the cases were 
due to or accompanied by gall-stones. In 268 operations upon the common 
and the hepatic ducts the pancreas was found diseased in 18.6 per cent., 
as contrasted with 4.45 per cent, of the cases in which the gall-bladder 
only was diseased.2 In the event of incomplete obstruction of the 
pancreatic duct, bile may be diverted into it, and lead to the production 
of acute hemorrhagic pancreatitis. 
Complications and Sequelae.-Of the many complications and sequelae 
of cholelithiasis, some infectious, some purely mechanical, but most of 
them infectious and mechanical, the following are the most important: 
1 Jour. Am. Med. Assoc., 1908, i, 1161. 
2 Consult also Mayo Robson, Surg. Gynecol, and Obstet., 1908, vi, 29; and Maugeret, 
Cholecysto-pancreatite, Paris, 1908. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
583 
(1) Infectious (inflammatory) lesions of the biliary tract and adjacent 
viscera; (2) chronic pericholecystic adhesions; (3) biliary Astute; and 
(4) intestinal obstruction. 
Infectious (Inflammatory) Lesions of the Biliary Tract and Adjacent 
Viscera.-It has been demonstrates that gall-stones are the consequence 
of infective (low-grade) inflammation of the biliary tract. Having been 
formed, gall-stones participate in a vicious circle and serve to keep alive 
the infective inflammation to which they owe their origin, in consequence 
of which and also on account of certain mechanical effects, divers inflam- 
matory lesions of the biliary tract and adjacent viscera ensue. These 
comprise especially varying grades of acute and chronic, suppurative 
and non-suppurative, cholangeitis and cholecystitis, progressing perhaps 
to ulceration, gangrene, perforation, etc., to which reference has already 
been made. The inflammatory phenomena may extend to adjacent 
structures and set up peritonitis, pylephlebitis, pancreatitis, etc., or, in 
consequence of adhesions, they may seriously compromise the functional 
activity of the gastro-intestinal tract; or progressing to necrosis and 
suppuration they may lead eventually to the formation of Astute. 
Chronic Pericholecystic Adhesions.-Adhesions are frequently encoun- 
tered in the upper abdomen; of 216 patients, 123 (56.6 per cent.) had 
adhesions about the gall-bladder; 22 (10.1 per cent.) had no adhesions; 
and of 71 (33 per cent.) there is no note of the presence or absence of 
adhesions (probably none were present). These adhesions represent the 
sequels of past subacute and chronic, sometimes acute, inflammation 
of the organs of the upper abdomen, of which the biliary tract is the 
chief; whence they are a direct result of biliary infection. 
The conditions are quite analogous to those in and about the vermiform 
appendix. Should the biliary infection be acute and virulent, the bacteria 
or their toxins penetrate the wall of the gall-bladder or the biliary ducts 
and engender a fibrinous exudation, a more or less local peritonitis. 
In the subacute and chronic infections, however, the formation of 
adhesions goes on less obtrusively, often entirely latently, whence the 
symptoms that develop later are commonly misinterpreted. In con- 
sequence of milder infections the less virulent toxins give rise to less 
inflammatory phenomena-sufficient, however, often to lead to more 
or less widespread adhesions. All gradations are encountered; fre- 
quently these are quite localized and very delicate (gall-spiders, resem- 
bling spider-webs, they have been aptly called by Morris); in other cases 
they are quite widespread and very dense. 
The clinical recognition of these adhesions is soBa£timfiaAJaatta& of 
difficulty but it Is perhaps not impossible-nn the majorityjoflcasas. It 
js essential, in the first place, that we recognize that many of the cases 
of so-called a sTrnnacff-acffeT' ^InliousnessT^ indigestion, etc:; in reality 
have an anatomical basis. Many of these cases are due to an unsuspected 
or latent gastric or "duodenal nicer, definite cholecystitis, chronic pan- 
creatitis, etc.; in other cases they are due to adhesions. We must study 
attentively patients who complain of general ill health, with more or 
less ill^efined-gastwc-xir .epigastric symptoms. Attacks of such symptoms 
may Come on periodically without definite cause; they may last a few 584 
DISEASES OF THE DIGESTIVE SYSTEM 
(lays, and cease quite as causelessly. Now and then the attack may be 
ushered in with chilliness (rarely a definite chill), and may be attended 
by a little fever. Examination may reveal some tenderness in the 
epigastrium, perhaps a little to the right of the median line, toward the 
region of the pylorus or the'gatbbladder, and some rigidity of the over- 
lying muscle. Deep pressure is sometimes very painful. Later, should 
the pylorus or the duodenum become obstructed, the commoner mani- 
festations of dilatation of the stomach supervene. Special diagnostic 
importance attaches to intractability of the symptoms and a history of 
past infection of the biliary tract. In the event of suspecting such 
adhesions, we must exclude other factors that may cause similar symp- 
toms, remembering that in many cases symptoms supposedly due to 
disease of the stomach or intestine are due to disease of the gall-bladder 
or adhesions of the upper abdomen. Much has been accomplished in 
the study of these adhesions by means of the z-ray. 
Biliary Fistulae.-Fistulous communications between the biliary tracts 
and adjacent viscera as well as the exterior of the body frequently result 
from cholelithiasis and the associated inflammatory and ulcerative 
processes. Courvoisier in a study of 499 cases found that fistulous 
communications had been established as follows: between different 
parts of the biliary passages in 8; into the portal vein in 5; into the 
peritoneal cavity in 70; into peritoneal adhesion in 49; into the retro- 
peritoneum in 3; with the stomach in 13; with the duodenum in 83; 
with the jejunum in 1; with the ileum in 1; with the colon in 39; with 
the urinary tract in 7; with the pleura and lung in 24; and externally in 
196. The external fistula? appear to be disproportionately numerous 
since by their very nature they command attention, whereas the internal 
fistulae frequently are not detected. In external fistulae the opening 
may be near the normal situation of the gall-bladder, near the umbilicus 
(being directed thither by the falciform ligament), in the right iliac fossa, 
in the thigh, etc. Biliary, gastric and intestinal fistulae are often unsus- 
pected; sometimes they are first revealed by the discharge of gall-stones 
with the feces (without concomitant gallstone colic), or by the sudden 
disappearance of long-standing obstructive jaundice, or by the onset 
of intestinal obstruction (gall-stone ileus). Bronchobiliary fistulae lead 
to cough, dyspnoea, and the expectoration of pus, bile, and perhaps 
gall-stones. Schlesinger1 and Eichler2 have added to the cases and there 
are now 47 cases on record, of which 28 were due to gall-stones. 
Intestinal Obstruction.-Intestinal obstruction is a rather rare event 
that may follow ulceration of a gall-stone from the gall-bladder into the 
duodenum or, less commonly, the colon. It is doubtful if a gallstone 
that has been able to pass through the biliary ducts and the ampulla 
of Vater into the duodenum is large enough to obstruct the intestine; 
in some cases a comparatively small stone may become arrested at the 
ileocecal valve; it may set up inflammation and localized spasm of the 
intestine with consequent obstruction; it may become increased in size 
after it reaches the intestine (enterolith); or it may become arrested in 
1 Mitth. a. d. Grenzgeb. d. Med. u. Chir., Jena, 1906, xvi, 240. 
2 Ibid., 1906, xvi, 550. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
585 
a part of the intestine narrowed by inflammatory or neoplastic disease, 
etc. The ratio of gall-stone ileus to other forms of intestinal obstruction 
varies between 1 to 13 (Fitz) and 1 to 45 (Barnard). Recently, Lesk1 
has collected 148 cases, of which 109 (73.5 per cent.) occurred in women 
and 39 (26.5 per cent.) in men. Only 6 of the patients were less than 
forty years of age; most of them were beyond fifty. In 104 of Lesk's 
cases the obstruction was in the ileum in 62 (59.6 per cent.), in the 
jejunum in 17 (16.3 per cent.), in the small intestine (without definite 
statement) in 13 (12.5 per cent.), in the colon in 6 (5.7 per cent.), in 
the duodenum in 5 (4.8 per cent.), and in the rectum in 1 (1 per cent.). 
In 26 of the 62 cases in which the obstruction was in the ileum it was 
near the ileocecal valve. The diagnosis rests upon the advanced age 
of the patient and a past history of gall-stones or other manifestations 
of biliary infection; in some cases the gall-stone causing the obstruction 
and the surrounding or adjacent tissues form a palpable mass in which 
the gall-stone may be distinguishable. In most cases, however, the cause 
of the intestinal obstruction cannot be diagnosed with certainty until 
it is seen. Sometimes the obstruction is relieved spontaneously, but at 
least one-half of the patients die unless the obstruction is relieved by 
surgical procedures. The operative mortality is high (about 45 per cent.), 
due largely to delay, but also to the advanced age of the subjects. 
Diagnosis.-This comprises the recognition of the gall-stone colic 
and of the many and varied associated lesions and sequels. Severe 
pain in the epigastrium or the right hypochondrium, radiating around 
the chest or to the right scapula, accompanied by nausea and vomiting 
and enlargement and tenderness of the gall-bladder, and followed by 
jaundice and the detection of a gall-stone in the feces, are characteristic 
of the passage of a gall-stone; but jaundice is by no means always present 
and the other symptoms may be provoked by cholecystitis in the absence 
of a gall-stone; indeed, with increasing experience it becomes often more 
and more difficult to say whether or not gall-stones are present in certain 
cases of obvious chronic biliary infections. 
Recourse to the ar-rays is seldom of much diagnostic utility, since the 
cholesterin stones produce scarcely any shadow, usually not more than 
the adjacent liver; in the rare cases of calcium stones more shadow is 
cast, but this also is obscured by the shadow of the liver. In a few cases, 
however, the x-rays afford trustworthy evidence. 
A diagnosis after the event is readily made in many cases, but during 
the prevalence of the severe pain one may be unable to determine the 
cause of the patient's suffering. A few whiffs of chloroform or a hypo- 
dermic injection of morphine may so relieve the patient as to permit of 
an examination, in which event tenderness and perhaps enlargement of 
the gall-bladder may be elicited. The severe pain of gall-stone colic may 
be imitated by renal colic or intestinal colic; but in renal colic the pain 
is usually in the back, loin, or groin, and radiates down the ureter to the 
testicle, which may become retracted; strangury or frequent micturition 
is common; the kidney is usually tender (the tenderness being in the 
1 Deutsche Ztschr. f. Chir., Leipz., 1908, xcix, 47. 586 
DISEASES OF THE DIGESTIVE SYSTEM 
loin rather than anteriorly in the region of the gall-bladder); and the 
urine subsequently contains blood and a proportionate amount of 
albumin, perhaps crystals or a calculus, and pus and epithelium from 
the pelvis of the kidney; and it does not contain bile. Intestinal colic 
is usually due to some more or less obvious cause; the pain is usually 
about the umbilicus, it radiates in different directions, remits and inter- 
mits, and subsides with the removal of the exciting cause, often with 
belching or the discharge of feces or gas or mucus by the bowel; and there 
is no localized tenderness in the region of the gall-bladder. In lead colic 
there is the history of exposure to the poison, a blue line on the gums, 
anemia, basophilic degeneration of the erythrocytes, etc. 
When the symptoms, especially the pain, are less acute, and do not 
merit the designation gall-stone colic, difficulty may be experienced in 
differentiating disorders of the stomach. Much assistance will be 
obtained by bearing in mind that the case of so-called chronic indigestion 
that is not benefited by several months of well-directed therapy com- 
monly has an anatomical basis. Gastric or duodenal ulcer is suggested 
by dependence of pain upon taking food or its occurrence as the chyme 
passes into the duodenum (which sometimes obtains also in cholelithiasis), 
by tenderness in the median line or slightly to the right, and posteriorly 
on the left side near the vertebne, hyperchlorhydria, hematemesis, etc., 
and the absence of jaundice and intermittent hepatic fever; prominence 
of nausea and vomiting is more significant of cholelithiasis. Perichole- 
cystitis and perigastric adhesions are often the cause of so-called chronic 
indigestion, and may give rise to pyloric obstruction and gastric 
dilatation. 
Malignant disease of the gall-bladder usually follows cholelithiasis; 
but so insidious, as a rule, is its onset that it is commonly not suspected 
until the advent of loss of flesh and strength and the progressive develop- 
ment of cachexia. In some cases of more or less apparent cholelithiasis 
the diagnosis of carcinoma is favored by the detection of progressive 
nodular enlargement of the gall-bladder, and the progress of the disease 
is shown in some cases by the occurrence of metastasis to the liver, 
ascites, etc. In the event of jaundice, its persistence unchanged suggests 
malignant disease of the ducts or pancreas, etc., although it may be due 
to a stone tightly impacted in the common duct; but there is less impair- 
ment of the general health than in carcinoma; in the majority of cases 
of gall-stones in the ducts, as contrasted with malignant disease or 
catarrhal cholangeitis, there is periodic variation in the intensity of the 
jaundice and fever (intermittent hepatic fever). 
Prognosis.-The prognosis, as a rule, depends more upon the associated 
conditions than upon the mere presence of the gall-stones. The prognosis 
in gall-stone colic is virtually that of a more or less acute cholecystitis; 
the outlook as regards permanent health depends upon the chronic 
gall-bladder infection. In almost all cases of gall-stone colic the acute 
symptoms subside spontaneously after several hours or several days; 
rarely a patient may die, it is said, from shock and cardiac failure; occa- 
sionally rupture of the gall-bladder ensues and gives rise to infectious 
peritonitis and a fatal issue; and in other cases a stone impacted in the DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
587 
neck of the gall-bladder or the cystic duct and the attendant infection 
and interference with the blood-supply may, after the lapse of several 
days, lead to severe suppurative or gangrenous cholecystitis. 
A first gall-stone colic is sometimes the last and the infection subsides. 
Usually, however, there are subsequent attacks, if not of severe colic, of 
more or less disturbance with digestion, and general impairment of 
health, due to the toxic absorption, etc.; some subjects pass into chronic 
invalidism from unrecognized chronic biliary infections. The likelihood 
of continuation of symptoms is increased by the duration of symptoms 
in the past; that is, those already ill for some time are likely to continue 
ill, and the lesions to progress. The detection of faceted stones in the 
feces suggests that other stones are still undischarged; the detection of 
rounded or ovoid stones in the feces, together with subsidence of the 
local symptoms, arouses the hope that there was but a single stone. 
The occurrence of intermittent hepatic fever, especially of severe ague- 
like paroxysms, renders the prognosis rather bad, since it shows active 
infection, which, although it may persist for years without suppuration, 
may neverthless lead to serious consequences. The prognosis as to final 
recovery of health is bad in pericholecystic adhesions, fistula, and 
intestinal obstruction without operative intervention. 
Treatment.-The intelligent treatment of cholelithiasis presupposes a 
clear conception of (1) the pathology of the disease, of its pathogenesis, 
pathological anatomy, and natural tendencies, and (2) of the means of 
treatment at our command and the objects attainable by their use. To 
attempt by internal medication to dissolve a gall-stone that is insoluble; 
to cause the passage through the biliary ducts of a gallstone when the 
ducts are impassable to a stone of its size; to attempt to cure supposed 
gastric symptoms by measures directed to the stomach when the cause 
of the symptoms is adhesions about the gall-bladder, and to cause the 
solution of these adhesions-is as futile as it is irrational. 
Prophylaxis.-A knowledge of the etiology suggests certain measures 
of prophylaxis. Although we may be quite unable to prevent the causative 
infection in the individual, we may advise useful measures. The fact 
that gall-stones are most common in women, in the obese, in those who 
lead a sedentary life, eat too much, are constipated, and addicted to 
alcohol, suggests the correction of certain very obvious etiological factors. 
Women who have been repeatedly pregnant and have lax abdominal 
walls should wear proper supports; but women, whether they have been 
pregnant or not, should avoid tight lacing. Men and women who lead 
a sedentary life should take properly regulated exercise; they should 
practise deep breathing (to promote the movements of the diaphragm), 
bathe frequently, be much in the open air, etc.; that is, they should 
apply to themselves the general principles of hygienic living. Constipa- 
tion should be overcome, and the diet should be such as will be presently 
pointed out. If these measures do not prevent the formation of gallstones 
in those who have or have had a biliary infection, they will at least 
promote a general well being, tend to reduce biliary infection, and per- 
haps obviate some of the serious consequences of cholelithiasis. 
When gall-stones have formed, the main indications for treatment are: 588 
DISEASES OF THE DIGESTIVE SYSTEM 
(1) To cause solution of the stone or stones; (2) to cause the discharge 
of the stone or stones; and (3) to treat the complicating infection. 
Solution of the Gall-stones.-As regards the solubility of the gall-stones 
Naunyn1 states that we have to consider cholesterin, bilirubin-calcium, 
calcium carbonate, and calcium phosphate. Of these, bilirubin-calcium 
and the inorganic salts of calcium are insoluble in the bile; cholesterin, 
however, is quite soluble in the bile, and even in conditions of disease 
the bile scarcely if ever contains so much cholesterin that it cannot take 
more in solution. We have, therefore, to admit the possibility of choles- 
terin stones being dissolved. In fact, there is some experimental evidence 
that goes to prove that not only in vitro, but also in vivo, cholesterin 
stones may be dissolved. Naunyn quotes Labes' experiments of thirty 
years ago, in which he introduced gall-stones into the gall-bladder of 
dogs, and, killing the animals two months later, found that partial 
solution of the stones had occurred. Bain2 and von Hansemann3 have 
published the results of studies that show the same possibility. In 
these experiments, however, the calculi were introduced into normal 
gall-bladders (or, as in one or two of Bain's experiments, into gall-bladders 
in which a cholecystitis has been artificially produced). The conditions 
are quite different in the human subject affected with gall-stones and 
it is exceedingly doubtful whether spontaneous solution of gall-stones 
ever occurs in the human subject-indeed, whether it is at all possible. 
Judging from clinical experience, it is exceedingly doubtful whether, 
with any means at our command, we can cause solution of gall-stones in 
the gall-bladder. We now know that the thousands of gall-stones said 
to have been passed by the bowel after the administration of olive oil 
are merely masses resembling gall-stones in outward appearance (saponi- 
fied oleic acid). There is also no reason to believe that olive oil, deriva- 
tives of olive oil and other oils, turpentine, ether, etc., have any influence 
whatever in dissolving gall-stones in the biliary tract. 
Discharge of the Gall-stones.-This is an occurrence which should not 
be hoped for nor awaited or sought by medical means, even were such 
at our command; it cannot be considered an object of rational 
treatment. 
Treatment of the Biliary Infection.-'The one worthy object is to 
restore the latency from which the gall-stones have been awakened-in 
other words, to control the infection at the basis of gall-stone activity. 
This must also be the object of medicinal or internal treatment of chole- 
cystitis in the absence of gall-stones. The infection of the biliary tract 
is what the physician has to treat. The surgeon may remove the stones 
and also treat the biliary infection. The physician, however, in many 
cases may lead his patient into a condition of virtual cure, that is, 
latency or sterility of the biliary tract; but he must recognize his 
limitations, and not subject his patient too long to useless treatment 
when early surgical intervention may restore him to health. The 
1 Mitt. a. d. Grenzgeb. d. Med. u. Chir., Jena, 1905, xiv, 537. 
2 Brit. Med. Jour., 1905, ii, 269. 
3 Arch. f. path. Anat, (etc.), Berl., 1913, ccxii, 1. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
589 
manifestations of the biliary infection calling for treatment may be 
acute, that is, gall-stone colic, or chronic. 
The pain of gall-stone colic is usually so severe as to require the admin- 
istration of morphine, which not only relieves the pain (and mitigates the 
attendant shock) but, by relaxing the spasm of the biliary musculature, 
favors the exit of bile from the tense gall-bladder and the transit of the 
calculus through the ducts (if it be already therein). A few whiffs of 
chloroform or ether will usually carry the patient through the painful 
period until the morphine has time to act; or, and this is often attended 
with excellent results, an additional dose of atropine (y^- grain) may be 
administered hypodermically. 
The use of coal-tar products for the relief of the pain is ill advised, 
since not only are they comparatively inefficacious but they also add 
to the depression of an already depressed patient; the salicylates and 
olive oil (even when tolerated) also are of no value during the acute 
stage, although olive oil by inducing vomiting may assist in dislodging 
the stone. Sometimes it may relieve an associated hyperchlor- 
hydria. 
In many cases relief may also be afforded by hot fomentations over 
the region of the gall-bladder and by lavage of„the slomavli ' with water 
as hot as can well be borne. All food IsnouIT the 
continuance of the acute symptoms; indeed, the nausea and vomiting 
lead the patient usually to decline food. Vomiting ceases with the 
cessation of the pain, so that the best treatment for the vomiting is that 
which tends to relieve the pain and the lesions upon which it is founded. 
Should the vomiting persist and be manifest especially by ineffectual 
retching, resort should be had to lavage: if it has not been previously 
used, sodium bicarbonate may be added to the hot water. fAjpoUhath 
may also be resorted to at the very beginning of the attach with hope 
of excellent result/ In other cases the vomiting may be relieved by 
bismutip carbolic acid, sips of hot water and brandy, champagne, etc. 
In some cases the pain leads to extraordinary depression of the patient, 
which, if it is not relieved by the morphine, should be met with whisky 
or brandy in hot water, or the hypodermic use of camphor. 
Upon the subsidence of the pain, as well as in the absence of a definite 
gall-stone colic, the medical treatment is that of the chronic biliary 
infection. By promoting the flow of bile one may effect the discharge 
of infecting bacteria and their toxins from the biliary passages and 
prevent their ascent to the smaller ducts, and by the constant irrigation 
thus produced, as well as by other measures, one may allay the inflam- 
matory phenomena. Ultimately, the biliary tract may be rendered 
sterile, and should the inflammatory phenomena subside completely a 
condition of latency, quiescence of the gall-stones, results. In rare cases 
this latency is permanent, and the patient experiences no further com- 
plaints. In most cases a low-grade chronic catarrh of the gall-bladder 
persists; in other cases the gall-bladder readily again becomes infected, 
and the patient in consequence is continuously or intermittently ill. 
Should gall-stones be passed by the bowel, one must remember that all 
the gall-stones harbored by the patient are seldom, if ever, thus passed, 590 
DISEASES OF THE DIGESTIVE SYSTEM 
and that even were this the case, the persisting catarrh of the gall-bladder 
is quite certain to give rise to the formation of new stones. 
The diet should be carefully regulated. In character and amount it 
should be such as may be readily digested, and not overtax the resources 
of the liver and promote congestion; and the time intervals between 
meals should be such as tend to frequent and free emptying of the gall- 
bladder. Cholelithitic subjects should have a sufficient but not an 
excessive diet; in character it should be based less upon the mere presence 
of gall-stones than upon the attendant gastro-intestinal catarrh, constipa- 
tion, and jaundice (if present). In general a mixed diet is the best; this 
should contain considerable and varied protein, w'hich is believed to 
promote an abundant supply of bile acids and to stimulate the flow7 of 
the bile. In the presence of jaundice, proteins and readily digested 
carbohydrates should be advised, and the fats should be much reduced 
or excluded for a time, since they are ill digested in the absence of bile; 
but in the absence of jaundice it is unnecessary to prohibit fat on the 
mistaken apprehension that a fatty diet tends to increase the cholesterin 
in the bile. Naunyn has said that ajull meal is an excellent chplago^up, 
so that w7ith the hope of preventing stagnation" of the bile an additional 
meal may be given at bedtime, unless in some w7ay contra-indicated. 
In most cases it is wise to prohibit the usp,uLalcol^ 
The utility of large amounts of water, especially""of alkaline mineral 
waters containing sodium salts, is unquestionable. Since they have no 
solvent action on the gall-stones, and do not influence the alkalinity of 
the bile, their beneficial effect is probably on the associated biliary and 
gastro-intestinal catarrh. There is sortie experimental evidence that 
these waters do not directly stimulate the flow of bile, and that the 
excessive amount of fluid does not dilute the bile, but this doubtless 
results indirectly, the removal of biliary constituents from the intestine 
leading to renewed formation; and an insufficient supply of water tends 
to inspissation and stagnation of the bile. 
The treatment can often be best carried out at one of the w7ell-known 
spas, but equally good results may be obtained at the patient's home 
although they are unlikely. Of Carlsbad or similar w7ater, from a half 
pint to a pint should be taken hot on an qi^ty stomach half-to one hour 
before breakfast, and a similar amount in the middle of the afternoon^ 
in some cases the best results follow7 smaller amounts half an hour before 
each meal and on retiring at night. It is wise to begin with small doses) 
and gradually increase; the amount and the frequency of administration 
should be gauged by the result, particular attention being paid to free 
evacuation of the bowels. The saline cathartics, magnesium or sodium 
phosphate, may be used instead of the natural waters. The effect on 
the bowels may be enhanced by large injections of hot or cold water. 
Many drugs have been advocated in the treatment of cholelithiasis 
from time to time, but few have withstood the test of experience. 
Cholagogue properties have been ascribed to many that need not be 
mentioned; ^aJigylic acid and its preparations and preparations of the 
bile itself are efficacious. Salicylic acid seems to augment the flow7 of 
bile by stimulating its production, and since it also possesses antiseptic 591 
DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
properties and is excreted with the bile, it exerts a most desirable influence 
on the biliary infection. No preparation is better than chemically pure 
salicylic acid; it may be combined with sodium bicarbonate or sodium 
benzoate; or the salicylates or other preparations of salicylic acid may 
be given. Crowe1 demonstrated that hexamethylenamine is excreted 
in the bile and the pancreatic juice, directly through the wall of the 
gall-bladder, etc., and that, especially after single large doses (75 grains 
within twenty-four hours), it appears in the bile in such amount as to 
exert a decided bactericidal action. Ox-gall also stimulates the secretion 
and outpouring of bile, and thus favors drainage of the biliary tract; 
it should be administered as salts of the bile acids, such as sodium glyco- 
cholate (10 to 15 grains daily). Ammonium chloride also is sometimes 
extolled for its effect upon inflamed mucous membranes; by promoting 
the free flow of thin bile it may assist in flushing the biliary tract. 
Surgical Treatment.-In many cases medication is altogether ineffi- 
cacious, and resort must be had to surgical intervention. The important 
question to decide is, When should an operation be undertaken? The 
writer is by no means prepared to say that the diagnosis brings with 
it the indication for surgical intervention. In many cases the question 
of early operation scarcely admits of discussion. These are cases in 
which there is acute cholecystitis (with or without cholangeitis-jaundice), 
with evidences of severe infection, and in which the symptoms and 
local signs, instead of abating, become more pronounced: these comprise 
cases of acute cholecystitis developing during or after an attack of 
typhoid fever, as well as during the course of previously latent or manifest 
cholelithiasis, and in which impending if not actual infection of the 
hepatic ducts is not unlikely. The risk attending the progress of the 
disease in such cases is more than the hazard of the operation; indeed, 
without operation many would unquestionably soon terminate fatally. 
Happily, however, most of the acute infections of the biliary tract 
subside spontaneously or under treatment. In general, it is much wiser 
that the acute manifestations should subside without operation-which, 
should it be deemed desirable later, may then be undertaken with much 
more reasonable hope of ultimate success. 
Immediate operation is imperative also in the event of acute intestinal 
obstruction in a cholelithitic subject, or in a person in whom adhesions 
have been suspected. Operation, although not always necessarily 
immediate, is indicated in all cases of persistently enlarged gall-bladder, 
whether due to simple hydrops, empyema, or gall-stones. 
The question of when to operate in cases of gall-stones that have 
become or have been active must be decided in each individual case; 
but one should bear in mind that, as a rule, it is not the many stones in 
the gall-bladder that do the most damage, but the one or two stones 
that get into the ducts, that the special risk attending operations for 
gall-stones increases with delay, and that whereas gall-stones are readily 
removed from the gall-bladder, their removal from the ducts is commonly 
attended with serious difficulties and is sometimes impossible. The 
1 Johns Hopkins Hosp. Bull., 1908, xix, 109. 592 
DISEASES OF THE DIGESTIVE SYSTEM 
time of election for operation, therefore, is before the stones have entered 
the ducts. This is by no means always possible, or, indeed, desirable. 
Thus one should not advise the removal of stones that are and always 
have been quiescent. If, however, the gall-bladder is enlarged and the 
stones have given warnings-local discomfort and distress-operation 
should be undertaken. Nor would the writer insist upon operation after 
a single short successful gall-stone colic (so-called), but he would by no 
means be averse to it. Two, certainly three, attacks should be looked 
upon as a positive indication for operative intervention. In the event 
of hesitation on the part of the patient, the pathological changes and 
the likely course of the disease should be explained, and he should be 
required to make the decision for or against operation. 
In impaction of a gall-stone with chronic jaundice operation is called 
for; personal conviction is for early rather than delayed intervention. 
The risk of gall-stone operations is the risk of delay, since with delay 
serious infections of the biliary tract supervene, the tendency to pro- 
nounced hemorrhage increases with the persistence of the jaundice, the 
general nutrition of the patient fails, he becomes less able to withstand 
the vicissitudes of the operation, and stagnation of the bile leads to 
dilatation of the ducts and seriously compromises the functional activity 
of the liver cells. The decision as to the time of operation must be made 
for each individual patient, but there scarcely seems any advantage 
attending a delay beyond one or two weeks, and this, too, in full knowl- 
edge of the fact that some patients have recovered without operation 
after a much longer period. Finally, operation is indicated in those 
obscure cases in which with reasonable certainty the presence of peri- 
cholecystic, perigastric, or periduodenal adhesions may be surmised. 
In each of the foregoing classes of cases operative measures attain that 
which is impossible of attainment, or attainable only with difficulty by 
medicinal measures-whence surgical measures find their justification. 
They find additional justification in the fact that early intervention 
tends to prevent the development of certain complications and sequelae. 
An operation, however, should not be lightly undertaken in persons 
suffering with disorders of nutrition, or in those with faulty kidneys, 
etc. The risk attending the operation is too great and the recuperative 
power of the patient too much reduced to expect from operation a great 
deal more than can probably be attained by well-directed medicinal, 
hygienic, and dietetic treatment, aside from the fact that in the one 
instance the patient will remain alive, although indisposed, while in the 
other he may be much longer dead. Finally, the fact that the operative 
results are not always what were hoped for is not in itself a contra- 
indication to operation; on the contrary, these untoward results are 
often attributable rather to the fact that in many long-delayed cases 
the anatomical lesions are such as to be almost if not quite irremediable 
by any and all means at our command. DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
593 
CARCINOMA OF THE GALL-BLADDER AND BILIARY DUCTS 
Carcinoma of the gall-bladder and biliary ducts may be primary or 
secondary. The secondary cases are of comparative rarity and of little 
clinical importance; usually the lesions constitute a subordinate part of 
a general carcinomatosis. The metastases in the gall-bladder consist 
of nodules of varying size, rarely of a more diffuse infiltration on or just 
beneath the peritoneum; the mucosa is seldom involved. The biliary 
ducts are much less rarely implicated, although occasionally invaded 
from without in carcinoma of the pancreas, stomach, etc. These second- 
ary growths form usually only an insignificant part of the general metas- 
tasis, and can scarcely be recognized clinically, unless the irregular, 
nodular enlargement of the gall-bladder becomes conspicuous, or the 
cystic or common bile duct becomes obstructed. In the first of these two 
events hydrops of the gall-bladder may ensue, and in the other, chronic 
jaundice, which only with difficulty can be distinguished from other 
types of chronic jaundice. 
Primary carcinoma of the gall-bladder and the biliary' ducts is a 
tolerably frequent disorder-three to four times as common in the 
gall-bladder as in the biliary ducts. At the necropsy it is often difficult 
to determine definitely where the lesion began, but it seems desirable 
to exclude from the cases of primary carcinoma of the biliary ducts those 
in which the new growth developed from the fine intrahepatic ducts; 
these are virtually cases of carcinoma of the liver. When the extrahepatic 
ducts are involved, the disease may spread along the ducts and involve 
the gall-bladder, the pancreas, the omentum, etc., or primary disease in 
any of these structures may spread to the ducts. Thus carcinoma of 
the gall-bladder and of the cystic duct is virtually one disease, although 
sometimes it may be differentiated; carcinoma of the gall-bladder and 
of the pancreas may spread to the biliary ducts, and vice versa; carcinoma 
of the gastrohepatic omentum may originate in the biliary ducts; and 
in some cases so widespread is the new growth and so dense and cicatricial 
the adhesions that carcinoma, if at all suspected, can only with the 
greatest difficulty be referred to its true point of origin. In some cases 
the condition is thought to be inflammatory, and only a microscopic 
examination will disclose its real nature. With care, however, most 
cases can be correctly interpreted. Rare cases of sarcoma of the gall- 
bladder and biliary ducts have been described. 
Etiology.-Primary carcinoma of the gall-bladder is a fairly common 
disease. In 1889 Musser1 collected 100 cases; in 1901 Fiitterer2 collected 
268 cases. The disease is much more common in women than in men; in 
Musser's cases there were 75 females to 23 males (3 to 1); in Fiitterer's, 
204 females to 52 males (4 to 1). It is especially prevalent in advanced 
life; the average age in Fiitterer's cases was fifty-eight years. An impor- 
tant etiological question is the interpretation of the relationship between 
carcinoma of the gall-bladder and cholelithiasis. Frequently they are 
1 Boston Med. and Surg. Jour., 1889, cxxi, 525, 553, 581. 
2 Ueber die Aetiologie des Carcinoms, 1901. 594 
DISEASES OF THE DIGESTIVE SYSTEM 
associated: in 69 per cent, of the cases (Musser), in 78 per cent. (Fiit- 
terer), in 81 per cent. (Winton), in 85 per cent. (Zenker), in 91 per cent. 
(Courvoisier), in 95 per cent. (Siegert), and in 100 per cent. (Janowski). 
Rolleston, from a study of many statistics, estimates that carcinoma of 
the gall-bladder occurs in from 4 to 14 per cent, of cases of cholelithiasis. 
At 262 operations on the gall-bladder and biliary ducts done by Dr. 
Deaver, carcinoma was found in 6, of which 5 had also gall-stones. 
Carcinoma of the extrahepatic biliary ducts has been attentively studied 
by Rolleston, who has collected 90 cases. Of 85 of these, 50 (58.8 per 
cent.) occurred in males and 35 (41.1 per cent.) in females. In 58 (69.8 
per cent.) of 83 cases the patient was beyond fifty years of age; extremes 
of age wTere eight-one years (a woman) and twenty-nine years (a man). 
In contrast with carcinoma of the gall-bladder, gall-stones are much less 
frequently associated with carcinoma of the biliary ducts; in 67 of 
Rolleston's cases, gall-stones were present in 23 (34.3 per cent.). 
Carcinoma of the ampulla of Vater (choledochopancreatic duct) also 
has been studied by Rolleston, who has collected 19 cases; of these, 14 
were in males and 5 in females; the average age was 55.2 years in both 
sexes, the extremes being thirty-four and eighty-one years. Since gall- 
stones were present in only 2 of the 19 cases, it is likely, as Rolleston 
maintains, that there is no relationship between gall-stones and carcinoma 
of the ampulla of Vater. 
Pathology.-Carcinoma of the gall-bladder most commonly involves 
the fundus, which is said to be due to the fact that, being the most 
dependent part, the fundus is especially subject to irritation by a gall- 
stone; second in point of frequency of growth is the neck of the gall- 
bladder or the beginning of the cystic duct-attributed to the attrition 
of impacted gall-stones; third, the growth may be situated anywhere 
in the gall-bladder or involve the entire organ. In 45 of Fiitterer's 
cases the growth was situated at the fundus in 17, at the neck in 13, in 
the posterior wall in 8, and on the anterior wall in 7. Two types of 
growth may be distinguished: that which projects into the lumen, a 
villous or cauliflower-like growth, and is believed by some to originate 
as a papilloma, and that which infiltrates the wall of the gall-bladder, 
and is believed by some to originate as an adenoma. In reality the 
two varieties cannot be differentiated; the one growth may exhibit 
appearances significant of both types. Extension to the liver ensues in 
more than 50 per cent, from direct growth into the adjacent liver, or 
by extension along the biliary ducts, by way of the lymphatics in the 
wall, or through the lumen of the ducts. Adhesions between the car- 
cinomatous gall-bladder and adjacent organs are common. 
In the 90 cases of carcinoma of the biliary ducts collected by Rolleston 
the situation of the growth was as follows: In the common bile duct, 
34 (lower end 23, midpart 11); at the junction of the common bile duct, 
cystic duct, and common hepatic duct, 27; in the common hepatic duct, 
19; in the right or left hepatic ducts, 3 (the last two classes constitute 
the so-called juxtahepatic cases); in the cystic duct, 6; and in the cystic 
duct and the lower end of the bile duct, 1. Usually the growth infiltrates 
the wall of the duct and forms a firm annular stricture; occasionally it DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
595 
extends in the wall of the ducts for a considerable extent, and transforms 
them into thick rigid tubes; in some instances the growth projects 
considerably into the lumen, and produces obstruction rather than 
annular stricture. Complete biliary obstruction is produced, due in part 
probably to added muscular spasm, since after death the stricture does 
not always appear to be absolutely impervious. 
Above the growth the biliary ducts are dilated, sometimes to such an 
extreme degree as to allow a finger or a thumb to be introduced. When 
the growth is in the common bile duct the gall-bladder is distended, 
except it be bound down and retracted on itself in consequence of former 
cholelithiasis; when the growth is in the common hepatic duct, the 
gall-bladder is nearly always small, except in the rare instances in which 
it may be distended with mucus from concomitant obstruction of the 
cystic duct, or may be occupied by a number of gall-stones; when the 
growth is situated at the junction of the cystic, hepatic, and common 
bile ducts, the gall-bladder, as a rule, is not enlarged, but from irregular- 
ities and variations in the degree of obstruction to the different ducts, 
corresponding differences in the gall-bladder are met with. 
The liver, in addition to dilatation of the biliary ducts, reveals atrophy 
of the parenchymatous cells, focal necrosis, relative increase in the 
connective tissue, and in the event of chronic infection of the biliary ducts 
pericholangeitic fibrosis, but no true cirrhosis; suppurative lesions may 
follow acute infections. Usually the growth does not invade adjacent 
tissues or organs, but it may grow into the pancreas, liver, or portal 
vein (and cause portal thrombosis). Metastases are uncommon, largely 
because of speedy death; they are most common in the liver (13 of 57 
of Rolleston's cases); but they occur also in the regional lymphatic 
glands, the peritoneum (causing ascites), etc. 
Carcinoma of the ampulla of Vater (choledochopancreatic duct) should 
be distinguished from carcinoma of the termination of the common bile 
duct, of the termination of Wirsung's duct, and of the duodenal surface 
of the biliary capillaries. The growth tends to obstruct the orifice of 
Wirsung's duct and thus to produce dilatation of the intrapancreatic 
ducts and chronic interstitial pancreatitis; the same result may ensue 
upon extension to the orifice of Wirsung's duct of carcinoma of the 
lower end of the common bile duct. 
Symptoms.-The onset of the symptoms referable to carcinoma of the 
gall-bladder may or may not be preceded by symptoms due to associated 
disease-cholecystitis and cholelithiasis. Some patients complain for 
years of what is commonly called dyspepsia, but which careful inquiry 
would show to be in reality chronic cholecystitis with perhaps peri- 
cholecystic adhesions; in other cases there is a more or less clear history 
of antecedent gall-stones. There may have been many and recent attacks 
of obvious colic (with or without jaundice), or there may have been 
few, perhaps only one, remote and ill-defined attacks; that is, as perhaps 
occurs in most cases, the gall-stones have remained latent. 
The onset of the symptoms referable to the carcinoma is insidious, 
and usually the disorder makes considerable progress before its true 
nature is suspected. The patient, usually an elderly woman, complains 596 
DISEASES OF THE DIGESTIVE SYSTEM 
of ill-defined gastric symptoms, associated with more or less severe, 
sometimes colicky, pain. These are usually ascribed to dietetic indis- 
cretions; in some cases, however, the pain is so severe and perhaps 
referred to the right of the median line, and some local tenderness is 
found on examination, that the symptoms are put down to cholecystitis 
or cholelithiasis. The attack subsides, perhaps it recurs; the patient is 
thought to be the subject of cholelithiasis, and, indeed, in most cases, 
for some time the symptoms may be quite indistinguishable from chole- 
cystitis with pericholecystic adhesions. 
Soon, however, the gall-bladder enlarges, jaundice supervenes, or 
the general health becomes impaired. An obvious palpable and often 
visible enlargement of the gall-bladder develops in more than half of 
the cases; in itself it is not significant of carcinoma, since it resembles 
that due to cholelithiasis or obstruction of the cystic duct; in advanced 
stages, however, it may become quite irregular and nodular, whereupon 
it is much more significant of new growth. Usually it reveals its attach- 
ment to the liver by moving with it during the phases of respiration and 
showing no intervening area of tympany; sometimes it is fixed to the 
abdominal wall by adhesions, and it may be quite tender. In some 
cases the tumor is the first obtrusive evidence of the disease. 
Jaundice occurs in three-fourths or more of the cases (69 per cent., 
Musser; 86 per cent., Meurrier); but it is not always due to the same 
cause. Rarely it may result from duodenal catarrh or catarrhal cho- 
langitis, last a short time and subside; or it may be due to a gall-stone 
in the common biliary duct, when it is likely to be intermittent and 
perhaps accompanied by intermittent fever; usually, however, it is due 
to extension of the new growth into the biliary ducts, or to pressure 
from without on the extrahepatic biliary ducts. The jaundice in this 
event is progressive, soon becoming very deep, and it is permanent. 
With the progress of the disease the general health becomes impaired; 
this may be the first noteworthy evidence of its malignant nature. The 
patient gradually loses weight and strength, becomes anemic, and 
presents the manifestations of cachexia. Dyspeptic symptoms develop, 
or become aggravated, in which event they may be due only not to the 
original cholecystitis or cholelithiasis, but also to an associated pyloric 
obstruction. Occasionally the carcinoma may invade the colon, giving 
rise to obstruction, or to a cholecystocolonic fistula. In other cases the 
gall-bladder forms adhesions with the peritoneum, and ultimately 
perhaps perforates thereinto, giving rise to a localized or more generalized 
peritonitis. Ascites occurs in about one-fourth of the cases, and is due 
most commonly to associated perihepatitis or peritonitis; rarely it may 
be due to obstruction of the portal circulation by the original growth or 
secondarily involved glands. Ultimately in the cases with jaundice 
the patient develops a condition attributed to hepatic insufficiency 
(hepatic toxemia, cholemia) and dies with asthenia, delirium, and coma. 
In the absence of jaundice, the patient generally dies of asthenia. The 
disorder may run a fatal course within six months. 
The symptoms of carcinoma of the extrahepatic biliary ducts are usually 
insidious. There may be antecedent dyspeptic ,/mptoms of variable DISEASES OF LIVER, GALL-BLADDER, AND BILIARY DUCTS 
597 
duration, and ill-defined complaints of disturbance of the general health. 
Jaundice is usually the first noteworthy symptom. In most cases it 
develops gradually; occasionally rather suddenly, imitating catarrhal 
cholangeitis or a gall-stone arrested in the common duct. The jaundice 
is progressive and permanent; it soon becomes extreme, and biliary 
coloring matter disappears from the stools and appears in the urine. 
Pain in the right hypochondrium or the epigastrium is quite common, 
and is usually dull in character; sometimes it is severe, suggesting gall- 
stone colic, but it is more likely due to spasmodic contraction of the 
gall-bladder against an obstruction. Obstruction to the flow of bile 
results in enlargement of the gall-bladder, which is palpable in one-half 
or more of the cases as a smooth pear-shaped swelling. Metastasis occurs 
in about one-half of the cases, but the nodules are usually small and 
not palpable during life. Should metastasis occur, it may lead to 
ascites. Infection of the biliary ducts and suppurative cholangeitis may 
ensue. The symptoms of carcinoma of the ampulla of Vater are practically 
identical with those of carcinoma of the common bile ducts. 
Diagnosis.-Carcinoma of the gall-bladder is suggested by a history 
of ill-defined dyspeptic symptoms, perhaps interrupted by definite 
signs attributable to cholelithiasis or cholecystitis; pain in the right 
hypochondrium; jaundice; hard, nodular, and progressive enlargement 
of the gall-bladder; and gradual loss of flesh and strength. Attention 
to the sequence and grouping of the symptoms would probably permit 
of the diagnosis before the onset of jaundice, which is not a phenomenon 
of carcinoma of the gall-bladder itself, but of extension of the disease; 
but in the great majority of cases jaundice supervenes before the patient 
is thought to be seriously ill. Carcinoma of the biliary ducts is suggested 
by insidious but persistent and progressive jaundice, smooth, uniform 
enlargement of the gall-bladder, loss of flesh and strength, in a patient 
about or over fifty years of age, without determinable cause of jaundice. 
Carcinoma of the gall-bladder and biliary ducts is simulated by a 
number of other conditions, such as chronic cholecystitis and cholelithi- 
asis, carcinoma and other tumors of adjacent organs. Chronic chole- 
cystitis and cholelithiasis are, in most cases, antecedent to carcinoma 
of the gall-bladder, so that it is extremely difficult if not impossible, 
in most cases, to say when the new growth begins. The diagnosis is 
favored by the detection of progressive nodular enlargement of the gall- 
bladder; but in many cases the carcinoma develops when the chronic 
inflammatory process has lasted a long time and caused much thickening 
and many adhesions to adjacent viscera, so that should the growth not 
attain at least moderate dimensions, no specially noteworthy enlargement 
of the gall-bladder becomes apparent. The diagnosis in these cases 
awaits the development of cachexia, or of metastasis, especially to the 
liver. Obviously then the diagnosis is often impossible until the disease 
has progressed so far as to be hopeless. 
In the early stages, carcinoma of the gall-bladder may sometimes be 
distinguished from carcinoma of the liver, by the absence of jaundice, 
due to limitation of the new growth to the gall-bladder; but in the 
more advanced stages, when the disease is more widespread and involves 598 
DISEASES OF THE DIGESTIVE SYSTEM 
the liver more or less extensively, the diagnosis may be quite impossible, 
although a history of antecedent cholelithiasis or cholecystitis, and the 
early development of a tumor in the region of the gall-bladder without 
jaundice, suggests that the primary growth originated in the gall-bladder; 
while antecedent gastric, intestinal, genital, etc., symptoms, jaundice, 
and the early absence of a' tumor in the region of the gall-bladder, 
suggest that the liver rather than the gall-bladder was originally involved. 
Carcinoma of the head of the pancreas, causing jaundice, can scarcely, 
if ever, be distinguished from carcinoma of the biliary ducts, aside from 
the fact that carcinoma of the head of the pancreas is much more common, 
the pain is more likely to be epigastric than hypochondriac; a tumor 
deep in the epigastrium (close to the vertebrae) may sometimes be felt. 
In the early stages, carcinoma of the gall-bladder and of the biliary 
ducts may sometimes be distinguished by the absence of jaundice and 
the presence of an enlarged and nodular gall-bladder, and the early 
presence of jaundice and a smooth and uniform enlargement of the 
gall-bladder. Later, when jaundice occurs in carcinoma of the gall- 
bladder, the jaundice being due to extension to the ducts or pressure 
by enlarged glands on the ducts, the differences are slight. 
Carcinoma of the ampulla of Vater closely resembles carcinoma of 
the biliary ducts. Rolleston states that there are a few points of differ- 
ence: in carcinoma of the ampulla (1) jaundice is said to be often inter- 
mittent, the feces becoming bile-stained, and the icteric tint of the skin 
diminishing or even passing off in the earlier stages when the obstruction 
is possibly valvular, or partly due to spasm of the ducts set up by the 
irritation of the growth. Confusion is apt to arise between carcinoma 
of the ampulla and carcinoma of the duodenal surface of the papilla, 
in which jaundice is by no means constant; (2) intermittent hepatic 
fever and suppurative cholangeitis are apt to occur; (3) diarrhoea is more 
often seen than in carcinoma of the ducts. Attacks of diarrhoea may 
alternate with periods of obstinate constipation (Rolleston). 
Prognosis.-Carcinoma of the gall-bladder and the biliary ducts is 
necessarily fatal, unless it can be removed by surgical intervention. 
Under non-surgical treatment patients seldom live more than six months 
from the onset of serious symptoms. The mortality is high also under 
surgical treatment, many patients succumbing to the operation or to 
postoperative hemorrhage; in others the growth is too extensive to be 
removed; in others, recurrences ensue or a fistula persists. 
Treatment.-The treatment is essentially surgical. Since there is no 
known means of cure at the hands of the physician, his energies should 
be directed toward making an early diagnosis and urging surgical inter- 
vention. Even the suspicion of malignant disease is an indication for 
operation; the hazard of the operation is less than the risks attendant 
upon delay. Since carcinomas occur in from 4 to 14 per cent, of chole- 
lithitic subjects, the operative treatment of cholelithiasis naturally tends 
to reduce the incidence of carcinoma of the gall-bladder. Aside from 
the removal of the growth, a fistula may be established between the 
gall-bladder and the intestine in cases of carcinoma of the common 
duct or of the ampulla of Vater. Aside from operation, the physician's 
efforts are limited to relieving distress and promoting comfort. CHAPTER VIII 
DISEASES OF THE PANCREAS 
EUGENE L. OPIE, M.D. 
GENERAL PATHOLOGY AND SYMPTOMS 
Although the pancreas is essential to the normal digestion of proteins, 
carbohydrates, and fats, and controls the assimilation of carbohydrates, 
in only a small proportion of cases does disturbance of these functions 
indicate with certainty disease of the organ. Evidence of disturbed 
function is obtainable only when the gland is the seat of advanced 
disease. Complete extirpation of the gland in animals is followed both 
by glycosuria and by changes in the digestion of proteins and fats; 
partial extirpation may be unaccompanied by glycosuria or by disturb- 
ances of digestion, since a small part of the gland has been found to 
fulfil both the internal or metabolic and the external or secretory function 
of the gland. The impairment of function resulting from slight injury 
may be unrecognizable under ordinary conditions, and demonstrable 
only by special means which tax the capabilities of the organ. More- 
over, complete occlusion of the duct of Wirsung, which is usually the 
larger duct of the gland, does not necessarily prevent access of the 
secretion to the intestine, since the duct of Santorini, anastomosing 
with it, may be large enough to act as an outlet for the entire secretion. 
Symptoms Due to Impairment of Pancreatic Secretions.-These 
concern (1) the external secretion of the gland, indicated by disturbance 
of digestion or by the effects of retained secretion, and (2) the internal 
function of the organ, causing disturbance of carbohydrate metabolism. 
Since the pancreatic juice contains ferments which are concerned in the 
digestion of proteins, fats, and carbohydrates, impaired absorption of 
these constituents of the food may follow destruction of the secreting 
parenchyma or such occlusion of the ducts that pancreatic juice no 
longer enters the duodenum. 
Incomplete digestion of various elements of the food in association 
with pancreatic disease is indicated by passage of voluminous feces first 
noted by Oser. Schmidt1 has determined the weight of the dried feces 
in individuals receiving a test diet and has found that it may be doubled 
in patients with pancreatic disease. Pratt2 has made similar observations 
and has shown that separation of the pancreas from the duodenum 
may double the weight of the dried feces in dogs receiving a uniform diet. 
Steatorrhcea.-Although this has been regarded by Friedreich and 
other writers as a symptom of much diagnostic value, they recognized 
1 Test Diet in Intestinal Disease (Trans.), Philadelphia, 1906. 
2 Amer. Jour. Med. Sc., 1912, cxliii, 313. 
599 600 
DISEASES OF THE DIGESTIVE SYSTEM 
the fact that it accompanies only a small proportion of even grave 
pancreatic disorders. Finding jaundice associated with cases of pan- 
creatic disease, in which steatorrhoea indicated impaired absorption 
of fat, Fr. Muller has attributed the symptom to obstruction of the 
common bile duct. A review of recorded instances of steatorrhoea with 
pancreatic disease, made by Fitz1 in 1903, does not confirm this view, 
but establishes the diagnostic value of the symptom in the relatively 
small number of cases in which it occurs. He was able to collect from 
the literature 29 cases in which autopsy, laparotomy, or the passage of 
a pancreatic calculus gave evidence of disease of the gland, and in only 
12 of these cases was jaundice found. In the 17 cases in which jaundice 
was absent the lesion of the pancreas was in 7 cases tumor, usually cancer; 
in 6 cases calculi within the ducts; in 2 cases cysts with atrophy; in 2 
instances the lesion wTas designated fatty degeneration. In a case with 
symptoms of obstruction of the pancreatic ducts and no jaundice, studied 
by Pratt and Morrison, 58.9 per cent, of the fat of the food reappeared 
in the feces, whereas in normal individuals not more than 5 to 10 per 
cent, of fat is lost. 
In the recorded cases the character of the feces has varied considerably. 
In some instances superficial examination demonstrates the presence 
of free fat, which is described as oily or like butter, while in other cases 
the feces are described as gray, silvery gray, or asbestos-like. The fat, 
which is liquid when passed, may solidify on cooling and form a layer 
covering the fecal mass. The presence of fat recognizable by the eye 
constitutes a true steatorrhoea. 
In the uniform metallic-gray or asbestos-like stools sometimes seen, 
the abnormal fatty contents are demonstrated with greater certainty 
by chemical methods which may show the amount of neutral fat, fatty 
acids, and soaps. Such fatty stools may occur in normal individuals 
who have ingested fat in quantity so great that the normal limit of 
absorption has been exceeded. Ability to digest and absorb fat is dimin- 
ished, according to Nothnagel, when bile fails to enter the intestine, 
when absorption is hindered by certain diseases of the intestine or its 
lymphatic apparatus-namely, amyloid disease, extensive atrophy of 
the mucous membrane, caseation of the mesenteric lymphatic glands, 
and tuberculous peritonitis, or when very active peristalsis prevents 
the normal action of the digestive juices. 
Although Muller found in 2 cases of pancreatic disease no increase in 
the percentage of fecal fat, chemical analysis demonstrated a diminution 
of split fat. In health, according to his observations, the unabsorbed 
fecal fats consist of approximately from 20 to 30 per cent, of neutral 
fat and from 70 to 80 per cent, of split fat, which is partly fatty acids 
and partly soaps. In his twTo cases the split fat was diminished to 22.4 
and 47.7 per cent, respectively. In some cases of pancreatic disease 
access of pancreatic juice in considerable amounts to the intestine, even 
though the duct is partially occluded or the parenchyma partially 
destroyed, may explain the absence of diminished splitting of fat. Katz2 
1 Transactions of the Congress of American Physicians and Surgeons, 1903, vi, 36. 
2 Wiener med. Woch., 1899, xlix, 153. DISEASES OF THE PANCREAS 
601 
has maintained that diminution of fatty acids and soaps below 70 per 
cent, of the total amount of fecal fat indicates diminished action of the 
pancreatic juice, and only in nursing infants and in patients with profuse 
diarrhoea is the diagnostic significance of this condition lost. Fitz has 
collected from the literature 11 cases of pancreatic disease, confirmed 
by autopsy, in which analyses of the fecal fat had been made during life; 
in 7 instances jaundice was absent. The total amount of fat determined 
in 4 instances was slightly increased, but in no case apparently was 
there macroscopic steatorrhoea. The percentage of neutral fat in 7 
instances of uncomplicated disease of the pancreas was normal or less 
than normal in only 1 case, and although the results have not been 
constant, a well-marked diminution in the proportion of split fat has 
been usually present in such cases. 
Macroscopic or chemical evidence of diminished digestion and absorp- 
tion of fat, obtained by examination of the feces, indicates the presence 
of pancreatic disease when other disturbing influences, such as jaundice 
or intestinal diseases preventing absorption or hastening peristalsis, 
can be excluded. In the absence of macroscopic fat in the feces, demon- 
stration of diminished splitting of fat by chemical examination may 
suggest the presence of pancreatic disease. With the data at present 
available little significance can be attached to the proportion of fatty 
acids to soaps, although Zoja1 found diminution of the latter with 
pancreatic disease. 
The capacity of different individuals to digest fat varies within such 
wide limits that little information concerning impaired power of digestion 
can be obtained by observing the effect upon the feces of the admin- 
istration of a fixed amount of fat. Hartsen found no increase of fecal 
fat after administration of from eight to ten teaspoonfuls of cod-liver 
oil to two diabetics, in each of whom autopsy showed advanced atrophy 
of the pancreas. P 
By administering fresh pancreas to animals from which the pancreas 
has been removed the consequent impairment of fat absorption has 
been diminished. Abelmann found that the pancreas of the pig fed to 
a dog, the pancreas of which had been extirpated, caused a decrease in 
the amount of undigested fat and of protein as well in the feces. Similar 
observations have been made by other experimenters, and are confirmed 
by a few observations made upon patients with pancreatic disease. 
Fles, quoted by Friedreich, records the case of a man suffering with 
diabetes mellitus who passed undigested meat and fat in such quantities 
with the feces that it could be separated by ounces. A part of the milky 
fluid obtained by rubbing in a mortar half of the fresh pancreas of a 
calf with six ounces of water and straining the mixture was administered 
after each meal in such quantity that one pancreas was consumed daily. 
At the end of two days all fat had disappeared from the feces and the 
number of undigested fibres of striped muscle was greatly diminished. 
Whenever the administration of the infusion was discontinued, fat and 
muscle fibres reappeared in the feces. The condition of the patient 
1 Quoted by Oser, Die Deutsche Klinik, 1901, v, 151. 602 
DISEASES OP THE DIGESTIVE SYSTEM 
improved for a time, but diabetes mellitus persisted, and death occurred 
as the result of tuberculosis. Advanced sclerosis of the pancreas was 
found at autopsy. In a patient with jaundice and suspected cancer of 
the pancreas Oser observed improved digestion of fats following the 
administration of one gram of pancreatin (Merck) taken daily in divided 
doses. Tileston1 has collected the published cases in which the effect 
of pancreas or pancreatic preparations upon absorption has been studied 
in patients with pancreatic disease and has found that loss of both fat 
and nitrogen may be decreased. 
Little is known concerning the effect of continued steatorrhoea upon 
nutrition and health. Walker has described the case of a man who for 
twenty years passed large colorless stools of putrid odor, containing 
free oily or solid fat. There was no jaundice. During this time he was 
in good health and engaged in the practice of medicine; there was no 
marked emaciation. He died at the age of ninety years. The pancreas 
was apparently replaced almost wholly by fat, and its duct was occluded 
by an irregular calculus situated about an inch from the duodenum. 
Azotorrhoea.-The presence of undigested protein material in the feces, 
so-called azotorrhoea, has been less frequently observed in association 
with pancreatic disease than disturbed digestion of fat. After causing 
almost complete destruction of the pancreas in dogs, Claude Bernard 
found undigested muscle fibres and even large pieces of meat in the 
feces. Abelmann found that less than 2 per cent, of the nitrogen of 
the food reappears in the feces of normal dogs; when the pancreas is 
completely removed, 56 per cent, of ingested nitrogen was lost with the 
feces, whereas after partial removal 46 per cent, was lost. When the 
pancreas of the pig was administered, loss of nitrogenous material was 
diminished to approximately 24 per cent. Other observers have obtained 
similar results. In a case described by Wientraub autopsy demonstrated 
advanced chronic interstitial pancreatitis; in the feces during life he 
recovered 45.2 per cent, of the ingested protein and only 22.2 per cent, 
of the fat taken as food. Ue suggests that pancreatic disease causes as 
great disturbance of the digestion of proteins as of fats, perhaps an even 
greater disturbance, and is therefore distinguishable from intestinal 
disturbances such as amyloid disease, caseation of the mesenteric lymph 
glands, etc., which hinder absorption of fat alone. With closure of the 
duct of Wirsung by carcinoma, Zoja recovered from the feces nitrogenous 
material equal in amount to 70 per cent, of that taken in the food. In 
patient with obstruction of the pancreatic ducts Pratt and Morrison 
recovered 50.9 per cent, of nitrogen. 
The presence of undigested meat in the feces may give indication of 
disturbed protein digestion. Fles found well-preserved muscle fibres 
in the feces of the patient previously mentioned, and administration of 
an extract made from the pancreas of a calf caused their disappearance. 
Fitz collected from the literature only 8 cases in which the presence 
of undigested muscle fibres in the feces had been associated with clearly 
demonstrated pancreatic disease; in 5 of these cases steatorrhoea was 
1 Trans. Assoc. Amer. Phys., 1911, xxvi, 537. DISEASES OF THE PANCREAS 
603 
present. The condition, as he pointed out, probably occurs only when 
there is extreme diminution of the pancreatic juice, and is significant 
only when gastric digestion is normal, when the diet contains no excess 
of meat, and where there is no diarrhoea. 
The persistence of nuclei in remnants of muscle fibres passed with the 
feces has been proposed by Adolph Schmidt as a test of the efficiency of 
pancreactic digestion. He maintains that the nuclear material of meat 
can be digested only by the pancreatic juice, and the presence of nuclei 
in muscle fibres expelled with the feces indicates defective pancreatic 
secretion. The test has no value if the cubes remain in the intestine 
less than six or more than thirty hours, for putrefaction may destroy 
the nuclei. Kashiwado1 has isolated the nuclei of the thymus by gastric 
digestion and stained them with hematoxylin; 0.5 gram of a powder 
composed of equal parts of partially digested thymus and lycopodium 
are administered in capsules. The nuclei, if undigested, are recognized 
in the feces. 
Beef muscle failed to lose its nuclei w'hen passed through the intestinal 
canal of three dogs from which the pancreas had been removed; Pratt 
has confirmed this observation. Steele2 found the test little more than 
an index of proteolytic digestion in the intestine, giving only vague 
information concerning the pancreatic secretion. 
With methods for demonstrating the presence of trypsin in the feces 
by digestion of the surface of serum agar plates (Edw. Muller and Schlect) 
or of casein (Gross) the attempt has been made to test the activity of 
pancreatic secretion. Boldyreff and later Volhard have demonstrated 
that regurgitation of trypsin into the stomach may be brought about 
by administration of olive oil, and Einhorn3 has devised a method which 
permits removal by intubation of duodenal contents. Absence of trypsin 
with these procedures has been regarded as evidence of impairment of 
pancreatic function. Methods of measuring the activity of diastatic 
enzymes in the feces have been employed with the same end in view. 
Since end-products of pancreatic digestion are readily attacked by 
bacteria, impairment of pancreatic excretion has been believed to 
diminish the amount of ethereal sulphates in the urine (Rosenberg). 
Edsall4 thinks that diminution of ethereal sulphates in the urine should 
suggest pancreatic disease when conditions are present which usually 
cause their increase. He recognizes, however, that ethereal sulphates may 
be diminished with a variety of diseases which do not affect the pancreas. 
In favor of his opinion he cites a case of carcinoma of the pancreas, 
demonstrated by autopsy, and the cases of LeNobel and of Taylor, in 
which the same lesion was probably present. 
By applying the phenylhydrazine test for sugar to urine previously 
boiled with strong hydrochloric acid, Cammidge5 has obtained sheaves 
of yellow crystals which he believes indicate pancreatic disease. 
1 Deutsch. Arch. f. klin. Med., 1911, civ, 584. 
2 University of Pennsylvania Medical Bulletin, 1906, xix. 
3 Jour. Amer. Med. Assn., 1910, Iv, 6. 
4 American Journal of the Medical Sciences, 1901, cxxi, 401. 
5 British Medical Journal, 1906, i, 1150. 604 
DlSEASES OF THE DIGESTIVE SYSTEM 
Impairment of the Metabolic Function of the Pancreas.-Glyco- 
suria and diabetes mellitus are so frequently associated with pancreatic 
disease that it is necessary to consider them among its symptoms and 
to define the peculiarity of those lesions which cause disturbance of 
carbohydrate metabolism. The relation of the islands of Langerhans 
to carbohydrate metabolism has been described in the chapter on 
Diabetes Mellitus. Study of the histological anatomy of pancreatic 
disease has furnished data by which it is possible to define the anatomical 
basis of diabetes mellitus. In 1904 Sauerbeck1 was able to collect from 
the literature of the subject 176 cases of diabetes mellitus studied by 
observers who have given attention to the islands of Langerhans; it has 
been possible to collect 112 additional cases which have since become 
available.2 In some instances different writers have described the same 
change under different names. For example, the same lesion has been 
designated atrophy and chronic pancreatitis, and rarely has a distinction 
been made between atrophy causing diminution in the size of the gland 
and congenital smallness of the gland. The lesion designated lipomatosis 
introduces further error, for in some cases it indicates a moderate increase 
of the interstitial fat, and is a trivial abnormality which is not responsible 
for the existing glycosuria, whereas in other cases increase of fat is the 
result of interstitial inflammation, and is accompanied by sclerosis or 
hyaline degeneration of the islands of Langerhans. From the available 
records it is often impossible to classify such cases. The findings are 
as follows: 
Interacinar pancreatitis 123 
Atrophy 65 
Lipomatosis 18 
Interlobular pancreatitis with no occlusion of ducts 13 
Lithiasis 9 
Cyst 1 
Carcinoma 5 
Focal necrosis 2 
Secreting parenchyma normal or approximately normal: 
Hyaline degeneration of islands of Langerhans 6 
Sclerosis " " 4 
Diminution " " 5 
Hypertrophy " " 3 
Normal 34 
288 
Among 90 cases of diabetes more recently studied by Cecil3 interacinar 
pancreatitis which represents the lesion often designated atrophy was 
present in 63 instances, interlobular pancreatitis in 4 instances; in 12 
instances these were lesions of the islands of Langerhans but no changes 
in the secreting parenchyma, and in 11 instances no pathological changes 
were found. 
Hypertrophy of the islands of Langerhans which has been observed 
with diabetes mellitus is of two kinds: (1) Simple hypertrophy, which 
1 Lubarsch and Ostertag, Ergebnisse der allgem. Path., 1904, viii, 588. 
2 Opie, Disease of the Pancreas, Philadelphia and London, 1910. 
3 Jour. Exper. Med., 1909, xi, 266. DISEASES OF THE PANCREAS 
605 
accompanies destructive lesions of these structures (Schmidt, Pearce1), 
and (2) adenoma-like hypertrophy, which may occur in young individuals 
without other lesions of the islands of Langerhans (Herxheimer, Reit- 
mann, MacCallum2). Hypertrophy doubtless occurs because existing 
islands of Langerhans are insufficient to meet the functional demand. 
It is noteworthy that in a considerable number of cases of diabetes 
no lesion of the pancreas is demonstrable. Experimental and pathological 
data establish with certainty that diabetes mellitus may be the result 
of pancreatic disease, and save in a comparatively small percentage 
of cases this origin is demonstrable. That the islands of Langerhans 
and secreting parenchyma are normal in a group of cases does not oppose 
the theory that lesions of the former are responsible when the pancreas 
is the source of the disease, for it equally opposes any theory of pancreatic 
diabetes. It is not improbable that complex carbohydrate metabolism 
may be disturbed by factors which do not concern the pancreas. 
The foregoing considerations make it possible to define with greater 
accuracy the conditions under which glycosuria and other symptoms 
of diabetes occur as symptoms of pancreatic disease, and to determine 
the relation which diabetes holds to steatorrhoea, azotorrhoea, and other 
evidence of an insufficient supply of pancreatic juice. Since sclerosis 
of the islands of Langerhans or hyaline degeneration of these structures 
may occur in the presence of little or no change affecting the secreting 
acini, diabetes may occur without digestive symptoms of pancreatic 
insufficiency, and indeed, the greater number of cases of pancreatic 
diabetes belong to this group. Destructive lesions, such as abscess, 
acute hemorrhagic pancreatitis and diffuse carcinoma invading the 
gland, destroy equally islands of Langerhans and secreting acini, and 
in the majority of instances affect a previously healthy gland. The 
resulting condition resembles that which follows partial extirpation, 
and is accompanied by diabetes only in the comparatively rare cases 
in which almost the whole gland is destroyed. 
Occlusion of the pancreatic ducts does not cause diabetes, and the 
resulting chronic interlobular pancreatitis is accompanied by the disease 
only when it has reached the advanced stage, in which the parenchyma 
is largely replaced by dense fibrous tissue. When the pancreatic ducts 
have been occluded by calculi or by new growth, steatorrhoea and perhaps 
other symptoms of deficiency of pancreatic juice may occur without 
diabetes; of the 29 cases of steatorrhoea collected by Fitz, in 11 diabetes 
was present. It is not improbable that the application of chemical 
methods to the examination of feces would demonstrate insufficiency 
of pancreatic digestion in a much larger number of instances of duct 
obstruction at a time when diabetes has not appeared. 
Histological studies have explained the relationship of a variety of 
diseases, such as arteriosclerosis and cirrhosis of the liver, to diabetes 
mellitus. Grube found arteriosclerosis 66 times among 117 cases of 
diabetes. Chronic interstitial pancreatitis accompanying sclerosis of 
the pancreatic vessels has been described; this change which affects 
1 Albany Medical Annals, 1904, xxv, 329. 
2 Amer. Jour. Med. Sci., 1907, cxxxiii, 432. 606 
DISEASES OF THE DIGESTIVE SYSTEM 
the interacinar tissue of the gland implicates the islands of Langerhans. 
G. Hoppe-Seyler,1 who has studied 18 such cases, found a close relation 
between the severity of the glycosuria and the degree of change affecting 
the islands of Langerhans. The frequency with which diabetes is caused 
by disease of the arteries is shown by 112 cases of diabetes which have 
been recently recorded; in association with general arteriosclerosis there 
was, in 23 cases, sclerosis of the pancreatic arteries and interacinar 
pancreatitis; in 26 additional cases there was either general or local 
arterial sclerosis, in 10 instances with interacinar pancreatitis. 
The frequency with which diabetes inellitus accompanies cirrhosis of 
the liver has been explained by the presence of chronic pancreatitis. 
Numerous studies have shown that conditions which cause cirrhosis 
of the liver act upon the pancreas and cause chronic inflammation. 
The literature contains numerous instances of this association, which 
is well exemplified by the disease known as hemochromatosis; pigmentary 
cirrhosis of the liver is accompanied by chronic pancreatitis, which 
invades the islands of Langerhans and causes diabetes (diabete bronze). 
That alimentary glycosuria demonstrable by the administration of a 
fixed quantity of sugar may accompany a variety of pancreatic lesions 
is shown by the investigation of Wille. From 70 to 100 gm. of grape 
sugar dissolved in half a liter of coffee were administered in the morning 
before other food had been taken to 800 patients suffering with a great 
variety of diseases. Subsequently 77 of them came to autopsy. Tem- 
porary glycosuria had been produced in 15 of these, and grave lesions 
of the pancreas were found in 10-namely, chronic interstitial inflam- 
mation, or carcinoma of the gland, either primary or secondary to tumors 
in the stomach, liver, or gall-bladder. Alimentary glycosuria may occur 
in the absence of pancreatic lesion with a variety of diseases, especially 
with hysteria and other neuroses, chronic alcoholism, and exophthalmic 
goitre. Its occurrence, however, may give information when other 
conditions suggest the presence of pancreatic disease of moderate 
intensity. Hoppe-Seyler tested the ability of individuals with arte- 
riosclerosis to assimilate 100 gm. of glucose. Alimentary glycosuria 
was present in 42 per cent, of 62 patients with arteriosclerosis, and was 
more frequently observed when arteriosclerosis was associated with 
acute alcoholism. 
FAT NECROSIS 
This lesion, characterized by the death of fat cells in sharply circum- 
scribed areas, is frequently associated with disease of the pancreas. By 
some writers (Balser) it has been regarded as an often fatal disease 
accompanied by certain somewhat indefinitely defined symptoms. The 
lesion when widely disseminated is, in the greater number of instances, 
the result of acute hemorrhagic pancreatitis. Its recognition is of great 
importance to the surgeon, since the presence of the characteristic 
opaque white foci studding the translucent abdominal fat will explain 
the nature of otherwise obscure conditions. 
1 Deutsches Arch. f. klin. Med., 1904, Ixxxi, 119. DISEASES OF THE PANCREAS 
607 
Etiology.-The inconstant results of bacteriological examinations 
do not support the opinion of a few observers (Ponfick) who have 
maintained that the lesion is caused by bacteria. Its relation to bacteria 
is doubtless that suggested by Welch, who obtained the colon bacillus 
from foci of fat necrosis in association with hemorrhagic pancreatitis; 
diphtheritic and ulcerative colitis apparently had facilitated the entrance 
of B. coli, which were found not only in the patches of necrotic fat but 
in the mesenteric lymph glands, liver, bile, lungs, spleen, and kidneys. 
Experimental Fat Necrosis.-Studies of II. Langerhans first brought 
the lesion into relation with the peculiar physiology of the pancreas. 
He was able to demonstrate that the fat of the necrotic cell is split into 
fatty acids, which are deposited as needle-like crystals, and glycerin, 
which is absorbed. The occurrence of the lesion in association with 
disease of the pancreas, its greatest intensity in the neighborhood of the 
gland, and the changes demonstrable within the fat cells have suggested 
the probability that the pancreatic ferments, particularly the fat-splitting 
ferment, have an important part in its production. Hildebrand and 
Dittmer subjected the pancreas to a variety of injuries and produced 
fat necrosis. If the gland were simply cut across, thus allowing the 
escape of the pancreatic secretion, foci of necrosis were found in the 
immediate neighborhood of the gland. If penetration of pancreatic 
secretion into fat tissue is facilitated by transplanting the duodenal part 
of the pancreas containing the severed ends of the ducts into the sub- 
cutaneous fat of the abdominal wall in cats, extensive subcutaneous 
necrosis of fat is thus produced (Opie). In these experiments conditions 
have been present which afford an opportunity for the escape of pancreatic 
secretion into the tissue surrounding the gland. Flexner has demon- 
strated the presence in the necrotic foci of a ferment capable of splitting 
neutral butter fat and setting free acids which are recognizable by suitable 
tests. That the lesion is caused by a ferment is further shown by the 
experiments of Wells;1 watery extracts of the pancreas of the hog con- 
stantly produce fat necrosis in cats and dogs, but fail to do so when 
boiled or after heating to a temperature above 71° C. Whether the 
lesion is wholly due to the action of the fat-splitting ferment or is the 
result of its action on tissue previously injured by some other constituent 
of the pancreatic juice, perhaps by the proteolytic ferment, is not yet 
definitely determined. 
Incidence of Fat Necrosis.-In human cases extensive fat necrosis 
is more frequently associated with hemorrhagic and gangrenous pan- 
creatitis than with other lesions of the gland, and constantly accompanies 
acute hemorrhagic pancreatitis produced experimentally by the introduc- 
tion of a great variety of irritant substances into the gland. The well- 
known fact that bile forms a favorable medium for the action of the 
pancreatic ferments, and particularly of the fat-splitting ferment, the 
activity of which may be increased by it twofold or threefold, probably 
explains in part the extent of the lesion accompanying many cases of 
hemorrhagic pancreatitis which may be caused by the penetration of 
1 Jour. Med. Research, 1903, ix, 70. 608 
DISEASES OF THE DIGESTIVE SYSTEM 
bile into the panereas. Fat neerosis has been found with obstruction 
of the duct of Wirsung caused by pancreatic calculi, by biliary calculi, 
or by carcinoma invading the head of the pancreas, but in such cases 
foci of necrosis are not abundantly distributed, nor does the lesion 
usually follow obstruction of the pancreatic duct. In a small proportion 
of cases chronic interstitial pancreatitis is accompanied by fat necrosis, 
which is probably caused by constriction of small branches of the 
pancreatic duct. 
In several cases of extensive fat necrosis no noteworthy lesion of the 
pancreas has been demonstrable. In such a case described by Fraenkel 
the lesion was explained by a gall-stone lodged in the diverticulum of 
Vater, while in a somewhat similar case of Flexner's, gall-stones were 
present in the common bile duct near its termination. A unique case 
described by Wulff1 is not in accord with other observations and with 
present knowledge of the lesion is unexplainable, unless an incomplete 
autopsy failed to disclose an aberrant pancreas, biliary calculi, or some 
cause of duct obstruction. 
Pathological Anatomy.-A feature of the lesion is its occurrence in 
sharply defined foci. On opening the abdomen the omentum and perhaps 
fat in other situations is found to be studded with rounded or oval areas, 
which vary in diameter from less than one to five or more millimeters. 
They are very conspicuous, on account of their opaque, white or yellowish 
color, in sharp contrast with the translucent golden yellow of the fat in 
which they occur. These areas are not infrequently surrounded by a 
narrow hemorrhagic zone. Such foci are most numerous upon the 
peritoneal surface, usually extending only a short distance below it, 
but also occur embedded in the fat. Particularly in the neighborhood 
of the pancreas, where they are most numerous, foci of necrosis may be 
large and confluent, giving a tallow-like whiteness to extensive areas of 
fat. Discrete foci in greater or less number may stud the perinephritic 
fat, the mesocolon, the mesentery, and the omentum. Foci of necrosis 
occur less frequently below the parietal peritoneum and upon the surface 
of the diaphragm. 
In some instances fat necrosis has extended beyond the peritoneal 
cavity. Hansemann has twice seen foci of necrosis in the subcutaneous 
fat, while in severeal instances the fat of the pericardial and pleural 
cavities has been implicated. Chiari has described a remarkable instance 
of widespread fat necrosis. Gangrenous pancreatitis had caused such 
complete disintegration of the gland that the duct of Wirsung was 
eroded and communicated directly with the cavity of the bursa omentalis; 
areas of the fat necrosis, often the size of a pea, were present about the 
lesser peritoneal cavity, in the mesentery, in the subperitoneal fat of 
the abdominal wall, in the subpericardial and subpleural fat, and in the 
subcutaneous tissue. 
Microscopic examination of the foci of necrosis shows that the cells, 
of which the outlines are still preserved, although the nuclei have dis- 
appeared, contain at an early stage crystals of fatty acid. Calcium 
1 Berliner klin. Woch., 1902, xxxix, 734. DISEASES OF THE PANCREAS 
609 
salts combine with these fatty acids to form calcium salts readily demon- 
strable by microchemical reactions. A few polynuclear leukocytes find 
their way into the necrotic tissue, but wThen numerous their presence 
is due to secondary infection. According to Wells the lesion experiment- 
ally produced may be recognizable three hours after the application of 
pancreatin to fat. Proliferation of fixed tissue cells occurs in the periphery 
of the necrotic area. The lesion may so completely disappear that its 
site is no longer recognizable. Wells found fat necrosis in a dog of which 
the abdomen wras opened four days after the injection of pancreatin, 
but seven days later the lesion had completely disappeared. In a case 
of acute cholecystitis Korte found at operation typical areas of fat 
necrosis; the patient recovered, but at a second operation, undertaken a 
year later for the relief of symptoms suggesting the presence of a gall- 
stone in the common bile duct, foci of necrosis were no longer present. 
Clinical Significance of Fat Necrosis.-The facts already cited demon- 
strate that the lesion is caused by pancreatic juice diverted from its proper 
channels into the tissues about the gland. When the outflow of bile is 
obstructed, the bile dammed back upon the liver reaches the interstitial 
tissue of the gland, and hence is transported to all parts of the body. 
When the secretion of the pancreas, likewise dammed back upon the 
gland, reaches the interstitial tissue of the organ, and hence, probably 
by way of the tissue spaces finds its way into tissues at some distance 
from the gland, its presence is not indicated by any colored constituent; 
as yet, moreover, there is no certain means of identifying constituents 
of the pancreatic juice in the urine. Focal fat necrosis is in such case 
the only readily recognizable effect of the aberrant secretion, and for 
diagnosis of pancreatic disease is available only to the surgeon who opens 
the abdomen. Hansemann has mentioned a unique case in which cir- 
cumscribed areas of cutaneous injections marked the site of foci of 
necrosis shown by postmortem examination to be situated in the sub- 
cutaneous tissue of the abdominal wall, but rarely does the characteristic 
lesion implicate fat outside of the abdominal cavity. 
Since disseminated foci of fat necrosis indicate in most instances acute 
hemorrhagic or gangrenous pancreatitis, its recognition at operation is 
of great importance. By those who have not previously seen the lesion 
it may be mistaken for caseous miliary tubercles or for carcinomatous 
nodules which have undergone necrosis, but the absence of elevation 
or other evidence of newly formed tissue shows that necrosis has affected 
the fat. 
Since abundant evidence has shown that fat necrosis is due to the 
action of the fat-splitting ferment secreted by the pancreas, the possibility 
suggests itself that the ferment which is free in the tissues may be excreted 
by the kidneys. Recognition in the urine of a fat-splitting ferment 
derived from the pancreas would afford means for the diagnosis of 
obscure pancreatic disease accompanied by fat necrosis. With the urine 
removed at autopsy from the bladder of an individual dead with acute 
hemorrhagic pancreatitis and fat necrosis, the writer obtained a reaction 
which indicated the presence of the fat-splitting ferment. The method 
of identifying this enzyme was that described by Kastle and Loevenhart, 610 
DISEASES OF THE DIGESTIVE SYSTEM 
who showed that the presence of fat-splitting ferment may be demon- 
strated by use of ethyl butyrate. Experiments of Hewlett1 show that 
a variety of injuries to the pancreas of dogs is followed by the appearance 
in the urine of a ferment which is capable of decomposing ethyl butyrate 
into butyric acid and alcohol. Very little if any of such ferment is 
present in the normal urine; after obstruction of the pancreatic duct he 
found it during a period of from three to five days, but it is present in 
greatest amount as the result of experimental hemorrhagic pancreatitis. 
The method which Hewlett describes in detail can be used to examine 
the urine when pancreatic disease with fat necrosis is suspected. 
HEMORRHAGIC NECROSIS OF THE PANCREAS 
The Middleton-Goldsmith Lecture of Fitz, published in 1889, contains 
a classification of acute pancreatic diseases which served as a basis for 
the first accurate description of their symptomatology. He found that 
acute inflammation of the gland may be hemorrhagic, gangrenous, or 
suppurative. His description of the symptomatology of so-called acute 
hemorrhagic pancreatitis has made typical instances of the condition 
recognizable during life. Gangrenous pancreatitis, according to Fitz, 
although it may follow other conditions, is usually the result of the 
hemorrhagic lesion. Suppurative pancreatitis resembles suppurative 
inflammation of other organs. Fitz noted the relationship of so-called 
fat necroses to acute pancreatic disease, already suggested by Chiari, 
and found that it more frequently accompanied hemorrhagic and 
gangrenous than suppurative inflammation. 
Suppurative pancreatitis does not differ from similar lesions of other 
organs and is described in a special section (page 622). Study of the 
changes which occur with the hemorrhagic and gangrenous lesions of 
the gland shows that necrosis is the underlying change. Inflammation 
is absent at the onset of the disease. Experimental studies have shown 
that the lesion with all the characters which occur in man, can be repro- 
duced in animals by a variety of irritants which produce necrosis of the 
pancreatic parenchyma. Necrosis implicating the walls of bloodvessels 
is accompanied by hemorrhage and at the margin of the necrotic tissue 
there is accumulation of inflammatory products. The condition described 
as gangrene, characterized by discoloration and softening of necrotic 
tissue infiltrated with blood, represents a late stage of the same lesion. It 
is unnecessary to describe gangrenous pancreatitis as a disease separable 
from hemorrhagic necrosis. 
Pancreatic Hemorrhage.-Those who have systematically described 
diseases of the pancreas have given special consideration to so-called 
pancreatic apoplexy or hemorrhage into the pancreas; the condition has 
medicolegal interest, since it is believed to be one of the causes of sudden 
death. Hemorrhage into the substance of the gland may be caused 
by traumatism, or by malignant growth, and minute extravasations 
1 Jour. Med. Research, 1904, xi, 377. DISEASES OF THE PANCREAS 
611 
may be associated with various infectious diseases; such hemorrhage 
presents nothing peculiar to the organ. The literature contains 
numerous cases in which a hemorrhagic lesion of the gland has been the 
only explanation of the rapidly fatal illness of an apparently healthy 
individual. In some cases cited as examples of pancreatic hemorrhage, 
as Seitz explains, it is improbable that the pancreatic lesion has been 
the cause; whereas, in other cases, such as those described by Reubold 
and Rehm, after poisoning with morphine, after strangling, or after 
hemorrhage from the femoral vein, the amount of blood in and about 
the gland has been so small that it may be referred to the hemorrhagic 
extravasation which Chiari has described in association with postmortem 
or agonal self-digestion. 
Numerous cases have demonstrated that extensive hemorrhage into 
the peripancreatic tissues may occur with so-called hemorrhagic pan- 
creatitis; necrosis is primary, and the hemorrhage and inflammation are 
its consequences. When both inflammation and hemorrhage coexist, the 
difficulty of deciding which preceded the other is obviously great, for 
an accumulation of blood in and about the duodenum would quickly 
become the seat of bacterial infection, and an abscess cavity would be 
formed. The existence of hemorrhage without evidence of inflammation 
has been believed to demonstrate the occurrence of so-called apoplexy. 
Atheroma of arteries and fatty degeneration of the pancreatic paren- 
chyma, cited as causes of hemorrhage, have been found in only a limited 
number of cases. Knowledge of the pathology of hemorrhagic necrosis 
of the pancreas, recently acquired, has facilitated the description of 
such cases, and the literature of the last few years contains few, if any, 
instances of so-called apoplexy. An instance of pancreatic hemorrhage 
is described by Simpson. The pancreas was the seat of hemorrhagic 
infiltration and the organ was surrounded by semifluid clotted blood. 
In view of subsequent observations the presence of a gall-stone lodged 
at the orifice of the common bile duct leaves little doubt that this case is 
a typical example of hemorrhagic necrosis. It is improbable that the 
pancreas is more susceptible to hemorrhage than other parenchymatous 
organs. 
Etiology.-Hemorrhagic necrosis of the pancreas occurs more frequently 
in men than in women. Among 41 instances of the hemorrhagic lesion 
Korte found 37 were in males and 4 in females; in 40 cases of so-called 
gangrenous pancreatitis, 21 were in males and 19 in females. The disease 
appears to have a more rapidly fatal course in men than in women. 
Of 121 cases of hemorrhagic and gangrenous pancreatitis cited by Reiser,1 
79 were in males and 42 in females. The greater number of cases occur 
between the ages of twenty and fifty years. 
A variety of conditions has been believed to favor the disease. Indi- 
viduals in apparent good health are not infrequently attacked; those 
with abundant adipose tissue are said to be specially susceptible. 
About half the cases of hemorrhagic and of gangrenous pancrea- 
titis, Fitz found, are preceded by attacks of indigestion, accompanied 
Deutsche Zeit. f. Chir., Ixv, 612 
DISEASES OF THE DIGESTIVE SYSTEM 
by pain either referred to the region of the stomach or believed to 
be biliary colic. In a few instances anatomical evidence of gastritis 
and duodenitis has been obtained, but its etiological relation is doubtful. 
In two cases Simon and Stanley found intense gastroduodenitis with 
cellular infiltration of the duodenal submucosa, and since the duct of 
Wirsung was inflamed, they thought that the pancreatic lesion was the 
result of ascending inflammation. In one of these cases there was 
jaundice, and a calculus was found in the gall-bladder; the passage of a 
gall-stone may perhaps explain the occurrence of the lesion of the pancreas. 
In a case of Reynold and Moore there was gangrenous duodenitis, and in 
six cases cited by Gessner there was severe gastritis. It is not improbable 
that such lesions may be secondary to the pancreatic disease. It has 
been suggested by Reiser, who has described a case in which hemorrhagic 
pancreatitis occurred two and a half weeks after childbirth, that pregnancy 
may favor its onset. Of the 8 cases which he cites, 5 occurred from five 
weeks to five months after labor and the relationship is doubtful. 
From the hemorrhagic pancreas and from the associated foci of fat 
necrosis, a variety of bacteria, in many instances B. coli, has been isolated, 
but according to almost all observers the results of bacteriological 
examination, which have been very inconstant, indicate that the various 
organisms bear no etiological relation to the disease and are secondary 
invaders. The acutely inflamed gland may contain no bacteria. 
Experimental Pancreatitis^-Experiments of Hlava have shown that 
the lesion of acute hemorrhagic pancreatitis can be reproduced by 
injecting artificial gastric juice into the pancreatic ducts of dogs. A 
similar lesion which has followed the introduction of cultures of B. coli, 
B. lactis aerogenes, and B. capsulatus of Friedlander, the same writer 
has attributed to the acid products of these organisms. Carnot repro- 
duced the lesion by injecting diphtheria toxin, and Flexner used weak 
solutions of hydrochloric, nitric, and chromic acids, sodium hydroxide, 
and formalin. Hlava has suggested that gastric juice may be driven 
by antiperistaltic action of the intestine into the pancreatic ducts. 
In a case described by Opie and Meakins1 hemorrhagic necrosis was 
limited to the domain of an unusually large accessory pancreatic duct 
which entered the duodenum between the pylorus and the orifice of the 
common bile duct. 
Traumatic Pancreatitis.-Hemorrhagic and gangrenous pancreatitis 
with disseminated fat necrosis has in a few instances so directly followed 
abdominal injury that the relation to traumatism cannot be doubted. 
Injury to the pancreas is usually associated with such severe damage 
to adjacent structures that a fatal result is rarely referable to the gland. 
Incisions into the pancreas of animals heal readily, while in 7 of 12 cases 
cited by Mikulicz-Radecki recovery occurred, although operation had 
demonstrated a wound of the pancreas. In a small number of cases 
hemorrhagic and gangrenous pancreatitis has followed blows upon the 
epigastric region which have not produced superficial wounds. A case 
is described by Selberg. A man, aged thirty-eight years, was kicked 
1 Jour. Exp. Med., 1908. DISEASES OF THE PANCREAS 
613 
by a horse in the region of the stomach, and was for a time unconscious. 
There was pain and tenderness in the epigastric region, with gradual dis- 
tension and vomiting. The temperature remained normal. At autopsy 
there was generalized fibrinopurulent peritonitis. The omentum was 
studded with foci of fat necrosis; the head of the pancreas was wholly 
necrotic, and the remainder of the organ was infiltrated with blood. 
Little is known concerning the pathogenesis of traumatic gangrene 
of the pancreas. Thrombosis of bloodvessels may perhaps explain the 
lesion. Repeating the experiments of Hildebrand and Dettmer and 
subsequent observers, Doberauer has shown that obstruction to the 
circulation, together with other injury to the gland, may be followed by 
hemorrhagic necrosis of the pancreas and fat necrosis. 
Cholelithiasis.-Acute hemorrhagic pancreatitis is not infrequently 
associated with cholelithiasis. In 1903 it was possible to collect from 
the literature 37 cases in which hemorrhagic or gangrenous lesions were 
associated with gall-stones, and at least 9 similar cases have since been 
described. In 9 cases of the hemorrhagic lesion a calculus has been lodged 
near the termination of the bile duct, and one case examined by the 
writer1 disclosed a mechanism by which a biliary calculus can produce 
the lesion. A corpulent man, aged forty-eight years, who had suffered 
with attacks of indigestion, was suddenly seized with severe pain in the 
abdomen, accompanied by nausea. The pain diminished in severity, 
but two days before his death returned with its former intensity. At 
autopsy widely disseminated fat necrosis was found, and the pancreas, 
which was much enlarged, had an almost uniform reddish-black color. 
A small gall-stone had lodged at the orifice of the diverticulum of Vater 
so that it had converted the common bile duct and the duct of Wirsung 
into a continuous closed channel, from which neither bile nor pancreatic 
juice could escape. Bile had penetrated into the pancreatic duct, 
doubtless injected by the gall-bladder. Bacteriological examination 
of the pancreas gave negative results. Experiments on dogs demon- 
strated that the bile of one animal injected into the pancreatic duct 
of a second is capable of causing typical hemorrhagic pancreatitis, 
which is fatal often within twenty-four hours. Bunting2 has described 
a case almost identical with that just cited. 
No data at present available indicate with how great frequency acute 
hemorrhagic pancreatitis is caused by gall-stones. In 5 of 8 cases seen 
by the writer cholelithiasis was present, and in 2 of these cases calculi 
were found lodged at the orifice of the common bile duct. In many 
cases gall-stones have been overlooked at autopsy. It is noteworthy 
that the gall-stones usually found in the bile passages and in the gall- 
bladder in these cases have been of such small size that they might readily 
occlude the duodenal orifice of the diverticulum of Vater without closing 
the communication between the common bile duct and the duct of Wir- 
sung. In only a limited number of individuals is the anatomical structure 
of the diverticulum of Vater such that a calculus could convert the two 
ducts into a continuous closed channel. In 1 of 10 individuals the two 
1 Johns Hopkins Hospital Bulletin, 1901, xiv, 182. 
2 Ibid,., 1906, xvii, 265. 614 
DISEASES OF THE DIGESTIVE SYSTEM 
ducts have no common channel but open separately at the summit of 
the bile papilla, and in only 32 of 100 normal specimens which have 
been examined was the diverticulum of Vater of such size that a small 
calculus might occlude its orifice without completely filling it and thus 
obstructing one or both ducts which enter it. 
Special Pathology.-The appearance of the pancreas varies with the 
duration of the disease. In instances in which death has occurred within 
forty-eight hours after the onset the organ is much enlarged, and in 
swelling assumes an irregularly cylindrical shape. The areolar tissue 
in the neighborhood of the gland may be infiltrated with blood and the 
lesser peritoneal cavity usually contains blood or blood-stained fluid. 
Opaque white foci of fat necrosis studding the retroperitoneal fat, 
transverse mesocolon, perhaps the mesentery elsewhere, and the sub- 
peritoneal tissue of the abdominal walls, are abundant, particularly in 
the immediate neighborhood of the gland. The tissue of the pancreas 
is firm in consistence and has in large part assumed a dark red, reddish- 
brown, or even reddish-black color, and not infrequently presents a 
mottled or marbled appearance due to the presence of sharply defined 
areas of yellowish white, relatively normal parenchyma. The proportion 
of transformed parenchyma varies considerably in different cases, but 
rarely, if ever, is the entire parenchyma affected by the lesion. 
Characteristic of the lesion is the widespread necrosis which affects 
secreting parenchyma, interstitial tissue, and the walls of bloodvessels. 
Cells are transformed into homogenous structures without nuclei. The 
architecture of the tissue may be preserved, but outlines of acini and 
fibrous tissue are often completely lost. Transition from such areas of 
complete death of tissue to normal parenchyma is abrupt and marked 
by a zone containing fragments of nuclei, polynuclear leukocytes, red- 
blood corpuscles, and fibrin. The interstitial tissue of the parenchyma 
which is still intact is infiltrated with blood, while in the necrotic and 
partially disintegrated areas occur larger collections of much changed 
blood. Soon after the onset inflammatory products, particularly leuko- 
cytes and fibrin, are found at the margin of the relatively normal 
tissue. 
The pathogenesis of the condition is best studied in the experimental 
lesion, which does not differ from that which occurs in human cases. 
Bile and a variety of irritant substances coming in contact with cells 
of the secreting parenchyma cause their death, and necrosis is associated 
with such injury to the walls of bloodvessels that red-blood corpuscles 
escape in great quantity. Hemorrhage may be the result of necrosis 
before inflammatory changes are well marked, but very quickly evidence 
of inflammation is found at the margin of relatively intact parenchyma. 
Flexner and Pearce have shown that degeneration, hemorrhage, and 
emigration of leukocytes occur within one or two hours after the injec- 
tion of artificial gastric juice into the pancreatic duct of dogs. There 
is probably much truth in the suggestion of Klebs that hemorrhage is 
the result of corrosive action of the pancreatic juice. The various irritant 
substances which produce the lesion acting injuriously upon the tissue 
of the organ not improbably subject it to the action of its own secretion. DISEASES OF THE PANCREAS 
615 
Gangrene of the Pancreas.-Fitz showed that acute hemorrhagic 
pancreatitis may terminate in the condition known as gangrene and in 
at least half of the recorded cases of what he designated gangrenous 
pancreatitis there was evidence of hemorrhage. In cases of hemorrhagic 
pancreatitis which have survived a week or more the gland assumes a 
dark red, reddish-black or black color, and the tissue is dry and covered 
by changed blood. At the end of the second week the organ may form 
a soft, black, friable mass, while the lesser omental cavity contains 
chocolate-colored fluid in which are bluish-black spots. Yellowish spots 
of softening may occur in the pancreas and the gland may be finally 
transformed into a soft mass attached by only a few shreds of tissue to 
the abdominal wall, or, having undergone complete sequestration, 
according to the description of some observers may lie free in the omental 
cavity. In such cases the lesser peritoneal cavity is distended with dark 
bloody or blackish, often foul-smelling, fluid containing particles of 
necrotic tissue. Infection with a variety of bacteria has occurred, and 
the abscess cavity thus formed is limited by the lesser peritoneal cavity; 
the foramen of Winslow is closed by adhesions, and there is in most 
instances no general peritonitis. The fat about the pancreas and in the 
wall of the lesser peritoneum is the seat of confluent areas of fat necrosis 
which as the result of softening and erosion show an irregular surface. 
In some instances an extension of the abscess cavity forms a pocket 
in the retroperitoneal tissue over the left kidney. Perforations, usually 
with ragged frayed edges, may be found in the wall of the stomach or 
duodenum, doubtless caused by penetration of the abscess into the 
viscus. In a case described by Chiari there were two perforations into 
the stomach and five into the jejunum. In a case recorded by Chiari 
part of the gangrenous pancreas was passed from the rectum. 
When, with the experimental lesion, recovery ensues, active prolifera- 
tion of connective tissue occurs and the newly formed tissue invades 
and in part or wholly replaces the necrotic parenchyma. Evidences of 
such reparative changes have been found in patients who have survived 
the severity of onset, and is doubtless present in the comparatively small 
number of instances in which complete recovery occurs. 
Symptoms.-Fitz carefully defined the symptoms of hemorrhagic 
and of gangrenous pancreatitis, and although he recognized that many 
cases showed varying combinations of the lesions thus designated, 
described them separately. Most writers who have subsequently 
described instances of either condition have adopted the classification 
of Fitz and have used that designation which more accurately describes 
the anatomical changes which have been found. 
Course.-In those cases in which death occurs within a few days after 
the onset the hemorrhagic character of the lesion is predominant, and 
those cases which pursue a rapidly fatal course have been described 
as hemorrhagic pancreatitis. The relation between the duration of the 
disease and the character of the changes found after death varies con- 
siderably, but toward the end of the second week, and in many instances 
earlier, the pancreas has assumed the appearance described as gangrenous, 
and those cases have been described as gangrenous pancreatitis in which 616 
DISEASES OF THE DIGESTIVE SYSTEM 
either the initial symptoms of shoek have not been fatal or the onset has 
been unusually mild. Since the disease apparently pursues a more 
violent course in men than in women, the hemorrhagic lesion has been 
more frequently encountered at autopsy in men. When the disease 
has assumed the subacute course which characterizes most cases of what 
has been called gangrenous pancreatitis, symptoms due to suppuration 
and accumulation of exudate in the lesser peritoneal cavity appear. 
Stage of Hemorrhagic Necrosis.-Characteristic of the acute disease 
is its sudden onset, the severity of the pain which is localized in the 
epigastric region, and the associated symptoms of shock and intense 
depression of the circulatory system. One group of cases described 
by Nimier as foudroyant terminate fatally within a few hours. Such 
cases have been described as instances of pancreatic hemorrhage or 
apoplexy. In a large proportion of instances death occurs within the 
first four or five days, while about half of the cases pursue a subacute 
course, death occurring after several weeks or months. 
The disease in many instances affects individuals who have suffered 
with repeated attacks of abdominal pain, but in many cases the patients 
have had good health, robust men often somewhat corpulent being not 
infrequently affected. The preceding attacks of pain are of two kinds, 
being referable either to the gastro-intestinal tract or to the bile passages. 
In nearly one-half of the cases collected by Fitz there had been attacks 
of indigestion, with pain at times of great severity, nausea, and vomiting. 
He regarded the previous digestive disturbance as gastric or gastro- 
duodenal rather than enteric. In about one-fifth of the recorded cases, 
according to Gessner,1 there have been, perhaps for several years, 
typical attacks of gall-stone colic often accompanied by jaundice, until 
an attack of unusual severity is accompanied by symptoms of collapse. 
The pain of onset, which appears with surprising suddenness, is of 
great violence and is localized above the umbilicus; it may be constant 
or occur in paroxysms, and in the acutely fatal cases persists until death. 
The pain has been occasionally described as present above the umbilicus 
and to the left of the median line following the course of the pancreas, 
but the seat of greatest intensity may be the left or right hypochondrium, 
or even the lower abdominal region. The epigastric region is sensitive 
to pressure, and there is usually rigidity of the abdominal muscles. 
Intense pain in the back radiating toward the legs has been described. 
The appearance of pain is rapidly followed by vomiting, rarely by 
nausea alone. Vomiting may recur at short intervals or may stop for 
several hours or even several days, to be repeated with perhaps equal 
severity. The vomitus is usually copious and bile-stained, but may be 
mucous, and in several instances has been dark brown or bloody. 
Symptoms of shock accompany the pain and vomiting of onset and 
usually precede death. There is profound weakness; the pulse is accel- 
erated, and in several instances cyanosis has been a conspicuous symptom. 
Experiments of Gulecke, Doberauer, and Egdahl2 indicate that substances 
1 Deutsche Zeit. f. Chir., 1899, xliv, 65. 
2 Journal of Experimental Medicine, 1907, ix, 385. DISEASES OF THE PANCREAS 
617 
perhaps formed by autodigestion of pancreatic tissue depress the circula- 
tion and cause profound poisoning. 
Although the abdomen is rigid and often distended, particularly in 
the epigastric region, a tumor mass referable to the pancreas is rarely 
if ever palpable. 
In about one-half of the cases there is constipation, but in a considerable 
number of cases diarrhoea is present from the beginning or may follow 
constipation. The occurrence of constipation in association with the 
severe symptoms of onset has made the diagnosis of intestinal obstruction 
in such cases frequent, and the nature of the disease has been determined 
at operation undertaken with the purpose of relieving obstruction. 
Gessner states that passage of feces occurs spontaneously or as the 
result of enemata in many cases on the fourth day. In six cases collected 
by this author the enlarged head of the pancreas was found either at 
autopsy or at operation to encroach upon the lumen of the duodenum, 
but in most cases no anatomical evidence of obstruction has explained 
the symptoms of intestinal obstruction. It has been suggested I that 
irritation of the solar plexus by hemorrhage or by pressure mayjfavor 
the occurrence of constipation. The stools are not infrequently^clay- 
colored; in only one case (Chantemesse and Griffon) fatty stools were 
present, although death occurred two days after the onset of symptoms. 
The feces rarely contain blood. 
Jaundice, varying in intensity, was present in 10 per cent, of the 
cases collected by Gessner, who has given special attention to the relation 
between acute pancreatitis and disease of the biliary passages. Fever is 
rarely present during the early stage and with symptoms of collapse the 
temperature may be subnormal. Elevation of temperature with chill 
has been observed. Leukocytosis has been found in cases in which the 
blood has been examined. In a case of Hunt1 the leukocytes numbered 
37,000 per cmm. on the first day of the disease. In a case of Sendler 
their number was not increased. Diastase in the feces and urine may be 
measured by a method introduced by Wohlgemuth; Wynhausen2 found 
the enzyme in the feces greatly diminished in two cases of hemorrhagic 
pancreatitis. Wohlgemuth found that experimental occlusion of the 
pancreatic ducts caused well-marked increase of diastase in the urine, 
and Ilirschberg3 was able to demonstrate a similar increase in two cases 
of so-called acute pancreatitis. Glycosuria has occurred in only a small 
proportion of cases of hemorrhagic pancreatitis (Benda and Stadelmann, 
Cutler, Sarfert and Simmonds). The case of Benda and Stadelmann is 
noteworthy, because the symptoms were those of rapidly fatal diabetic 
coma. The patient became comatose soon after the onset of violent 
abdominal pain; 3.4 per cent, of sugar was found in the urine. The 
pancreas, with the exception of a part of the head, formed a soft, bloody 
mass. 
Stage of Gangrene.-Cases in which the early stage has been survived 
have been described as instances of gangrenous pancreatitis. At the 
1 Boston Medical and Surgical Journal, 1905. 
2 Berliner klin. Woch., 1909, xlvi, 1406. 
3 Munchen, med. Woch., 1908, Iv, 225. 618 
DISEASES OF THE DIGESTIVE SYSTEM 
end of several days-Gessner regards the fourth day as critical-the 
symptoms of onset may diminish in violence; pain and tenderness in 
the epigastric region are still present, or may recur at intervals, and 
are not infrequently associated with vomiting. Constipation, if present, 
disappears and may be followed by diarrhoea. Symptoms which indicate 
the presence of so-called gangrene, with bacterial invasion of the necrotic 
gland and adjacent peritoneal surfaces, are fever and epigastric tumor. 
The transition to the stage of necrosis and suppuration usually occurs 
toward the end of the second week. 
The temperature, which during the early stage shows no elevation, is 
moderately increased and irregular. Although usually little more than 
100°, it may reach 104° F., and in some instances there are repeated 
chills. The disease may, however, pursue its course without fever. 
Leukocytosis was present in two cases of gangrenous pancreatitis de- 
scribed by Thayer. In one case the leukocytes on the nineteenth day 
numbered 18,300; in the second case during the fourth week they num- 
bered 33,700, although the temperature at the same time varied from 
97.6° to 98.6° F. 
The tumor mass, due in great part at least to accumulation of exudate 
in the lesser peritoneal cavity, usually appears in the epigastric region 
and, extending toward the spleen, varies considerably in size and dis- 
tinctness. It has been described at times as a rounded mass the size 
of a child's head situated above the umbilicus, while in other cases there 
has been an ill-defined resistance in the same region. In all of 5 cases 
of gangrenous pancreatitis Korte found a tumor mass which in 3 instances 
was first found on the left side in the region of the left hypochondrium 
and flank, subsequently becoming palpable between stomach and colon. 
In 5 cases described by Thayer a tumor mass was found in the epigastric 
region; in 2 cases pancreatic gangrene was demonstrated by autopsy, 
while in 3 recovery followed operation and the nature of the lesion was 
not clearly defined. 
In stout individuals palpation may be difficult, but is facilitated by 
the emaciation which usually occurs with long continuance of the disease. 
The muscular spasm which hinders palpation during the acute stage 
disappears. The lower border of the tumor mass may descend with 
respiration; occasionally pulsation is transmitted from the aorta, and 
has been found to disappear in the knee-chest position. Inflation of 
the stomach and perhaps of the colon may aid in the localization of the 
mass. Tympany of the stomach separates the mass from the liver, and 
after inflation of the viscus tends to cover it. The colon lies along the 
lower border of a tumor mass due to an exudate within the lesser peri- 
toneal cavity. When the abscess cavity eroding the tissue over the 
left kidney tends to make its way toward the left lumbar region, resist- 
ance may be felt below the left costal margin extending downward as 
far as the rim of the pelvis. 
The stools, which are not infrequently diarrhoeal, in a few instances 
have^contained blood. Steatorrhoea has rarely if ever been observed, 
but in a case of von Noorden's chemical examination showed that the 
proportion of split fat in the feces was greatly diminished. In 2 cases DISEASES OF THE PANCREAS 
619 
described by Chiari recovery followed the expulsion from the rectum of 
necrotic pancreatic tissue. 
Jaundice may occur, and was present in one-fifth of the cases of 
gangrenous pancreatitis collected by Fitz. 
Glycosuria is an infrequent symptom of pancreatic necrosis. In the 
cases of Israel and of Fleiner the disease occurred in individuals who 
had previously suffered from diabetes. In the case of Middleton sugar 
was found in the urine removed from the bladder at autopsy. In the 
case of Brentano 6 'per cent, of sugar was found in the urine ten days 
after operation and four days after the discharge from the wound of a 
mass of necrotic tissue 12 cm. in length; previous examination of the 
urine had not been made. Peiser found sugar in the urine two months 
after the onset of symptoms; it is probable that almost the entire gland 
was affected, since a few days after the operation a sequestrum of pan- 
creatic tissue 19 cm. in length was discharged from the wound. 
Complications and Sequelae.-The most important complications- 
namely, cholelithiasis and suppurative peritonitis affecting the lesser 
peritoneal cavity-have been described. Erosion of the tissue over the 
left kidney and sinking of the bursal abscess toward the left lumbar 
region has also been mentioned. Perforation of the stomach, duodenum, 
and transverse colon occur not infrequently, and in a case described by 
Thayer the three organs were the seat of erosion. Blood or fetid pus 
rarely appears in the feces as the result of such accidents. Within the 
necrotic tissue of the pandreas bloodvessels become the seat of thrombi 
which not infrequently extend to adjacent vascular trunks. The splenic 
vein may be occluded and in a case described by Fitz thrombosis of the 
splenic vein was present in a patient who died ten days after the onset. 
Diabetes is infrequently associated with pancreatic gangrene, but 
may occur either as a complication or a sequel. Such instances have 
already been cited. In a case of Korte 2 per cent, of sugar was found 
in the urine twenty months after an operation at which necrotic pan- 
creatic tissue had been removed. Sugar was not present before or 
immediately after operation; seven years after operation the patient 
was living but much emaciated as the result of diabetes. 
An unusual accident has been described by Langdon. Two years 
after an operation, at which bloody fluid had been removed from the 
lesser peritoneal cavity, death occurred suddenly. The pancreas was 
in large part replaced by scar tissue; the scar was in contact with the 
portal vein from which fatal hemorrhage had occurred. 
In a considerable number of cases pancreatic and peripancreatic cysts 
are preceded by acute symptoms which are similar to those of hemorrhagic 
pancreatitis, but in most instances it is impossible to determine by 
anatomical examination after a considerable lapse of time the character 
of the primary pancreatic lesion. A few cases indicate that peripancreatic 
cysts formed within the bursa omentalis or even pancreatic cysts may 
follow hemorrhagic pancreatitis. In a case described by Francke1 
intense pain associated with vomiting appeared with great suddenness; 
1 Deutsch. Zeil. f. Chir., 1900, liv, 399. 620 
DISEASES OF THE DIGESTIVE SYSTEM 
two weeks later a tumor was found in the left hypochondriac region and 
gradually increased in size. At operation, five weeks after onset, an 
elastic thin-walled cyst, the size of a man's head, occupied the lesser 
peritoneum and surrounded the pancreas, which was the seat of necrosis 
and old hemorrhage; foci of fat necrosis were present in the omentum 
and mesentery. In a similar case of Hasumosky a tumor mass in the 
epigastrium was noted five hours after the onset of symptoms, and at 
operation three weeks later was found to be due to a cyst in which 
necrotic pancreatic tissue was found. Adler1 has described a so-called 
pseudocyst of the pancreas which was probably the result of acute hem- 
orrhagic pancreatitis; the pancreas which formed part of the cyst wall 
was necrotic and the site of old hemorrhage. When blood and necrotic 
pancreatic tissue remain sterile the digestive ferments of the pancreas 
may perhaps cause softening and encapsulation by fibrous tissue. The 
possibility that this process might take place wholly within the substance 
of the pancreas is suggested by a case of acute hemorrhagic pancreatitis 
with fat necrosis described by Dressel; a cavity filled with clotted blood 
the size of a child's head was present within the substance of the gland. 
Diagnosis.-For the recognition of hemorrhagic necrosis of the pancreas 
the mode of onset is important-namely, its suddenness and violence with 
intense epigastric pain, vomiting, and symptoms of profound collapse. 
When hemorrhagic necrosis accompanied by constipation resembles 
intestinal obstruction, the epigastric localization of pain and distension, 
the intensity of the pain, and collapse point to pancreatic disease. Ster- 
coraceous vomiting is rarely present, and the increase of peristalsis 
recognizable with intestinal obstruction is not present. 
Since the disease may be preceded by repeated attacks of typical 
biliary colic, and when caused by the lodgement of a small calculus in 
the diverticulum of Vater is associated with symptoms of gall-stones, a 
differential diagnosis may be very difficult. When an attack of biliary 
colic is accompanied by pain of unusual intensity, present throughout 
the epigastric region and perhaps more intense on the left side, especially 
when there are symptoms of sudden and profound collapse, hemorrhagic 
pancreatitis should be suspected. With perforation of the gall-bladder 
following cholecystitis the symptoms are usually localized on the right 
side. Ulcerative processes associated perhaps with malignant tumors 
of the stomach, duodenum, or transverse colon may produce suppurative 
inflammation limited to the lesser peritoneal cavity, particularly when they 
cause perforation. The suddenness of onset, the intensity of the pain, 
and the rapidity of collapse indicate the presence of hemorrhagic necrosis 
of the pancreas, especially when there is no history suggesting gastric 
or duodenal ulcer or other lesion which might cause perforation of the 
stomach, duodenum, or transverse colon. Pulsation of a tumor caused 
by exudate in the lesser peritoneal cavity, being transmitted from the 
aorta, is not expansile and disappears when the patient rests upon his 
side or on knees and elbow's; Langdon has described such a case simulating 
ruptured aneurism. 
1 Virchows Archiv, 1904, clxxvii, Suppl. Heft 154. 621 
DISEASES OF THE PANCREAS 
When the disease has assumed a subacute course, the recognition of a 
tumor mass in the epigastric region between stomach and colon suggests 
the presence of an exudate within the bursa omentalis, but gives positive 
evidence of pancreatic gangrene only when its appearance follows the 
acute symptoms already described. Symptoms indicating disturbed 
pancreatic function such as glycosuria or steatorrhoea are rarely present, 
but both in the acute and subacute stages chemical methods applied to 
the examination of urine and feces may give additional information. 
Treatment.-Although pancreatic necrosis cannot be directly influ- 
enced by any available means, in some instances the profound collapse 
of onset may be overcome, so that the disease may reach the subacute 
stage, in which it is more susceptible to successful surgical interference. 
Intense epigastric pain usually requires morphine, but in several instances 
the violent pains of onset have been controllable only by inhalation of 
chloroform. For the vomiting Korte recommends the withholding of food 
and lavage of the stomach. Enemata of warm water may serve to over- 
come constipation and distension, while stimulating and nutrient enemata 
may serve to sustain the strength. For collapse subcutaneous or intra- 
venous infusions of normal salt solution may be employed. 
The value of operation during the early stage, when symptoms of 
circulatory depression are predominant, has been much disputed. Loss 
of blood is rarely an important feature and it is improbable that hemor- 
rhage from the necrotic tissue could be controlled under the condition 
which such an operation would present. A mistaken diagnosis, usually 
of intestinal obstruction, has been the incentive for a majority of the 
operations undertaken at this stage, and the recognition of characteristic 
foci of disseminated fat necrosis in the great omentum has given the 
first indication that the pancreas has been diseased. Careful searching 
of the intestine drawn out through the abdominal wound, together with 
prolonged anesthesia, has doubtless had an unfavorable result in many 
instances. Mikulicz-Radecki recommends evacuation of the hemorrhagic 
exudate contained in the lesser peritoneal cavity and free drainage of 
the omental bursa with gauze after exposure of the vault of the diaphragm 
by resection of the tenth and eleventh ribs, if necessary. 
Statistics collected by Gessner indicate that operations undertaken 
up to the end of the second week and therefore during the stage of 
hemorrhagic inflammation, are much more frequently fatal than those 
undertaken at a later period when the disease has become subacute and 
so-called gangrene with peripancreatic abscess is present. Of 41 instances 
in which operation was performed upon patients suffering with the 
disease, 21 occurred during the first two weeks, and in only one case 
(Halsted) did recovery follow. In most instances a laparotomy in the 
middle line was performed, the nature of the disease was not determined, 
the abdomen was closed, and death followed within a few hours. Of 20 
cases operated upon at a later period, when peripancreatic abscess had 
formed, 6 recovered. In the larger statistics of Mikulicz-Radecki, 
published about five years later (1903), there were 46 operations in the 
acute stage, with 9 recoveries, and 35 operations in the subacute stage, 
with 18 recoveries. This surgeon was ^unwilling' to attribute much 622 
DISEASES OE THE DIGESTIVE SYSTEM 
significance to these figures, since the relative proportion of untreated 
cases which die in the first stage is unknown. He maintained that early 
operation limits the extent of necrosis and sequestrum formation, and 
gives diminished opportunity for serious complications, such as venous 
thrombosis and pyemia. Operation under local anesthesia may diminish 
the tendency to shock. 
Since the disease is frequently caused by gall-stones, it is desirable to 
examine the biliary passages at operation, and to determine if calculi 
are present. The continued presence of a calculus at the duodenal orifice 
of the diverticulum of Vater may increase the severity of an existing 
lesion, and its removal is desirable. The calculus which causes the 
obstruction is usually of small size and not infrequently the gall-bladder 
has contained a large number of minute calculi, which during expulsion 
can perhaps repeatedly divert bile into the pancreatic duct. In a patient 
operated upon ten days after the onset of symptoms Kelly found fat 
necrosis; he removed from the gall-bladder about fifty very small calculi 
of almost uniform size; the patient recovered. That the existence of 
diabetes mellitus should not necessarily prevent operation for pancreatic 
necrosis is indicated by a case described by Peiser. Before operation 
the urine contained 4 per cent, of sugar, acetone, and diacetic acid; the 
excretion of sugar was not influenced by the evacuation of a peripancreatic 
abscess, accomplished by two operations. The patient lived five months 
after operation, and death was the result of diabetes mellitus. 
SUPPURATIVE PANCREATITIS 
Suppurative inflammation of the pancreas, characterized by accumu- 
lation of inflammatory products and softening of tissue, with consequent 
formation of one or more cavities containing purulent fluid, does not 
differ from similar changes in other organs. In many instances the disease, 
which is the result of bacterial invasion, occurs as a primary infection, 
but in other cases it follows hemorrhagic necrosis of the pancreas, the 
hemorrhagic and necrotic tissue being particularly susceptible to bacterial 
infection; hence the so-called gangrenous pancreas may contain abscess 
cavities, and in such instances a distinction between gangrene and 
suppuration is impossible. Moreover, acute inflammation of the pan- 
creas, which has persisted for several weeks, almost constantly extends 
to the lesser peritoneal cavity, which with bacterial invasion becomes the 
seat of suppurative inflammation. In many cases described as instances 
of suppurative pancreatitis operation has disclosed an abscess in this 
region, but no subsequent postmortem examination has shown the 
exact anatomical condition; in reports of many such cases no attempt 
has been made to distinguish between pancreatic and peripancreatic 
abscess. With gangrenous pancreatic inflammation, symptoms of 
peripancreatic abscess may be more conspicuous than those referable to 
the gland itself, and the lesion at autopsy, several weeks after the onset, 
may present nothing characteristic of the hemorrhagic and gangrenous 
lesion. DISEASES OF THE PANCREAS 
623 
Etiology.-When suppurative inflammation is not the result of simple 
extension from an adjacent organ, there are two possible paths of infec- 
tion-namely, the bloodvessels and the ducts. Metastatic abscesses 
are rarely found in the pancreas. Infection by the bloodvessels may 
explain some cases but more readily demonstrable and probably of far 
greater frequency is ascending infection by way of the ducts. Experi- 
mental studies show that suppurative lesions may follow the injection 
of bacteria into the pancreatic ducts. Suppurative pancreatitis has been 
produced by Korte and by Carrot by injection of bacilli of the colon 
group into the duct. 
Valve-like folds within the diverticulum of Vater prevent the entrance 
of the duodenal contents, so that after death it is impossible to force 
material from the intestine into the duct. The flow of secretion doubtless 
exerts a protective influence by washing foreign material from the duct. 
Obstruction of the duct of Wirsung favors the entrance of microorganisms, 
and many cases of pancreatic suppuration are associated with occlusion 
of the duct of Wirsung by gall-stones lodged in the diverticulum of Vater, 
by pancreatic calculi, and by malignant growths compressing the duct. 
In a case described by Pearce multiple abscesses in the head of the pan- 
creas followed obstruction of the duct by carcinoma of the diverticulum 
of Vater. 
The probability of infection is much increased when the presence of 
gall-stones has previously caused suppurative inflammation of the bile 
ducts. In two cases of Mayo Robson's, abscess of the pancreas accom- 
panied cholelithiasis with suppurative cholangeitis. In a case of suppura- 
tive pancreatitis recorded by Dieckhoff biliary calculi had actually 
found their way into the duct of Wirsung. Ina case described by Fuchs1 
it is probable that pancreatic abscess had been secondary to localized 
hemorrhagic necrosis caused by a gall-stone lodged in the diverticulum 
of Vater. 
In the small number of cases in which bacteriological examination of 
the purulent fluid has been made, a variety of microorganisms has been 
found. In the case of Maas and of Etienne both cocci and bacilli were 
found. In one of the cases described by Fitz several varieties of bacilli 
and a staphylococcus were isolated. An organism resembling Bacillus 
proteus has been isolated (Ilauser); Dieckoff found diplococci resembling 
Diplococcus pneumonic? and in a case of Korte streptococci were found. 
Pathology,-With acute inflammation of the pancreas there may be 
polynuclear leukocytes within and about the ducts of the gland, and the 
interstitial tissue may be distended by oedema. Such inflammation, 
which doubtless begins as an ascending infection of the ducts, does not 
necessarily proceed to suppuration, and may be unaccompanied by 
macroscopic change. It is, however, not improbable that similar infection 
of greater severity may cause diffuse suppuration in the organ. 
In a case described by Etienne2 the entire gland, which was enlarged, 
was infiltrated with thick, yellowish, purulent fluid, which collected 
upon the cut surface; drops of pus escaped from the incised ducts. In 
1 Deutsch, med. Woch., 1902, xxviii, 829. 
2 Arch, de med. exper., 1898, x, 177. 624 
DISEASES OF THE DIGESTIVE SYSTEM 
other instances destruction of tissue is more advanced and the organ 
contains communicating cavities of irregular shape filled with pus, or 
there may be numerous isolated abscesses. In some cases almost total 
destruction of tissue has been described, a large cavity filled with pus 
being found to occupy the site of the pancreas. Localized abscesses 
may be situated in any part of the gland, but are most frequent in the 
head. The abscess cavity may be surrounded by a fibrous capsule. 
Fitz observed that fat necrosis occurs less frequently in association with 
suppurative inflammation than with hemorrhagic or gangrenous pan- 
creatitis; foci of fat necrosis are found when purulent inflammation is 
the result of hemorrhagic pancreatitis. 
Symptoms.-Since suppurative pancreatitis may occur as a compli- 
cation of acute hemorrhagic pancreatitis, of lithiasis, of cyst, or of cancer, 
while it is sometimes the result of ascending infection from the inflamed 
duodenum or bile passages, its mode of onset and symptomatology vary 
considerably. In one group, including more than one-half of the cases 
collected by Korte, the onset is sudden and associated with intense 
epigastric pain, vomiting, and collapse; the symptoms of onset do not 
differ from those of hemorrhagic necrosis of the pancreas, and it is not 
improbable that in a considerable proportion of these cases infection 
and suppurative inflammation have followed hemorrhagic necrosis. The 
severity of the symptoms diminishes, and the disease in most instances 
pursues a chronic course, with exacerbations of pain and gastro-intestinal 
disturbance occurring at irregular intervals. In a smaller group the 
onset is gradual, and for a considerable time there is abdominal pain, 
or perhaps only a sense of discomfort in the epigastric region, together 
with gastric symptoms of variable intensity. 
The tendency of suppurative pancreatitis to pursue a chronic course 
is shown by 14 cases cited by Fitz; 6 were fatal in the first month, 3 
during the second month, and 5 between the fourth and eleventh months. 
In 22 of 46 cases collected by Korte death occurred between one month 
and one year after the onset. In a few cases death occurs more rapidly. 
In most cases there is either diarrhoea or constipation, the former 
being present in considerably more than half of the cases. In the case 
described by Nicholas hemorrhage from the bowel occurred several 
times, and at autopsy an abscess in the pancreas was found to com- 
municate by a fistulous opening with the duodenum. Hiccough was 
present in 5 cases collected by Etienne, in 2 of which it was incessant. 
In 2 of the cases peritonitis may have caused the symptoms. Jaundice 
occurs in a considerable number of cases, and may be due to cholelithiasis, 
which has afforded conditions favoring infection of the pancreatic ducts. 
Jaundice may be caused by an abscess situated in the head of the gland 
and compressing the bile ducts. 
Symptoms indicating the occurrence of suppuration are fever and 
abdominal tumor. In the greater number of cases there is elevation of 
temperature, which is moderate in degree, but in some instances the 
temperature has been normal or even subnormal. In one group of cases, 
according to Fitz, the onset is violent and there are frequent chills and 
irregular, often high, temperature, exceeding 105° F.; chills may occur DISEASES OF THE PANCREAS 
625 
at the onset and recur during the course of the disease. In another group 
of cases the early symptoms present little that suggests the presence of 
suppuration; there is loss of appetite, progressive weakness and emacia- 
tion, perhaps diarrhoea or jaundice, but no pain or fever. Leukocytosis 
has been present in cases in which purulent fluid has been removed from 
the lesser peritoneal cavity (Thayer, Murray). 
A more or less clearly definable tumor mass occupying the position of 
the pancreas has been noted in hardly more than a fourth of the recorded 
cases (Korte), but when present this symptom is significant for both 
diagnosis and operative treatment. In many cases there is abdominal 
distension not infrequently localized in the epigastric region, and pain 
and tenderness in the same situation may further prevent satisfactory 
palpation, which may be more readily performed after the subsidence 
of the violent symptoms of onset. The detection of deep-seated resistance 
behind the stomach or between stomach and colon, absent perhaps during 
the early stage may suggest that the pancreas is the seat of disease. 
Disturbances of pancreatic function, although significant when present, 
are not commonly associated with pancreatic abscess, which in most 
instances leaves relatively normal a considerable part of the gland. 
Glycosuria has been present in a small number of cases. Einaciation 
associated with suppurative pancreatitis is referred by some writers to 
functional disturbance of the gland, but is, in part at least, referable 
to continued suppuration. The accompanying weakness is often extreme. 
Sequelae.-Peritonitis due to extension of the inflammatory process 
to the surface of the organ and subsequent infection of adjacent serous 
surfaces is almost constantly associated with suppurative pancreatitis. 
Adhesions binding the posterior wall of the stomach to the pancreas 
may be the site of fistulous communications with this organ. Encysted 
peritonitis with effusion limited to the lesser peritoneal cavity is present 
in cases which pursue a subacute course. General peritonitis has been 
present in a considerable number of cases examined at autopsy. Rupture 
of the pancreatic or peripancreatic abscess may occur into a variety of 
organs. Perforation of the stomach or of the duodenum is not infrequent. 
Vomiting of purulent fluid and hemorrhage from the bowel have occa- 
sionally been associated with perforation of the duodenum. Rupture of 
an abscess into the general peritoneal cavity has been observed in 4 
cases cited by Korte. Thrombosis of the splenic vein extending to the 
portal vein may occur. In a case described by Bamberger the portal 
and splenic veins were almost completely occluded by a thrombus which 
had undergone puriform softening in the neighborhood of an abscess in 
the head of the pancreas; the liver was enlarged and contained numerous 
abscesses, the largest of which was the size of a hen's egg. Abscesses 
in the left lobe of the liver were present in cases of Frison and of Drasche. 
Diagnosis.-Since suppurative pancreatitis in a considerable number 
of instances follows hemorrhagic inflammation, the symptoms of onset 
are those of the last-named condition, and indeed, even at operation, 
the distinction between abscess of the pancreas and gangrenous inflam- 
mation with peripancreatic abscess is often difficult, although fortunately 
not of much clinical significance. It is not improbable, however, that 626 
DISEASES OF THE DIGESTIVE SYSTEM 
pancreatitis which is primarily suppurative may begin with equal 
severity. In another group of cases the onset is gradual, and there are 
vague symptoms of gastro-intestinal disturbance with epigastric pain 
of variable intensity; irregular fever, perhaps with chills, may suggest 
suppuration. When a deep-seated mass in the region of the pancreas 
appears, the diagnosis of peripancreatic abscess can be made, but it is 
rarely if ever possible to decide if peripancreatic abscess accompanies 
gangrenous inflammation or is the result of an abscess within the sub- 
stance of the gland. Hence the differential diagnosis between hemor- 
rhagic necrosis and suppurative pancreatitis is rarely possible, since, 
especially in the early stages the symptoms are those of hemorrhagic 
necrosis of the pancreas, although the early onset of fever with chills 
and irregular temperature may suggest primarily suppurative pan- 
creatitis. The symptoms appearing in association with recognizable 
cyst, lithiasis, or neoplasm of the pancreas, may suggest that suppuration 
has occurred as a complication of one of these lesions. 
When a tumor-like resistance can be felt in the epigastrium behind 
the stomach and colon, its ill-defined character and its rapid appearance 
in association with acute symptoms serve to distinguish it from cyst 
or carcinoma. Nevertheless, the difficulty of diagnosis, especially when 
the abscess is small, is well illustrated by a case cited by Thayer. An 
abscess at the junction of the head and body of the gland caused complete 
obstruction of the common bile duct and presented a picture suggesting 
carcinoma of the head of the pancreas or of the common bile duct. 
Treatment.-Efficient treatment of abscess of the pancreas can be 
obtained only by surgical methods. Diagnosis is often impossible, but 
symptoms which indicate the occurrence of suppuration in or about the 
pancreas suggest the advisability of an exploratory laparotomy, and 
delay may be followed by grave complications, such as general peritonitis 
or thrombosis of the portal vein. Nevertheless, the success of surgical 
treatment is limited by the character of the lesion; with diffuse purulent 
infiltration and with multiple abscesses of the gland, surgical procedures, 
according to Korte, will probably be unsuccessful; but when a large 
accumulation of pus is present within or about the gland, incision of the 
abscess, removal of its contents, and drainage of the cavity offer oppor- 
tunity for recovery. Suppuration within the substance of the gland is 
in most instances rapidly followed by peripancreatic suppuration, but 
the surgeon who has evacuated pus contained within the bursa omentalis 
may be unable to examine the gland with thoroughness. In some of 
the cases upon which operation has been performed an abscess cavity 
has been limited to the substance of the pancreas. 
CHRONIC INTERSTITIAL PANCREATITIS 
Chronic inflammation is characterized by increase of interstitial tissue 
which partially replaces the parenchymatous cells, and is doubtless the 
most common disease to which the pancreas is subject. It is, however, 
accompanied by such ill-defined symptoms that it is rarely recognized PLATE XI 
FIG. 1 
Chronic Interstitial Pancreatitis Following Obstruction of 
Pancreatic Duct. 
Showing unchanged islands of Langerhans embedded in sclerotic tissue 
FIG. 2 
Chronic Interacinar Pancreatitis with Diabetes Mellitus. 
Showing invasion of the islands of Lanuerhans by fibrous tissue. 
(From Journal of Experimental Medicine.) DISEASES OF THE PANCREAS 
627 
during life unless an abdominal operation reveals its existence. When 
the lesion is associated with advanced destruction of the secreting 
parenchyma, digestive disturbances due to loss of pancreatic juice may 
result; in some cases the lesion is accompanied by diabetes mellitus. 
Etiology.-The incidence is well illustrated by a series of 30 cases 
examined in the Johns Hopkins Hospital, 17 being in males and 13 in 
females. In five-sixths of the cases death occurred after the fortieth 
year, while more than two-thirds of the number occurred during the 
fifth and sixth decades of life. The relation of the disease to gall-stones, 
carcinoma, and cirrhosis of the liver explains its occurrence during and 
after middle life. 
Partial and complete occlusion of the duct of Wirsung, brought about 
by pancreatic calculi within it, by large gall-stones lodged in the diver- 
ticulum of Vater, or by carcinoma or other new growth, is the most 
frequent cause. The two ducts of the pancreas anastomose within the 
gland in nine of ten individuals, and occasionally the duct of Santorini 
is of large size, being in one of ten cases as large or larger than the duct 
of Wirsung, but in a much greater number of subjects it is rudimentary 
in some part; the duodenal orifice especially is often very minute and 
cannot act as an outlet for the entire pancreatic secretion. 
Ligation of the pancreatic ducts in animals is followed by chronic 
inflammation. The irritant action of the retained secretions and in many 
cases bacterial invasion of the obstructed duct combine to produce 
sclerosis, but in human cases the relative importance of the two factors 
is difficult to determine. Pancreatic calculi, for example, are doubtless 
in many instances at least produced by an infectious process within the 
ducts of the gland, and the associated sclerosis may be of such severity 
that the gland is converted into a fibrous band. 
Much attention has been directed to the occurrence of chronic inter- 
stitial pancreatitis with cholelithiasis; the consequent induration of the 
gland when observed at operation undertaken for the removal of gall-stones 
has not infrequently been mistaken for carcinoma affecting the head of 
the pancreas. Riedel found in 3 of 122 operations upon the bile passages 
such dense induration of the head of the gland that malignant growth 
was suspected; 2 of these patients recovered, while autopsy in a third 
demonstrated the presence of chronic interstitial pancreatitis. Robson 
and Moynihan have described cases in which jaundice and other symp- 
toms have suggested biliary colic, for the relief of which operation has 
been undertaken; the indurated condition of the head of the pancreas 
made a diagnosis of malignant disease not improbable, but the subsequent 
histories excluded this possibility. There is little doubt that chronic 
pancreatitis may follow cholelithiasis, even though no occlusion of the 
pancreatic duct has been caused by calculi; in such cases acute inflam- 
mation of the ducts of the pancreas accompanies similar inflammatory 
changes in the biliary passages consequent upon the presence of gall-stones 
in the gall-bladder. There is abundant evidence that ascending infection 
of the pancreatic duct, either from the inflamed bile passages or from 
the duodenum, may be a cause of chronic pancreatitis. Both Korte 
and Flexner have caused chronic pancreatitis by injecting colon bacilli, 628 
DISEASES OF THE DIGESTIVE SYSTEM 
and other microorganisms into the pancreatic duct of animals. In cases 
of advanced chronic interstitial inflammation examined at autopsy, 
persistent vomiting accompanied by nausea and epigastric pain afforded 
evidence during life of gastric or gastro-intestinal disease. It is not 
improbable that the persistent vomiting produced conditions favoring 
ascending infection of the pancreatic ducts. 
The causes of chronic pancreatitis just considered are such as affect 
the gland by way of its ducts. In a smaller group of cases the lesion is 
referable to the bloodvessels or to toxic substances carried to the gland 
by them. Arteriosclerosis causes chronic pancreatitis, according to 
Hoppe-Seyler and Fleiner, and the lesion is analogous to the contracted 
kidney and to the changes in the liver, heart, and brain following arterial 
disease. In a case of diabetes with calcification of the posterior tibial 
artery and gangrene of the foot, chronic pancreatitis, included among 
the 30 cases previously cited, accompanied advanced sclerosis of the 
pancreatic vessels; Hoppe-Seyler has recently described 9 similar cases. 
Since alcohol is regarded as one of the most important factors in the 
production of cirrhosis of the liver, its relation to the similar lesion of the 
pancreas has much interest. The literature of pancreatic disease contains 
numerous instances in which the lesion has been found in individuals 
addicted to the excessive use of alcohol. Specially noteworthy is the fact 
that the lesion in these cases is frequently, although not necessarily, asso- 
ciated with cirrhosis of the liver. Factors other than alcohol producing 
chronic inflammation act simultaneously upon the liver and pancreas, 
and chronic pancreatitis and cirrhosis have been found associated by 
many observers, notably by Kasahara, by Lefas, and by Steinhaus.1 
Among 30 cases of chronic pancreatitis, in 8 cirrhosis was present. 
Pathology.-Interest in chronic pancreatitis has in large part limited 
itself to the relation of the lesion to diabetes mellitus, and since it may 
occur with or without diabetes attempts have been made to define the 
peculiarities of those lesions which cause a disturbance of carbohydrate 
metabolism. Hansemann has described a form of chronic pancreatitis 
which is, he believes, peculiar to diabetes. He designates the condition 
atrophy, but carefully distinguishes it from simple atrophy due to 
cachexia, and defines it as a type of chronic inflammation resembling 
certain forms of granular atrophy of the kidney. In a later paper Hanse- 
mann has defined with greater detail the microscopic characters of 
so-called granular atrophy and states that it agrees substantially with 
what has been subsequently called interacinar pancreatitis. 
Two types of chronic interstitial pancreatitis are distinguishable. In 
one type broad bands of newly formed connective tissue occupy the site of 
the larger trabeculae of the gland and separate the lobules or groups of 
lobules; areas of surrounded parenchyma are often wholly uninvaded 
by the sclerotic process; the lesion may be designated chronic interlobular 
pancreatitis. With the second type of chronic inflammation newly 
formed connective tissue does not form broad bands, but occurs diffusely 
scattered in small patches and strands, invading the lobules of parenchyma 
1 Deutsch. Arch. f. klin. Med., 1902, Ixxiv, 537. DISEASES OF THE PANCREAS 
629 
and separate individual acini. The lesion may be called chronic inter- 
acinar pancreatitis. Among 30 instances of chronic pancreatitis, in 21 
the lesion was of the interlobular and in 9 of the interacinar type. 
Chronic interlobular pancreatitis results when the duct of the gland is 
occluded or when the inflammatory process is the result of ascending 
infection of the ducts. Typical interlobular pancreatitis can be produced 
in cats by ligation of the ducts of the gland; at the end of a week or more 
each lobule, which in this animal is unusually sharply defined, is separated 
from its neighbors by thickened bands of connective tissue. In human 
cases the most intense grades of pancreatic sclerosis occur with duct 
obstruction resulting from the presence of pancreatic calculi. The organ 
may be converted into a narrow band of dense scar-like tissue surrounding 
the moderately dilated duct filled with numerous concretions. To the 
naked eye the tissue of the organ altered by interlobular inflammation 
is firmer than usual, and on section is compact in texture, the areolar 
character of the interstitial tissue being lost. 
At an early stage of the lesion the newly formed tissue shows little 
tendency to invade the lobules of the parenchyma, and in most instances 
only their peripheral parts contain invading strands of tissue. At a 
later stage entire lobules and groups of lobules are completely destroyed, 
so that a group of several widely separated and atrophied acini embedded 
in cellular interstitial tissue may be all that remains of one or more 
lobules. Characteristic both of the experimental and of the human 
lesion which follows occlusion of the pancreatic ducts is the behavior 
of the islands of Langerhans. Since the cells forming the islands of 
Langerhans have no communication with the ducts of the pancreas and 
take no part in the elaboration of the pancreatic juice, it is not surprising 
that they are less affected than the cells of the secreting acini, and often 
remain wholly uninjured, although the secreting parenchyma has almost 
completely disappeared. Since intervening acini are replaced by scar- 
like connective tissue, islands of Langerhans which have been previously 
separated are brought close together, so that in a given area their number 
may appear to have greatly increased. Embedded in dense, fibrous tissue, 
which in time undergoes contraction, the resisting islands of Langerhans 
finally suffer, possibly as the result of interference with their blood supply. 
The cells atrophy, and small groups of much atrophied cells scattered 
in dense stroma may be all that remains of these bodies. 
With chronic interacinar pancreatitis, characterized by a diffuse new- 
growth of interstitial tissue penetrating between the acini, the organ is 
tough rather than hard, and does not exhibit the nodular surface seen 
with the interlobular type. In some instances the organ shows no 
noteworthy macroscopic change. The newly formed interstitial tissue 
is somewhat irregular in distribution, so that at one point there may be 
diffuse thickening of the strands of connective tissue between the acini, 
while elsewhere occur larger bands or masses of stroma. The interlobular 
tissue is not unaffected, but its proliferation is not a constant feature 
of the lesion, so that the lobulation of the organ is not accentuated, but 
rather obscured, since irregularly scattered strands of new tissue tend 
to obscure the interlobular boundaries. 630 
DISEASES OF THE DIGESTIVE SYSTEM 
With the interlobular type of inflammation the islands of Langerhans 
persist, and are affected only when the lesion has reached a very advanced 
stage; but with the interacinar type, on the contrary, these islands are 
implicated even when the lesion is little advanced. They are surrounded 
by fibrous tissue, which forms a capsule separating them from adjacent 
acini. Within the islands there may be proliferation of interstitial tissue 
forming coarse strands, which follow the course of the capillaries and 
separate the columns of epithelial cells. With increase of stroma the 
cells atrophy or disappear, so that the entire structure is replaced by a 
minute fibrous scar. 
Chronic interlobular pancreatitis, in many instances at least, is refer- 
able to an irritant which attacks the glands by way of its ducts. In 
those instances in which the etiology of the interacinar type is evident, 
the exciting cause, on the contrary, seems to reach the organ by way of 
the bloodvessels. Where chronic inflammation is a consequence of 
arteriosclerosis, it is of the interacinar type; observations of Lefas and 
of the writer show that many cases of chronic pancreatitis associated 
with atrophic cirrhosis of the liver, and presumably due to the action of 
the same cause, which is in many instances alcohol, are interacinar. In 
some cases the etiology of interacinar pancreatitis is obscure. 
Chronic interstitial inflammation of the pancreas, which accompanies 
the disease known as hemochromatosis (or when accompanied by diabetes 
mellitus as bronzed diabetes), affects the interacinar tissue and implicates 
the islands of Langerhans; there may be in addition some thickening 
of the strands of connective tissue between the lobules of the gland. The 
deposition of an iron-containing pigment in the liver, pancreas, and 
other glands is accompanied by degeneration of the parenchymatous 
cells and chronic interstitial inflammation of these organs. Bronzing 
of the skin due to deposition of pigment occurs, and in the later stages 
of the disease there is diabetes mellitus, which is the usual cause of death. 
The pancreas is firm in consistence and of a chocolate-brown color due 
to the presence of yellowish-brown pigment both in the parenchymatous 
cells and in the interstitial tissue of the organ. 
Clinical Significance of Chronic Interstitial Pancreatitis.-Chronic 
pancreatitis is rarely accompanied by such definite symptoms that its 
diagnosis is possible, but the relation of the disease to other recognizable 
lesions and its association with diabetes mellitus may suggest its probable 
existence. Symptoms such as severe pain in the epigastrium and in the 
midscapular region, vomiting, and loss of weight and strength have 
been noted in association with chronic inflammation of the gland, but 
are referable with certainty to the disease which frequently accompanies 
grave disturbances of the stomach, duodenum, or bile passages. Dis- 
turbance of digestion due to loss of pancreatic juice and indicated by the 
presence of fatty stools may occur with chronic pancreatitis, but is 
usually the result of carcinoma, cysts, or calculi, which occlude the 
duct and as a consequence cause chronic inflammation. 
Probable existence of chronic pancreatitis may be suggested by lesions 
of adjacent organs, particularly when such lesions are accompanied by 
glycosuria. Chronic interlobular pancreatitis is almost constantly DISEASES OF THE PANCREAS 
631 
present in association with carcinoma of the head of the pancreas and 
with pancreatic calculi, but only when the lesion is advanced and partial 
destruction of the islands of Langerhans has occurred does diabetes 
mellitus ensue. Hence glycosuria is present in a relatively small pro- 
portion of instances of pancreatic lithiasis and of carcinoma of the gland, 
and rarely, if ever, accompanies chronic pancreatitis caused by biliary 
calculi. Since glycosuria in association with carcinoma, cyst, or calculi 
indicates far-advanced chronic disease of the pancreas, it has grave 
prognostic significance. 
Riedel and Mayo Robson have emphasized the importance of recogniz- 
ing at operation chronic interstitial pancreatitis occurring with chole- 
lithiasis. In a certain number of operations for the relief of gall-stones 
the head of the pancreas is so indurated that carcinoma is suspected. 
In several cases a grave prognosis has been based upon the discovery of 
induration, but the recovery of the patient has proved the absence of 
malignant growth. Mayo Robson believes that chronic pancreatitis 
should be regarded as a serious complication of gall-stones, at times 
causing death with increasing weakness and emaciation; cholecystotomy 
with drainage of the gall-bladder and removal of the calculi, when 
necessary, is, he maintains, followed by recovery. 
While chronic interlobular pancreatitis is accompanied by diabetes 
mellitus in only a small proportion of cases, and occurs only when the 
lesion is far advanced, chronic interacinar pancreatitis which implicates 
the islands of Langerhans is in almost all cases accompanied by glycosuria. 
The disease causes relatively slight destruction of the secreting paren- 
chyma and is rarely accompanied by symptoms, other than glycosuria, 
referable to the gland. In a large proportion of cases it will be impossible 
to decide during life if diabetes is referable to interacinar pancreatitis. 
When, however, diabetes mellitus occurs in an individual suffering from 
cirrhosis of the liver, the former disease is with considerable probability 
dependent upon the coexistence of chronic interacinar pancreatitis. In 
another group of cases diabetes mellitus accompanied by advanced 
arteriosclerosis may with much probability be referred to chronic inter- 
acinar pancreatitis caused by the arterial disease. 
TUBERCULOSIS OF THE PANCREAS 
Miliary tuberculosis of the pancreas in association with acute or 
chronic tuberculosis of other organs is not uncommon, but widespread 
tuberculosis causing functional disturbance or recognizable enlarge- 
ment of the gland is almost unknown. Among 128 cases of tubercu- 
losis Kudrewetsky found tubercles in the pancreas in nearly a tenth of 
them; they were common with acute miliary tuberculosis and with 
tuberculosis in children. Large tuberculous lesions are uncommon. 
Chvostek described a case in which the enlarged pancreas formed a 
fibrous mass containing caseous areas the size of a walnut. In a case 
described by Sendler a small tumor was felt above the umbilicus in a 
woman who had suffered with pain and vomiting during nine months; 632 
DISEASES OF THE DIGESTIVE SYSTEM 
a small mass removed at operation from the head of the pancreas was 
found to be a tuberculous lymphatic node. Carnot mentioned a case 
in which the splenic end of the pancreas in contact with a tuberculous 
kidney was the seat of tuberculosis. 
SYPHILIS OF THE PANCREAS 
Congenital syphilitic pancreatitis was found by Birch-Hirschfeld in 
29 of 124 syphilitic newborn infants. With this lesion increase of the 
interstitial tissue prevents the development of the secreting parenchyma; 
the islands of Langerhans resist the process better than the secreting 
parenchyma, and persist, surrounded by connective tissue. Aliliary 
gummata occur occasionally within the connective tissue which has 
undergone proliferation. The pancreas is rarely the seat of gummata 
occurring as the result of acquired syphilis. From the older literature 
Friedreich cited three cases in which gummata of the pancreas were 
associated with characteristic syphilitic lesions of other organs. Cases 
of pancreatic syphilis in which the lesion is analogous to that of syphilis 
of the liver have been described by Drozda and by Schlagenhauf er; 
in association with syphilitic lesions in other parts of the body the 
pancreas has been found to contain scar-like masses of connective tissue 
within which are caseous gummata. In a case of Chvostek the tail of 
the pancreas was penetrated by sclerotic bands which gave it a lobed 
appearance; gummata were not present. There are no data with refer- 
ence to the symptoms or diagnosis of syphilis of the pancreas. 
I 
CALCULI OF THE PANCREAS 
Pancreatic calculi occur much less frequently than gall-stones, which 
in most instances are formed within the gall-bladder, and not like pan- 
creatic stones within ducts. Two instances occurred among 1500 autopsies 
at Johns Hopkins Hospital. Unlike gall-stones, pancreatic calculi occur 
more frequently in men than in women; among 57 cases collected from 
the literature by Lazarus,1 47 were in men and 10 in women, a ratio of 
about 5 to 1. In almost two-thirds of these cases the disease affected 
individuals between the ages of thirty and fifty years. 
Etiology.-The presence of calculi is usually associated with acute 
and chronic inflammatory changes in the ducts and in the parenchyma 
of the gland, but etiological relation of these factors to lithiasis is doubtful, 
since, in part at least, they are caused by occlusion of the ducts or by 
secondary invasion of bacteria. Giudiceandrea was able to demonstrate 
the colon bacillus together with numerous long bacilli within pancreatic 
calculi, while in a second case he found in the centre of a calculus 
numerous cocci and bacilli. 
The association of pancreatic and biliary calculi in a considerable 
number of cases cited by Ancelet (eight cases), and observed by Curnow, 
1 Beitrage zur Pathologic und Therapie der Pankreaserkrankrungen, Berlin, 1904. DISEASES OF THE PANCREAS 
633 
Dieckhoff, and Lazarus, suggests the possibility that ascending affection 
from the bile passages, favored perhaps by temporary obstruction of the 
pancreatic ducts by passing gall-stones, may have caused pancreatic 
lithiasis, although perhaps both biliary and pancreatic calculi may have 
been due to the same cause. That stagnation of pancreatic secretion 
favors the formation of calculi is indicated by cases in which calculi, at 
times in considerable number, are found within pancreatic cysts. Occa- 
sionally an impacted stone has caused the formation of a retention cyst, 
but in other cases large cysts of obscure origin have contained numerous 
calculi; Lazarus has observed 4 such cases. 
Pathology.-In some cases the pancreatic ducts contain fine sand- 
like concretions, but more frequently several stones, perhaps a centimeter 
or more in diameter, are present. The largest recorded calculus (Schupp- 
mann) was stellate in shape and measured one and a half inches in its 
largest diameter. A solitary calculus is rarely found, while several 
hundred varying greatly in size may be present. In some instances 
projections from a large stone situated in the large duct extend into 
adjacent branches, so that a cast of the dilated ducts is produced. In 
consistence pancreatic concretions vary considerably, being at times 
mortar-like and friable, but usually hard; they may have a nucleus of 
organic material consisting of cell detritus. Pancreatic calculi are white, 
often grayish or yellowish white, but in rare instances black or brownish- 
black concretions have been found within the ducts. 
Biliary calculi have in several cases been found within the duct of 
Wirsung near its junction with the common bile duct. In an example 
of suppurative pancreatitis, described by Dieckhoff, the duct of Wirsung 
was dilated and contained a gall-stone. 
Pancreatic calculi are composed in great part of inorganic salts, of 
which calcium carbonate and calcium phosphate are most abundant, 
although sodium phosphate, magnesium phosphate, and other salts may 
be present. Calculi consisting almost wholly of calcium carbonate or 
calcium phosphate have been described. The composition of calculi 
from two cases described by Johnston1 was as follows: (1) Calcium 
phosphate, 72.3 per cent.; calcium carbonate, 18.9 per cent.; organic 
matter, 8.8 per cent. (2) Calcium carbonate, 91.65 per cent.; magnesium 
carbonate, 4.15 per cent.; organic matter, 3 per cent. In most instances 
inorganic constituents are more abundant than organic material, but 
in a case described by Baldoni organic material formed the greater part 
of the concretion. A calculus having a nucleus of calcium carbonate 
surrounded by a layer of cholesterin has been described by Freyhan. 
A calculus consisting of calcium oxalate has been found at operation 
in a pancreatic cyst by Shattuck.2 
Calculi may be situated in the larger ducts or their branches, but 
calculi of considerable size are usually found in the duct of Wirsung, 
of which the lumen is frequently so completely occluded that outflow 
of secretion is prevented and dilatation behind the obstruction results. 
Stones embedded in ampulla-like diverticula of the large duct have been 
1 Amer. Jour. Med. Sc., 1883, Ixxxvi, p. 404. 
2 Brit. Med. Jour., 1896, i, 1034. 634 
DISEASES OF THE DIGESTIVE SYSTEM 
described. Since the duct of Wirsung is narrower near its duodenal orifice 
than elsewhere, calculi tend to lodge in this situation, and the duct may 
be uniformly dilated to a diameter of a centimeter or more. Stones lodged 
in the terminal part of the duct of Wirsung may compress the common 
bile duct and cause jaundice; Gould found in the diverticulum of Vater 
a pancreatic calculus which had caused jaundice. 
Obstruction to the outflow of pancreatic juice, doubtless in association 
with bacterial infection, causes chronic interstitial inflammation of the 
pancreas, which may reach such an advanced stage that the gland is 
converted into dense fibrous tissue surrounding the dilated duct, secreting 
parenchyma having almost completely disappeared. The most intense 
sclerosis occurs in association with calculi. In the contracting fibrous 
tissue the islands of Langerhans finally undergo changes, being com- 
pressed and invaded by the sclerotic tissue. In cases of diabetes with 
pancreatic lithiasis the islands of Langerhans had suffered similar changes 
(Lazarus, Pearce, Lancereaux, etc.). 
Calculi situated within the ducts not infrequently cause ulceration of 
the mucosa by pressure. In the immediate neighborhood of a stone 
chronic inflammation more intense than elsewhere may produce abundant 
scar tissue, distorting the duct. The presence of bacteria may result in 
pancreatic abscess, not an infrequent result of pancreatic calculi. 
Symptoms.-Pancreatic lithiasis may be unaccompanied by note- 
worthy local symptoms indicating disease of the organ. Lazarus de- 
scribed such a case in which death occurred with diabetes and pulmonary 
tuberculosis. At autopsy the pancreas was found to be converted into 
a fibrous sac and notwithstanding the fact that the duct contained 
numerous jagged concretions, there had been no pain. 
The most frequent symptom is pain, which may be continued or 
intermittent; in some instances there is merely a sense of pressure. More 
characteristic are attacks of colicky pain, which in some instances have 
been regarded as sufficiently distinctive for diagnosis. Friedreich doubted 
the occurrence of pancreatic colic analogous to gall-stone colic. Subsequent 
observations have shown that severe attacks of colic-like pain occur in 
association with the passage of calculi. In a case of Leichtenstern's, 
symptoms of biliary colic without jaundice were followed by the passage 
with the feces of three concretions, the largest the size of a pea; analysis 
showed that they were composed of calcium carbonate without traces 
of either bile pigments or cholesterin. Pain has been localized in the 
epigastrium and under the left costal margin in the mammillary line, 
radiating on the left side to the spine or to the left shoulder-blade. Pain 
with pancreatic lithiasis does not necessarily occur to the left of the 
midline, but may be limited to the region of the epigastrium or of the 
umbilicus, or may even radiate to the right side (Eichhorst). 
As with biliary colic, the attacks of pain associated with passage of 
pancreatic calculi are often accompanied by vomiting. Reflex circulatory 
disturbances, such as weak pulse and temporary collapse, may occur. 
The pain is at times accompanied by a chill which is followed by fever, 
possibly referable to bacterial invasion of the occluded duct. 
The passage of a pancreatic calculus through the diverticulum of diseases of the pancreas 
635 
Vater may cause temporary jaundice. A patient of Leichtenstern suffered 
during two years with attacks of a severe abdominal pain accompanied 
by vomiting and on one occasion by jaundice, but cholecystotomy 
undertaken for the relief of gall-stones demonstrated their absence; 
autopsy showed the presence of numerous pancreatic calculi. The 
relatively frequent association of cholelithiasis with pancreatic lithiasis 
may explain the occurrence of jaundice in some instances. 
In several instances a diagnosis of pancreatic lithiasis has been made 
during life from the passage with the feces of calculi composed of calcium 
carbonate or phosphate and free from bile pigments or other constituents 
of the bile. In a case of Minnich during twelve days following an attack 
of colic, soft friable concretions as large as a cherry pip were found, 
containing carbonate and phosphate of calcium. 
Diabetes mellitus, or alimentary glycosuria, has been a symptom of 
pancreatic lithiasis in a large proportion of the recorded cases; Lazarus 
has collected 80 cases, among which glycosuria occurred in 36 (45 per 
cent.). Pancreatic lithiasis is an infrequent cause of diabetes, occurring 
only 5 times among 288 cases of diabetes recently collected from the 
literature. Pancreatic lithiasis may exist for years without diabetes, 
and in the case described by Caparelli glycosuria appeared six years 
after the first attack of colic. Since glycosuria is not the result of occlusion 
of the pancreatic ducts but of consequent chronic interlobular inflam- 
mation, diabetes results only after the lesion has become far advanced 
and has injured the islands of Langerhans. At one stage of the disease 
the organ is subject to such slight impairment of function that alimentary 
glycosuria occurs; in the cases of Lichtheim, Lazarus, and Opie, glycosuria 
disappeared when the patient was given a diet poor in carbohydrates. 
In the cases of Polyakoff and of Minnich transient glycosuria occurred 
only after attacks of colic, and was doubtless analogous to that which 
not infrequently follows experimental injury to the gland, insufficient to 
cause permanent diabetes. 
Steatorrhoea has been present in 10 of the cases collected by Lazarus. 
In the table of Fitz, which contains 29 cases in which visible fatty stools 
have accompanied demonstrable pancreatic disease, pancreatic lithiasis 
was present in 7 instances. In none of the cases of Fitz was jaundice 
present, while in 4 there was glycosuria. In cases studied by Muller 
and by Kinnicutt and Herter, although fat was not visible in the feces, 
chemical analysis demonstrated that the percentage of split fat was 
much less than normal. Azotorrhoea, shown by the presence of undigested 
muscle fibres in the feces, is even less common than fatty stools, and in 
only one (Lichtheim) of the eight instances in which this symptom 
accompanied well-authenticated pancreatic disease (Fitz) was the 
pancreatic lesion caused by calculi. 
The loss of weight in association with pancreatic lithiasis in the absence 
of diabetes or disturbances of digestion is probably referable, in part at 
least, to inflammatory changes or other complications of the disease. 
Complications.-Among these the most frequent and serious is abscess. 
Rupture may occur into the peritoneal cavity causing a localized bursal 
abscess or fatal general peritonitis. A fistulous communication with the 636 
DISEASES OF THE DIGESTIVE SYSTEM 
intestinal tract may be formed; in a case described by Nicholas and 
Molliere one liter of blood was passed by rectum two and a half months 
after an attack of severe epigastric pain; a second attack of colic and 
subsequent hemorrhage, together with chills, fever, and glycosuria, 
preceded death. The duct of Wirsung contained about twenty con- 
cretions, while in the substance of the gland communicating by a fistulous 
opening with the duodenum was an abscess from which hemorrhage had 
occurred. In the case of Caparelli an abscess opened near the umbilicus, 
and calculi were passed from the fistula which persisted for six years. 
The association of cysts with pancreatic calculi has already been 
mentioned. Cases in which carcinoma of the pancreas has been described 
in association with calculi date from a time when chronic inflammation 
was not infrequently mistaken for scirrhous carcinoma. In a case of 
Schupmann carcinoma occupied the tail of the gland, and in the region 
of the tumor within the duct was a large jagged concretion. 
Diagnosis. - Kinnicutt collected from the literature seven cases in 
which a diagnosis of pancreatic lithiasis was made during life. In the 
case of Caparelli calculi were discharged from a fistula in the epigastric 
region, and in the cases of Leichtenstern, Minnich, and Kinnicutt calculi 
consisting of phosphate or carbonate of calcium without mixture of bile 
salts were passed with the stools after attacks of epigastric colic. An 
additional case has been described by Cipriani.1 
A review of the recorded cases gives no data by which it is possible 
to distinguish pancreatic from biliary colic, although localization of the 
pain below the left costal margin may be suggestive of pancreatic lesion. 
Diabetes mellitus, or alimentary glycosuria, may indicate a lesion of 
the gland. Fatty stools have been less frequently observed, and in the 
absence of jaundice have diagnostic value; diminution of split fat in 
the feces is believed to have similar significance. Jaundice may be 
caused by a pancreatic calculus lodged in the diverticulum of Vater, or 
by biliary calculi, which occur with relative frequency in association 
with pancreatic calculi, and does not exclude pancreatic colic. 
Treatment.-Statements concerning this are necessarily vague, since 
few cases have been recognized during life. Attacks of colicky pain 
have been treated by sedatives applicable to biliary colic. Measures 
which increase the flow of pancreatic juice have been suggested for the 
purpose of overcoming obstruction to its outflow, particularly since 
duct obstruction is believed to be an important factor in the production 
of calculi. Physiological observations according to Lazarus suggest 
that this may be accomplished by water in abundance, especially when 
cabonized or acidified by other means; alkalis are thought to diminish 
pancreatic secretion. To increase the flow of pancreatic juice, Eichhorst 
injected pilocarpine subcutaneously in a case believed to be pancreatic 
lithiasis, and found that attacks of colic disappeared. It is noteworthy 
in this connection that pilocarpine administered to animals with the 
pancreatic ducts ligated caused necrosis of almost the entire abdominal 
fat, and death within four days. 
1 Amer. Jour. Med. Sc., 1902, cxxiv, 948. DISEASES OF THE PANCREAS 
637 
The presence of glycosuria indicates that the pancreas has undergone 
grave sclerotic change; nevertheless, in several instances with diabetic 
diet the sugar has disappeared. 
Analogy with gall-stones suggests the possibility of surgical treatment. 
Gould1 found at operation upon a patient suffering with symptoms of 
cholelithiasis a lump at the posterior part of the lesser peritoneal cavity, 
and on incision removed a calculus from the duct of Wirsung. Obstruc- 
tion to the flow of bile was not relieved, and at a second operation a 
stone was removed from the head of the pancreas; although bile sub- 
sequently entered the intestine, death occurred as the result of suppura- 
tion twelve days later. Moynihan2 removed through the duodenum a cal- 
culus lodged in the duct of Wirsung and projecting into the diverticulum 
of Vater. Straehlin and Roeber3 cut into the head of the pancreas and 
successfully removed several calculi from the duct of Wirsung. 
CYST OF THE PANCREAS 
Varieties of lesions are described as cysts of the pancreas; their 
common character is the presence in the upper part of the abdominal 
cavity of an encapsulated collection of fluid in contact with the gland 
and apparently derived wholly or in part from it. Since the greater 
number of such cysts are observed at operation, the exact nature of the 
disease is often obscure and its relation to the pancreas is not always 
established, particularly because fluid encapsulated by the thickened 
wall of the bursa omentalis may produce signs indistinguishable from 
those of pancreatic cysts situated within the substance of the gland. 
Classification.-True cysts derived from the ducts or acini of the 
pancreas and lined by a layer of epithelial cells have been distinguished 
from so-called pseudocysts, which have walls of thickened connective 
tissue and are without epithelial lining. True cysts may be formed by 
dilatation of the pancreatic duct or its branches due to obstruction, 
and are retention cysts, or may be the result of spontaneous proliferation 
of epithelial structures, and are tumors. Pseudocysts are the result of 
trauma or of degenerative changes within the substance of the gland, 
and frequently contain blood or blood mixed with products of pancreatic 
secretion; pseudocysts may be situated wholly within the substances 
of the pancreas, or, when associated with rupture of the anterior surface 
of the gland may be limited in part by the walls of the bursa omentalis. 
Pseudocysts, it has already been shown, may be the result of acute 
hemorrhagic pancreatitis. The etiology and course of these diverse 
lesions vary so greatly that it would be desirable to consider them sep- 
arately were they not characterized by certain physical signs common 
to all encapsulated collections of fluid having their origin in the pancreas. 
The relation of different parts of the pancreas to adjacent structures 
determines the location of such cysts and the point at which they present 
1 Lancet, 1898, ii, 1632. 
2 Ibid., 1902, ii, 355. 
3 New York Med. Jour., 1905, Ixxxii, 904. 638 
DISEASES OF THE DIGESTIVE SYSTEM 
upon the surface of the body. From an analysis of 133 cysts upon which 
operation had been performed Korte described the various positions. 
A. In the majority the cyst grows directly forward, and, pushing the 
stomach upward, comes in contact with the anterior abdominal wall 
between the stomach and colon; in order to reach the tumor at operation 
it is necessary to cut through the gastrocolic omentum. The cyst occupies 
and distends the cavity of the bursa omentalis, and, stretching the 
gastrocolic ligament, may, with increased growth, push downward the 
transverse colon so that it may reach the symphysis pubis. Pseudocysts 
which arise from the pancreas and, as the result of rupture of its overlying 
Fig. 6 
Fig. 7 
Cyst projecting into the lesser peritoneal cavity 
behind the stomach and above the colon. (Oser.) 
Cyst projecting into the lesser peritoneal 
cavity, and in contact with the abdominal wall 
between the stomach and pancreas. (Oser.) 
peritoneum, communicate with the bursa omentalis, and are in large 
part limited by this cavity, occupy the position described and present 
upon the surface of the abdomen between stomach and colon. Jordan 
Lloyd has shown that accumulations of fluid in the lesser peritoneal 
cavity due to a variety of causes may closely resemble these cysts of 
the pancreas. The stomach is compressed and flattened, but usually 
pushed upward. Should adhesions be formed between the cyst and 
the stomach, the latter may be held in front of the tumor and drawn 
downward by it. 
B. Less frequently the cyst makes its way above the lesser curvature 
of the stomach between the stomach and liver, stretching the gastro- DISEASES OF THE PANCREAS 
639 
hepatic omentum which covers it. The upper border of the pancreas 
is at a higher level than the lesser curvature of the stomach, so that a 
cyst arising from this part of the gland may present above the stomach, 
which, with further growth of the tumor, is pressed downward; with 
gastroptosis the extent of pancreas above the lesser curvature of the 
stomach is increased. Korte cites 9 cases in which the cyst presented 
at operation above the stomach, and in 2 cases described by Riegner 
and Finotti a diagnosis of the position was made. 
Fig. 8 
Fig. 9 
Cyst projecting from the upper surface of the 
mesocolon and presenting between stomach and 
colon. (Oser.) 
Cyst occupying position of mesocolon, with colon 
overlying. (Oser.) 
C. In a third group the cyst in growing penetrates the layers of the 
mesocolon. Growth into the mesocolon is more likely to occur when 
the cyst is situated toward the tail of the gland, since this part of the 
organ is situated between the layers of the mesocolon; the head of the 
pancreas being situated in the loop formed by the duodenum, cysts from 
this part do not find their way into the mesocolon. Korte cites 7 instances 
in which the cyst situated in the mesocolon pushed forward the upper 
layer of the membrane and reached the anterior abdominal wall between 
the stomach and colon. The transverse colon may be forced downward 
to the pelvis, and the descending colon may overlie the tumor. In 3 
instances the cyst projected upon the under surface of the membrane, 
so that the transverse colon was found upon its upper margin. Lazarus 
mentions an intermediate position in which the cyst distends the upper 640 
DISEASES OF THE DIGESTIVE SYSTEM 
and lower layers of the mesocolon equally so that the transverse colon 
is found to cross the summit of the tumor. 
A case described by Dreyzehner, according to Lazarus,1 does not 
belong to any of the groups already defined; this type may be designated 
prevertebral. A tumor arising from the head of the pancreas forced its 
way behind the peritoneum to the right of the midline and displaced 
the right kidney. Payr2 described a cyst of the pancreas which was 
found at operation within the larger peritoneal cavity between the liver 
and pancreas; it had made its way through the foramen of Winslow. 
Fig. 10 
Cyst projecting from lower surface of the mesocolon and presenting below the colon. (Oser.) 
Etiology and Pathology.-Cysts of the pancreas occur with approxi- 
mately equal frequency in males and in females. Railton has described 
an instance of pancreatic cyst occurring in an infant six months old, and 
Shattuck found a cyst of the gland in a boy thirteen months old. About 
half the cases occur between the ages of twenty and forty years. 
Retention Cysts.-Cysts formed as the result of obstruction of the 
larger pancreatic ducts or their branches, designated retention cysts, 
are often of small size and unaccompanied by clinical symptoms. Under 
the name of ranula pancreatica Virchow described dilatation of the duct 
of Wirsung due to occlusion caused by a villous tumor of the duodenum; 
the duct had numerous sacculations, giving it a beaded appearance. 
1 Beitrdge zur Pathologic und Therapie der Pankreaserkrankungen, Berlin, 1904, and 
Zeit. f. Heilk., 1901, xxii, 165. 
2 Wiener klin. Woch., 1898, xii, 629. DISEASES OF THE PANCREAS 
641 
Klebs described as acne pancreatica multiple small cysts containing fluid, 
sometimes clear and sometimes opaque, yellowish, and thick. 
Ligation of the ducts of the pancreas causes only slight dilatation of 
the occluded channels, and is followed by chronic inflammation of the 
gland. Complete obstruction to the outflow of secretion in man is usually 
followed by similar changes. It has been thought that partial or inter- 
mittent occlusion may cause cysts. Cysts of the pancreas apparently 
due to retention of pancreatic secretion have been found associated with 
obstruction of ducts due to a variety of causes, but the conditions which 
favor their formation are not understood. Cysts of large size have been 
found in association with pancreatic calculi, von Recklinghausen found, 
with a cyst almost the size of a child's head, the duct of Wirsung occluded 
by a calculus. Lazarus found calculi in the contents of pancreatic cysts 
in 2 of 14 cases, but suggests that the cyst may afford conditions which 
favor the formation of concretions. 
The walls of pancreatic cysts are usually several millimeters in thick- 
ness and are composed of dense fibrous tissue in which remains of 
pancreatic parenchyma may be found. The inner surface may be 
smooth and lined by a single layer of cylindrical cells. The presence of 
such cells indicates the cyst has had its origin in a dilated duct. 
Proliferation Cysts.-The occurrence of multilocular cysts of the 
pancreas, the presence of numerous small cysts in the wall of a large 
cyst, or the presence of papillary projections upon the inner surface 
have been regarded as evidence that cysts may be formed by proliferation 
of epithelial tissue of the gland. In some instances cysts of the pancreas 
resemble the cystadenomas of the ovary and other organs, and have 
been regarded as true tumors. Fitz1 described a multilocular cystoma 
which apparently had its origin in the pancreas, and collected 9 somewhat 
similar cases from the literature; 8 cases occurred in women, and in 
most instances the growth existed for a number of years without causing 
severe inconvenience. In no case was there evident obstruction of ducts, 
but a description of some of the cysts does not exclude the possibility 
that they may have been due to occlusion of small ducts. Korte collected 
from the literature only 13 instances of proliferation cysts (cystad- 
enomas); Munzer2 (1903) cites 5 additional cases. In two cases cysts 
have been associated with malignant growths. 
Traumatic Cysts.-Since many cysts of the pancreas contain blood the 
relation of cyst formation to hemorrhage into the gland has been much 
discussed, and so-called apoplectic cysts have been described. Hemor- 
rhage may occur into a preformed cyst, and the presence of blood does 
not indicate that the lesion is the result of hemorrhage. Nevertheless, 
there is abundant evidence that injuries which cause local hemorrhage 
may result in the formation of cysts. Lazarus has shown that a small 
hematoma may be formed by crushing the exposed pancreas of the dog; 
at the end of a week the extravasated blood may have undergone encapsu- 
lation by fibrous tissue. By crushing the pancreas of a dog he caused the 
formation of a hematoma about the size of a pigeon's egg which, after 
1 Amer. Jour. Med. Sc., 1900, cxx, 184. 
2 Cent. f. d. Grenzgeb. d. Med. u. Chir., 1903, vi, 490, 529, 573, 619, 664. 
vol. hi-41 642 
DISEASES OF THE DIGESTIVE SYSTEM 
forty days was converted into a cyst with a smooth, fibrous capsule 
containing 100 cc. of watery fluid. Lazarus thought that the hematoma, 
together with injured tissue and adjacent parenchyma, had undergone 
digestion by the secretion of the gland, while a reactive inflammation 
at the periphery of the lesion had resulted in the formation of a capsule, 
which in turn prevented the resorption of the fluid contents. 
Among 117 cases of pancreatic cyst, Korte found 33 (28 per cent.) in 
which trauma had preceded the appearance of a cyst; Lazarus has 
collected 8 additional cases more recently published. In the greater 
number the epigastric region or the upper left quadrant of the abdomen 
had been the seat of the injury; in several cases there had been compres- 
sion of the body or a wheel had passed over it. A violent blow from 
a fist or the kick of a horse has preceded the appearance of a cyst. 
Repeated injury of less severity has been cited as the cause of the 
lesion; energetic massage is mentioned by Gussenbauer. 
The contents of many cysts which have followed traumatism are 
bloody, but not infrequently such cysts have contained clear fluid free 
from blood. The demonstration of one or more ferments either in the 
contents of the cyst or in the fluid escaping from a fistula after operation 
has been cited as evidence of connection with the pancreas. Drainage 
of the cyst has usually been followed by recovery, and in only a few 
instances have these cysts been studied at autopsy. In the case of 
Richardson the pancreatic duct communicated with the cyst. Jordan 
Lloyd has maintained that accumulations of fluid in the lesser peritoneal 
cavity following contusions of the upper part of the abdomen are often 
mistaken for true cysts of the pancreas. In a case which he recorded 
fluid removed at operation had the power of rapidly converting starch 
into sugar, and was derived in part, he believed, from the injured 
pancreas. 
A number of cases furnish evidence that cysts may follow acute hem- 
orrhagic pancreatitis. The pathogenesis of the lesion doubtless resembles 
that of traumatic cysts. Hemorrhagic and necrotic tissue undergoes 
partial solution and subsequent encapsulation by fibrous tissue. 
Contents.-These vary greatly, being in many instances mixed with 
fresh or altered blood. Occasionally clear and watery in appearance, 
more frequently the fluid is viscid, and in several instances the 
presence of mucus has been demonstrated. In most instances hemor- 
rhage has occurred into the cyst, and while occasionally the contained 
fluid may appear to be pure blood, subsequent changes, due in part to 
the action of digestive ferments, may produce a greenish, brownish, 
coffee-colored, or even black fluid. 
Much significance was formerly attached to the presence of ferments 
resembling those of the pancreatic secretion, but the absence of one or 
more of these ferments in the contents of pancreatic cysts and the pres- 
ence of similar ferments in cysts of other organs has greatly diminished 
their diagnostic value. The presence of tryptic, diastatic, and emulsifying 
ferments may suggest the character of fluid removed by operation, but 
rarely is it possible to demonstrate all three ferments, while most fre- 
quently the diastatic ferment alone can be found. The antitryptic DISEASES OF THE PANCREAS 
643 
action of the blood serum may explain occasionally the absence of 
trypsin in cysts with hemorrhagic contents. Only when the cyst is in 
communication with the secreting parenchyma can the ferments of the 
gland find their way into its contents, while observation on animals 
(Heidenhain) shows that the secretion of the chronically inflamed 
pancreas may contain little, if any, ferment. 
Fat-splitting, diastatic, or proteolytic ferments, moreover, have been 
demonstrated in a variety of fluids which do not have their origin in the 
pancreas. Since Korte has found a weak diastatic ferment in the contents 
of a mesenteric cyst, he thinks that fluid from a cyst must exhibit active 
diastatic action in order to suggest a probable pancreatic origin. Boas 
thinks that tryptic ferment is characteristic of these cysts, but Lazarus 
has found a fibrin-digesting ferment in the contents of an ovarian cyst, 
and it is probable that any fluid containing leukocytes in considerable 
number will exert proteolytic action in an alkaline medium. 
Symptoms.-A rounded tumor fluctuating on palpation and situated 
in the epigastric region behind the stomach and in greater part to the left 
of the median line suggests the presence of a pancreatic cyst, but the 
variation to which these characters are subject often makes recognition 
of the tumor difficult. In the majority of cases the tumor is situated 
between the ensiform cartilage and the umbilicus, and may produce a 
rounded protrusion of the abdominal wall. In 48 cases collected by 
Korte the tumor occupied the median line; in 40 instances the greater 
part of the mass was to the left of the median line, extending to the 
left costal margin, and in some instances into the lumbar region. In 
only 10 cases was the larger part of the cyst to the right of the median 
line. Very large tumors extend into the lower part of the abdominal 
cavity, and in 16 cases the tumor extended below the level of the umbili- 
cus, sometimes as far as the symphysis pubis. 
The size of the cyst is subject to equal variation; in many instances 
it is described as the size of a man's head, but may distend the abdominal 
cavity, extending from the ensiform process to the symphysis pubis. 
In shape the cyst is usually spherical and the surface is smooth. Fluctua- 
tion can usually be felt, but rarely the fluid contents have distended the 
sac so tensely that the tumor has appeared to be solid. When the cyst 
is grasped between the hands, one placed upon its abdominal surface, 
the other upon the lumbar region, pressure of one hand is transmitted 
to the other. Pancreatic cysts, contrary to the statements of some 
writers, are not infrequently movable, and, particularly when in contact 
with the diaphragm, move with respiration. Cysts arising from the tail 
of the gland are particularly movable, and unless fixed by adhesions can 
be pushed both from above down and laterally. Cysts which lie in 
front of the aorta may, when sufficiently tense, transmit its pulsation, 
but cease to pulsate when the patient is in the knee-chest position. 
Of much importance is the relation of the cyst to adjacent organs, and 
especially to the stomach and colon, between which in most instances 
it reaches the abdominal wall. Small cysts may be wholly covered by 
the stomach, but with increase of their size the organ is pushed upward, 
so that when artificially distended its tympany separates the dulness 644 
DISEASES OF THE DIGESTIVE SYSTEM 
produced by the cyst from that of the liver. The colon, best mapped 
out after inflation with air, is found along the lower border of the cyst, 
being in some instances pushed downward to the symphysis pubis. 
When the cyst occupies the mesocolon, the colon may be below the tumor, 
may cross its summit, or lie along its upper border in accordance with 
the previously described relation which the cyst bears to the upper or 
lower surface of the membrane. When the cyst projects upon the lower 
surface of the mesocolon, the tumor may occupy the lower part of the 
abdominal cavity, with its margin in contact with the symphysis pubis. 
Cysts which force their way between the liver and the stomach produce 
dulness in contact with that of the liver while their lower part is covered 
by the stomach, which, when distended, almost completely covers the 
tumor. 
Sudden disappearance of the tumor of a pancreatic cyst may be the 
result of rupture into the peritoneal cavity. In some instances rupture 
has followed puncture undertaken for the purpose of diagnosis, or, 
as in the cases of Halsted and of Schwartz, has followed injury the 
result of a fall. Of greater interest is the spontaneous disappearance 
accompanied by temporary diarrhoea of a peculiar character, suggesting 
that the contents of the cyst have been discharged into the duodenum. 
Disappearance of the tumor in the cases of Bull and of Karewski was 
accompanied by the appearance of dark-colored masses in the stools. 
In the case described by Parson the sudden disappearance of a tumor 
the size of an orange situated in the epigastrium was followed by profuse 
whitish diarrhoeal discharge; a second tumor appeared in the lower part 
of the abdomen at the end of several weeks, disappeared with profuse 
diarrhoea, and again returned. A large cyst in the epigastrium, described 
by Payr, disappeared with occurrence of diarrhoeal discharges containing 
whitish particles three times during two months. The conditions which 
cause the periodic discharge of the cystic contents have not been explained. 
Pain is one of the most constant symptoms, and is not infrequently 
present before a tumor is demonstrable. In a few instances the presence 
of the tumor has been unaccompanied by pain, or has merely caused a 
feeling of distension. Pain is usually deeply seated in the epigastric 
region, or may be referred to the small of the back. In some instances 
it has been referred to the right or left hypochondrium in accordance 
with the localization of the cyst in the head or tail of the gland, but little 
reliance can be placed upon these subjective symptoms. The intensity 
of the pain varies greatly. It may occur in paroxysms which in some 
instances have the character of gastric crises, and may be accompanied 
by vomiting and collapse. 
Various symptoms have been produced by the pressure of the grow- 
ing cyst upon adjacent organs. Most constant are those referable to 
the stomach, which in some instances is flattened by the tumor. Dis- 
comfort after eating, loss of appetite, vomiting, and other symptoms of 
disturbed digestion are present, and may have long preceded other 
evidence of disease. Compression of the intestine may be accompanied 
by colicky pain and constipation. In a case of Lazarus the transverse 
Colon situated along the lower margin of the tumor was frequently the DISEASES OF THE PANCREAS 
645 
seat of colic, and in four cases collected from the literature by this author 
complete intestinal obstruction had occurred. 
Cysts situated in the head of the pancreas may cause jaundice. The 
relative infrequency of this symptom is explained by the fact that cysts 
occur more frequently in other parts of the gland. Retention cysts 
caused by tumors or by biliary calculi compressing the pancreatic duct 
are accompanied by jaundice due to the same cause. 
Compression of the portal vein may be followed by ascites and by 
the establishment of collateral circulation. Dilatation of the mesenteric 
veins and vessels upon the surface of the cyst adds to the danger of 
puncture. Compression of the vena cava has been accompanied by 
oedema of the lower extremities. In two instances (Dreyzehner, Reeve) 
one ureter has been obstructed. 
Functional disturbance of the pancreas has been noted with only a 
small proportion of the described cases, but careful chemical observation 
of the feces and tests for alimentary glycosuria would probably disclose 
their presence in a larger proportion. Cysts in the body or tail of the 
pancreas do not so readily cause such disturbances as the rarer cysts 
which arise from the head of the gland, since they do not occlude the 
large duct, and therefore do not cause chronic inflammation of the entire 
organ. Among 29 instances of steatorrhoea accompanying well-authen- 
ticated disease of the pancreas collected by Fitz the symptom was refer- 
able to cysts in only 2 cases (Bull, Goodman), in both of which diabetes 
was present as well. In some cases disturbance of protein digestion was 
indicated by the presence of undigested muscle fibres in the feces. 
Diabetes mellitus results from the presence of cysts only when the 
gland is the seat of advanced chronic interstitial inflammation. Diabetes 
is, however, rarely present. It occurred in only 9 of 134 cases collected 
by Oser. Alimentary glycosuria in association with pancreatic cyst 
has been observed in a case described by Lazarus. 
Loss of weight and weakness commonly accompany pancreatic cysts 
and may be referred in part to the digestive disturbances and vomiting 
caused by the pressure of the tumor. Lazarus thinks that the cause of 
cachexia is more obscure, and in several instances has seen loss of weight, 
although there was no disturbance of digestion, no diabetes, and no 
jaundice. One of his patients, a healthy man who developed a cyst in 
consequence of traumatism, became much emaciated, but after operation 
recovered so quickly that within six weeks he had regained fifteen pounds. 
Diagnosis.-Recognition of pancreatic cysts depends almost wholly 
upon physical signs, although in a comparatively small number of cases 
diabetes or steatorrhoea confirms the diagnosis. The presence of fluctua- 
tion may serve to distinguish cysts from solid tumors of the pancreas 
or of retroperitoneal structures, but with cysts so tensely distended that 
this sign is absent some uncertainty may exist, although the spherical 
shape and smooth surface may indicate the character of the lesion. In 
determining the origin of such a tumor, of greatest significance is its 
relation to the stomach and colon, behind which it is situated. This is 
done best by percussion after inflation. In some instances information 
is obtained by noting the change in position of the stomach during the 646 
DISEASES OF THE DIGESTIVE SYSTEM 
progress of inflation; as the organ enlarges, it gradually overlaps an 
increasing area at the upper or lower margin of the tumor, in some 
instances completely covering it. The difficulty of diagnosis is greatest 
with those unusual cysts which present above the stomach or along the 
lower margin of the colon, the typical position being between stomach 
and colon and behind both. 
Possible etiological factors may have an important bearing upon 
diagnosis. A history of injury in the epigastric region may suggest the 
presence of a pancreatic cyst of traumatic origin. Symptoms of hemor- 
rhagic pancreatitis may precede the appearance of a tumor mass. 
Since cysts of the pancreas may occupy almost any part of the abdom- 
inal cavity, their differential diagnosis presents many difficulties. Cysts 
may occur in the liver, spleen, mesentery, omentum, ovaries, retro- 
peritoneal tissue, and adrenals, while a distended gall-bladder or hydro- 
nephrosis may resemble a cyst of the pancreas. 
Echinococcus cysts of the left lobe of the liver may form large, fluctuating 
tumors in the epigastric region. The dulness produced by pancreatic 
cysts occupying their usual position between the stomach and colon is 
separated by the tympany of the former organ from the area of hepatic 
dulness, but should the cyst present between liver and stomach, diagnosis 
is more difficult. The stomach, particularly when distended, is found 
in front of the pancreatic tumor, which is pushed backward and becomes 
less palpable, but the organ cannot bear the same relation to a hepatic 
cyst which lies in contact with the abdominal wall. Should the cyst 
be punctured, the well-known booklets, or perhaps particles of the 
chitinous layer of the cyst wall, may be found in an echinococcus cyst. 
The distended gall-bladder, situated in the usual position of this organ, 
has the respiratory movement of the liver, and, lying in contact with the 
abdominal wall, is rarely covered by the stomach or intestine. Cysts of 
the head of the pancreas, suggesting a distended gall-bladder, may be 
accompanied by jaundice. 
Cysts of the mesentery have usually been found in the neighborhood 
of the umbilicus, and, unless fixed by adhesions, are movable in both 
vertical and horizontal directions. Cysts of the mesocolon are indis- 
tinguishable from similarly situated cysts of the pancreas. 
The diagnosis between ovarian cysts and pancreatic cysts is in most 
instances made with little difficulty. Pancreatic cysts which arise from 
the tail of the gland and are situated in the mesocolon lie in contact with 
the pelvis and may closely simulate ovarian cysts, while cysts of great 
size distending the abdominal cavity may offer the same difficulty. In 
some instances the tumor has been first observed in the epigastric region, 
from which it has subsequently extended downward. Bimanual examina- 
tion by vagina and rectum of an ovarian cyst may demonstrate a pedicle 
connecting it with the uterus and perhaps dragging the latter upward. 
With pancreatic cysts the uterus occupies its normal position, and the 
ovaries are often palpable. Pancreatic cysts of great size are situated 
behind the stomach and colon, while ovarian cysts push these organs 
upward. 
Pancreatic cysts may closely simulate hydronephrosis. The history DISEASES OF THE PANCREAS 
647 
indicating that the tumor has had its origin in the epigastrium 
may suggest pancreatic cyst. The tumor of hydronephrosis fills the 
lumbar region and can be forced even farther backward by distend- 
ing the colon; pancreatic cysts, as a rule, do not extend beyond the 
axillary line behind which there is tympany. Periodic disappearance of 
the tumor may occur both with hydronephrosis and with pancreatic 
cyst, but abundant flow of urine or simultaneous onset of diarrhoea 
may suggest one or other condition. 
Since pancreatic cysts when tensely distended have been known to 
transmit pulsations from the aorta, aortic aneurism may be suspected. 
The tumor rises and falls, but has no expansile pulsation; in the knee- 
chest position pulsation disappears. 
Treatment.-Cysts of the pancreas have been treated by puncture, 
by extirpation, and by incision and drainage. Puncture followed by 
aspiration has proved an ineffectual and dangerous procedure. Kuster 
and Lazarus have mentioned the occurrence of hemorrhage into a cyst 
due to puncture of enlarged vessels in the wall. When the cyst is infected, 
purulent, general peritonitis may follow puncture. Removal of cystic 
contents by aspiration is usually followed by reaccumulation of fluid, 
even when the cyst is of traumatic origin and has walls which are not 
lined by epithelium. 
Complete extirpation of a pancreatic cyst was successfully performed 
in 1882 by Bozemann. The operation is difficult and dangerous, on 
account of the close proximity of important bloodvessels, and may be 
followed by diabetes mellitus when a considerable part of the gland is 
removed. The operation is rarely practicable, unless the cyst has a 
well-defined wall, and is therefore not applicable to traumatic cysts and 
other so-called pseudocysts. In several instances complete extirpation 
has been performed after the multilocular character of the cyst or the 
presence of papillary projections upon its inner surface has suggested 
the existence of an adenomatous growth. Complete removal of these 
proliferation cysts has been believed to offer the best chance of avoiding 
recurrence, although in several instances incision and drainage of cysts 
believed to belong to this type have been followed by recovery. A 
fatal result is due to gangrene of the intestine, hemorrhage, or peritonitis; 
when dense adhesions, the proximity of bloodvessels, or the deep situation 
of the tumor has prevented the completion of attempted extirpation, 
the mortality has been greater. When a cyst occupies the usual position 
between stomach and transverse colon, it is in most instances bound by 
adhesions to adjacent structures, and removal is difficult; when, how- 
ever, the cyst lies within the mesocolon, adhesions are usually less 
abundant, and a considerable proportion of cysts which have been 
extirpated have had this situation. The operation is least difficult when 
the cyst occupies the tail of the gland, which serves as a pedicle and 
allows the tumor to be drawn into the wound; it is more difficult the 
nearer the cyst approaches the duodenum. 
When cysts have been partially removed the wound has been drained 
and healing has occurred by granulation. In most instances of complete 
extirpation, pancreatic fistula has been avoided, but in two cases cited 648 
DISEASES OF THE DIGESTIVE SYSTEM 
by Korte pancreatic secretion discharged through the wound. Zweifel 
removed the entire pancreas save a part of the head 3 cm. in length; 
glycosuria was present ten days later, and persisted about twelve days, 
but at the end of two months had disappeared. 
The disadvantages of incision and drainage are the occurrence of pan- 
creatic fistula persisting for a considerable period, the possibility of 
hernia at the site of operation, and the occasional recurrence of the 
tumor. The resulting wound often heals slowly, and is complicated by 
the formation of a pancreatic fistula, from which there may be copious 
secretion; in the case of Cushing from 500 to 600 cc. of fluid were dis- 
charged during twenty-four hours. Pancreatic ferments may be demon- 
strable in the secretion from the wound immediately after operation, 
or may make their appearance several weeks later; unless care is exercised, 
there may be erosion of the skin about the wound. The cyst walls 
collapse, and by formation of granulations from the surrounding con- 
nective tissue the cavity is finally obliterated. This process cannot be 
completed when the cyst has an epithelial lining. 
A fistula may persist a considerable time; in a case described by 
Murray a fistula was present during three years. The danger of injecting 
irritant substances into a fistulous tract is illustrated by a case described 
by Lazarus; death with collapse, due perhaps to hemorrhagic necrosis 
of the pancreas, followed the injection of silver nitrate. Infection of a 
fistulous tract may occur. In some instances there has been hemorrhage 
from a fistula; curetting of the tract is attended with danger, since 
dilated bloodvessels may be present in the wall. Closure of a pancreatic 
fistula has been hastened by making a second posterior opening, thus 
affording better drainage, or rarely by extirpation of the entire tract. 
Healing of a pancreatic cyst is associated with the formation of scar 
tissue in the pancreas, and chronic inflammation resulting from the 
presence of the cyst may persist. In four cases in which recovery has 
followed operation diabetes mellitus has resulted. 
CARCINOMA OF THE PANCREAS 
Incidence.-In the statistics of Bashford malignant growth was 
primary in the pancreas in males in 526 among 33,788 instances of cancer, 
and in females in 474 among 50,660 cases. In the statistics of Segre, 
among 11,472 autopsies, there was carcinoma of the pancreas in 127 
and sarcoma in 2 instances. Among 106 reported cases of primary 
cancer collected by Mirallie1 in 1893, 69 were in men and 37 in women, 
the disease being almost twice as frequent in men as in women. Cancer 
of the pancreas like that of other organs usually occurs during middle 
life, although there have been instances of its appearance at a very early 
age. Kuhn has described carcinoma of the pancreas in a child two years 
old, and Simon found the same disease in a boy thirteen years of age. 
Secondary Carcinoma.-Since the pancreas is surrounded by organs 
which may be the seat of primary new growth, it is often difficult, when 
1 Gaz. des Hopitaux, 1893, Ixvi, 889. DISEASES OF THE PANCREAS 
649 
the tumor has attained considerable size, to determine whether it is 
primary in the pancreas or has invaded it from without. Metastatic 
tumors occasionally occur in the pancreas, but the organ is more fre- 
quently the seat of secondary invasion by cancer of the stomach, duo- 
denum, biliary passages, or other organs. Since the pyloric region and 
the posterior wall of the stomach are the most frequent situations of 
gastric cancer, secondary involvement of the head of the pancreas readily 
occurs and is followed by chronic interstitial inflammation of the body 
and tail as the result of compression of the duct of Wirsung. Olivier has 
described adenocarcinoma occupying the head of the pancreas, apparently 
originating from Brunner's glands of the duodenum. 
Pathology.-Carcinoma of the pancreas is much more common in 
the head than in other parts of the gland. Among 57 cases collected 
by Segre, the tumor in 19 instances occupied the whole gland, in 35 the 
head, in 2 the body, and in 1 the tail. In the cases of primary cancer 
collected by Marallie the head of the pancreas was affected in 82 of 113 
cases. Hansemann has described a type of pancreatic cancer which 
affects diffusely the whole gland. In most cases alveoli of cancer cells 
are embedded in abundant, dense, fibrous stroma; the tumor is hard 
and of the scirrhus type. Less frequently the neoplasm is cellular and soft 
or encephaloid; several cases of colloid carcinoma have been described. 
A cystic epithelioma is described by Roux. 
Since the pancreas contains several distinct structures-namely, gland- 
ular alveoli, ducts, and islands of Langerhan-the attempt has been 
made to determine the histogenesis of different types of new growth. 
In most instances epithelial neoplasms of the pancreas are adenocar- 
cinoma. These tumors, according to Hulst, are probably derived from 
the ducts of the gland. Where the glandular type is absent and alveoli 
of the tumor are formed by irregular polygonal cells closely packed 
together, Hulst1 thinks it more probable that the tumor has its origin 
in the secreting alveoli. Nevertheless, in a case carefully studied by 
Olivier a tumor of the tail of the gland which in part exhibited the last- 
named type could be traced to the ducts with which alveoli of cancer 
cells were in places continuous. Fabozzi, from a study of 5 cases of 
this kind, designated by him carcinoma solidum, reaches the conclusion 
that such tumors are derived from the islands of Langerhans, but Hulst, 
on the contrary, found no relation between the islands of Langerhans 
and the alveoli of tumor cells. Ssobolew has suggested the possibility 
that a cancer derived from the islands of Langerhans might exert upon 
carbohydrate metabolism that influence which is attributable to the 
normal gland, and might prevent the occurrence of diabetes even though 
the entire gland were destroyed. 
Adenoma.-Adenoma, unassociated with cyst formation, occurs 
rarely, and in most instances found at autopsy has given no discomfort 
during life. An exception is the encapsulated tumor of the head of the 
pancreas described as fibro-adenoma by Biondi; it was palpable and 
caused slight jaundice. Nicholls described a tawny yellow tumor which 
1 Virchows Archiv, 1905, clxxx, 228. 650 
DISEASES OF THE DIGESTIVE SYSTEM 
was the size of a large pea and had the structure of the island of Langer- 
hans; a similar tumor is described by Helmholtz. 
Sarcoma.-Sarcoma of the pancreas occurs with far less frequency 
than carcinoma. Kakeis,1 in 1902, collected 21 instances, among which 
only 10 were certainly primary in the gland; in 3 of the latter the tumor 
occupied the tail of the pancreas. Lymphosarcoma, angiosarcoma, 
fibrosarcoma, and medullary sarcoma have been described. The age 
of those affected has varied from four to seventy-four years. 
Pathology of Complications.-Since diabetes mellitus not infrequently 
occurs with carcinoma, and is due to complete or partial destruction of 
the organ, the changes in the gland caused by the new growth are of 
considerable importance. Compression of the duct of Wirsung caused 
by the tumor mass, which is usually situated in the head of the gland, 
is followed by chronic interlobular inflammation of that part of the 
gland from which the outflow of secretion is hindered. The secreting 
parenchyma is destroyed, while the islands of Langerhans tend to persist 
in the newly formed fibrous tissue. Pearce2 has studied the changes 
caused by the presence of carcinoma. At the edge of the advancing 
cancer the secreting parenchyma is invaded and replaced by new growth 
and newly formed connective tissue, but the islands of Langerhans 
persist in the stroma, and occasionally are uninvaded, even though 
enclosed by a mass of tumor cells; much hypertrophied islands are 
found. Carcinoma with permanent glycosuria was present in only one 
case studied by Pearce, and was associated with advanced chronic 
inflammation, implicating the islands of Langerhans. 
As the tumor increases in size, adhesions may bind it to the stomach, 
duodenum, and adjacent organs, and symptoms are frequently caused 
by pressure of the enlarging mass. The following possibilities are named 
by Friedreich, who cites cases in illustration of each. There may be 
closure of the duodenum or the pylorus, with consequent dilatation of 
the stomach; occasionally the cardiac end of the stomach is compressed. 
In one case the stomach was compressed against the anterior abdominal 
wall. Compression of the transverse colon may cause symptoms of 
intestinal obstruction. Carcinoma affecting the tail of the pancreas 
has compressed the left ureter, causing hydronephrosis. Compression 
of the common bile duct causes jaundice. The growth may compress 
the superior mesenteric artery and vein, or the splenic artery and vein; 
pressure upon the portal vein causes ascites, while pressure upon the 
inferior vena cava causes oedema of the lower extremities. Pulsation 
of the aorta may be transmitted to the abdominal wall. Necrosis and 
ulceration may occur in tumor tissue which has invaded adjacent organs, 
and ulceration of the stomach or of the duodenum may cause the symp- 
toms which are usually associated with primary cancer of these organs. 
Symptoms.-When the tumor occupies the head of the gland, jaundice 
is usually present, and, being due to progressive compression of the duct, 
never recedes, but gradually increases in intensity until finally it merits 
the designation "black jaundice;" the gall-bladder is distended and is 
1 Amer. Jour. Med. Sc., 1902, cxxiii, 471. 
2 Ibid., 1904, cxxviii, 478. DISEASES OE THE PANCREAS 
651 
palpable in the usual situation. In 23 of 35 cases of carcinoma of the 
pancreas described by Heiberg1 the tumor was limited to the head of the 
pancreas and in 19 of these cases jaundice was present; in two instances 
there were no symptoms of pancreatic disease. Cancer of the body 
or tail of the gland may be unaccompanied by jaundice and other 
symptoms referable to compression of the biliary passages. 
Pain is one of the earliest and most constant symptoms, and is usually 
seated in the epigastric region radiating toward the back, shoulders, or 
sternum; the right hypochondrium may be the seat of greatest pain when 
the tumor is situated in the head of the gland. The character and severity 
of the pain vary considerably; it may continuously increase in intensity 
until death, and may be of the intense severity which has been referred 
by many writers to pressure upon the cceliac ganglion and its branches. 
Intermittent colicky pain has been regarded as true pancreatic colic 
due to obstruction to the outflow of the pancreatic secretion caused by 
compression of the pancreatic duct. Similar pain may be the result of 
compression of the bile passages. 
A tumor mass has been palpable in a relatively small proportion of 
the reportefl cases. Mirallie found that the tumor was palpable in from 
one-fourth to one-fifth of 113 cases which he collected. In the statistics 
of Ancelet, from which secondary tumors of the pancreas were not 
excluded, a tumor was present in 36 in the epigastrium, in 4 in the 
right, and in 2 in the left hypogastrium, while in 4 its situation was not 
accurately designated. The tumor must be of considerable size to be 
felt, especially when the abdominal wall contains abundant fat or is 
muscular; extreme tenderness may interfere with palpation. Although 
the tumor is usually immovable, it may descend with inspiration, and 
occasionally transmits pulsation from the aorta. In some cases the 
distended gall-bladder has been mistaken for a tumor mass, while at 
times both tumor and enlarged gall-bladder have been distinguishable. 
Symptoms referable to the gastro-intestinal tract not infrequently 
precede more definite evidence of pancreatic carcinoma. There may be 
lack of appetite or actual distaste for food, especially, it has been thought, 
for meat. There may be discomfort after eating, eructations, nausea, 
or vomiting. Compression of the pylorus or of the duodenum may cause 
dilatation of the stomach, and in some instances symptoms referable to 
this condition have been the only evidence of the disease (Pilliet). The 
vomitus in such cases may contain blood. Constipation has been found 
much more often than diarrhoea, while constipation and diarrhoea may 
alternate; the stools may be normal. 
Disturbance of digestion referable to lack of pancreatic juice in the 
intestine has been noted more frequently with carcinoma than with 
other diseases of the gland; nevertheless, Mirallie found only 9 cases 
with fatty stools among 113 instances of pancreatic carcinoma. Oser 
has collected 8 and Fitz 3 additional cases from the literature of the 
subject. Fitz found only 2 cases in which cancer of the pancreas was 
accompanied by disturbed digestion of proteins manifested by the 
1 Zeil. f. klin. Med., 1911, Ixxii, Heft 5. 652 
DISEASES OF THE DIGESTIVE SYSTEM 
presence of numerous undigested muscle fibres in the feces. Bulky stools 
are believed by Oser to be a symptom of pancreatic disease, and occur 
as the result of imperfect digestion of fats, proteins, and carbohydrates. 
Since carcinoma of the pancreas in a large proportion of the cases 
invades the head of the gland, jaundice due to compression of the common 
bile duct is a frequent symptom, occurring in three-fourths of the cases, 
and, since the lesion in a large proportion of the cases has its origin in 
this part of the gland, frequently occurs as one of the earliest symptoms. 
Moreover, carcinoma of the pancreas, save for cholelithiasis, is the most 
frequent cause of occlusion of the common bile duct, and has been the 
cause of obstruction in 54 of 139 cases of non-calculous occlusion cited 
by Ecklin.1 Jaundice due to compression of the duct may appear 
suddenly, and, once established, exhibits no remission, but steadily 
increases in intensity. When its sudden appearance is accompanied 
by colicky pain, cholelithiasis is closely simulated. 
The condition of the gall-bladder and of the liver with obstruction 
of the common bile duct by cancer of the pancreas has been much 
discussed. From a study of a considerable number of cases of obstruction 
of the common bile duct due to a variety of causes, Courvoisier found 
that with obstruction due to biliary calculi the gall-bladder is usually 
contracted, while with occlusion due to other causes the gall-bladder is 
usually dilated. The statistics collected by Ecklin confirm this view. 
Among 172 instances of obstruction of the common bile duct due to 
gall-stones, the gall-bladder was contracted in 110, normal in 34, and 
dilated in 28 cases. On the other hand, among 139 instances in which 
the common bile duct was obstructed by other causes, the gall-bladder 
was contracted in only 9, normal in 9, and dilated in 121 cases; among 
62 of these cases constriction of the common bile duct was due to car- 
cinoma of the pancreas, and the gall-bladder was dilated in 58 instances. 
Contraction of the gall-bladder with biliary calculi is the result of inflam- 
matory changes, whereas, with obstruction due to carcinoma of the 
pancreas or other cause, inflammation is usually absent and the gall- 
bladder is dilated. 
Bard and Pic attached much importance to absence of enlargement 
of the liver with carcinoma of the pancreas. Mirallie, nevertheless, 
found the liver enlarged in 17 cases. Oser cites the cases of Friedreich 
and of Kellermann, in which the liver contained, during the terminal 
stage of the disease, secondary nodules as large as an apple, and maintains 
that the liver with cancer of the pancreas has no constant character. 
Compression of the portal vein may cause ascites and other evidences 
of portal obstruction, such as swelling of the spleen and hemorrhoids. 
In 13 of 113 cases of primary carcinoma collected by Mirallie, ascites 
was present. Cases with chylous ascites presumably due to rupture of 
the thoracic duct have been described. 
Glycosuria and other symptoms of diabetes mellitus not infrequently 
accompany cancer of the pancreas; among 50 cases Mirallie has found 
glycosuria in 13, and Oser subsequently collected 8 additional instances 
1 Inaug. Diss., Basel, 1896. DISEASES OF THE PANCREAS 
653 
of persistent glycosuria and 2 of alimentary glycosuria. Diabetes was 
present in 2 cases described by Pearce, and alimentary glycosuria in 1. 
Cancer of the pancreas is an infrequent cause of diabetes. Islands of 
Langerhans persist within the stroma of the new growth and prevent 
glycosuria until destruction of the pancreas is far advanced. The 
glycosuria of pancreatic cancer disappears before death. 
The cachexia usually associated with malignant growth is said to 
proceed with special rapidity when the pancreas is the seat of the 
disease. Partial exclusion of pancreatic juice from the intestine and 
obstruction to the outflow of bile doubtless contribute to cause weakness 
and emaciation. Kellermann, who has described a case of cancer of the 
pancreas unaccompanied by cachexia, has been able to find only three 
similar cases in the literature of the subject. 
The temperature with carcinoma of the pancreas is normal or subnornial 
unless there are complications accompanied by infection. 
Diagnosis.-The features of greatest importance are jaundice increas- 
ing gradually, attaining great intensity, and associated with dilatation 
of the gall-bladder, the presence of a tumor in the epigastric region, 
rapid emaciation, and advanced age. In the absence of both tumor and 
jaundice diagnosis is hardly possible. Symptoms indicative of impaired 
pancreatic function are present in a relatively small proportion, but give 
definite evidence that the disease is located in the gland. 
When jaundice is present, differential diagnosis between cholelithiasis 
and carcinoma is important. In certain cases of pancreatic carcinoma 
biliary symptoms serve to distinguish the two lesions. Jaundice usually 
appears gradually with carcinoma and increases without remissions, 
while with biliary colic the onset is more sudden and the progress more 
interrupted. Impacted calculi may, however, cause progressively in- 
creasing jaundice of great intensity; the gall-bladder is dilated in only 
a sixth of the cases, but with carcinoma of the pancreas, on the contrary, 
the gall-bladder is dilated with few exceptions. A palpably enlarged 
gall-bladder, therefore, gives evidence that cholelithiasis is not present, 
but the absence of this symptom is not equally significant, since the 
dilated organ is not always palpable, particularly when the abdominal 
wall contains abundant fat. Rapid emaciation and intense epigastric 
pain point to cancer of the pancreas. With carcinoma the temperature 
is usually normal or subnormal, but with cholelithiasis fever is not 
infrequently present. 
Jaundice caused by carcinoma of the liver, bile passages, duodenum, or 
stomach, compressing the common bile duct, has the gradual onset and 
progressive character already mentioned, but emaciation and weakness 
are said to occur less rapidly than with carcinoma of the pancreas. 
Tumor has been recognized in a relatively small proportion of cases of 
cancer of the pancreas, but doubtless this proportion would be much 
increased by examination under anesthesia with the stomach and colon 
empty. A tumor mass having its origin in the head of the pancreas is 
deeply situated in the epigastric or umbilical region, and is usually defined 
with difficulty. The tumor is usually less movable than tumors of the 
pylorus or of the colon, and its position is unaffected by distension of 
these organs. Pulsation transmitted from the aorta is not expansile. 654 
DISEASES OF THE DIGESTIVE SYSTEM 
Both dilatation of the stomach and intestinal obstruction may be caused 
by carcinoma of the pancreas. The diagnosis between primary carcinoma 
of the pancreas and malignant growth arising from the common bile 
duct or duodenum is scarcely possible. 
Tumor mass due to carcinoma of the tail of the pancreas may be mistaken 
for cancer of the cardia or of the colon. Takayasu describes a case in 
which an apparently immovable tumor, the size of a hen's egg, was felt 
behind the left rectus muscle. With inflation of the stomach, which lay 
above it, the tumor partially disappeared, and with inflation of the colon, 
which was at its lower margin, disappeared completely. Operation 
confirmed the diagnosis of carcinoma of the pancreas. 
Treatment.-Medical treatment is directed to alleviation of symptoms, 
such as pain, jaundice, digestive disturbances, and diabetes. The 
administration of an emulsion prepared from the fresh pancreas of a pig 
has been found to aid digestion of fats and of protein when obstruction 
of the pancreatic ducts prevents entrance of pancreatic juice into the 
intestine (Fles); for the same purpose commercial pancreatin, which 
contains both trypsin and steapsin, has been recommended. 
In a small number of cases tumors of the pancreas have been removed 
by operation. In a considerable proportion of the cases the patient has 
survived the immediate effects of the operation. Of 13 cases collected 
by Korte and by Mayo Robson, 5 died as the immediate result of the 
operation, whereas 5 are known to have died within from a few weeks 
to five months after the operation. In one instance (Biondi) a tumor, 
palpable on the left side of the abdomen, was removed from the head and 
body of the pancreas, and was found to be a fibro-adenoma; one and a 
half years later the patient was well. It is noteworthy that among the 
tumors which have been removed those types which are found least 
frequently have been relatively common; sarcoma has occurred three 
times, and in six cases the growth arose from the tail of the gland, causing 
a palpable tumor on the left side of the abdomen. Franke1 believed that 
he had removed the entire pancreas, but its complete absence was not 
confirmed by autopsy; sugar was found in the urine from the fifth to the 
nineteenth day after operation, and death occurred in five months. 
For the relief of complications a variety of palliative operations have 
been performed, but it is doubtful that they have materially prolonged 
life or added to the comfort of the patient. When jaundice due to 
compression of the common bile duct has caused much discomfort, 
cholecystenterostomy has been performed. In several instances the 
patient has lived from six to eighteen months, and the condition appar- 
ently has been improved. Little improvement has followed the forma- 
tion of an external biliary fistula, and death has usually occurred a 
short time after operation (Nimier). When persistent vomiting and 
dilatation of the stomach indicate compression of the pylorus or of the 
duodenum, gastro-enterostomy may give relief, 'but since the biliary 
and pancreatic ducts are usually compressed, the operation has not the 
advantages which it offers for the relief of the symptoms of pyloric 
carcinoma. 
1 Verhandl. d. Deutschen. Gesell. f. Chir., xxx, Congress, 1901, 265, CHAPTER IX 
DISEASES OF THE PERITONEUM 
HUMPHRY DAVY ROLLESTON, M.A., M.D. (Cantab.), F.R.C.P. 
Introductory.-The peritoneum is a serous sac of extensive dimensions. 
In fact, when all its reflections and fossae are taken into account, its 
superficial area is but slightly less than that of the skin. In the female 
it differs from all other serous cavities in that its potential cavity opens 
indirectly externally through the Fallopian tubes, but in the male it is 
completely shut off from the exterior. 
The peritoneum has remarkable powers of absorption. Thus in a dog or 
rabbit, fluid equal to 10 per cent, of the body weight of the animal can 
be absorbed from the peritoneal cavity in half an hour. Fluid and soluble 
substances are conveyed away by the bloodvessels, while, in addition, 
the lymphatics, with the aid of phagocytes, carry off insoluble bodies, 
including microorganisms. It was formerly thought that the peritoneal 
cavity was in direct communication with lymphatic vessels by open 
apertures or "stomata," and that it was an appendage of the lymphatic 
system or an immense lymph space. Muscatello1 and MacCallum,2 
however, have shown that the endothelial lining of the peritoneum is 
everywhere continuous and complete, and that there is no actual com- 
munication between its cavity and the lymphatics, through which its 
contents can be pumped by purely physical means, viz., the contractions 
of the diaphragm. 
The peritoneum covering the under surface of the diaphragm differs 
from the rest of the peritoneum in having a number of depressions 
or pits, formerly described as stomata or lacunae, opening into the 
lymphatic vessels, but in reality closed by a continuous layer of endo- 
thelial cells. These cells, however, by phagocytic action, play an impor- 
tant part in the absorption of solid particles, and Buxton3 has shown 
that bacteria injected into the peritoneal cavity of animals are imme- 
diately absorbed by the lymphatics of the diaphragm and reach the 
general circulation in a few minutes. When the endothelial layer of 
the peritoneum is intact, microorganisms are probably not absorbed 
by the bloodvessels, but damage to these delicate cells allows rapid 
absorption of bacteria to take place, and hence septicemia may result. 
The preservation of the endothelial lining of the peritoneum is therefore 
of the greatest importance. 
In health, secretion of fluid, mainly by the great omentum, into the 
peritoneal cavity and its absorption therefrom are so evenly balanced 
1 Virchows Archiv, 1895, cxlii, 327. 
2 Johns Hopkins Hosp. Bull., 1903, xiv, 105. 
3 Jour. Med. Research, Boston, 1907, xvi, 25. 
655 656 
DISEASES OF THE DIGESTIVE SYSTEM 
that there is just enough fluid to keep the serous surfaces moist and 
free from friction. In morbid conditions this state of equilibrium is 
disturbed and the amount of fluid may become excessive-ascites. The 
pathological effects produced by the drying of the peritoneum are not 
so well known. It has been shown experimentally that it diminishes the 
power of absorption, and in practice it is clear that it impairs the vitality 
of the peritoneum, since it readily splits or tears on handling. The 
small amount of fluid also plays an important part in the defense of the 
peritoneum against infection by exerting a bactericidal action. 
The lymphatic trunks draining the peritoneal cavity run up into the 
thorax, especially to the anterior mediastinal glands (Durham1). The 
peritoneum covering the diaphragm and the omentum is particularly 
active in this process of absorption, removing not only inert bodies but 
microorganisms from the peritoneal cavity; the omentum is, further, 
a most important factor in preventing peritonitis, since it removes 
microorganisms from the abdominal cavity before they can exert their 
pathogenic effect locally. Thus, twenty-four to forty-eight hours after 
the injection of bacteria into the peritoneal cavity the omentum may 
have rendered the peritoneum perfectly sterile, although cultures from 
the omentum itself or from glands in the anterior mediastinum show 
the path by which absorption has been effected. The omentum is apt 
to attach itself to any inflamed organ or possible source of infection, 
and thus to localize the peritoneal infection. The absorptive powers 
of the peritoneum are diminished by the backward pressure of chronic 
venous engorgement, probably by lymphatic obstruction, and by less 
vigorous peristaltic and diaphragmatic movements. 
The visceral peritoneum is quite insensitive to pain, while the parietal 
layer is extremely sensitive (Lennander, Franke2). Excessive peri- 
stalsis and dragging on the mesentery cause pain because traction is 
thus exerted on the parietal peritoneum which is supplied by the nerves 
of the abdominal wall. The deep tenderness on pressure in localized 
or universal peritonitis is due to inflammation involving the parietal 
layer, and tenderness in inflammatory conditions of the stomach, appen- 
dix, etc., depends on lymphangitis and extension of inflammation to 
the parietal peritoneum. The insensibility of the visceral peritoneum 
and abdominal viscera is seen in abdominal operations under cocaine. 
Further, when inflamed, the visceral peritoneum is as insensitive as in 
health (Lennander). But the cocaine may be partly or wholly responsible 
for the anesthesia (East and Meltzer, Franke). 
Comparison of the Peritoneum with Other Serous Membranes.-Like 
the other serous membranes the peritoneum is extremely resistant to 
the spread of inflammation from the tissues of the body wall covering 
it. It, however, is often affected, together with the adjacent pleurae 
and pericardium, and infection and inflammation readily spread through 
the diaphragm. This associated inflammation is spoken of as polyorrho- 
menitis, or multiple serositis, and may be acute or chronic, but is more 
often localized or at least partially circumscribed than universal. 
1 Jour. Path, and Bacterio!., Edinburgh and London, 1897, iv, 338. 
2 Franke, Berlin, klin. Wchnschr., 1912, xlix. DISEASES OF THE PERITONEUM 
657 
In common with the other serous membranes the peritoneum suffers 
mainly from infections derived from the organs which it surrounds and 
protects. Thus, like the lungs and synovial membranes, it is often 
affected by tuberculosis, because that form of infection commonly attacks 
the intestines. While unlike the pericardium, it may be regarded as 
immune to acute rheumatic inflammation, which is not recognized as 
attacking any of the organs covered by the peritoneum, with the possible 
exception of the vermiform appendix. Like the other serous membranes, 
it may be infected by the blood-stream, but hematogenous infection of 
the peritoneum is subordinate in importance to the local origin of infec- 
tion. In common with other serous membranes inflammation of the 
peritoneum has a great tendency to lead to adhesions. 
Immunity.-The natural resistance of the peritoneum varies in 
individuals. Different parts of the peritoneal cavity probably differ 
in their power of resistance; the pelvic peritoneum is thicker in women 
than in men, and it is possible that this has some influence in its com- 
parative immunity to infection. An attack of peritonitis leaves thicken- 
ing of the affected area, and thus may to some extent account for the 
increased resistance to infection which a past attack confers. 
The defensive powers of the peritoneum are further considered under 
the heads of Pathogeny (page 671) and Morbid Anatomy (page 675 of 
Acute Peritonitis. 
ASCITES 
Ascites is the presence of free fluid in the peritoneal cavity, and is 
the counterpart of a pleural effusion. The name hydroperitoneum 
indicates that the fluid effusion is not manifestly due to inflammation. 
The presence of fluid in excessive amounts in the peritoneal cavity may 
depend on the passage of fluid in increased quantities into the sac, 
the rate of absorption failing to keep pace with this; or on interference 
with the normal process of absorption, the secretion of fluid into the 
cavity remaining normal or being increased. The passage of increased 
amounts of fluid into the peritoneal cavity mainly depends on changes 
in the endothelial cells of the peritoneum brought about by poisons; 
this process occurs in inflammation, and is then spoken of as an exudation. 
When the action of poisons cannot be assumed and the ascites appears 
to be the result of increased venous or lymphatic pressure-passive or 
mechanical effusion-the process is spoken of as a transudation. It is 
obvious that these two processes overlap; thus, passive venous engorge- 
ment, by interfering with the vitality of the endothelium, will produce 
changes analogous to those wrought by poisons. 
Etiology.-The causes of ascites in the order of their importance are: 
1. Backward pressure from tricuspid regurgitation may give rise to 
copious ascites. In 224 cases in which ascites to the extent of a quart or 
more was found after death, 89 (or 40 per cent.) were due to various forms 
of heart disease (Cabot1). Although in many of such instances chronic 
1 Amer. Jour. Med. Sci., Phila., 1912, cxliii, 1. 658 
DISEASES OF THE DIGESTIVE SYSTEM 
peritonitis may be the determining cause of ascites, this is not always 
so. In some cases the brunt of the backward pressure seems to fall on 
the hepatic veins, with the result that there is ascites without oedema of 
the feet. This condition, which has been called hepatic asystole, may 
imitate cirrhosis of the liver. In some cases of adherent pericardium 
there is a high grade of nutmeg liver, ascites, and little chronic peri- 
tonitis. The adherent pericardium may be the result of rheumatic 
fever, or be tuberculous; in some cases the tuberculous nature is only 
revealed by microscopic examination. Pick1 described pericarditic 
pseudocirrhosis, but doubt has been cast on its existence as a distinct 
morbid entity; it is advisable to keep an open mind on this difficult 
question, but probably some of the cases so described may be included 
under the heading either of advanced nutmeg liver or of chronic peri- 
tonitis associated with adherent pericardium. Acute cardiac failure 
gives rise to a small amount only of ascitic effusion, which in itself is 
of no clinical importance. Stricture of the hepatic veins, or thrombosis 
of the inferior vena cava occluding the orifices of the hepatic veins, 
may give rise to marked ascites. 
2. Chronic Peritonitis.-(a) Simple, either universal or diffuse, which 
does not involve the whole of the peritoneum, but is more or less limited 
to part of the abdominal cavity, especially the upper half over the liver 
and spleen, (b) Associated with infection of the peritoneum by malig- 
nant disease. It may be associated with so-called "cirrhosis of the 
stomach," which is generally regarded as carcinomatous, (c) In rare 
instances innocent tumors, such as ovarian cystadenomas and fibromas, 
and uterine fibromyomas, set up sufficient chronic peritonitis to cause 
ascites. Papilloma of the ovaries may give rise to multiple implantation 
growths on the peritoneum, which irritate the peritoneum and so cause 
ascites, (d) Tuberculous peritonitis. Simple or "idiopathic" ascites, 
especially in young girls, is in many cases tuberculous. 
3. Cirrhosis of the Liver.-Hypertrophic biliary or Hanot's cirrhosis, 
which is comparatively rare, is either not complicated by ascites or only 
at a very late stage, and then to a slight degree. In portal or common 
cirrhosis, ascites is met with in 80 per cent, of the cases fatal from the 
effects of the disease. It may be due to the cirrhosis alone, and is then 
a late or terminal phenomenon, and rarely requires tapping more than 
twice. Ascites may be merely associated with cirrhosis and be caused 
by chronic simple or tuberculous peritonitis, or by cardiac failure. In 
these cases numerous tappings may be necessary. 
4. Other Morbid Conditions of the Liver.-Hepatic syphilis is often 
associated with chronic perihepatitis and peritonitis; but as it cannot 
always be proved that the accompanying ascites is set up in this indirect 
manner, syphilis of the liver may be regarded as a cause of ascites. Out 
of 56 cases of hepatic syphilis, ascites occurred in 23, or 41 per cent. 
(T. McCrae2). A lardaceous liver in rare instances, and then usually 
in children, appears to be responsible for ascites. In malignant disease 
of the liver ascites is common; in most cases the growths project from 
1 Ztschr. f. klin. Med., Berlin, 1896, xxix, 385. 
2 Amer. Jour. Med. Sci., Phila., 1912, cxliv, 625. DISEASES OF THE PERITONEUM 
659 
the capsule and by irritating the peritoneum induce ascites; but growths 
may press upon or invade and block up large branches of the portal 
vein inside the liver, especially in primary carcinoma with cirrhosis. 
In some cases new growth may block up the capillaries in the liver so 
widely as to produce marked portal obstruction and ascites, as is well 
shown in secondary melanotic sarcoma of the organ (Hektoen and 
Herrick1). Ascites may occur in hepatic and abdominal lymphadenoma, 
and is explained in the same way as in malignant disease. From an 
analysis of 100 cases of ascites in Egypt, Phillips2 finds that 30, and 
possibly 52 per cent., of these cases were due to the effects of chronic 
malaria in the liver and spleen. 
Perihepatitis is considered under Simple Chronic Peritonitis. 
5. Thrombosis of the portal vein is rare but usually causes a rapid and 
extensive ascitic effusion, which speedily recurs after tapping. Pressure 
on the portal vein may, but does not necessarily, produce ascites. 
6. In universal renal dropsy the peritoneum may contain free fluid. 
7. Inflammation of the Peritoneum.-Subacute and acute inflammation 
of the peritoneum will, of course, give rise to an effusion. 
In addition, rupture of hydatid, ovarian, or other cysts may give rise 
to free fluid in the peritoneal cavity; in the case of ruptured hydatid 
cysts, absorption will, as a rule, rapidly lead to its removal. Rupture 
of lymphatic vessels or lacteals will cause a chylous effusion. Effusions 
of bile (choleperitoneum) and of pure blood (hemoperitoneum) are 
referred to elsewhere. 
Pathology.-The morbid anatomy of ascites is, except for the mechanical 
effects due to abdominal distension, that of the underlying cause, such 
as chronic peritonitis, cirrhosis, and new growth. Portal obstruction 
when present increases the anastomotic channels between the systemic 
and the portal veins. The veins of the peritoneum, especially at the 
back of the abdomen, become manifestly enlarged; veins in any adhesions 
become prominent, and the parumbilical vein in the falciform ligament 
may reach a large size; the veins at the lower ends of the oesophagus 
and rectum also become tortuous and dilated. The abdominal muscles 
become stretched and atrophied; the diaphragm is pushed up, and may 
show hypertrophy from increased work. Upward displacement of the 
diaphragm may compress the lower lobes of the lungs. The presence of 
adhesions may produce encysted or loculated ascites. 
The characters of ascitic fluid vary according to the causes at work. 
Thus, when there is inflammation of the peritoneum (exudates) the 
specific gravity and amount of contained protein are higher than in 
ascites associated w'ith backward pressure (transudates). Serous ascitic 
fluid is clear, transparent, and greenish or faintly yellow in color. The 
reaction is alkaline, and the specific gravity under 1.012 in mechanical 
effusions, or hydroperitoneum, and 1.018 or higher in the exudations in 
subacute or chronic peritonitis. The amounts of solids and contained 
proteins vary. In simple effusions due to renal disease there may be 
only 0.3 per cent, or less of protein, while in inflammation the amount 
1 Amer. Jour. Med. Sci., Phila., 1891, cxvi, 255. 
2 Records of the Egyptian Government School of Medicine, 1904, ii, 47. 660 
DISEASES OF THE DIGESTIVE SYSTEM 
may be 4 per cent. In some instances, especially of ascites associated 
with rupture of ovarian cystadenomas, the fluid is sticky from the 
presence of pseudomucin. Occasionally cholesterin, urea in traces or 
in larger amounts, and various extractives are present. After repeated 
tappings the character of the effusion may alter, and from added inflam- 
matory changes in the peritoneum be of higher specific gravity and show 
a higher percentage of proteins. 
In jaundiced patients the ascitic fluid contains bile pigment. A blood- 
stained or hemorrhagic ascites may occur in (1) intra-abdominal malig- 
nant disease, from leakage; this is rare in carcinoma and is more often 
associated with vascular or hemorrhagic sarcomas or endotheliomas. 
(2) Some cases of hepatic cirrhosis; here it is usually the result of trauma, 
such as rupture of a dilated vein in the peritonum or in vascular adhesions, 
either from traction or from direct injury by the trocar. As a rule, the 
blood-stained character of the effusion is seen not at the first but at a 
subsequent tapping. (3) Ascites is blood-stained in about one-fourth of 
the cases associated with ovarian cysts, and in about one-sixth of the cases 
of ascites associated with uterine fibromyomas (Cabot1). (4) Red-blood 
corpuscles have been found exceptionally on microscopic examination 
of the ascitic fluid in tuberculous peritonitis (Grenet and Vitry2). (5) A 
certain amount of blood-stained fluid, but rarely sufficient to be recog- 
nized clinically, may be associated with strangulated hernia, volvulus, 
infarction of the intestines, and hemorrhagic pancreatitis. Sometimes 
the ascitic fluid clots spontaneously on standing. 
The cells seen on microscopic examination vary in the different kinds 
of ascites. As in the cytodiagnosis of pleural effusions, a preponderance 
of any one form of cell is correlated with a special causal factor. Thus 
in ascites due to mechanical causes, e. g., heart disease and hepatic 
cirrhosis, endothelial cells are those found; in tuberculous peritonitis 
small lymphocytes are present in a high percentage; and in other 
infections the predominant form of cell is the polymorphonuclear 
leukocyte. (For the cytology of ascites associated with new growth 
see p. 666.) 
Bacteriology.-Ascitic fluid, at any rate, at the first tapping is usually 
sterile; as a result of paracentesis infection may occur. The colon 
bacillus and the tubercle bacillus are sometimes present. Jousset,3 
by the method of inoscopy which consists in examining the clot produced 
spontaneously or by the addition of salted plasma, has proved that 
the tubercle bacillus is present in many cases of ascites in which a tuber- 
culous origin was not suspected. 
Chylous, Chyliform, and Milky Non-fatty Ascites.-These three forms 
are alike in their naked-eye resemblance to milk. 
1. Chylous ascites is due to the escape of chyle from the lymphatics 
or receptaculum chyli. Wallis and Scholberg4 collected 102 cases in 
1910. The fluid is yellowish white, tends to accumulate very rapidly, and 
1 Amer. Jour. Med. Sci., Phila., 1912, cxliii, 1. 
2 Com.pt. rend. Soc. biol., Paris, 1903, Iv, 959. 
3 Arch, de med. exper. et d'anat. path., Paris, 1903, xv, 289. 
4 Quart. Jour. Med., Oxford, 1910-11, iv, 15 DISEASES OF THE PERITONEUM 
661 
its opalescence is constant at successive tappings. The specific gravity 
is usually about 1.015. The fluid resists putrefaction and does hot clot 
on standing, thus differing from chylous urine. It, however, separates 
into layers on standing, the fat accumulating on the surface. The 
distinctive odor of some special article of diet such as butter may be 
perceptible in it (Straus' sign). The amount of solids is about 4 to 6 
per cent.; the percentages of fat and of protein vary considerably, and 
may be modified by changes in the diet; there is from 0.4 to 4 per cent, 
of fat in a very fine state of division; the amount of protein is usually 
about 3 per cent. Cholesterin is always present, but lecithin occurs 
only in traces. The reaction-is alkaline or occasionally neutral. It 
accumulates very rapidly. The important characters of true chylous 
ascites are (1) the finely divided fat, and (2) the absence of leukocytes 
and other cells showing fatty change. 
Chylous ascites is caused by obstruction of the thoracic duct or lym- 
phatic vessels. Pressure from without by tumors or dense adhesions may 
obstruct the thoracic duct and lead to rupture of the receptaculum chyli 
or to leakage from its tributaries. Thrombosis inside and infiltration of 
the walls of the thoracic duct or receptaculum chyli with new growth, 
or even with tuberculosis, have also been responsible for chylous ascites. 
Malignant disease, by compressing the lacteals, may so raise the pressure 
that rupture occurs. Traumatic rupture and rupture attributed to 
whooping-cough (Wilhelm), to vomiting, and to muscular exertion have 
been recorded. Chylous ascites may be due to rupture of a chylous 
mesenteric cyst. It has been met with in only a few cases of filariasis. 
It should be explained that the free lymphatic anastomosis often 
obviates chylous ascites when from obstruction due to tumors and other 
factors it might be expected. A chylous peritoneal effusion may be 
accompanied by a similar condition in one or both of the pleurae. 
2. Chyliform or fatty differs from true chylous ascites in (a) that it 
is due not to leakage of chyle but to the formation of fat in the peritoneal 
effusion; (b) that the globules of fat are large, and (c) that cells containing 
fat are present in the fluid. The opalescence is not, however, always 
due to suspended fat, for in some instances it persists after all the fat 
has been removed; there is then a mixture of the two forms of adipose 
and milky non-fatty ascites. For this reason Wallis and Scholberg 
group these two forms together as pseudochylous. Chyliform ascites 
is usually associated with intra-abdominal new growth or with chronic 
peritonitis, tuberculous or simple. The fat may be derived from the 
cells of the new growth, or a poison generated in the growth may lead 
to the production of fat in the leukocytes and other cells suspended in 
the ascitic fluid. In chronic peritonitis the fat is thought to be formed 
in the cells in the exudation. In some instances fat in the ascitic fluid 
may depend on lipemia, which in its turn may be the result of milk diet. 
It has been suggested that a lipemic ascitic effusion may depend on 
disease of the pancreas (Gaultier1). It is much more common than true 
chylous ascites. 
1 Compt. rend, el mem. Soc. biol., Paris, 1906, Ixi, 429. 662 
DISEASES OF THE DIGESTIVE SYSTEM 
3. Lactescent, Milky, Non-fatty Ascites.-In some cases the milky 
opacity is "due not to fat, as it is either absent or present in quantities 
insufficient to account for the milkiness, but to some other body such 
as a protein resembling casein, mucinoid bodies, or lecithin. Although 
resembling chylous and chyliform ascitic fluid to the naked eye in most 
respects, it does not separate into layers on standing. This form of 
ascites may occur in intra-abdominal malignant disease and in other 
conditions. In some instances only the later tappings may show this 
condition, the earlier ones being clear; or later tappings may be more 
milky than the first. In such cases it would appear to be in some way 
related to a low form of chronic peritonitis. 
Physical Signs.-The abdomen is enlarged, especially in chronic 
ascites in which the abdominal muscles have become stretched and 
atrophied. Measurements of fifty inches are sometimes seen. An 
extreme grade of abdominal distension was recorded in a woman who 
has been very frequently tapped and measured eleven feet around the 
abdomen, which contained forty-seven and a half gallons of fluid after 
death (Duncan1). The abdominal distension is not exclusively due to 
fluid, but may vary from day to day from flatulency; considerable 
flatulent distension often precedes the discovery of recognizable ascites. 
Fetal ascites may be so extreme as to obstruct the birth of the child; 
the abdomen of a fetus has contained nine pints of fluid (Luker2). 
In recent and acute ascites the distension is mainly anteroposterior, 
the abdomen being prominent, especially above the umbilicus, tense, 
and hard. This is probably due to contraction of the abdominal muscles 
which are irritated by the distension. In ascites of some duration the 
muscles become atrophied, flaccid, and thus separation of the recti 
abdominales and bulging in the flanks result. When, however, ascites 
comes on in a patient whose abdominal walls are already thin and weak, 
as in women after repeated pregnancies, the abdomen bulges in the 
flanks from the outset. The distension is, generally speaking, uniform. 
But in encysted ascites there is a more or less localized prominence 
which does not alter in position on movement. There is a positive 
ntra-abdominal pressure (6 to 30 mm. Hg.) in ascites, which diminishes 
during paracentesis (Pitres,3 Quirin4). 
The skin is tightly stretched and may be shiny and present distended 
veins; in portal obstruction, as in cirrhosis, the large veins are chiefly 
above and around the umbilicus and in the line of the falciform ligament; 
but when the obstruction is in the inferior vena cava the veins running 
from the middle of Poupart's ligament to the costal arch are prominent, 
and, when considerably enlarged and tortuous, produce the condition 
spoken of as a "caput Medusae." This venous dilatation is sometimes 
due to the pressure of enlarged glands, as in tuberculous or malignant 
peritonitis, but, as a rule, it is due to the pressure exerted by the ascitic 
fluid on the inferior vena cava, and therefore disappears after tapping. 
1 Brit. Med. Jour., 1906, i, 1157. 
2 Lancet, Lond., 1913, i, 1309. 
3 Compt. rend. Soc. biol., Paris, 1899, li, 674. 
4 Deut. Arch. f. klin. Med., 1901, Ixxi, 79. DISEASES OF THE PERITONEUM 
663 
In cirrhosis both sets of veins may be present, and after paracentesis 
the "caval" veins disappear while the portal veins persist (Gilbert and 
Villaret1). The caval veins are most prominent in the lower and lateral 
part of the abdomen. Occasionally a bruit is audible over these dilated 
veins in the epigastrium. The umbilicus becomes flush with the surface, 
after a time everted and tense, appearing as a thin-walled bulla, and 
has been known to burst when tapping has been unduly delayed. Any 
existing hernial sacs become distended with fluid. From stretching, the 
deeper layers of the skin rupture, and in a recent state reddish lines 
are seen, especially when the abdominal wall is lax after tapping; sub- 
sequently these lines appear as crinkled cicatrices, the well-known 
'Tinea? albicantes." They are seen in the lower half of the abdomen. 
(Edema of the abdominal walls may accompany and obscure the signs 
of ascites. The costal margins are expanded, and the abdomen moves 
little on respiration. 
On palpation the resistance is fairly uniform. The characteristic 
thrill is readily brought out by flicking the surface in one flank. When 
the hand is placed flat on the abdomen and the tips of the fingers are 
sharply flexed, fluid between the abdominal wall and the liver or spleen, 
if enlarged, or an abdominal tumor, may be displaced and the firm 
surface of the previously obscured organ is distinctly felt; this is spoken 
of as "dipping." 
Percussion brings out a dull note over the fluid, which collects first 
in the pelvis and then passes upward into the loins and hypogastric 
region, producing a horseshoe-shaped area of dulness. The umbilical 
and epigastric regions remain resonant except in those cases of chronic 
peritonitis in which, from shortening of the mesentery, the intestines 
cannot reach the front of the abdomen. The characteristic horseshoe- 
shaped distribution of dulness is sometimes disturbed by flatulent 
distension of the large intestine, especially in the right iliac fossa; while, 
conversely, dulness in the flanks may be due to liquid feces and not to 
free fluid in the peritoneum. Light percussion gives a duller note than 
more forcible percussion, as pressure displaces a layer of fluid between 
the abdominal wall and an adjacent coil of distended intestine. A very 
important sign of free fluid in the abdominal cavity is shifting dulness. 
The presence of adhesions may interfere with this test, and for its success 
some of the intestines must contain gas. In cases in which the amount 
of fluid is not sufficient to give this sign the patient may be put in the 
knee-elbow position and the anterior surface of the abdomen then 
percussed in the most dependent position for an impaired note. 
Results.-Distension of the abdomen gives rise to fulness, weight, 
and pain in the tense parietes; "pain is a very common symptom in 
ascites, but is seldom or never described in accounts of that condition" 
(Gee2). The abdominal viscera are embarrassed, so that dyspepsia 
and constipation are common, the latter being partly due to the flabby 
1 Rev. de med., Paris, 1907, xxvii, 334. 
2 Clinical Aphorisms from Dr. Gee's Wards, St. Bartholomew's Hospital Reports, 
1896, xxxii, 44. Aphorism No. 128. 664 
DISEASES OF THE DIGESTIVE SYSTEM 
condition of the stretched abdominal muscles. The uterus may be 
displaced and fluctuation can be detected by the finger on pelvic exami- 
nation. The abdominal muscles atrophy, and the recti separate so that 
a hernial protrusion may occur. Pressure on the inferior vena cava may 
induce (edema of the legs, while compression of the renal veins leads 
to chronic venous engorgement of the kidneys and scanty high-colored 
urine of increased specific gravity with sometimes a trace of albumin- 
resembling that of a failing heart. Albuminuria may, of course, be 
due to renal disease which is often associated with chronic peritonitis. 
The upward displacement of the diaphragm pushes the heart up, so 
that the apex beat may be in the third interspace; in some cases there 
is a soft, systolic apex murmur, which may disappear when the abdominal 
distension is relieved. The breathing may be embarrassed and cyanosis 
appear, the underlying condition being collapse and oedema of the 
lower lobes of the lungs. In rare cases the pulmonary engorgement is 
so extreme that there is hemoptysis. The percussion note at the bases 
of the lungs behind is impaired. 
Diagnosis.-Differential Diagnosis.-The physical signs of free fluid 
in the abdominal cavity may, to a certain extent, be reproduced by 
large cysts occupying almost the whole of the abdominal cavity. In 
women confusion sometimes arises between a large ovarian or par- 
ovarian cyst and ascites. An ovarian cyst may, as shown by the history, 
have been first noticed in one position and subsequently spread upward 
into the abdomen; the maximum abdominal girth is below instead of 
above the umbilicus; the umbilicus may be displaced toward the thorax 
or to one side of the middle line, dulness is present in the middle line 
and not in the flanks, and there is little constitutional disturbance, the 
ill effects being almost entirely mechanical. Ovarian cysts, however, 
may be accompanied by ascites set up by chronic inflammation of the 
peritoneum covering them, or they may rupture. In rare instances a 
huge hepatic abscess, hydatid cyst, pancreatic cyst, or hydronephrosis 
has been regarded as ascites; but in these cases there may be a history 
of localization of the cyst at an earlier period, and even at a later stage 
the abdomen is hardly ever so fully occupied as to present all the physical 
signs of ascites. In encysted peritonitis the physical signs are those 
of a large cyst, and the dulness does not shift as it does in ascites. 
Among solid or semisolid tumors the rare but remarkable fatty tumors 
may very closely simulate ascites and their true nature be only suspected 
after repeated fruitless tappings (see page 733). 
Diffuse colloid carcinoma is rare, but, unless complicated by ascites, 
thrill and fluctuation are absent. In exceptional instances a distended 
urinary bladder, or even gall-bladder, has been regarded as ascites. As 
the patient should always pass water, or, if he cannot, be catheterized 
before the abdomen is tapped, the possible error of regarding a greatly 
dilated urinary bladder as ascites would be corrected. A greatly dilated 
stomach and a pregnant uterus with hydramnios have also been thought 
to be ascitic effusions. The absence of the concomitant signs of pregnancy 
should prevent ascites from being regarded as that condition; but a 
case of a uterine fibroid combined with ascites has been regarded as DISEASES OF THE PERITONEUM 
665 
pregnancy (Montgomery1). Great obesity with abdominal distension 
may imitate ascites, and in such cases it may be very difficult to exclude 
the presence of, at any rate, some free fluid in the abdomen. The dis- 
tension due to tympanites should not be mistaken for ascites, since the 
abdomen is everywhere resonant, but when the abdominal parietes 
are laden with fat the percussion note may thereby be much impaired. 
Occasionally in adults with chronic intestinal obstruction distension 
of the intestines with fluid may simulate ascites, and in children with 
chronic enteritis this condition of pseudo-ascites has led to laparotomy. 
In such cases succussion due to the presence of gas as well as fluid feces 
in the intestines can often be obtained. Conversely, the writer has 
seen a case of ascites with constipation and vomiting due to gastritis 
regarded as intestinal obstruction. 
The Diagnosis of the Cause of Ascites.-Jaundice points to malignant 
disease or cirrhosis of the liver, being deep in malignant disease and 
comparatively slight in cirrhosis. Recurrent ascites usually indicates 
simple chronic peritonitis. The evidence of a growth elsewhere makes 
the diagnosis of malignant disease almost certain. Heart disease or 
tuberculosis elsewhere renders backward pressure or tuberculous peri- 
tonitis probable. A history or evidence of alcoholism points to cirrhosis. 
Thrombosis of the portal vein, which is often a complication of cirrhosis, 
can hardly be diagnosed, but melena and rapid onset of ascites 
may suggest it. A history or the manifestations of syphilis point to 
this form of liver affection; the Wassermann reaction may be more 
marked in the ascitic fluid than in the blood (Esmein and Parvu2). 
Enlargement of the liver, if quite smooth, may point to lardaceous 
change; if rough, to cirrhosis; and if extreme or definitely nodular, to 
malignant disease. Less marked enlargement and irregularity may 
suggest syphilis of the liver, a conclusion which would be strengthened 
by other evidence of syphilis, and may be clincher! by recovery under 
antisyphilitic treatment. If ascites be associated with general oedema 
and albuminuria, renal disease is the probable cause. Multiple palpable 
tumors in the abdomen point to malignant disease, or in a less degree 
to tuberculous peritonitis. Fever and concomitant pleurisy are in 
favor of tuberculosis, as are scars in the neck. But enlarged glands 
above the left clavicle point to malignant disease. 
By laparoscopy or inspection of the peritoneal cavity by means of a 
fine cystoscope introduced through a trocar after the ascites has been 
avacuated and air introduced, Jacobsens3 has been able to recognize the 
cause of the ascites. 
Age has some bearing on the diagnosis. Ascites in stillborn children 
is generally due to inherited syphilis. Tuberculous peritonitis is the 
commonest cause of ascites in children and young women, and cirrhosis, 
simple chronic peritonitis, and malignant disease in adults over forty 
years of age. Examination of the fluid drawn off may be of practical 
value. If blood-stained at the first tapping, malignant disease should 
1 American Gynecology, 1902, i, 449. 
2 Compl. rend. Soc. biol., Paris., 1909, Ixii, 159. 
3 Trans. XVII Internal. Congress, 1913, London (Sect. Med.). 666 
DISEASES OF THE DIGESTIVE SYSTEM 
be suspected; microscopic examination may show pieces of malignant 
growth or fragments of ovarian papilloma. In malignant disease multi- 
nuclear endothelial cells and a large number of cells showing atypical 
mitoses may be found, but in many instances the ascites is mechanical 
and due to pressure exerted by the growth, and shows a predominance 
of endothelial cells, the condition found in passive effusions, as in heart 
disease or cirrhosis. In other cases, again, there may be a considerable 
number of polymorphonuclear leukocytes, probably as the result of 
subacute inflammation; hence a diagnosis of malignant disease cannot 
always be made from examination of the cells in the effusion alone. 
Tenacious fluid may be due to rupture of an ovarian cystadenoma, and 
microscopic examination of the cells may confirm this. 
Turbid fluid of a high specific gravity (1.020) points to inflammation. 
If the predominating cells are polymorphonuclear leukocytes there is 
subacute inflammation; but if the cells are mainly lymphocytes, tuber- 
culous infection should be suspected and guinea-pigs should be inoculated 
with the fluid. It should be remembered that many cases of clear ascites 
are tuberculous in origin. The detection of tubercle bacilli in the feces 
has established the diagnosis in doubtful cases of ascites (Rosenberger1). 
In hepatic cirrhosis the fluid is clear and shows a preponderance of 
endothelial cells (Cade,2 Ross,3 Gilbert and Villaret4). If complicated 
by infection, as may occur after tapping, there may be a large number 
of polymorphonuclear leukocytes. When tuberculous peritonitis super- 
venes the number of small lymphocytes will increase, but the lymphocyte 
count may be high in uncomplicated cirrhosis (Cabot5). The main 
diagnostic importance of a high percentage of endothelial cells is that it 
excludes acute or subacute infections and tuberculosis. If the opsonic 
index for tubercle bacilli be low in the ascitic fluid as compared with 
that of the blood serum, and if the opsonic index of the blood serum 
rises markedly after abdominal massage, tuberculous peritonitis is 
indicated. The tuberculin tests can also be employed. 
Prognosis.-This depends in the first place on the cause. Thus, 
ascites in malignant disease leaves no room for hope of recovery, while 
that of tuberculous peritonitis is often followed by permanent cure. 
The ascites that recurs again and again in cases with secondary ovarian 
papillomas implanted on the peritoneum or in some cases of solid ovarian 
growths (Osler6) may be cured by removal of the primary growth. 
When ascites supervenes in an emaciated subject of hepatic cirrhosis, 
the prognosis is bad, and tapping is not likely to be required more than 
twice before death closes the scene. The association of jaundice with 
ascites is rare except in malignant disease and hepatic cirrhosis, and is 
therefore a bad prognostic. In simple chronic peritonitis paracentesis 
may be necessary for a prolonged period; Rumpf's7 patient was tapped 
1 Amer. Jour. Med. Sci., 1907, cxxxiv, 830. 
2 Arch, de med. exper. et d'anat. path., Paris, 1906, xviii, 769. 
3 Transactions of the Pathological Society of London, 1906, Ivii, 361. 
4 Compt. rend. Soc. biol., Paris, 1906, lx, 820. 
8 Jour. Amer. Med. Assoc., Chicago, 1912, lix, 2295. 
6 Lancet, 1907, i, 1409. 
7 Deut. Arch.f. klin. Med., Leipsic, 1895, Iv, 272. (Festschrift zu F. A. von Zenker.) DISEASES OE THE PERITONEUM 
667 
301 times in sixteen years, and cases in which the abdomen has been 
punctured more than a hundred times are not very rare. The results 
of hepatic cirrhosis, of cirrhosis complicated by chronic peritonitis, 
and of chronic peritonitis alone, may be arranged in this order from the 
point of view of the severity of the prognosis. Thus, in 31 cases of 
uncomplicated hepatic cirrhosis the average duration of life after the 
first appearance of ascites was 98.6 days; in 12 cases of cirrhosis com- 
plicated with chronic peritonitis, 288 days; and in 9 cases of uncompli- 
cated chronic peritonitis, 624 days (Ramsbottom1). In milky ascites 
the prognosis is bad. In rare cases ascites spontaneously disappears, 
and great diminution has been noted during an attack of fever. 
Treatment in the first instance should be directed to the under- 
lying cause, if this be known and amenable to cure, for example, syphilis 
of the liver or heart disease. In simple chronic peritonitis and hepatic 
cirrhosis no known drug exerts any direct action on the morbid process. 
The palliative treatment consists in attempts to diminish the passage 
of fluid into the peritoneal cavity and to effect its removal. A restricted 
intake of fluids or a "dry diet" has been recommended, but is usually 
very disappointing. The results of a salt-free diet are not very 
striking. 
The means for the removal of fluid from the abdominal cavity fall 
under three heads: (1) By paracentesis, (2) by diuretics, and (3) by 
purgatives. 
1. Paracentesis abdominis is indicated when the abdominal distension 
causes pain or vomiting, when upward displacement of the diaphragm 
gives rise to dyspncea, or to collapse and oedema of the lung, as shown 
by moist sounds at the bases behind, and when there is considerable 
diminution in the amount of urine. In cirrhosis, hematemesis or signs 
ofj incipient delirium tremens indicate the advisability of tapping an 
ascitic abdomen. 
The abdomen is most advantageously tapped below the umbilicus 
in the middle line. If from adherent omentum no fluid is withdrawn 
in this position, the trocar and cannula must be introduced elsewhere. 
It has been recommended that the middle point of a line drawn from 
the anterior superior spine of the ilium to the umbilicus should be chosen, 
and that in order to avoid wounding the cecum or liver the left side 
should be selected. In rare instances fatal hemorrhage has followed 
puncture in this position from a wound of the deep epigastric artery 
(Boidin,2 Lian3). This accident may be suspected if, on withdrawing 
the cannula, pure blood comes in spirts, and should be met by ligature 
of the vessel. 
Before the abdomen is tapped the urinary bladder should be emptied, 
and the site of the puncture percussed and be found to be dull. The 
patient should lie on his back with the head slightly raised; the skin 
in the neighborhood of the intended puncture should be cleaned and 
rendered aseptic. If necessary, the skin may be anesthetized by ethyl 
1 Medical Chronicle, Manchester, 1906, xlv, 7. 
2 Bull. Soc. anal., Paris, 1903, Ixxviii, 415. 
3 Ibid., 1907, Ixxxii, 665. 668 
DISEASES OF THE DIGESTIVE SYSTEM 
chloride and cocaine injected under the skin at the site of puncture. 
A comparatively small cannula should be used, so as to remove the 
fluid slowly. Rapid removal of fluid may lead to faintness. The sterilized 
trocar and cannula should then be introduced, the trocar withdrawn, 
and the shield fixed in position by plaster. The fluid is then allowed to 
run away through a thin india-rubber tube. This takes some hours 
to drain away, and during this period the abdomen may be protected 
by a cradle, and a many-tailed bandage or a binder should be kept 
comfortably tight over the abdomen. If the flow stops before the abdo- 
men has been fairly well evacuated, the india-rubber tube should be 
"milked," starting from the cannula. When the fluid has finally ceased 
to run, the cannula should be withdrawn and the small wound closed 
by a pad of absorbent cotton-wool soaked in collodion. The abdomen 
should be bandaged or tightly strapped with adhesive plaster, to prevent 
rapid accumulation of the fluid and flatulent distension. In some 
instances good results have followed the injection through the cannula, 
after the abdomen has been nearly emptied, of a dram of adrenin chloride, 
1 to 1000, in an ounce of water. It has been shown experimentally 
that injection of adrenin into the peritoneal cavity increases absorption 
of fluid (Fleischer and Loeb1). Apart from wounding a bloodvessel in 
the abdominal wall, there are very few dangers connected with para- 
centesis. In extremely rare instances acute pulmonary oedema has 
occurred. Wounding of the abdominal viscera should be avoided if 
proper care be taken. Repeated tapping may set up some degree of 
chronic peritonitis; acute peritonitis is, with ordinary attention to 
aseptic precautions, very rare. Prolonged or permanent drainage is 
not advisable. 
2. Diuretics are disappointing and their use should not be persisted 
in when there are indications that paracentesis is necessary. They some- 
times succeed after paracentesis, probably because the kidneys are 
then in a better position to act; for a large ascitic effusion exerts pressure 
on the renal veins and thus chronic venous engorgement is induced. 
The diuretics employed are numerous, and the use of any one will to 
some extent be determined by the cause of the ascites. In heart cases 
Baillie's or Addison's pill, containing digitalis, squill, and mercury, is 
commonly used; citrate of caffeine, diuretin, or theocin combined with 
digitalis may also be given. In ascites due to other causes acetate, 
citrate, or tartrate of potash, spirit of juniper, copaiba resin (in capsules), 
and urea may be tried. 
3. Purgation.-Moderate purgation by calomel or jalap and salts, 
such as tartrate of potassium or sulphate of magnesium and sodium 
combined, may be tried; but drastic purgatives, such as elaterium and 
gamboge, should be avoided, as the patient's strength may be seriously 
impaired. Such treatment in the past has been thought to have purged 
patients to death. 
Operative treatment in tuberculous peritonitis and hepatic cirrhosis 
is considered elsewdiere (pages 535, 729). 
1 Jour. Exper. Med., 1910, xii, 288. DISEASES OF THE PERITONEUM 
669 
Hemoperitoneum.-The presence of pure blood free in the peritoneal 
cavity is somewhat rare, and must be distinguished from blood-stained 
ascitic effusions. The causes of intraperitoneal hemorrhage are: (1) 
Rupture of ectopic gestation; this is the most frequent cause; of 20 
cases of intraperitoneal hemorrhage examined by Dudgeon and Sargent,1 
17 were due to this cause. Rupture of a lutein hematoma may cause 
extensive intraperitoneal hemorrhage. (2) Traumatic rupture of the 
spleen, liver, or mesentery. (3) Rupture of aneurisms of the cceliac 
axis, or of the superior mesenteric, hepatic, or other intra-abdominal 
arteries. Aneurisms of the abdominal aorta usually rupture behind 
the peritoneum in the first instance, but may subsequently leak into 
the peritoneal cavity. (4) From leakage of a hemorrhagic or vascular 
new-growth, such as an angiosarcoma of the liver or adrenals. (5) 
From rupture of varicose or dilated veins; thus, most profuse hemorrhage 
may occur from rupture of a dilated vein on the surface of a subperitoneal 
fibromyoma; Wallace2 has collected 16 cases. Rupture of a varicose 
vein in the broad ligament is rapidly fatal, but is fortunately extremely 
rare. The writer has seen a large quantity of blood in the peritoneal 
cavity from traumatic rupture of a vein in peritoneal adhesions. (6) 
From rupture of a hemorrhage into the suprarenals. (7) In very rare 
instances repeated peritoneal hemorrhages may occur without any 
known cause. In Cheeseman and Ely's3 case the abdomen was tapped 
forty-three times in five years and then spontaneous cure occurred. Both 
pleurae had previously presented recurrent hemorrhagic effusions. 
Intraperitoneal hemorrhage, although sterile at first, rapidly becomes 
infected. Of Dudgeon and Sargent's 20 cases, only one was completely 
sterile, and that was operated upon two hours after the onset; the organ- 
ism isolated by these observers was a white staphylococcus. This 
explains (a) the fever which may follow intraperitoneal hemorrhage, and 
was formerly referred to the absorption of fibrin-ferment; and (6) the 
onset, if the patient survived sufficiently long, of peritonitis. 
Symptoms.-Sudden pain which marks the extravasation of blood 
into the peritoneal cavity is followed by faintness, rapid and feeble 
pulse, restlessness, sighing respiration, vomiting, attacks of colicky 
pain, bloodlessness and extreme pallor, sweating, and collapse. In 
some cases, for example, rupture of an aneurism, death occurs at once. 
In other cases, especially when the blood is poured out less rapidly, the 
symptoms may imitate those of peritonitis due to perforation of a gastric 
ulcer. 
Sequelae.-If the patient is not operated upon and survives, acute 
general peritonitis will follow, unless,, indeed, the extravasation be 
sufficiently localized to become encysted and form a peritoneal san- 
guineous cyst (see page 738). 
Diagnosis.-In the presence of symptoms of internal hemorrhage and 
a history of recent and severe trauma the diagnosis is easy. On the 
other hand, ruptured ectopic gestation may so closely resemble acute 
1 Lancet, 1905, i, 474. 
2 Brit. Med. Jour., 1910, ii, 1226. 
3 Amer. Jour. Med. Sci., 1899, cxviii, 166. 670 
DISEASES OE THE DIGESTIVE SYSTEM 
perforative peritonitis that the condition is not suspected until the 
abdomen is opened. When collapse occurs in a patient known to have an 
intra-abdominal tumor the occurrence of hemorrhage may be suspected. 
Prognosis is best in ruptured ectopic gestations, but it is necessarily 
fatal in ruptured aneurisms and eventually, of course, in leaking malig- 
nant growths. 
Treatment.-When the cause is a ruptured extra-uterine gestation 
or spleen the only course is removal of the ruptured organ. 
Choleperitoneum.-Rupture of the bile passages with effusion of 
bile into the peritoneum usually sets up peritonitis, because the bile 
is commonly infected; but escape of aseptic bile into the peritoneal 
cavity need not cause inflammation; and in rare instances large bilious 
effusions result. This condition was named choleperitoneum by Deve,1 
and in 1906 Beaudet2 collected 47 cases due to rupture of a hydatid 
cyst which either before or after the rupture was in communication 
with a bile duct. The abdomen usually enlarges slowly, but it may 
do so rapidly. There is no fever, and jaundice does not occur. The 
effusion is very apt to recur, and several tappings may be required. 
Johansson3 has collected 5 cases, and Wolff4 has published 3 more 
examples of copious effusion of bile into the peritoneum, associated 
with cholecystitis but without any perforation of the biliary tract. 
Possibly the effusion is connected with the occasional presence of 
Luschka's canals or hernial protrusions of the mucosa into the wall of 
the gall-bladder (Johansson). 
ACUTE DIFFUSE PERITONITIS 
Although acute peritonitis means acute inflammation of the peri- 
toneum, the term is used to describe cases showing the clinical effects 
of acute infection of the peritoneum, namely, septicemia and toxemia, 
in which there may be very little or no manifest inflammatory reaction 
on the part of the peritoneum. These cases are more suitably described 
as "acute peritoneal infection." Thus, although it may sound para- 
doxical, the most severe cases of peritoneal infection often show the 
least evidence of inflammatory reaction. Acute diffuse peritonitis is 
not necessarily universal and coextensive with the whole area of the 
peritoneum. Strictly speaking, cases of acute peritonitis might be 
divided into (1) circumscribed, (2) diffuse or spreading, and (3) universal 
or total. But in practice acute peritonitis is usually considered as either 
(1) circumscribed or localized, or (2) general or diffuse. There is some 
unavoidable vagueness about the terms general and diffuse as descriptive 
of the extent of the peritonitis seen at an operation; thus the words 
employed may be meant to imply universal infection and inflammation 
of the peritoneum throughout the whole of the abdomen, or only that 
1 Rev. de chir., Paris, 1902, xxvi, 67. 
2 Gaz. des h6p., Paris, 1906, xlxix, 1065. 
3 Rev. de chir., Paris, 1912, xlvi, 892. 
4 Berlin, klin. Wchnschr., 1912, xlix, 2355. DISEASES OF THE PERITONEUM 
671 
at the time of the operation the peritonitis was not strictly localized. 
It has, therefore, been suggested that the term universal should be 
employed instead of general, and progressive instead of diffuse. The 
term diffuse will be employed here. 
Pathogeny.-Although chemical poisons, such as turpentine, croton 
oil, and nitrate of silver, when introduced into the peritoneal cavity 
of animals can set up acute inflammation, it is safe to assume that in 
practice all cases of acute peritonitis in man are due to infection. 
The mere entry of microorganisms into the peritoneal cavity is not 
alone enough to produce peritonitis. The defensive powers of the 
peritoneum, viz., the phagocytic action of the endothelial and other 
cells, the bactericidal power of the peritoneal fluid depending on the 
presence of antibodies, and absorption-which destroy and remove the 
invading bacteria-are able to prevent the production of inflammation. 
With regard to absorption from the peritoneal cavity, it should be 
explained that, while the removal of bacteria in comparatively small 
quantities and their destruction in the lymphatic glands and other 
organs prevent the onset of peritonitis and are therefore beneficial, 
the passage of large numbers of virulent bacteria into the general cir- 
culation, which occurs when the endothelial cells of the peritoneum 
are damaged, gives rise to a grave and often fatal bacteriemia. Death 
from "shock" after perforation may in all probability be explained in 
this way. The absorptive powrers of the peritoneum also militate against 
peritonitis by removing fluid in which microorganisms might multiply. 
The defensive powers of the peritoneum have been divided by Andrewes1 
into those which are physiological, or the "first line of defense," and 
those which come into play when inflammation is set up, or the " second 
line of defense." These two lines of defense merge into each other, 
for example, in phagocytosis, but the formation of fibrinous adhe- 
sions which localize the infective focus is a frankly inflammatory 
process. 
When the defensive powers of the peritoneum are inhibited or pre- 
vented from exerting their full effects, bacterial invasion is enabled to 
set up peritonitis. Factors which reduce the resistance of the peritoneum, 
such as the sudden entrance of poisonous fluids, drying or trauma during 
the course of an operation, and possibly cold, may interfere with the 
absorptive and bactericidal powers of the peritoneum. The presence 
of solid bodies, such as particles of food, feces, blood-clot, concretions, 
or foreign bodies, or of ascitic fluid, may protect the bacteria, provide 
a nidus for their multiplication, inhibit absorption, and so enable them 
to produce their toxins and set up inflammation of the peritoneum. 
Etiology.-Acute diffuse peritonitis may be (1) primary or (2) 
secondary. 
1. The term primary idiopathic peritonitis has been employed in 
two senses. Formerly it was used to imply that inflammation attacked 
the peritoneum alone, the rest of the body being healthy, and that its 
cause and origin wrere unknown. Peritonitis formerly thought to be 
1 General Pathology and Bacteriology of Acute Peritonitis. System of Medicine 
(Allbutt and Rolleston), 1907, iii, 897\ 672 
DISEASES OF THE DIGESTIVE SYSTEM 
due to rheumatism or to cold comes under this heading. More recently, 
since it has been recognized that acute peritonitis is practically always 
infective, the term primary peritonitis has been applied by Flexner1 
to cases in which, as there is no local focus in the abdomen to account 
for the infection of the peritoneum, it is assumed that microorganisms 
have reached the peritoneum by the blood- or lymph-stream. Hema- 
togenous peritonitis occurs as a terminal infection in chronic nephritis, 
arteriosclerosis, cancer, and other conditions which reduce the bactericidal 
power of the blood. Some cases of peritonitis complicating erysipelas 
or other infections, and about half of the instances of pneumococcic 
peritonitis, would also appear to be primary and so of hematogenous 
origin. Since a minute local focus, such as a microscopic abscess in the 
appendix, may be easily overlooked, a most exhaustive postmortem 
examination is necessary before a case of primary idiopathic peritonitis 
can be accepted, and many writers are somewhat unwilling to admit 
its existence. Of this, however, there can be no doubt, and probably 
about 10 per cent, of the fatal cases of general peritonitis are of this 
nature. It occurred in 12 out of 106 cases examined by Flexner and in 
9 out of 105 cases at the Massachusetts General Hospital (Manahan2). 
The infection is usually single; thus out of Flexner's 12 cases no bacteria 
were found in 2, in 9 there was a single infection, and in 1 a mixed 
infection. 
2. Secondary peritonitis, in which infection is due to some local lesion 
either in or in the immediate neighborhood of the abdomen, accounts 
for the great majority of cases of acute diffuse peritonitis. 
(a) Wound or operation introducing infection into the peritoneal 
cavity, e. g., after herniotomy. To this group Flexner applies the term 
exogenous. But it must, of course, be remembered that postoperative 
peritonitis may be due to bacterial infection derived from the viscera. 
(6) Due to infection derived from the abdominal viscera. This 
may depend on gross perforation of their walls or be due to inflammation 
allowing microorganisms to pass through the intestinal walls. This 
is Flexner's endogenous group. It will be convenient to mention the 
affections of the abdominal viscera which may cause acute peritonitis. 
Stomach.-Perforation of a gastric ulcer; perforation due to rapidly 
growing, soft, and necrosing carcinoma; acute suppurative (or phleg- 
monous) gastritis; acute gastritis due to corrosive poisons. 
Small Intestines.-Traumatic rupture, perforation by sharp foreign 
bodies; perforating ulcers, duodenal; jejunal peptic ulcer, occurring in 
cases of gastrojejunostomy, especially, it is said, after the anterior 
operation; typhoid ulcer (peritonitis in rare instances occurs in the 
absence of any gross perforation); uremic ulcer; acute enteritis; 
strangulation, kinking, volvulus, intussusception; internal hernia; 
infarction. 
Appendix.-Perforation as a result of acute infective inflammation; 
from rupture of an abscess in the walls of the appendix or in its neigh- 
borhood, or from acute appendicitis. 
1 Philadelphia Med. Jour., 1902, ii, 1019. 
2 Boston Med. and Surg. Jour., 1905, clii, 345. 673 
DISEASES OF THE PERITONEUM 
Colon.-Perforation, traumatic or by a foreign body from within. 
Perforating ulcer, stercoral or dysenteric; in connection with carcinoma, 
either from rupture of a distension ulcer or leakage through necrosing 
growth. Extremely acute inflammation, in strangulation, volvulus, 
intussusception. Wounds, perforation of the rectum by a bougie, or 
by the nozzle of an enema syringe. 
Gall-bladder.-Acute, phlegmonous, or gangrenous cholecystitis. Rup- 
ture of an inflamed gall-bladder. 
Liver.-Rupture or leakage of an abscess or of a suppurating hydatid 
cyst. Abscess may be multiple and due to arterial infection, suppura- 
tive pylephlebitis or cholangeitis. In new-born infants phlebitis of the 
umbilical vein gives rise to peritonitis. 
Spleen.-Rupture of an abscess, or of a suppurating infarct. 
Mesenteric Glands.-Rupture of a suppurating lymphatic gland into 
the general cavity of the peritoneum. 
Ulceration and perforation of the urinary bladder or of sacculi in 
connection with it. • 
Suppurating and gangrenous ovarian cysts. 
Pyosalpinx and infection spreading from the Fallopian tubes. Riedel1 
has shown reasons for believing that salpingitis is a more important 
cause of general peritonitis under ten years of age than in adults. 
Perforation of the uterus by a sound. 
Rupture of an abscess into the peritoneal cavity, especially of a peri- 
appendicular abscess; this may follow rough manipulation. It is remark- 
able how rarely erysipelas or suppuration in the abdominal parietes 
gives rise to peritonitis; this probably depends on the lymphatics being 
independent. Although peritonitis may lead to infection of the pleurae, 
an empyema hardly ever ruptures into the abdominal cavity. Inflamma- 
tion readily spreads from the pancreas to the peritoneum of the lesser 
sac. Retroperitoneal suppuration, such as that due to tuberculous ostitis 
of the spine or to renal calculi seldom infects the peritoneum. 
As giving the relative importance of the various starting-points of 
acute peritonitis, Benda's2 446 cases of acute diffuse peritonitis examined 
after death may be referred to. The vermiform appendix was the 
starting-point in 115 cases, the stomach and duodenum in 68, the rest 
of the intestine in 118, the female genitals in 81, the gall-bladder in 10, 
the kidney and urinary bladder in 10, the pancreas in 2, the spleen in 
1; 35 were unknown, 4 were postoperative, and 2 hematogenous. 
The sex and age incidence depend on those of the commonest causes 
of peritonitis, perforating gastric ulcer and pelvic infections being the 
most frequent etiological factors in women, and appendicitis in children 
and young males. In 200 fatal cases at St. George's Hospital there 
were 107 males and 93 females; the average age of the 200 cases was 
thirty-two years, being 34.26 in the males and 29.3 years in the females. 
In infants acute peritonitis is usually due to infection from the umbilicus. 
1 Arch. f. klin. Chir., Berlin, 1906, Ixxxi, 186. 
2 Quoted in A System of Surgery, von Bergmann, von Bruns, and von Mikulicz, 
translation, vol. iv, 165. 674 
DISEASES OF THE DIGESTIVE SYSTEM 
Bacteriology.-In the following account the results obtained by 
Dudgeon and Sargent will be freely utilized. A large number of micro- 
organisms have been found in human peritonitis. In many instances 
there is a mixed infection, and difficulty arises in apportioning the share 
that the organisms present have taken in producing peritonitis. The 
organisms found in peritonitis are in nearly all instances morphologically 
the same as those commonly present in the healthy intestine. 
Bacillus coli is very commonly found, and considerable discussion 
has taken place whether its importance is commensurate with its fre- 
quency. It has been regarded as the all-important factor in peritonitis, 
and, on the other hand, it has been thought that the B. coli, being 
more hardy than other bacteria, may overgrow them and so be found 
postmortem to the exclusion of other microorganisms which are the 
real factors in producing peritonitis. It is naturally found most often 
in cases of peritonitis due to infection from the alimentary canal, and 
is very frequently present in association with some other organism. 
In 50 cases of peritonitis due to bowel infection, Flexner found the 
Bacillus coli in 43, in pure culture in 8, and in association with other 
organisms in 35. Dudgeon and Sargent,1 as the result of bacteriological 
examination of 270 cases, came to the conclusion that the colon bacillus 
is the most important factor, and that it is found in the largest number 
of fatal cases. Its virulence varies greatly, and while less dangerous 
than the streptococci and Bacillus pyocyaneus, it is more frequently 
present. With mixed cultures a very virulent peritonitis is set up. 
A white staphylococcus, which is not the same as the Staphylococcus 
pyogenes albus described by Rosenbach, and has often been regarded 
as due to contamination from the skin, and is probably Welch's Staphyl- 
ococcus epidermidis albus, has been found by Dudgeon and Sargent to 
be the first organism to appear in the peritoneal cavity in cases of early 
peritonitis, and to pass through the walls of the inflamed intestine before 
more virulent organisms. They found it in 108 out of 258 peritoneal 
lesions.2 It gives rise to an exudation rich in phagocytes, and thus 
exerts a protective action against more virulent microorganisms. 
Streptococci are found in a considerable percentage of the cases. 
Flexner found them second in order of frequency both in his primary 
and secondary groups of peritonitis. As streptococci are among the 
normal saprophytes of the intestinal canal, it is natural that they should 
be commonly present in cases of peritonitis due to intestinal lesions; 
but it must be remembered that the Streptococcus pyogenes has not been 
found normally in the alimentary canal, and that streptococci found 
in the peritoneum are not necessarily Streptococcus pyogenes, and may 
be the saprophytes of the intestine (Andrewes and Horder3). Peritonitis 
due to Streptococcus pyogenes is the most severe and fatal form; there is 
little or no local reaction, the phagocytes being powerless against the 
virulent microorganisms which, as shown by Buxton's4 experiments, 
1 The Bacteriology of Peritonitis, Constable & Co., London, 1905 
2 Lancet, 1906, ii, 1337. 
3 Ibid., 1906, ii, 708. 
4 Jour, Med, Research, 1907, xvi, 39. DISEASES OF THE PERITONEUM 
675 
are rapidly absorbed into the circulation and give rise to fatal bacteriemia 
in the course of twenty-four to forty-eight hours from liberation of 
their endotoxins. 
Staphylococcus pyogenes aureus was found by Flexner in 15 out of 
34 cases of exogenous peritonitis, being in pure culture in 12 and mixed 
in 3. It was present in 3 only in 39 cases of endogenous peritonitis. It 
gives rise to a virulent form of peritonitis. 
Bacillus pyocyaneus is responsible for a certain number of cases of 
acute peritonitis, and ranks next to the Streptococcus pyogenes in its 
virulence. It does not produce green pus in the peritoneal cavity, as 
it often does in a local abscess. Dudgeon and Sargent have shown that 
Bacillus coli will not grow in the presence of B. pyocyaneus. 
Bacillus typhosus has been found in a few cases of peritonitis due to 
perforation of typhoid ulcers, and even after rupture of the spleen. But 
it is combined with saprophytic organisms, and it is doubtful what 
importance should be attached to its presence. 
Other organisms such as Bacillus lactis aerogenes (Churchman1), 
B. influenzae (Hull and Fisch2), B. proteus, B. anthracis, are occasionally 
found. With regard to anaerobic organisms, there has been a good deal 
of discussion; Veilion and Zuber and Tavel and Lanz conclude that 
anaerobic organisms are of importance in the production of appendicitis 
and peritonitis, while Dudgeon and Sargent employed strictly anaerobic 
precautions in a number of cases of appendicitis and in other varieties 
of peritonitis, but failed to find anaerobic organisms except in one case 
of gangrenous appendicitis with abscess in which Bacillus aerogenes 
capsulatus was found in addition to B. coli and a streptococcus. As 
the result of the presence of anaerobic organisms the peritonitic exudate 
may become putrid. 
It may be well to summarize the data at our disposal as to the bacteri- 
ology of peritonitis due to various anatomical lesions. In perforative 
peritonitis due to gastric ulcer the pneumococcus and a streptodiplo- 
coccus, an organism of low virulence (Dudgeon and Sargent), have been 
thought to be the responsible organisms. In perforation of the small 
intestine the B. coli and streptococci, and in appendicitis various organ- 
isms, especially streptococci (Low, Lartigau), B. coli, and diplococci 
have been regarded by different observers to be the causal organisms. 
In puerperal peritonitis and peritonitis in the new-born streptococci 
are most often the responsible organisms. 
Morbid Anatomy.-The appearances necessarily vary with the causes 
and stages of acute peritonitis. In the most rapidly fatal cases, there 
may be little or no morbid change. In other cases the earliest visible 
change is congestion of the small bloodvessels of the peritoneum; this 
is not uniformly distributed, but is naturally best marked and at first 
confined to the starting-point of the inflammation and to the omentum 
which is often adherent to the focus of infection. Further, it is more 
marked on the visceral than on the parietal peritoneum, and is in most 
instances not diffuse, but is confined to longitudinal lines which 
1 Johns Hopkins Hosp. Bull., Baltimore, 1911, xxii, 116. 
2 St. Louis Med. Rev., 1903, xlviii, 55. 676 
DISEASES OE THE DIGESTIVE SYSTEM 
correspond with the spaces left between contiguous and distended coils of 
intestine. The next change is the exudation; at first there is slight dulling 
of the smooth peritoneal surface, which appears finely granular, and on 
scraping yields a little fibrin. This fibrin is sticky and as it increases 
in amount glues the intestines together and collects in the triangular 
chinks left between adjacent coils. At first the fibrin is thin and clear, 
but it becomes opaque, and may be yellow or even of a green tint. Large 
masses of fibrin may eventually form and show a somewhat spongy or 
reticulated structure. 
The fluid portion of the exudation, usually comparatively small, 
may in some instances be considerable (several quarts). It collects 
between the intestinal coils; during life it is often mainly in the loins, 
but after death it is more commonly seen in the pelvis. Its characters 
vary much in different cases: it may be (1) serous; (2) serofibrinous, 
turbid, with pieces of fibrin floating in it, and of a specific gravity of 
1.018 or upward; (3) fibrinous; (4) fibrinopurulent; (5) purulent; (6) 
sanious; (7) putrid, due to the presence of putrefactive anaerobic organ- 
isms, such as the Bacillus aerogenes capsulatus. In such cases there 
may be free gas in the peritoneal cavity without any perforation of 
the hollow' viscera. In virulent streptococcic infection there is a little 
thin, odorless fluid; in gonococcic infection there is a dry, fibrinous 
exudate with hardly any pus or serum; in pneumococcic peritonitis the 
exudate resembles that in a pneumococcic empyema, and in B. coli 
infections there is a thick, creamy pus. In some instances of peritonitis 
secondary to cholecystitis the exudation may be bilious without any 
gross perforation of the biliary tract (Wolff,1 Johansson2). 
The progressive fibrinopurulent form of peritonitis described by Mikulicz 
is transitional between circumscribed and diffuse peritonitis. There is 
a gradually extending area of foci of pus enclosed in fibrinous adhesions 
and in rare instances the whole of the peritoneal cavity may be involved. 
Rupture of an encysted collection of pus may cause purulent peritonitis. 
The intestines are in a state of paralytic distension, the walls somewhat 
swollen, oedematous, and softened from inflammation so that the peri- 
toneum readily strips off and the intestine may rupture if pulled upon. 
In children there may be retrograde intussusceptions produced during 
the death agony. The peritoneum may show scattered small hemor- 
rhages, and small extravasations of blood are not uncommon in the 
ovaries. The omentum is often adherent to the starting-point of the 
peritoneal infection, e. g., the appendix. 
The lymphatics become filled with exudations and cells, and infection 
is, as shown by Durham3 both experimentally and by observations on 
fatal cases of peritonitis in man, conveyed to the lymphatic glands in 
the anterior mediastinum; these glands are swollen, reddened, and 
contain microbes. As the result of toxic absorption the solid viscera, 
such as the liver, pancreas, spleen, kidney, show cloudy swelling of their 
cells and areas of focal necrosis. Rarely other serous membranes, 
1 Berlin, klin. Wchnschr., 1912, xlix, 2355. ' 
2 Rev. de chir., Paris, 1912, xlvi, 892. 
3 Jour, of Path, and Bacterial., Edinburgh and London, 1897, iv, 361, DISEASES OF THE PERITONEUM 
677 
especially the pleurae, are inflamed as the result of a concomitant 
infection-an acute polyorrhomenitis. In prolonged cases, especially 
in pneumococcic and puerperal peritonitis, local abscesses may form. 
These if left alone may perforate in various directions, into hollow 
viscera, or even externally at the umbilicus. 
Microscopically the endothelium of the peritoneum, especially of the 
omentum, early shows proliferative changes; the cells enlarge; their 
nuclei become swollen and divide by direct and then by indirect nuclear 
division. The cells ("macrophages" of Metchnikoff) thus produced 
vary in size, but some are indistinguishable from lymphocytes. The 
surface of the endothelial cells is covered by a layer of fibrin containing 
leukocytes, and there is small round-celled infiltration of the subendo- 
thelial tissues. Coarsely granular eosinophilic cells constitute a consider- 
able proportion of the immense number of leukocytes attracted to the 
bloodvessels of the part; this local accumulation is correlated with the 
diminution of eosinophilic cells in the peripheral circulation (Opie1). 
At a later stage the cell infiltration of the underlying structures becomes 
more intense and extensive, and the peritoneal endothelium is destroyed. 
If the inflammatory process be short-lived the endothelium survives and 
the fibrin is eventually absorbed, so that the formation of adhesions is 
prevented. If the inflammatory process be continued the endothelial 
cells are destroyed and adhesions form. 
The exudation and fibrin present on the surface of the peritoneum 
are protective by (a) enabling phagocytosis and bacteriolysis to take 
place, (6) by blocking up the lymph channels and so preventing absorp- 
tion from the peritoneal cavity, and (c) by preventing the passage of 
microorganisms from the lumen through the walls of the inflamed intestine. 
Cytology.-As the result of experimental bacterial infection, Durham 
found a leukopenic stage lasting an hour, the normal hyaline and 
eosinophilic cells disappearing from the peritoneal fluid, which becomes 
increased in amount, while the lymphocytes remain. The disappearance 
of the cells is due to their being collected into balls on the surface of 
the peritoneum, especially on the omentum. In very virulent infections 
the leukopenic stage may persist until death. According to Dudgeon 
and Ross's2 experiments the first cells found in the exudation are either 
small lymphocytes or coarsely granular eosinophiles; subsequently 
there are polymorphonuclear leukocytes (Metchnikoff's "microphages," 
microxycytes) which are derived from the blood; these cells have been 
found by Beattie3 to diminish in number in non-fatal cases in from 
forty-eight to sixty hours after the onset, but to persist until death in 
fatal cases. They are active phagocytes, as are also the mononuclear 
cells (macrophages) derived from the endothelial cells of the peritoneum, 
which, however, according to Buxton,4 are unable to digest bacteria 
effectively in the absence of an early and marked polymorphonuclear 
reaction. Dudgeon and Ross state that the coarsely granular eosinophilic 
1 Transactions of the Association of American Physicians, 1904, xix, 136. 
2 British Medical Journal, 1905, ii, 1043. 
3 Journal of Pathology and Bacteriology, Edinburgh and London, 1903, viii, 129. 
4 British Medical Journal, 1907, ii, 1422. 678 
DISEASES OF THE DIGESTIVE SYSTEM 
leukocytes (megoxycytes), which are usually regarded as non-phagocytic, 
are, in the early stages of peritoneal infection, among the important if 
not the most important phagocytes. 
The peritoneal exudation is not infrequently free from microorganisms 
and from phagocytes containing bacteria, while the surface of the intestine 
and the omentum shows their presence. This observation is important 
in the consideration of the question of ''chemical" peritonitis, for it is 
clear that the peritoneal exudate may be sterile, and so suggest a non- 
bacterial peritonitis. The wall of the intestine shows small-celled 
infiltration around the vessels and fibrinous and serous exudation; the 
nerve cells of Meissner's, Auerbach's and the solar plexuses show degen- 
eration (Laignel-Lavastine1). 
After-results.-Acute peritonitis leaves behind it some slight thickening 
and opacity of the peritoneum; in cases in which blood has been extrava- 
sated pigmentation may be due to altered blood-pigment. As the 
result of organization of fibrin, adhesions are commonly seen, but it 
is remarkable how completely they may disappear in course of time. 
Symptoms.-The signs and symptoms of diffuse peritonitis vary quite 
widely in different cases; this depends on the cause of the peritonitis 
and on the virulence of the infecting organisms. It will, therefore, be 
best to give a very brief description of a common form of peritonitis, 
then to detail the manifestations that may occur in the various forms 
of peritonitis, and lastly to refer to special forms, pneumococcic, gono- 
coccic, and puerperal. 
The course of diffuse acute peritonitis can be most satisfactorily 
sketched by a short account of an ordinary case of perforative peri- 
tonitis. There is a sudden onset with agonizing burning pain and a 
feeling that something has given away; this is rapidly followed by 
collapse. These symptoms are due to the perforation. The abdomen 
is rigidly contracted and extremely tender. Tympanitic distension 
from escape of large quantities of gas into the peritoneal cavity is very 
rare at this stage. There is widespread and very severe pain which is 
exaggerated by any movement, so that respiration is costal and shallow, 
and there is frequent vomiting. The collapse passes off in a few hours, 
and for a time the patient appears fallaciously better; this period of 
latency or "stage of repose" (Symonds2) may be prolonged by the 
administration of opium or morphine. But when the disease is allowed 
to run its natural course, symptoms reappear and those of peritoneal 
inflammation become unmistakable; the abdomen gradually becomes 
distended, the legs being drawn up to relax the abdominal parietes, 
the arms usually lying above the head. There is extremely severe and 
constant pain, which becomes exaggerated in paroxysms and is made 
worse by the slightest movement, such as micturition; vomiting is fre- 
quent; the tongue becomes dry, the mouth parched, there is constant 
thirst, the temperature is somewhat raised, the pulse of high tension, wiry 
and rapid, the face pinched, anxious, and generally pale, and its aspect 
that of grave toxemia and of progressive exhaustion. As time goes on the 
1 Arch, de med. exper. et d'anat. path., Paris, 1905, xvii, 54. 
2 British Medical Journal, 1899, i, 520 DISEASES OF THE PERITONEUM 
679 
abdominal distension increases, the pulse becomes thready, more rapid, 
and weaker, the skin is cold and clammy, and the extremities icy and 
blue, although the internal temperature may be considerably raised. 
Restlessness and anxiety persist, there is little or no sleep, the mind 
is usually clear to the end, but occasionally there is wandering or delirium. 
Pain, tenderness, and vomiting occasionally pass off shortly before 
death, which may be sudden from cardiac failure, but sometimes there 
is profuse vomiting just before death, and aspiration of the foul fluid 
into the lungs may be the last straw. 
The Clinical Picture.-The underlying factors which are responsible 
for the clinical manifestations are: (1) Acute inflammation involving 
an extensive area. (2) Paralysis of the muscular walls of the intestines. 
(3) Septicemia and toxemia, due to the absorption of microorganisms 
and toxins from the peritoneal surfaces and of toxins from the paralyzed 
intestines. (4) Abstraction of water from the tissues. 
The onset varies with the cause. When this is perforation of a hollow 
viscus, as in gastric or duodenal ulcer, the moment of the accident can 
usually be absolutely fixed. In typhoid fever, however, perforation 
may not be marked by sudden and acute pain, and from dulling of the 
patient's powers of perception the existence of acute peritonitis may be 
an anxious problem. In the late stage of renal disease, intra-abdominal 
new growths, cirrhosis, pulmonary tuberculosis, etc., the onset and 
even the existence of peritonitis may be latent and not suspected during 
life. In some cases, especially after abdominal operations and in intestinal 
obstruction, the onset of peritonitis is so gradual that it cannot be 
definitely fixed. In puerperal and occasionally in slowly progressive 
forms of peritonitis, such as may occur in connection with appendicitis, 
the development is gradual and insidious. With an acute onset there 
is more or less shock due to the damage done to the peritoneum by the 
sudden entry of the contents of an abscess or of a hollow viscus into 
the abdominal cavity. This shock may prove fatal before peritonitis 
has had time to develop. 
The facial aspect of advanced peritonitis is characteristic, and has 
been described as "a composite photograph of hemorrhage, pain, and 
infection" (Crile). The face is pinched, the skin being tightly drawn 
over the bones, the eyes sunken and surrounded by dark rings, the 
skin gray or somewhat livid from failure of the circulation, and the 
expression anxious. This is the abdominal or Hippocratic face. In 
early stages, however, there may be nothing characteristic in the face, 
and the cheeks may be flushed. 
The tongue, at first furred and moist, subsequently, from the loss 
of fluid and absence of saliva, becomes shrivelled, dry, and stained 
by the vomit. Unless the mouth is carefully and constantly cleaned, 
sordes collect on the teeth. There is complete loss of appetite, and 
extreme thirst. 
Position.-The patient lies on his back, the shoulders raised, and 
the thighs flexed so as to relax the abdominal walls as far as possible. 
The arms and head are tossed about and manifest the mental restlessness, 
but the rest of the body is kept as still as possible. 680 
DISEASES OF THE DIGESTIVE SYSTEM 
Pain is practically a constant symptom. It is only in cases in which 
a terminal peritonitis supervenes in the course of a chronic exhausting 
disease, such as gastric carcinoma or renal disease, or of an acute disease, 
such as typhoid fever, in which the mental faculties are greatly dulled, 
that pain is absent. The pain may be continuous with that of the causal 
perforation; in other forms of peritonitis it comes on more gradually, 
and steadily increases until it becomes intolerable. It is constant, but 
becomes worse from time to time, the exacerbations probably depending 
on movements of the intestines; vomiting, cough, or any kind of move- 
ment aggravates the pain, and accordingly the patient keeps the abdomen 
and trunk absolutely still, and holds the arms above the head, while 
the movements of the diaphragm are greatly restricted. 
The pain is general all over the abdomen, but may be more marked 
in some one part, such as the umbilicus or the right iliac fossa, and 
may thus correspond with the starting-point of the disease. But this 
may be fallacious; for example, the pain may be most marked in the 
appendix region in perforated duodenal ulcer, and in pelvic appendicitis 
the pain is not uncommonly referred to the umbilicus. Toward the end 
the pain may disappear; this may be in part the result of the effusion 
and of intestinal paralysis, which prevent the intestines from rubbing 
against the parietal peritoneum; in part to the continued effect of toxemia 
on the exhausted sensorium. The diminution or disappearance of pain,' 
therefore, does not mean that there is any improvement. 
Tenderness.-Opinions differ as to cutaneous hyperesthesia. In 
order to test accurately for it, the skin, without any of the underlying 
tissues, should be carefully picked up between the finger and thumb. 
Head1 states emphatically that it is absent, and Sherren2 has never 
found it in general peritonitis due to appendicitis. Hale White,3 however, 
says that it is often present, and II. Robinson4 who found it in some cases 
suggests that it is only when the parietal peritoneum becomes inflamed 
that it appears. In acute peritonitis the abdominal reflexes are not 
exaggerated, as they would be if the tenderness were cutaneous (Head). 
Tenderness of the deeper tissues is due to implication of the parietal 
peritoneum and its somatic nerve supply in the inflammatory process. 
The tenderness gets progressively worse, and may be so extreme that 
the patient cannot bear the weight of the bedclothes; it is universal 
and corresponds with the extent of the peritoneum, being elicited by 
rectal and vaginal examination. Rectal examination may show balloon- 
ing of the rectum. 
Rigidity of the Abdominal Walls.-In the early stages the muscles 
are firmly contracted from spasm, and there may even be retraction; 
this is most marked in perforative peritonitis. In strong and muscular 
men the rigidity is prominent and lasts for a considerable time; in fact, 
in very acute cases it may persist until the end. In women with very 
flaccid abdominal parietes there may be no appreciable rigidity. Although 
this muscular defense is one of the most common events in the course of 
1 Brain, 1893, xvi, 94. 
3 Manual of Medicine (Allchin), 1903, v, 490. 
4 Quart. Jour. Med., Oxford, 1907-08, i, 406. 
2 Lancet, 1903, ii, 816. DISEASES OF THE PERITONEUM 
681 
acute peritonitis, it may be absent throughout; this is seen in gonococcic 
peritonitis, and even in cases in which there is no special atrophy of 
the abdominal muscles. This absence of rigidity is more likely to occur 
in non-perforative cases and in the somewhat slowly progressive fibrino- 
purulent peritonitis. As a result of this muscular spasm, the abdomen 
becomes more or less immovable; this is a valuable sign of peritonitis, 
but movement of the abdomen does not prove that peritonitis is absent. 
Muscular rigidity passes off when the patient is anesthetized. 
Tympanites.-Except in the fulminating and rapidly fatal cases, 
the early rigidity gradually passes off, and in about forty-eight hours 
is succeeded by abdominal distension; in less acute cases this may be 
delayed for a day or two longer. The abdominal distension may come 
on more rapidly after rupture of the stomach and escape of gas into the 
abdominal cavity. The tympanites'or meteorism of peritonitis is due 
to distension of the paralyzed intestines with flatus; to a slight degree 
accumulation of liquid feces in the dilated intestines, and inflammatory 
peritoneal exudate contribute to it. Its onset is naturally favored by 
a flaccid condition of the abdominal parietes, such as may result from 
parturition, abdominal tumors, or ascites. The abdomen becomes 
prominent, hyperresonant, and the skin tight, stretched, and shiny. 
Abdominal movement is abolished. 
The distension pushes up the liver in such a manner that the normal 
relation of that organ to the parietes is altered, and very little of it 
remains in contact with the body wall; in extreme instances the thin 
edge of the liver looks upward and backward instead of downward and 
forward. As a natural consequence, the hepatic dulness is diminished 
or obliterated, and this without any free gas in the abdominal cavity. 
Absence of liver dulness must not be taken as evidence of perforative 
peritonitis. The diaphragm is pressed up, so that the lower lobes of 
the lungs become oedematous and partially collapsed, and the breathing 
thus further embarrassed. The apex of the heart may be displaced 
upward. 
The intestinal paralysis, which is one of the most important factors 
in acute peritonitis, is probably nervous and due to reflex shock; it 
may be increased by oedema and inflammation of the muscular walls 
and the local action of toxins on the neuromuscular apparatus of the 
intestinal wall. But from the rapid onset of distension in some cases 
of peritonitis, before inflammation can have spread sufficiently into 
the intestinal wall to produce muscular paralysis, this is certainly not 
the only factor concerned. Distension is lessened by copious vomiting. 
The distension may force a coil of intestine into a hernial sac, and so 
suggest that the symptoms are due to strangulation of the bowel, but 
examination will show that the hernia is reducible. 
Percussion is painful; when there is distension the note is usually tym- 
panitic, but certain areas, especially the flanks, may be dull due to collec- 
tions of peritoneal exudate or to the intestine being full of fluid. In 
rare instances a friction-rub can be heard. On the other hand, a valuable 
sign of intestinal paralysis is the entire absence of any gurgling sound 
when the abdomen is auscultated for five minutes at a time (Greig Smith). 682 
DISEASES OF THE DIGESTIVE SYSTEM 
(Edema of the abdominal wall is extremely rare; when it does occur 
it is usually in connection with a localized collection of pus, for example, 
appendicular abscess. It is not a sign of diffuse peritonitis. 
Vomiting is one of the most characteristic and, next to pain, the 
most constant manifestations. It may be absent, however, especially 
in young children. In the early stages, of which it is often the first 
symptom, it is probably a reflex result of irritation of the peritoneum, 
although it has been regarded as due to the action of toxins on the 
medulla. In the later stages it is, like the vomiting of acute obstruction, 
due to a reflux flow of fluid into the stomach from the paralyzed intestines. 
That it depends on paralysis of the intestines and overflow into the 
stomach of their stagnating contents is supported by the rule that it is 
less prominent or absent in cases in which the bowels act or in which 
there is diarrhoea, as in puerperal peritonitis; further, washing out the 
stomach prevents the vomiting. It is commonly excited by taking 
fluid to relieve the urgent thirst. 
The vomited materials are first those of the stomach, then those of 
the upper part of the small intestine containing easily recognizable 
bile, and lastly feculent or stercoraceous matter of an extremely offensive 
character. In severe cases the vomit is often brown or dark in color 
from the presence of blood. The fluid is brought up with comparatively 
little effort, welling up into the mouth. The amount varies somewhat, 
but is much less than in mechanical obstruction. It is rather remarkable 
that vomiting occurs in cases of perforation of the stomach. The move- 
ment entailed in vomiting exaggerates the abdominal pain. Nausea 
is common, there is a bad taste in the mouth, and foul gas may be belched 
up. In the later stages retching may be substituted for vomiting. The 
loss of fluid entails continual thirst. 
Hiccough, when it occurs, usually comes on in the late stages of peri- 
tonitis when the abdomen is considerably distended. It is a reflex 
phenomenon, due to implication of the phrenic nerve. 
Rigors are not common; they are seen in some cases of puerperal 
peritonitis, and in the prolonged form of progressive fibrinopurulent 
peritonitis. 
Constipation is the rule, and, from intestinal paralysis, is often so 
marked, both for flatus as well as for feces, as to give the case the aspect 
of acute mechanical obstruction. An enema will, however, usually 
bring away some fecal matter in acute peritonitis without any improve- 
ment in the patient's condition; this does not hold good for mechanical 
obstruction. So constant is constipation in acute peritonitis that cases 
in which it is absent or in which the bowels can be made to act may 
generally be regarded as hopeful. In puerperal peritonitis, however, 
diarrhoea, due presumably to some peculiar form of toxin, is the rule. 
In other forms, except in that due to pneumococcic infection, it is 
exceptional 
Respiration.-As diaphragmatic and abdominal movements are 
greatly reduced or abolished, the respiratory excursions mainly depend 
on the intercostal muscles. The upper parts of the lungs are therefore 
employed to a larger extent as a means of compensation for the impaired DISEASES OF THE PERITONEUM 
683 
movements of the lower lobes, and some of the extraordinary muscles 
of inspiration come into action. The respirations are painful, shallow, 
and considerably increased in rate (40 to 50 per minute); coughing and 
deep breaths are restrained. 
The pulse varies in character at different stages of the disease. It 
is nearly always regular, quickened, and becomes progressively more 
rapid, being 100 to 120 in the early stages, and becoming running, 170 
or uncountable, toward the end. In some instances the pulse may be 
little if at all accelerated, although there is extensive purulent peri- 
tonitis; this has been ascribed to interference with toxic absorption 
from blocking of the stomata and lymphatics, but is not necessarily a 
sign that the patient is improving. There is no correspondence between 
the rate of the pulse and the temperature; the temperature may be low 
and the pulse extremely rapid. The pulse is small, hard, and wiry in 
the early stages; Crile,1 who found the average blood-pressure in 20 
cases to be 166 mm. Hg., ascribes the small volume to the accumulation 
of blood in the splanchnic area and the hardness to reflex stimulation 
of the vasomotor centres from the peritoneum. In collapse and in the 
later stages the blood-pressure falls and the pulse becomes thready. 
The temperature is so extremely variable as to be of little or no value 
in diagnosis or as to the degree and gravity of the peritonitis. There 
is usually a more considerable difference between the rectal and the 
surface temperatures, such as the axillary, than in other diseases; this 
is connected with the stagnation of blood in the splanchnic area and the 
correspondingly small amount of blood in the cutaneous vessels. 
In perforative peritonitis the initial shock nearly always depresses 
the temperature; this is most noticeable in typhoid fever, in which the 
writer has seen a fall of eight degrees. But this is not an absolute rule; 
the variation probably depends on how much of the peritoneum is 
inundated by the contents of the bowel. The form of infection may 
influence the temperature, and a particularly virulent microbic invasion 
may so paralyze the power of resistance that there is less febrile reaction 
than in a less severe infection. In the vast majority of the cases of 
diffuse peritonitis the temperature is raised in some period of its course; 
it may be raised continuously, usually not to any great extent, and 
very seldom above 104°. A relatively high temperature, especially in 
the early stages, is more likely to occur in the healthy and vigorous. 
A persistently low temperature may depend on the severity of the 
infection and on failure of the organism to react, and is a grave sign. 
Blood.-There is anemia, but the erythrocyte count is not greatly 
diminished; probably the concentration of the blood accounts for this. 
In 16 cases examined by DaCosta, the average was 3,970,000 reds, 
and the color index 0.78. In fulminating cases in which the resisting 
powers of the body are paralyzed by the intensity of the toxemia, leuko- 
cytosis is absent and there may be leukopenia. In less severe peritonitis 
there is a leukocytosis which may be extremely marked. It is of the 
ordinary polymorphonuclear neutrophile form. According to Locke2 
1 Blood Pressure in Surgery, Philadelphia, 1903. 
2 Boston Med. and, Surg. Jour., 1902, cxlvii, 287. 684 
DISEASES OF THE DIGESTIVE SYSTEM 
and Gulland1 the glycogenic reaction seen in the polymorphonuclear 
neutrophiles is much more trustworthy, for it is present in cases of 
peritonitis with such a "brutal" infection-that leukocytosis does not 
appear. Cabot2 lays stress on the importance of the increase of the 
fibrin network (hyperinosis) iii the diagnosis from mechanical obstruction 
for this increase does not occur in obstruction, while leukocytosis does. 
Blood-cultures.-Although the fatal results of peritonitis are usually 
considered to depend upon septicemia as well as on toxemia, and although 
organisms can often be found after death in the heart's blood, it does 
not appear that the presence of organisms in the blood during life has 
been proved. In this connection it may be pointed out that in human 
septicemia pyogenetic cocci are demonstrated with difficulty in the 
blood, thus contrasting with experimental peritoneal infection and 
septicemia in animals. Libman3 found that in 25 cases of peritonitis, 
mainly of intestinal origin, the blood was sterile, although in some 
instances the blood-cultures were made shortly before death. 
The urine is scanty, high-colored, and may contain a small quantity 
of albumin, diacetic acid, and acetone. The most important point, 
however, is the large quantity of indican, which may rise from the 
normal 5 to 20 mg. in adults to 150 mg. Indicanuria takes some twelve 
to twenty-four hours to appear after the onset of perforative peritonitis. 
According to Lennander, the urine contains the organisms responsible 
for the peritonitis. Their presence, especially as he states they may 
appear within twenty-four hours of the onset of the disease, may possibly 
in the future be of some value in directing the treatment. From the 
presence of peritonitis over the bladder micturition is painful, and 
usually urine is retained. Occasionally, on the other hand, micturition 
is more frequent than normal. 
The mental faculties are often clear to the end, but sometimes they 
are somewhat obscured by the progressive toxemia. Sleeplessness is 
necessarily the rule, headache is common, and great anxiety and a painful 
form of restlessness are often present. 
Death may be quite sudden from cardiac failure, due to the action of 
toxins on the heart muscle, and may follow almost immediately after 
copious vomiting. Death sometimes comes gradually from progressive 
asthenia. 
The duration is very variable and depends on the cause and on the 
nature of the infection, the previous state of the patient, young and 
vigorous, or old and the subject of some exhausting disease, and on the 
treatment. Thus, in the most virulent and fulminating forms, as in 
some cases of appendicular and puerperal infection, death may occur 
in thirty-six to forty-eight hours from the onset, whereas the more usual 
and less severe forms generally last four, five, or even more days. A 
previously healthy boy may live through several days with severe 
peritonitis, while a patient with carcinoma of the stomach may only 
survive the onset of perforative peritonitis for eighteen to twenty-four 
1 Brit. Med. Jour., 1904, i, 880. 
2 Examination of the Blood, 1904, p. 282. 
3 Johns Hopkins Hospital Bulletin, 1906, xvii, 221. 685 
DISEASES OF THE PERITONEUM 
hours. In pneumococcic peritonitis the duration may be considerably 
prolonged, as the peritonitis may become localized into residual abscesses, 
so that the symptoms abate without disappearing. Progressive fibrino- 
purulent peritonitis may go on for weeks. 
Pneumococcic peritonitis presents some rather special features. The 
disease is much commoner in children than in adults. It may occur 
very early in life; Gossage1 reported 4 fatal cases of primary pneumococcic 
peritonitis in infants under three months, and Dudgeon and Sargent 
its occurrence in a male infant aged seven weeks. Under the age of 
fifteen years it occurs more often in girls than in boys; among 234 cases 
in children 62, or 27 per cent., were males, and 172, or 73 per cent., females 
(Barling2), but after that age its incidence is equal in the two sexes. 
The following channels have been regarded as enabling the pneumococci 
to reach the peritoneum: (1) Through the blood-stream, the organisms 
being absorbed from pneumococcic foci in the thorax or possibly from 
the throat or ear; (2) from the stomach and intestines in inflammatory 
conditions, appendicitis, or foci in the abdominal viscera; (3) from the 
pleurae through the diaphragm; and (4) through the Fallopian tubes. 
Probably infection of the peritoneum occurs by different channels 
in different cases; but when associated, and in children, Rischbieth3 
finds that this is almost always the case, with other pneumococcic 
lesions, such as pneumonia, pleurisy, pericarditis, polyorrhomenitis, 
miningitis, otitis, and arthritis, it is probably septicemic. Diffuse peri- 
tonitis is rare in pneumonia; in 4454 cases4 of lobar pneumonia in 
patients over ten years of age in the hospitals of London there were 11 
fatal cases, or 0.25 per cent. In most cases the peritoneum has been 
previously healthy; in a few instances there has been ascites due to 
cirrhosis or to chronic nephritis (Sevestre and Aubertin5). Pneumococcic 
peritonitis was primary, that is, the chief or only focus of infection in 
47 out of 74 cases, and in 34 of these 47 cases the peritonitis was encysted 
(Lenormant and Lecene6). 
In about half the cases the peritonitis is encysted or localized; in the 
other half it is diffuse or widespread. A localized abscess may either 
be primary or a result of diffuse pneumococcic peritonitis. The exudate 
is like that of a pneumococcic empyema; it is highly fibrinous and 
prone to coagulate, yellowish green in color, and odorless. The character 
of the exudation renders thorough drainage of the peritoneum difficult. 
In some instances, however, a much more fluid exudate has been found. 
When the peritonitis is localized an abscess results which is usually 
below the umbilicus, and is particularly prone to point at the umbilicus. 
Clinically the disease may run a very acute course and prove fatal in 
two or three days, or death may not occur until the sixth or seventh day. 
There may be the following stages: (1) Without prodromal symptoms 
1 Proceedings of the Royal Society of Medicine, London, 1908, i (Med. Sect.), 64. 
2 Practitioner, London, 1912, Ixxxviii, 557. 
3 Quart. Jour. Med., Oxford, 1910-11, iv, 205. 
4 Statistics of Hadley, Pasteur, Fawcett, Owen, Gossage, Proceedings of the Royal 
Society of Medicine, London, 1908, i, (Med. Sect.), 61 et seq. 
5 Bull, et mem. Soc. med. d. h6p., Paris, 1906, xxiii, 215 
6 Rev. de gyn. et de chir. abdom., Paris, 1905, ix, 225, 686 
DISEASES OF THE DIGESTIVE SYSTEM 
there is an acute onset with vomiting, followed by signs of peritonitis, 
often mainly in or near the pelvis, so that appendicitis may be diag- 
nosed. (2) After a few days the symptoms subside, the temperature 
falls, but diarrhoea is usually present, and for this reason typhoid fever 
may be suspected. (3) A prolonged stage in which residual abscesses 
may form, usually in the upper part of the abdomen, giving rise to con- 
tinued fever and imitating tuberculous peritonitis. Herpes labialis may 
occur. 
The prognosis in encysted pneumococcic peritonitis is fairly good, but 
it is very grave in the diffuse form; thus Rohr1 found that recovery 
occurred in 86 per cent, of the encysted and in only 11 per cent, of the 
diffuse form. 
Gonococcic Peritonitis.-The gonococcus alone, i. e., in pure culture, 
is capable of setting up diffuse peritonitis (Cushing2 and Hunner3). 
When the normal resistance of the peritoneum is diminished by men- 
struation or by cold, gonococci in the Fallopian tubes have a better 
chance of infec+ing the peritoneum. Gonococci enter the peritoneum 
from the ostia of the Fallopian tubes, but gonococcic peritonitis has 
followed leakage from a pyosalpinx during removal by operation. In 
males infection is said to travel up the lymphatics of the spermatic cord. 
The disease is very rare in men and its frequency in women has not 
yet been established by extensive statistics; but diffuse gonococcic 
peritonitis is not common. In 1907 Goodman4 collected 75 cases, but 
only 30 of these had been established by bacteriological examination 
at autopsy or operation. It may attack girls under puberty, and it is 
highly probable that it is often overlooked. It usually follows or precedes 
menstruation, and may appear shortly after delivery. The lesions are 
comparatively slight; there is a. dry, fibrinous exudate without pus or 
serum, and the peritoneum is uniformly injected in the diffuse cases. 
Clinically, gonococcic peritonitis comes on suddenly with great severity, 
which usually becomes greatly mitigated in twenty-four or forty-eight 
hours. Comby5 speaks of the condition as one of peritonism rather 
than of peritonitis. It appears to be more fatal in children than in adults; 
the mortality in children has been estimated at 20 per cent. It may 
imitate appendicitis, as it mainly affects the lower part of the abdomen. 
Abdominal distension is usually not marked, and muscular rigidity is 
absent. Its existence should be suspected in the presence of gonorrhoea 
when the peritonitis is mainly in the lower part of the abdomen. At 
the onset of the disease the gonorrhoeal discharge may be slight, and 
as its existence is often firmly denied careful examination is necessary 
to avoid overlooking it. It is usually agreed that the patients should 
not be operated upon, but in 20 cases in which laparotomy was per- 
formed there were only four deaths (Goodman). 
Puerperal Peritonitis.-The infection gains entry through tears or 
wounds of the genital passages, and is more frequent in primiparse than 
1 Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1911, xxiii, 658. 
2 Johns Hopkins Hospital Bulletin, 1899, x, 75. (This article contains the detailed 
history of gonococcic peritonitis.) 
3 Ibid., 1902, xiii, 247. 4 Annals of Surgery, 1907, xlvi, 111. 
6 Arch. mol. d. enfants, 1901, iv, 512, 687 
DISEASES OF THE PERITONEUM 
in multiparae. It is not uncommon in criminal abortion. The infection 
spreads from the genital organs by the lymphatics, and may be localized 
or widespread in the peritoneal sac. The organism is most commonly 
Streptococcus pyogenes, but staphylococci or the gonococcus may be the 
causal agent. The exudation may be purulent, sanious, or putrid. 
Clinically there is grave intoxication and usually diarrhoea; vomiting 
is less prominent than in other forms; meteorism is marked, partly no 
doubt from the weakened abdominal walls; and a high mortality, which 
may be correlated with the presence of Streptococcus pyogenes. At 
its onset the lochia may be offensive and the mammary secretions be 
suppressed. Complications are prone to occur, and include septicemia, 
empyema, pericarditis, arthritis, and phlebothrombosis. 
Diagnosis.-In characteristic cases the association of the prominent 
symptoms of acute pain, tenderness, distension, and immobility of the 
abdomen, vomiting, constipation, prostration and collapse, together 
with the history, make the existence of acute peritonitis clear. But 
in many cases the decision is far from easy. When peritonitis supervenes 
late in the course of chronic nephritis it may be almost latent, when it 
occurs in typhoid fever it may be difficult to distinguish from tympanites, 
and in acute intestinal obstruction its manifestations are combined 
with and obscured by those of the primary disease. Further, the symp- 
toms may be almost entirely masked by opium or morphine. In some 
cases the majority of the signs and symptoms may be absent, although 
there is advanced peritonitis. This masked or latent form of peritonitis 
may occur in patients in the last stages of exhausting diseases, such as 
cancer. After operations on the abdomen the only evidence of peritonitis 
may be vomiting and a rapid pulse. 
Diagnosis of Acute Peritonitis from Conditions Simulating It.-In 
hysteria a condition of peritonism may occur and give rise to considerable 
anxiety, as the diagnosis between it and genuine peritonitis occurring 
in a hysterical patient may be difficult. The history of the patient 
and any concomitant nervous symptoms must be taken into account. 
As an important point the occurrence of exactly similar attacks in the 
past should be specially noted. In such cases there is cutaneous hyper- 
esthesia; deep tenderness is not more marked than the superficial hyper- 
esthesia, and may disappear if the patient's attention be distracted. 
Severe colic, whether due to lead, constipation, or the passage of a 
gall-stone or renal calculus, may to some extent imitate acute peritonitis. 
In colic there is, as a rule, no real tenderness, and the pain may be 
relieved by firm pressure. In severe lead colic there may, however, 
be tenderness, but the pupils are often unequal and there may be 
tenderness over the vagus in the neck (T. Oliver1). In a doubtful case 
with abdominal tenderness the possibility of lead-poisoning should 
always be considered. In colic due to the passage of a calculus vomitmg 
occurs, but it is rare in the other forms. The history and examination 
for evidence of lead-poisoning, renal, or hepatic disease should be carefully 
considered. A raised temperature at the onset is strongly in favor of 
1 System of Medicine (Allbutt and Rolleston), 1906, ii, part i, 1045. 688 
DISEASES OF THE DIGESTIVE SYSTEM 
peritonitis and against ordinary colic. Colic, however, is more likely 
to be confused with the causes of peritonitis-such as appendicitis- 
than with the disease itself. The rare and puzzling condition of enteralgia 
may also imitate peritonitis; here again the history of repeated similar 
attacks is of importance. Extremely acute enterocolitis is accompanied 
by the same collapse as in peritonitis, but there is marked diarrhoea 
and the pain is of a colicky character. 
Tympanites should be readily distinguished from acute peritonitis 
by the absence of tenderness and vomiting. 
In acute mechanical intestinal obstruction acute peritonitis supervenes 
after some three or four days, and, conversely, acute peritonitis produces 
intestinal paralysis and the symptoms of obstruction, so that the diagnosis 
as to the primary lesion may be difficult. In acute obstruction the 
temperature is not raised, and the abdomen is not tender or rigid before 
the onset of secondary peritonitis. In mechanical obstruction feces 
and wind are not passed, while in peritonitis an enema will often bring 
some away. In mechanical obstruction vomiting is more profuse, the 
pain is colicky and not continuous, as in peritonitis. 
Extensive hemorrhage into the peritoneum, usually due to rupture 
of an ectopic gestation, may imitate perforative peritonitis very closely; 
in fact, the manifestations in both instances are those of shock. A 
similar clinical condition of peritonism may follow hemorrhage into the 
mesentery, torsion of an undescended testis, of an ovarian cyst, of a 
floating kidney, or of a wandering spleen. Rupture of an abdominal 
aneurism and embolism of the superior mesenteric artery have imitated 
acute peritonitis (Osler). 
Acute hemorrhagic pancreatitis may imitate acute perforative peri- 
tonitis; great collapse, abdominal distension, complete constipation, 
and vomiting follow the sudden onset of pain in the epigastric region. 
If the abdomen be opened, turbid fluid and fat necrosis may be found. 
It may be noted, however, that fat necrosis may be due to the escape 
of pancreatic fluid through the perforation of a duodenal ulcer,1 so that 
its discovery, although almost pathognomonic of pancreatitis, does not 
absolutely exclude perforation. In pancreatitis there is extreme feeble- 
ness of the pulse, the temperature is often not raised, and the symptoms 
are more suggestive of mechanical obstruction than of peritonitis. 
Acute inflammatory conditions in the thorax, such as lobar pneumonia 
or pleurisy, may, especially at the onset before physical signs have 
appeared, imitate peritonitis. The sharp pain of pleurisy, the onset of 
which may wake a patient up in the night, has been mistaken for per- 
foration of a gastric ulcer or of a gangrenous appendix. Difficulty is 
especially likely to arise in children in whom the appearance of the 
physical signs of pneumonia, particularly when apical, is often much 
delayed. In pneumonia the respirations may be jerky and grunting. 
The rigidity of the abdominal muscles sometimes seen in pneumonia, 
especially in children, relaxes between the respirations, and may even 
disappear on prolonged and deep pressure (Clogg2), while the referred 
1 White, Archives of the Pathological Institute of the London Hospital, 1906, i, 48. 
2 Clinical Journal, London, 1906, xxix, 93. DISEASES OF THE PERITONEUM 
689 
pain of thoracic disease is mainly superficial and not increased on deep 
pressure, as in peritonitis. The temperature may be of some assistance; 
low at the onset of perforative peritonitis, it then rises, but may fall 
after some hours,- although the patient's condition is not improved. It 
thus differs from the continuous fever of pneumonia. Indicanuria is 
in favor of peritonitis. Tuberculous peritonitis in rare cases comes on 
with such acute symptoms in children as to imitate very closely peri- 
tonitis due to appendicitis. 
In women about the menstrual period sudden acute pain may imitate 
perforation of a hollow viscus or rupture of an ectopic gestation. The 
symptoms pass off, as a rule, but are alarming enough at the time. 
The underlying cause has been thought to be hemorrhage into the 
ovary. In one case attended by great temporary collapse the real cause 
appeared to be synthetic drugs taken to relieve the pain on the first 
day of the period. 
Uremia may imitate diffuse peritonitis, and it must be remembered 
that uremic ulceration of the intestine may lead to perforative peri- 
tonitis, and that hematogenous peritonitis may supervene in chronic 
renal disease. 
In very rare instances acute abdominal symptoms imitating appen- 
dicitis or even peritonitis supervene in Addison's disease (Nattan- 
Larrier1) and appear to be allied to the vomiting in that disease. 
Pernicious malaria, due to estivo-autumnal parasites, may cause 
symptoms suggesting peritonitis. The diagnosis depends on the detection 
of the parasite. 
When the presence of peritonitis has been determined it is most impor- 
tant to diagnose the cause and to decide whether it is due to perfora- 
tion of a gastric, duodenal, or an intestinal ulcer, to appendicitis, to 
rupture of an abscess, and, if so, where, to gonococcic or pneumococcic 
infection, and so on; for on the correct diagnosis of the cause depends 
the site of the abdominal incision in the first instance. As bearing on 
the cause of peritonitis in any given cause the following points may be 
taken into consideration: 
Age.-In children peritonitis of sudden onset is most commonly due 
to fulminating appendicitis; but pneumococcic and gonococcic peritonitis 
must be considered. 
Sex.-In young women perforated gastric ulcer and pelvic infection 
are the most common causes. 
History.-Symptoms of dyspepsia in young women at once suggest 
a perforated gastric ulcer, while in patients about fifty years of age 
carcinoma of the stomach with perforation should not be forgotten. 
When peritonitis comes on suddenly in a patient who has had gastro- 
enterostomy done for gastric ulcer, the possibility of perforation of a 
peptic jejunal ulcer should be thought of. The existence of typhoid 
fever, advanced kidney disease, or of a pelvic abscess will indicate the 
probable starting-point of the peritoneal infection. 
The position in which the pain is first felt should be considered, but 
1 Clinique medicale de I'Hotel-Dieu, Paris, 1906, v, 250. 690 
DISEASES OF THE DIGESTIVE SYSTEM 
it is by no means a certain guide, for, although pain starting in the 
right iliac fossa naturally suggests appendicitis, pain in this situation 
may be due to perforation of a gastric or duodenal ulcer. 
The sudden onset of peritonitis in a person in good health up to that 
time may be due, especially in children, to fulminating appendicitis, 
in young women to perforation of a latent gastric ulcer, ami in men to 
perforation of a duodenal ulcer which is relatively more often latent 
than a gastric ulcer is in women. 
Prognosis.-This is very bad. Statistics differ very much in the 
percentages of mortality, because, as has been pointed out, a case which 
at operation one surgeon may describe as diffuse another would regard 
as general or universal. In 100 cases at the London Hospital there were 
70 deaths and 30 recoveries (Treves), but the different forms of peri- 
tonitis vary so much in their severity that no conclusion of any value 
can be obtained from statistics in which cases of the various kinds are 
indiscriminately included. Other things being equal, peritonitis is more 
fatal at the two extremes of life. The previous health of the patient, 
the presence of disease elsewhere, cachexia, and alcoholism, of course, 
have a bearing on the prognosis. 
As the fatality of peritonitis depends on toxemia and septicemia, 
the prognosis to some extent varies with the degree of the toxic symptoms; 
the cases of acute peritoneal sepsis in which there is very little reaction 
on the part of the peritoneum are almost always fatal. Bad as the 
prognosis is in purulent peritonitis, it occasionally happens that the 
inflammation becomes localized and an abscess results. A very rapid 
pulse, a persistently low temperature, abdominal distension, and absence 
of leukocytosis are a bad prognosis. 
From a bacteriological point of view peritonitis due to Dudgeon and 
Sargent's white staphylococcus is the most benign form, while that 
due to gonococci is comparatively mild. In pneumococcus peritonitis 
the prognosis is graver than in the forms just referred to, but is not so 
serious as in those now to be mentioned. The commonest cause of 
peritonitis is infection with virulent colon bacilli; if present alone in 
the peritoneal cavity at a distance from the infecting focus the outlook 
is bad; and if all the phagocytes are degenerated the prognosis is prac- 
tically hopeless. If B. coli and the white staphylococcus are associated, 
the outlook is not so bad, but is still very serious. The Streptococcus 
pyogenes gives rise to the most acute and fatal peritonitis, and it is 
doubtful if any surgical procedure offers a prospect of success. Perito- 
nitis due to the B. pyocyaneus is hardly less fatal (Dudgeon and Sargent). 
The prognosis is almost necessarily fatal in perforative peritonitis 
unless operated upon; when operation has been performed the outlook 
is much better in traumatic rupture or bullet wounds of the intestine 
than in perforation due to disease. Similarly the prognosis is better in 
perforation of a gastric or duodenal ulcer than in perforation of an 
intestinal ulcer lower down, because, as shown by Cushing and Livin- 
good,1 the number of colon bacilli steadily diminishes from the ileocecal 
1 Contributions to the Science of Medicine by the pupils of W. H. Welch, 1900. DISEASES OF THE PERITONEUM 
691 
valve to the stomach, and the duodenum is often sterile when empty. 
The interval between the onset of peritonitis and the time at which 
the operation is performed has an important bearing on the prognosis; 
operation within twelve hours of the onset should be successful, while 
an interval of twenty-four hours makes the outlook very grave. 
Treatment.-Prophylaxis.-Under this heading the briefest reference 
only need be made to the desirability of preventing or curing the causes 
of general peritonitis, such as gastric or intestinal ulceration, appendicitis, 
pelvic inflammation, and intra-abdominal abscesses. Among these 
the importance of timely surgical interference in acute appendicitis 
cannot be exaggerated. It is almost unnecessary to insist that strict 
precautions should always be taken to avoid the introduction of organisms 
into the peritoneal cavity when the abdomen is tapped for the relief 
of ascites or when laparotomy is performed. 
Various prophylactic measures have been adopted in order to immunize 
the peritoneum against probable infection during the course of lapar- 
otomy. These measures are mainly based on Issaeff's1 observation that 
injection of saline and other fluids into the peritoneal cavity produces 
a local leukocytosis, and so protects the animal against some forms of 
microbic infection; this ("Issaeff's resistance period") lasts four or five 
days. Buxton and Tracy2 consider the protection mainly mechanical 
and due to blocking of the lymphatics by the inflammatory products, 
by means of which bacteriemia is prevented. Horse serum and nuclein ate 
of sodium have been injected eleven or twelve hours before operation 
so as to induce a protective leukocytosis. The introduction into the 
abdominal cavity, at the end of operations on cases of peritonitis, of 
hot horse serum or salt solution has been advocated in order to increase 
leukocytosis; about 30 cc. of sterilized horse serum is poured through 
the drainage tube, and has given good results (Petit3). 
Surgical Treatment.-The great majority of cases depend on infection 
from some local focus in the abdominal cavity, and are therefore rightly 
treated by removal of the cause. In the small minority of cases in 
which the infection is hematogenous, operative interference is not so 
necessary, but is required to drain a local abscess, as may be seen in 
pneumococcic peritonitis. 
The objects of laparotomy are: (1) to remove the focus of infection, 
such as a perforated appendix, or to prevent continued reinfection, 
as is done in suture of a perforated ulcer; and (2) to give exit to the 
inflammatory exudate and if necessary provicfe efficient drainage. In 
order to prevent absorption of bacteria by the lymphatics of the dia- 
phragm, the pelvis is lowered and the patient placed in the semi-sitting 
(Fowder's) position, at an angle of 35 to 40 degrees, both before operation 
and for some days afterward. 
When the intestines are greatly dilated from paralysis, the danger 
of fatal toxemia from absorption of the foul contents of the bowel may 
be met by emptying the intestines. This can be done at the time of 
1 Ztschr. f. Hyg., Tubingen, 1894, xvi, 287. 
2 Jour. Med. Research, Boston, 1907, xvii, 1. 
3 New York Medical Record, 1907, Ixxi, 1017. 692 
DISEASES OF THE DIGESTIVE SYSTEM 
the operation by incising the bowel and expressing its contents, or, in 
more urgent cases, by inserting a Paul tube into the intestine and 
leaving it for some hours in situ. Other methods have been employed, 
such as injecting purgatives of magnesium sulphate by a syringe 
directly into the intestine during the operation (McCosh1), after removing 
some of its contents (Mayland2); by hypodermic injections of physos- 
tigmine or extracts of the posterior or infundibular lobe of the pituitary; 
by the administration of enemas, methods often quite unsuccessful; 
or by the administration of calomel in one-grain doses every hour until 
the bowels act; the calomel probably does good by its antiseptic action, 
as well as by leading to evacuation of the intestinal contents. Lawson 
Tait, who first advocated this line of treatment, gave saline purgatives. 
The purgative treatment of peritonitis has, however, met with consider- 
able opposition both in the past and at the present time; it is useless 
when the intestines are paralyzed, and should only be adopted after 
operation and removal of the infecting focus. If employed before 
operation, it does harm by spreading the infection. 
Transfusion.-In order to meet the urgent need for fluid and to combat 
collapse and toxemia, enemas of saline solution should be given; the 
introduction of saline solution either intravenously or subcutaneously 
has also been extensively employed. Of the last two the subcutaneous 
method is the more convenient and can be frequently repeated if needed. 
The solution should be of the strength of a dram of salt to a pint of 
water (0.6 per cent.) and should be introduced by gravitation, the 
fluid in the reservoir being kept at 115° F. In this way as much as 15 
pints can be infused in the twenty-four hours (Barnard). By filling 
the vascular system, absorption of poisons from the peritoneal cavity 
is inhibited, the current of the stream between the peritoneal cavity 
and the circulation being reversed, the toxins already in the blood 
being diluted and their excretion by the kidney favored. Continuous 
administration of fluid per rectum has been employed with good results. 
Medical Treatment.-The patient must, it need hardly be said, be 
kept in bed; the shoulders should be raised with pillows, so that the 
exudation will gravitate toward the pelvis rather than toward the 
diaphragm. If tenderness is extreme the bedclothes may be kept off 
the abdomen by means of a cradle. The abdomen should be manipulated 
as little as possible, both because of the tenderness and because infection 
may thus be spread. The mouth should be frequently cleaned and kept 
moist. 
The administration of purgatives must be prohibited, for by promoting 
peristalsis they would increase the pain and spread the infection more 
widely in the peritoneal cavity. 
No food or fluid should be given by the mouth, and the urgent thirst 
should be relieved by enemas of saline solution. In the later stages 
the administration of sterilized olive oil hypodermically has been 
advised. Vomiting may be treated by washing out the stomach. It 
is doubtful if bismuth, hydrocyanic acid, and drugs that calm an 
1 Annals of Surgery, xxvi, 691. 
2 Brit. Med. Jour., 1899, i, 842. DISEASES OF THE PERITONEUM 
693 
irritable stomach in other diseases are worth giving. Tympanites is 
difficult to relieve; enemas containing turpentine may be tried; or a long 
rectaPtube may be passed every three hours and left in situ for half an 
hour. 
The administration of opium in acute peritonitis has given rise to a 
good deal of discussion, but it may safely be said that when given now 
it is for humanitarian reasons, and not with the expectation of any 
permanent benefit. The reasons for giving opium or morphine are the 
severity of the pain, and also, it was formerly urged, to keep the intestines 
at rest and so prevent further spread of the infective process throughout 
the abdomen. It is also given when the condition of the patient appears 
hopeless, so as to relieve pain and suffering. The objections to opium 
are weighty. It masks the symptoms in a marvelous manner, and so 
should never be given before a diagnosis has been made. But after a 
diagnosis has been arrived at, and especially when it is thought that 
the patient is too ill to stand operation, opium is not uncommonly given. 
Even in these conditions it is undesirable, for since it induces intestinal 
paralysis and inhibits phagocytosis (Dudgeon and Sargent1), it may 
just turn the scale against recovery. 
Various local applications to the abdomen have been employed to 
relieve pain, such as hot and cold fomentations, the ice-bag, turpentine 
stupes, but often the slight pressure they exert gives rise to pain, and it is 
doubtful how much good is done in this way. 
Collapse may be treated by the external application of warmth, 
bandaging the limbs, and the hypodermic injection of strychnine or 
pituitary extract; adrenalin has proved disappointing. 
Serum Treatment.-In 25 cases of peritonitis due to appendicitis, 
treated by injections of the serum of a horse immunized against thirty- 
one strains of B. coli, recovery occurred in 9, or 36 per cent., and improve- 
ment was produced in all the others (Makins and Sargent2). Wilkie3 
treated 6 cases of very severe peritonitis with intravenous injections of 
human immune serum from patients recovering from similar infections 
and obtained 3 recoveries. Polyvalent antistreptococcic serum has 
been tried in numerous cases, especially in puerperal septicemia, unfor- 
tunately in the majority of cases without success. 
ACUTE CIRCUMSCRIBED PERITONITIS 
Acute circumscribed or localized peritonitis may be conveniently 
divided into (1) non-suppurative and (2) suppurative. 
Non-suppurative acute circumscribed peritonitis is extremely frequent 
and is due to extension of inflammation to the peritoneum. This is 
usually from organs in the abdominal cavity covered by peritoneum, 
such as the vermiform appendix, the intestines, the female genital 
organs, the gall-bladder and liver; but acute inflammation of the pleura 
1 The Bacteriology of Peritonitis, 1905, p. 188. 
2 Transactions of the Clinical Society of London, 1907, xl, 146. 
3 Jour. Path, and Bact., Cambridge, 1910, xiv, 270. 694 
DISEASES OE THE DIGESTIVE SYSTEM 
or pericardium may spread through the diaphragm to the surfaces of 
the spleen and liver; the results of this process are comparatively often 
seen in adhesions found after death on both sides of the diaphragm. A 
good example is that produced by an infarct in the spleen. There is 
pain on breathing like that of pleurisy, local tenderness, and from 
organization of the localized exudate adhesions frequently follow. 
The chief clinical manifestation is pain, which may vary in intensity 
but is confined to one area, and is made worse on pressure. A friction 
rub may be audible over the spleen or liver. In rather infrequent cases 
acute circumscribed peritonitis may, by producing local paralysis of a 
coil of intestine, set up acute obstruction; Mayo Robson1 and Halsted2 
have described this as the result of acute cholecystitis. The main 
importance, however, of sharply circumscribed acute peritonitis lies 
not so much in its immediate effects as in results which it produces by 
the formation of local adhesions. By enclosing the affected area and 
shutting it off from the general peritoneal cavity, rupture of a perforating 
ulcer or of an abscess into the general peritoneal cavity may be prevented. 
On the other hand, the evil effects of a past attack of acute circumscribed 
peritonitis are shown by the occurrence of internal hernia due to strangu- 
lation of the intestine by bands and by " adhesion dyspepsia." 
The treatment is mainly symptomatic and directed to the relief of 
pain by external applications, such as hot fomentations or ice, the 
patient's feelings being consulted as to which is most effective. Opium 
or belladonna may be applied to the abdomen, or, if the pain be obstinate, 
leeches may be employed. The underlying conditions should, when 
possible, be treated. 
Acute Pericolitis.-This occurs in a number of conditions, and neces- 
sarily forms part of diffuse peritonitis and of various intraperitoneal 
abscesses and localized inflammations. As a descriptive heading, how- 
even, acute pericolitis should be confined to inflammation of the serous 
coat due to causes arising in the colon itself. Windscheid3 first described 
cases under the name of pericolitis in 1889. 
Etiology.-It may be due to causes which allow microorganisms to 
traverse the walls of the colon, such as acute inflammation, ulceration, 
injury, or the passage of sharp foreign bodies through the walls of the 
colon. There is often a history of previous constipation, but constipation 
is so common and pericolitis so comparatively infrequent that some 
further factor appears to be necessary. This additional factor is prob- 
ably stercoral ulceration, especially in acquired diverticula of the colon. 
The writer has recorded several examples,4 and Rixford5 described a 
closely allied condition in which inflammation of the appendices epi- 
ploicse is due to infection conveyed from the colon. It has been suggested 
that pericolitis is rheumatic, but so far without convincing evidence. 
As stercoral ulcers and false diverticula are more often present in the 
1 Medico-Chinirgical Transactions, London, 1895, Ixxviii, 117. 
2 Johns Hopkins Hospital Bulletin, 1900, xi, 1. 
3 Deutsch. Arch. f. klin. Med., Leipsic, 1889, xlv, 233. 
4 Lancet, London, 1905, i, 854. 
5 California Stale Journal of Medicine, October, 1904, p. 296. DISEASES OF THE PERITONEUM 
695 
sigmoid flexure and descending colon, pericolitis is commoner in these 
parts of the large intestine. It is spoken of as perisigmoiditis and peri- 
colitis sinistra, but it may occur in the transverse or descending colon, 
especially at the flexures, where, from organization of adhesions (chronic 
pericolitis), the bowel may become narrowed, fixed, or kinked. Acute 
pericolitis may resolve, become chronic, or go on to the formation of 
a pericolic abscess. 
The symptoms are pain, loss of appetite, occasionally vomiting, some 
elevation of temperature, and quickened pulse. There is constipation, 
which, indeed, is often concerned in the causation, and also an absence 
of the manifestations of colitis, such as loose stools and mucus. The 
skin over the area may be hyperesthetic, there is local muscular rigidity 
and deep tenderness, and in some instances an elongated tumor can be 
felt. Leukocytosis and indicanuria have been noted in some cases. 
The clinical manifestations, therefore, run into those of coprostasis or 
fecal accumulation with an acute exacerbation. The symptoms, apart 
from their position, are very much like those of appendicitis. Cases 
on the left side, or pericolitis sinistra, can be readily recognized, but 
on the right side the diagnosis from appendicitis is necessarily extremely 
difficult, and can hardly be regarded as established before operation 
has shown that the appendix is healthy. The treatment consists in rest 
in bed, soothing applications to the abdomen, and the relief of constipa- 
tion, first by repeated enemas and subsequently by laxatives. The diet 
should be light and composed of food leaving little residue. 
Epiploitis.-Epiploitis, or inflammation of the great omentum, is of 
course common in intraperitoneal inflammations on account of the 
tendency of the omentum to become attached to any focus of infection. 
It has been especially described as a result of abdominal operations in 
which silk ligatures have been applied to the omentum. Schnitzler1 
collected 28 cases after herniotomy, and it has also been met with two 
years after appendicectomy (Walther2). In some cases the condition 
has appeared long after the operation, there being a latent period of 
years. Cobb3 has described epiploitis due to a needle which appeared 
to have entered from the umbilicus. The condition of the omentum 
varies; it may be thickened and rolled into a firm mass showing inflam- 
matory changes, and it may be adherent to other structures, or free. 
In a woman under my observation two radical cures for hernia had 
been done in 1899 and 1900; in 1903 the appendix was removed, and 
about two months later a definite, firm abdominal tumor appeared on 
the left side and a hectic temperature developed, but on laparotomy 
there was no abscess formation; part of the omentum was rolled up into 
a round mass which microscopically showed developing connective 
tissue ami some diminution in the number of fat cells. The inflammatory 
process may go on to the formation of an abscess. 
The symptoms usually come on gradually, with fever, pain, constipa- 
tion, and the presence of definite resistance or a tumor in the abdomen. 
1 Wien. klin. Rundsch., 1900, xiv, 4. 
2 Bull, et mem. Soc. de chir. de Paris, 1905, xxxi, 275. 
3 Boston Med. and Surg. Jour., 1907, clvii, 18. 696 
DISEASES OF THE DIGESTIVE SYSTEM 
The tumor may be lumpy, firm, adherent to the abdominal wall, tender, 
and imitate a new growth. It may be chronic and eventually undergo 
resolution, but from contraction of adhesions the intestines may become 
kinked or otherwise obstructed. Epiploitis of this nature is rare, but 
if the conditions after which it occurs be borne in mind, the diagnosis 
should not be difficult. 
Treatment in the early stage, when there is inflammation but not 
necessarily an abscess in the omentum, consists of soothing local appli- 
cations. If fever persists and it appears probable that suppuration has 
occurred, laparotomy is the only course. 
There are transitional forms between non-suppurative and suppurative 
acute circumscribed peritonitis. It is not very rare in appendicitis to 
see a tumor-like swelling, which gradually disappears in a few days 
without any evidence that pus has been discharged into the bowel. 
The swelling is probably due to adherent intestines, with some inflam- 
matory exudate enclosed between the coils of the bowel. In other 
cases, e. g., epiploitis, which at first show exactly the same features, an 
abscess eventually forms. 
SUPPURATION IN THE MESENTERY AND OMENTUM 
Suppuration in the mesentery is usually secondary to disease of the 
intestine. As the result of infection conveyed from the small intestine, 
a mesenteric gland may suppurate, or pyogenetic infection may be 
engrafted on an old tuberculous adenitis. In cases of suppurative 
inflammation of the mesenteric veins there may be pus between the 
layers of the mesentery. Suppuration may also spread from the appendix 
into the mesentery. Barling1 has published a series of cases, and has 
summarized the clinical aspect of the tumor; it is usually close to the 
umbilicus, mainly to the left side; when of considerable size it is prac- 
tically fixed, but when of small size the swelling may not be palpable 
or if it can be detected is movable. Rupture of the abscess may set 
up general peritonitis. 
Omental abscesses are rare. As has been mentioned above, suppuration 
may supervene after epiploitis. Thus, several abscesses have been 
found in the omentum more than a year after an operation. 
z 
PERIGASTRIC ABSCESS 
By a perigastric abscess is meant one that is due to infection, from the 
stomach but does not come in contact with the under surface of the 
diaphragm, and, strictly speaking, is therefore not included in the more 
striking category of subphrenic abscess. It is true that suppuration 
due to disease of the pancreas, gall-bladder, or liver may be in contact 
1 Clinical Journal, London, 1907, xxx, 62 DISEASES OF THE PERITONEUM 
697 
with the stomach, but these abscesses should not be described as peri- 
gastric. 
Etiology.-In exceptional instances a simple perigastric abscess may 
be due to a minute perforation in the stomach wall, such as is produced 
by a sharp foreign body, or to slight leakage from a gastric ulcer, but, 
generally speaking, perforation of a gastric ulcer is followed by a gaseous 
subphrenic abscess. A perigastric abscess occurs in from 3 to 5 per cent, 
of all cases of gastric carcinoma (Fenwick1) and is a late event. It is 
more often met with, so far as personal experience goes, in connection 
with rapidly growing and necrotic growths near the cardiac end; suppu- 
ration may then invade the left lobe of the liver. An abscess may form 
between the greater curvature of the stomach and the colon and then 
open into the large bowel, or may arise between the abdominal wall 
and the anterior surface of the stomach, and even point anteriorly or 
track down to the umbilicus. When a growth on the posterior wall 
of the stomach perforates, an abscess may form in the lesser sac of the 
peritoneum. The pus may be offensive, and if the abscess be opened 
during life, food may be discharged. 
Signs and Symptoms.-A superficial perigastric abscess may be 
palpable as a definite swelling, and even give rise to a projection and to 
reddening of the skin. But usually, especially in gastric carcinoma, a 
perigastric abscess gives few physical signs; any increased resistance 
may be indistinguishable from that of the growth, and as fever occurs 
in 50 per cent, of the cases of gastric carcinoma (Osler and McCrae2) 
it is no proof of perigastric abscess. 
Diagnosis.-It is practically impossible to diagnose between a peri- 
gastric abscess and the circumscribed form of phlegmonous gastritis, 
which is the same as an abscess in the walls of the stomach. A rapidly 
growing retroperitoneal sarcoma or hypernephroma may form a tender 
swelling in the left hypochondrium and imitate a perigastric abscess. 
PERICOLIC ABSCESSES 
Abscesses due to infection from the bowel may occur in the immediate 
neighborhood of the large intestine from a number of causes: (1) From 
ulceration of the mucous membrane of the bowel, due to dysentery, 
accumulation of feces (stercoral), or, more rarely, to other factors, and 
by perforation by foreign bodies, circumscribed peritonitis may be set 
up, and sometimes a localized abscess may result. The abscess may be 
intraperitoneal, and may open into the bowel (exogenous ulceration) 
or into the peritoneal cavity, or may be retroperitoneal. (2) The mucous 
membrane of false diverticula of the colon, which are more often found in 
connection with the sigmoid flexure, may, as the result of the accumula- 
tion of fecal material inside them, undergo ulceration; perforation of 
these diverticula may lead to an abscess in the immediate neighborhood. 
(3) Suppuration may occur in connection with a carcinoma of the large 
intestine. This may depend on perforation of the growth itself, on the 
1 Cancer and Tumors of the Stomach, 1902, p. 46. 
2 Cancer of the Stomach, 1900, p. 46. 698 
DISEASES OF THE DIGESTIVE SYSTEM 
passage of microorganisms through the floor of stercoral ulcers above 
the malignant stricture, or on perforation of these ulcers. The resulting 
tumor may be of considerable size, and on the right side must be differ- 
entiated from appendicitis with much inflammatory swelling, actino- 
mycosis, and hyperplastic tuberculosis of the cecum. An abscess formed 
in connection with a malignant stricture of the bowel may extend and 
open into the urinary bladder or even externally; rupture into the peri- 
toneal cavity, however, appears to be infrequent. (4) Small but sharp 
foreign bodies present in food may penetrate the wall of the colon and 
set up a fecal abscess in an appendix epiploica (Bland-Sutton1). This 
accident is more likely to occur in fat persons, for in thin individuals 
the foreign body more readily escapes into the peritoneal cavity. 
The symptoms are abdominal pain, tenderness, resistance, local 
prominence or distension, and perhaps a tumor, usually on the left 
side and suggesting left-sided appendicitis or even a new growth. Con- 
stipation is commonly present, and also, not infrequently, vomiting. 
The abscess may increase in size and may rupture into the peritoneal 
cavity; the acute onset of peritonitis following on a period of pain and 
constipation may then suggest perforation above a malignant growth of 
the colon. Power2 says that in some instances the abscess may become 
stationary, and from thickening of its walls give rise, for a time at least, 
to few clinical manifestations. The abscess may rupture into the intes- 
tine (Mayor3), or even into the urinary bladder, or externally (Patel4). 
The diagnosis of these pericolic abscesses may be difficult, as from 
their comparative rarity some commoner condition, such as appendicitis 
in an unusual position, fecal accumulation, or malignant disease of the 
colon, may be suspected. 
The treatment is purely surgical. 
RESIDUAL PERITONEAL ABSCESSES 
Residual peritoneal abscesses may occur in patients who have re- 
covered from more or less general acute peritonitis. These abscesses 
may be found in any part of the abdomen, but are most often seen in 
the loins, pelvis, over the right lobe of the liver, or around the spleen. 
In tuberculous and pneumococcic peritonitis, and in suppuration in 
connection with the gall-bladder, abscesses may point at the umbilicus. 
RETROPERITONEAL ABSCESSES 
Suppuration behind the peritoneum may be due to many causes, 
and when starting in one spot may spread to a considerable distance 
along the fascial planes by the lymphatics. A retroperitoneal abscess 
may be in contact with the diaphragm. A psoas or iliac abscess due to 
tuberculous disease of the spine is, of course, retroperitoneal, but belongs 
1 Lancet, London, 1903, ii, 1148. 
2 Brit. Med. Jour., 1906, ii, 1171. 
3 Rev. med. de la Suisse Rom., Geneve, 1893, xiii, 421. 
4 Rev. de chir., Paris, 1907, xxxvi, 420, 698. DISEASES OE THE PERITONEUM 
699 
to a somewhat different category, as does an iliac abscess due to calculous 
or tuberculous disease of the kidneys. Retroperitoneal suppuration may 
also be set up by disease of the bones of the pelvis or of the ribs. An 
abscess sometimes follows injury, especially in the neighborhood of 
the kidneys, and may be caused by minute rupture of viscera, or follow 
a hematoma. In other instances infection conveyed from the intestines 
to the retroperitoneal glands may result in the formation of an abscess. 
Perforation of viscera in situations where they are uncovered by peri- 
toneum may be followed by retroperitoneal suppuration. Thus traumatic 
rupture, a penetrating bullet wound, or perforation of a stercoral ulcer 
in the colon may lead to a pericolic abscess, and an abscess around a 
carcinomatous stricture of the large bowel has been known to track into 
the thigh. Viscera entirely surrounded by peritoneum may, after 
contracting adhesions, perforate into the retroperitoneal tissues and 
set up an abscess; this is most commonly seen in connection with the 
vermiform appendix, but it also occurs in disease of the female genital 
organs. Retroperitoneal suppuration may be set up by infection intro- 
duced at operations, e. g., herniotomy. These abscesses may rupture 
into the bowel or into other hollow viscera, such as the bladder or vagina. 
Clinical Picture.-The constitutional manifestations-fever, rigors, 
loss of flesh, rapid pulse, and leukocytosis-are more constant than the 
local. There is often abdominal pain or uneasiness/-while some deep 
tenderness on pressure may be present, and in some cases a palpable 
tumor. Focal signs may, however, be absent, and the condition may 
be thought to be typhoid fever, generalized tuberculosis, or some obscure 
septicemia. In some instances a diagnosis of an abnormally situated 
appendicular abscess may appear the most probable. 
Treatment is purely surgical. 
SUBPHRENIC ABSCESS 
Any abscess in contact with the under surface of the diaphragm, 
except when in the liver or in the spleen-the latter being rare-is 
spoken of as a subphrenic abscess. From a clinical standpoint there 
are two forms of subphrenic abscess: (1) without any contained air- 
simple subphrenic abscess; and (2) containing gas-the subphrenic 
pyopneumothorax. Their aspects are so different that separate de- 
scriptions are necessary, but their anatomy is the same, the differences 
between them depending on the nature of the contents, and the same 
cause may, in different cases, give rise to either of these forms of abscess. 
Thus an appendicular subphrenic abscess, although generally simple, 
may contain gas, and an abscess due to gastric ulcer, although usually 
gaseous, is not so in all instances. Nothnagel states that about half 
the subphrenic abscesses contain gas. In 59 cases of subphrenic abscess 
at St. George's Hospital, tabulated by Wahby, 32 were gaseous and 
27 non-gaseous. 
Subphrenic Abscess without any Gaseous Contents.-Etiology.- 
The simple subdiaphragmatic abscesses which do not contain gas may 
in the first instance be due to pyogenetic infection derived from a solid 700 
DISEASES OF THE DIGESTIVE SYSTEM 
abdominal viscus in the neighborhood of the diaphragm; but suppuration 
may track up from the vermiform appendix or from the pelvis, e. g., 
from a pyosalpinx. A simple subphrenic abscess may in rare instances 
arise in connection with ulceration, simple or malignant, of the stomach 
or colon, but, as a rule, the resulting abscess in cases of perforating 
gastric ulcer contains air. 
The causes of simple subphrenic abscesses may be conveniently 
tabulated in the order of their frequency: 
1. Appendicitis is the most frequent cause and the resulting abscess 
is nearly always on the right side, but a left-sided abscess may follow. 
The formation of a subphrenic abscess is a grave complication or sequel 
of appendicitis; thus among 86 fatal cases of acute appendicitis, sub- 
phrenic abscess occurred in 7, or 8.13 per cent. (Christian and Lehr1). 
In some cases of subphrenic abscess the causal appendicitis may remain 
latent and be quite unsuspected. Appendicitis may give rise to a sub- 
phrenic abscess in several different ways, (a) An appendix which is 
retrocecal, or runs up behind and to the outer side of the ascending colon 
and over the right kidney, may almost touch the right lobe of the liver; 
an appendicular abscess in this position (i. e., the right kidney-pouch) 
has a very short distance to travel to reach the under surface of the 
diaphragm. (6) An abscess around the appendix may spread upward in 
the paracolic groove to the right kidney-pouch and extend upward over 
the liver and under the diaphragm; this is the intraperitoneal route. 
The abscess may be retrocolic or retroperitoneal, and track upward. 
An appendicular abscess situated in the pelvis may extend upward 
along the paracolic grooves on both the right and the left sides of the 
abdomen, and so give rise to bilateral subphrenic abscesses, (c) A sub- 
phrenic abscess may be secondary to pylephlebitis set up by appendicitis; 
such a pylephlebitic abscess on the convexity of the liver may rupture 
and produce an abscess between the liver and diaphragm. (<Z) A residual 
abscess, the result of widespread peritonitis due to appendicitis, may 
form over the right lobe of the liver or around the spleen. 
2. Suppuration in the liver frequently sets up a non-gaseous sub- 
phrenic abscess. Collections of pus in the substance of the liver, such 
as tropical abscess, a suppurating hydatid cyst, multiple abscesses due 
to pylephlebitis or to cholangeitis, whether associated with gall-stones 
or not, may by extension set up an abscess between the convexity of 
the organ and the diaphragm, or between the layers of the coronary 
ligament. Operations on the liver or bile ducts may give rise to leakage 
of infective material from inflamed areas in the liver. As rare causes 
of a subphrenic abscess, attention may be called to leakage of a tuber- 
culous or of an actinomycotic abscess near the surface of the liver, or 
even of a softened and infected gumma in that*situation. 
3. An abscess of the spleen, by leaking or rupture, readily sets up a 
subphrenic abscess. Trauma, by giving rise to hemorrhage from or 
around the spleen, may be the first step in the production of a subphrenic 
abscess on the left side. 
1 Medical News, New York, 1903, Ixxxii, 147. DISEASES OF THE PERITONEUM 
701 
4. Although a localized abscess following perforation of a gastric 
ulcer nearly always contains gas, a very minute perforation, such as 
that produced by a pin, may set up a simple abscess. It is possible 
that microorganisms may pass through the floor of an ulcer, and that 
suppuration may occur without any gross perforation. Among 27 
non-gaseous subphrenic abscesses at St. George's Hospital, 2 were 
associated with a non-perforated gastric ulcer. A non-gaseous abscess 
occurs in about 3 per cent, of all cases of gastric carcinoma, but the 
resulting abscess is usually not in actual contact with the diaphragm, 
and therefore rather comes within the category of perigastric abscess. 
The writer has seen a subphrenic abscess in connection with breaking 
down carcinomatous lymphatic glands close to the cardiac orifice of 
the stomach, the primary growth being in the lower end of the oesophagus. 
5. Perforation of a duodenal ulcer usually floods the peritoneal cavity 
and sets up general peritonitis, but there are two ways in which it may 
set up a localized abscess (Maynard Smith1): (a) Perforation of the 
serous surface of the duodenum may be followed by the escape of a 
moderate amount of fluid into the right kidney pouch, and by the forma- 
tion of an extensive abscess, (b) Perforation of the duodenum behind 
the peritoneum may give rise to a localized abscess. Osler estimates 
that 6 per cent, of subphrenic abscesses are due to duodenal ulcer. In 
his digest of 184 cases of duodenal ulcer, Cullen2 finds that in 10 per 
cent, an abscess forms outside the duodenum, and that ultimately 
the ulcer opens into the abscess. In most exceptional instances a left- 
sided subphrenic abscess is due to a duodenal ulcer (Rolleston,3 Box4). 
6. A pericolic abscess may, but often does not, lie in contact with 
the diaphragm. Pericolic abscesses at the hepatic or splenic flexures 
of the colon will necessarily be those likely to become subphrenic. 
7. Suppuration in or around the pancreas may spread so as to lie 
immediately under the diaphragm. 
8. Suppuration in connection with the Fallopian tubes may, like an 
appendicular abscess in the pelvis, track up along the colon and give rise 
to a subphrenic abscess. 
9. Retroperitoneal suppuration starting from the kidneys, and from 
tuberculous disease of the spine or even of the ribs, must be mentioned, 
since the abscess may be subphrenic, but the clinical picture is usually 
different from that of the other simple subphrenic abscesses. 
10. It is sometimes stated that an empyema, other forms of intra- 
thoracic suppuration, or even pneumonia, may lead to a subphrenic 
abscess. Tuberculous ostitis of the dorsal spine is commonly followed 
by a psoas abscess, but subphrenic abscess undoubtedly due to intra- 
tboracic causes is extremely rare; in 448 collected cases there were 18 
in which a subphrenic abscess was due to intrathoracic infection (Archi- 
bald5). In any given instance, therefore, it is more probable that the 
1 Lancet, London, 1906, i, 895. 
2 Scottish Med. and Surg. Jour., Edinburgh, 1897, i, 643. 
3 Brit. Med. Jour., 1912, i, 423. 
4 Ibid., 1912, i, 889. 
5 Ibid., 1906, i, 1148. 702 
DISEASES OF THE DIGESTIVE SYSTEM 
subphrenic abscess was the primary condition, but remained latent or 
was undetected for a time. Exploration of an empyema, however, may 
convey infection into the subphrenic space and so start an abscess below 
the diaphragm. In very rare cases suppuration in the posterior medias- 
tinum, due to oesophageal ulceration, may track down and produce a 
subphrenic abscess. The infrequency with which infection spreads from 
the thorax to the abdomen is in marked contrast to the ease with which 
infection passes by the lymphatics from the peritoneum to the pleura. 
In 62 cases of streptococcic empyema, 14 spread from the abdomen 
(Pitt1). 
11. In some instances the focus from which a subphrenic abscess arose 
cannot be found. Possibly a minute traumatic rupture of a solid organ 
allowing hemorrhage to occur, or perforation of some part of the alimen- 
tary tract by a small foreign body may be the real cause in some cases. 
Trauma may appear to be the only antecedent event. 
Age and Sex. In 27 non-gaseous subphrenic abscesses at St. George's 
Hospital the average age was thirty-five years, being thirty-eight in 14 
males and thirty-one in 13 females; in this series the incidence in the 
sexes was practically equal. 
Morbid Anatomy.-Since a simple subphrenic abscess is in the majority 
of cases due to disease of the appendix or liver, it is much more often 
met with on the right than on the left side. It may be intraperitoneal 
or extraperitoneal, but is more commonly intraperitoneal. In 73 cases 
of subphrenic abscess due to appendicitis collected by Elsberg,2 35, or 
48 per cent., were intraperitoneal; 20, or 27 per cent., extraperitoneal; 
and in 18, or 25 per cent., the position was not determined. Retro- 
peritoneal abscesses due to lesions of the spine or kidney are more allied 
to lumbar than to subphrenic abscesses. From a pathological point 
of view the greater cavity of the peritoneum is divisible into two parts: 
(a) Above the transverse mesocolon and omentum, supra-omentai or 
supramesocolic; and (b) below the transverse mesocolon and omentum, 
or infra-omental. Intraperitoneal subphrenic abscesses occur in the 
supra-omental division of the greater sac. The anatomical boundaries 
of subphrenic abscesses vary according to the position of the abscess, 
and are further modified by the presence of old adhesions. The following 
descriptions may be regarded as applying both to simple and to gas- 
containing subphrenic abscesses. 
The anatomical boundaries of subphrenic abscesses have been described 
by Box and Eccles,3 and Carnot.4 Barnard5 described six forms of sub- 
phrenic abscess corresponding to six areas on the under surface of the 
diaphragm, four intraperitoneal and two extraperitoneal; the four 
intraperitoneal forms of subphrenic abscess are named (1) right anterior, 
(2) right posterior, (3) left anterior, and (4) left posterior; the areas 
on the diaphragm corresponding to these are defined and separated from 
1 Clinical Journal, London, 1907, xxxi, 81 
2 Ann. Surg., 1901, xxxiv, 729. 
3 Clinical Applied Anatomy, 1906. 
4 Sem. med.,Paris, 1906, xxvi, 85. 
8 Bril. Med. Jour., 1908, i, 371. DISEASES OF THE PERITONEUM 
703 
each other by the cruciform arrangement of the peritoneal ligaments- 
the falciform, coronary, and right and left lateral-of the liver. The two 
extrahepatic subphrenic abscesses are (5) the right and (6) the left. 
1. The right anterior subphrenic abscess is between the diaphragm 
and the convexity of the liver, and is bounded to the left by the falciform 
ligament, behind by the right lateral ligament of the liver, and in front 
by adhesions which vary somewhat in position; toward the right it 
communicates, unless shut off by adhesions, with the subhepatic or 
right kidney-pouch (Rutherford Morison), in which the right posterior 
intraperitoneal subphrenic abscess is situated. 
Fig. 11 
The abdominal signa when a right anterior intraperitoneal subphrenic abscess (RAIA) is com- 
bined with a subhepatic abscess (SA) in the right kidney-pouch as often occurs in appendicular cases. 
The former (RAIA) produces signs of compression and inflammation at the base of the right lung 
(RB). The latter (SA) produces a triangular swelling below the liver margin, limited toward the 
abdomen by a band of tender rigid adhesions running from the ensiform cartilage (E) back into the right 
loin, usually as low as the iliac crest, IC. Pus or gas may be found in contact with the abdominal wall 
within the triangle. This and the two following figures are reproduced from Barnard's paper in the 
Brit. Med. Jour., 1908, i, 371. 
2. This right kidney-pouch may contain a pint of fluid before its 
contents run over into the remainder of the peritoneal cavity. Its 
boundaries are the right lobe of the liver above and in front, the hepatic 
flexure of the colon below, the parietal peritoneum of the lumbar region 
externally, the descending duodenum and lumbar spine internally, 
and the right kidney posteriorly. An abscess in this position commonly 
tracks up over the convexity of the liver into the right anterior subphrenic 
intraperitoneal space, and it may pass through the foramen of Winslow 
into the lesser sac of the peritoneum. 
3. The left anterior intraperitoneal abscess (Barnard) is in the dome 
of the stomach chamber and is in relation with the stomach and the 704 
DISEASES OF THE DIGESTIVE SYSTEM 
spleen, or perigastric and perisplenic, and occupies a pouch which 
corresponds to the right kidney-pouch (Box and Eccles) (Fig. 12). The 
phrenicocolic peritoneal ligament, binding the splenic flexure of the colon 
to the diaphragm and forming the suspensory ligament of the spleen, 
constitutes the lower margin of this pouch and, so to speak, dams up 
fluid in this peritoneal recess. The boundaries of left-sided intraperito- 
neal subphrenic abscesses are subject to some variation and Barnard's 
Fra. 12 
Left anterior intraperitoneal subphrenic abscess (LSA) due to infection conveyed from pelvic 
appendicular abscess (PA) along (LIL) the left internal lumbar fossa (Barnard), or left internal 
paracolic groove (Jenkins and Maynard Smith). It has set up left-sided empyema (LE) which has 
burst into the trachea. (Barnard.) 
description is not followed here. Usually the abscess is between the left 
lobe of the liver, the diaphragm, the cardiac end of the stomach, and 
the spleen; the abscess passes deeply toward the back of the abdomen 
in relation to the spleen, and has the left kidney, adrenal, and tail of 
the pancreas behind. The spleen may lie in the middle of the abscess, 
and the abscess is often tortuous and irregular in outline as it passes 
around the margins of liver and spleen. In some cases the abscess is 
mainly to the left of the spleen, between it and the diaphragm; according DISEASES OF THE PERITONEUM 
705 
to Hunt1 this position of the abscess follows perforation of an ulcer 
on the posterior wall of the stomach. The abscess may also occupy 
the space between the diaphragm and the left lobe of the liver, passing 
downward and to the right, under the liver, and in front of the stomach. 
Such an abscess is usually the result of suppuration in the left lobe of 
the liver or in connection with the anterior surface of the stomach. 
4. An abscess confined to the lesser sac of the peritoneum is rare; 
it constitutes Barnard's left posterior intraperitoneal abscess. 
Fig. 13 
The signs of a right extraperitoneal subphrenic abscess (RES') pointing in the epigastrium below 
the ensiform process (E) and having separated the layers of the falciform ligament (FL) so that the 
abscess may be opened extraperitoneally. The liver is pushed down. (Barnard.) 
The median boundary of abscesses in contact with the under surface 
of the diaphragm is formed by the falciform ligament of the liver, which 
may be displaced by the pressure of the abscess, but is hardly ever 
perforated. It is extremely rare to find suppuration on both sides of 
the falciform ligament at the same time; but suppuration starting in 
the pelvis may track up in the paracolic grooves on both sides of the 
abdomen, and so give rise to abscesses in contact with the hepatic and 
splenic flexures of the colon. 
5. The right extrahepatic abscess is in the uncovered space between 
the layers of the coronary ligament of the liver, and is closely allied 
to if not the same as the suprahepatic abscess described by Cantlie.2 
It is nearly always due to intrahepatic suppuration. 
6. The left extraperitoneal abscess (Barnard) is near the left kidney 
and is rare. Barnard finds that the right anterior and left anterior 
intraperitoneal abscesses, due in the main to appendicitis and to 
1 Transactions of the Medical Society, London, 1905, xxviii, 75. 
2 Brit. Med. Jour., 1899, ii, 646. 706 
DISEASES OF THE DIGESTIVE SYSTEM 
perforated gastric ulcer respectively, are the commonest; next in order 
of frequency comes the right extraperitoneal abscess. 
The walls of the abscess are formed of shaggy fibrin, the diaphragm, 
surface of the liver, intestines, and so forth, being infiltrated for a con- 
siderable distance with organizing granulation tissue. The size of the 
abscess varies very considerably in different cases; it may be as small 
as a man's fist or larger than a child's head, and contain several pints 
of pus. In cases of appendicular origin the pus is often putrid. 
A subphrenic abscess readily sets up inflammation of the adjacent 
pleura and leads to an effusion which may be serous and sterile, fibrinous 
or purulent. This occurs in about half the cases of subphrenic abscess, 
lake an abscess in the liver, it may perforate the diaphragm and open 
into the pleura, leading to empyema, into the lung, thus setting up 
gangrenous pneumonia, multiple abscesses, and extensive disorganization 
of the lower lobe, or in very rare cases it may open into the pericardium. 
In Lang's1 173 cases of subphrenic abscess the diaphragm was perforated 
in 67, and in Martinet's2 138 cases in 33; both these series include gaseous 
as well as non-gaseous abscesses. Intraperitoneal abscesses are less 
prone than extraperitoneal abscesses to perforate the diaphragm. The 
pus in the empyema may be extremely offensive; Dieulafoy3 reported 
cases in which a non-gaseous subphrenic abscess of appendicular origin 
gave rise to a pyopneumothorax, the gas being due to bacterial activity 
and not to a communication with the lung or any of the hollow viscera. 
As the result of the rupture into the lung of a subphrenic abscess, set up 
by intrahepatic suppuration, a bronchobiliary fistula, with copious bile- 
stained expectoration, may be established. Rupture externally or into 
the hollow viscera-the stomach or colon-is rare. Inflammation may 
extend to the portal vein and set up adhesive or, as a later stage, suppura- 
tive pylephlebitis. Rupture into the peritoneal cavity is usually fatal. 
It occurred once only among 23 cases of spontaneous rupture of a 
subphrenic abscess (Barnard). 
Bacteriology.-The colon bacillus is commonly present; streptococci, 
staphylococci, pneumococci, Bacillus pyocyaneus, B. typhosus, actino- 
myces, and Micrococcus melitensis have also been found. 
Symptoms.-These are somewhat obscure and vary to some extent 
according to the origin and the position of the abscess. Thus an abscess 
between the convexity of the liver and the diaphragm will resemble 
an intrahepatic abscess, while a purulent collection in the lesser sac of 
the peritoneum (bursa omentalis) will present features like those of a 
pancreatic cyst. In fact, subphrenic abscesses in these two positions 
are, from a clinical point of view, closely bound up with diseases of the 
liver and pancreas respectively. 
The onset of symptoms is usually gradual, and it may be difficult 
to distinguish between those due to the primary disease, such as appen- 
dicitis or calculous cholangeitis, and those depending on pus formation 
under the diaphragm. After an operation for an appendix abscess. 
1 Thesis, Moscow, 1895. 
2 These de Paris, 1898. 
3 Clinique medicale de V Holel-Dieu de Paris, 1901-1902, iv, 105. DISEASES OF THE PERITONEUM 
707 
continued fever, diarrhoea, and quick pulse may persist, and after some 
time signs at the base of the right lung suggest that an abscess has formed 
under the diaphragm. In some instances the thoracic manifestations, 
such as pleurisy, are the first to attract attention. This gradual onset 
contrasts with the sudden pain which marks perforation of the stomach 
in the majority of the cases of subphrenic pyopneumothorax. In some 
instances there is a sudden onset with a rigor. 
Physical signs may be absent or so slight as to be easily overlooked, 
and are less obvious than in gaseous subphrenic abscess. From the 
point of view of physical signs, simple subphrenic abscesses have been 
divided into two groups: (1) those in which the thorax is mainly affected, 
and (2) those in which the signs are mainly abdominal. 
1. Since a subphrenic abscess is usually nearer the spinal attachment 
of the diaphragm than the epigastrium, the signs are chiefly found poste- 
riorly, and are more thoracic than abdominal. There is dulness at the 
base of one, usually the right, lung, which slowly increases upward 
toward the inferior angle of the scapula; there may be bronchial breathing 
from compression of the lung, a friction rub from concomitant pleurisy, 
or, from pleural effusion, absence of breath sounds. The physical signs, 
therefore, resemble those of pleural effusion. Examination with the 
z-rays may be of the greatest use by showing that the diaphragm on 
the affected side is pushed upward by a dark area, and that the excursions 
of the diaphragm are restricted or absent. 
2. In some cases, in which the manifestations are abdominal, a sub- 
phrenic abscess may pass forward, present anteriorly below the costal 
margin, and give rise to tenderness, fulness, and prominence of the 
hypochondrium and epigastrium, restricted movement of the ribs, 
muscular resistance, and a more or less definitely palpable tumor, which 
is dull on percussion. The dulness is constant and does not alter when 
the patient's position is changed. Under an anesthetic the muscular 
rigidity passes off, and the intestine may pass in front of the abscess 
cavity and so lead to resonance where there was previously dulness on 
percussion (Godlee1). As the abscess approaches the surface the skin 
may become oedematous and red, and fluctuation may be obtained. 
The manipulation necessary to elicit this sign is, however, not without 
risk of producing rupture into the general peritoneal cavity. Pain is 
usually not a severe symptom, and, as a rule, is pleuritic and transient; 
it may be felt at the angle of the scapula. The temperature is nearly 
always raised and may show the oscillations of suppuration, but in a 
few instances fever is absent. The pulse is quick, the respirations are 
often irregular, painful, and rapid, especially when the thorax is much 
invaded; cough is exceptional. Leukocytosis up to 30,000 may be present. 
The appetite is poor, wasting is considerable, and there may be frequent 
perspirations, especially at night, and considerable secondary anemia. 
When clubbing of the fingers occurs in a case thought to be one of sub- 
phrenic abscess the lesion will probably turn out to be above the dia- 
phragm (Acland2). With continued temperature and progressive loss 
1 Lancet, London, 1905, i, 482. 
2 System of Medicine (Allbutt and Rolleston), 1907, iii, 1007, 708 
DISEASES OF THE DIGESTIVE SYSTEM 
of strength the patient steadily goes down hill unless the abscess be freely 
drained. The abscess may extend and open into the pleura, lung, bron- 
chus, into the peritoneum, one of the abdominal viscera, or even externally 
through the ribs or at the umbilicus. In exceptional instances the 
abscess has burst into the pericardium, or has tracked up into the neck 
(Cullen). Pulmonary embolism may result from thrombosis of branches 
of the inferior vena cava. Death usually results from exhaustion. The 
duration of the disease, if it be left to run its natural course, is from 
two to three months. 
Diagnosis.-When there is no antecedent condition, such as appendicitis 
or suppuration elsewhere in the abdomen, the existence of a subphrenic 
abscess may not be suspected unless there be a palpable swelling. On 
the other hand, when after operation on an appendix abscess or on the 
gall-bladder or biliary passages, the patient's general condition still 
suggests suppuration, careful examination of the bases of the lungs by 
percussion, auscultation, and the z-rays may show signs compatible 
with a small abscess or effusion. The affected area should then, as 
Barnard directs, be systematically explored with a syringe, the needle 
of which is at least three inches long and sufficiently large to enable 
thick pus to be withdrawn. The patient is fully prepared for operation 
and anesthetized, and the needle is passed deeply-for three inches- 
into the 10th intercostal space in the scapular line, and then, if no pus 
be found, into the 9th, 8th, 7th, and 6th spaces in turn; if necessary, 
the same spaces in the midaxillary line are explored from below upward. 
When a subphrenic abscess presents under the anterior abdominal wall 
the exploring syringe should not be used. 
Differential Diagnosis.-The chief difficulty in distinguishing between 
subphrenic abscess and other intra-abdominal conditions on the right 
side is in deciding whether the collection of pus is inside the right lobe 
of the liver or between it and the diaphragm. Enlargement of the liver 
downward is in favor of intrahepatic suppuration, but in many instances 
it is impossible to come to a positive conclusion, and, indeed, a subphrenic 
abscess is often due to leakage of an intrahepatic focus of suppuration. 
A subphrenic abscess on the left side presenting as a palpable swelling 
must be distinguished from soft tumors^ innocent, such as perirenal 
lipomas, or malignant, such as retroperitoneal sarcomas. The raised 
temperature and signs of septic absorption should be taken into account 
in forming an opinion, but a swelling in the left hypochondrium of rather 
sudden onset, accompanied by pain and a raised temperature, has turned 
out to be a retroperitoneal sarcoma. In some instances a large, false 
abdominal aneurism on the left side does not pulsate and no bruit is 
audible over it; the diagnosis may then be very difficult (T. Holmes1). 
Persistent leukocytosis is in favor of abscess, but a posthemorrhagic 
leukocytosis may occur in aneurism. 
The main difficulty, however, is not in distinguishing between sub- 
phrenic abscess and other abdominal conditions, but between sub- 
phrenic abscess on the one hand and an empyema or pleural effusion 
1 St. George's Hospital Reports, 1875, vii, 173. DISEASES OF THE PERITONEUM 
709 
on the other. It has happened that when an abscess diagnosed as 
an empyema is drained, particles of food are found in the discharge, 
and for the first time indicate the underlying cause. In a simple sub- 
phrenic abscess on the right side the liver is more depressed, the breath 
sounds less cut off at the base of the lung behind, and the constitutional 
symptoms are more marked in comparison with the thoracic dulness 
than in an empyema. Skiagraphy shows that the diaphragm is pushed 
up instead of being depressed. 
The question whether the collection is above or below the diaphragm 
is often rendered more difficult by the not infrequent presence of a 
pleural effusion secondary to the suppurative process under the dia- 
phragm. When a pleural effusion and a subphrenic abscess are both 
present the latter is extremely likely to be overlooked. This combina- 
tion, if suspected, may be recognized by the withdrawal by the exploring 
syringe of pus from one interspace and serous fluid from one above it. 
This sign, however, is not infallible, for in rare cases a loculated pleural 
effusion may contain serum in one loculus and pus in another. 
Brief reference may be made to two signs which have been employed 
in order to decide whether a given collection of fluid is above or below 
the diaphragm. If the aspirating needle is introduced into a cavity 
above the diaphragm no movement of the needle occurs on respiration; 
if the needle passes through the diaphragm the extrathoracic part of 
of the needle moves upward in inspiration and downward in expiration; 
this is Fiirbringer's sign. The second sign is Pfuhl's; when the needle 
enters a subphrenic abscess the manometric pressure and the outflow 
of pus are greater during inspiration and less during expiration, while 
the reverse holds good in the case of an empyema. These two signs 
depend on the normal excursions of the diaphragm being maintained, 
but this does not always hold good; for example, a pleural effusion may 
paralyze the diaphragm and so lead to mimicry of the condition in a sub- 
phrenic abscess. Further puncture of the diaphragm may convey 
infection from the abdomen to the thorax, or vice versa, and is therefore 
not devoid of danger. 
Prognosis in non-gaseous subphrenic abscess depends on the condition 
being recognized and promptly treated by exploration and thorough 
drainage. If the abscess be not opened the case will almost certainly 
terminate fatally; further, it is most important that the abscess should 
be opened before it has extended into the lung or given rise to septicemia. 
Even when opened there is a risk that some loculus of the abscess 
may not drain properly. The difficulty in diagnosing and, when the 
existence of the abscess is suspected, in accurately locating the abscess 
makes the prognosis grave. A subphrenic abscess may be opened 
successfully, but an empyema may be overlooked and subsequently 
prove fatal. 
Most of the available statistics contain both simple and gas-containing 
abscesses, so that it is difficult to compare the mortality of the two forms. 
In Elsberg's 73 cases of subphrenic abscess (15 per cent, of which were 
gaseous) due to appendicitis, 51 were operated upon, with recovery in 
40, or 78.4 per cent., while of 22 not operated upon 18, or 82 per cent. 710 
DISEASES OF THE DIGESTIVE SYSTEM 
died. Out of Barnard's 76 cases, 36, or 47.4 per cent., died; 12 cases 
were only recognized after death and were not operated upon. Of the 
remaining 64 the mortality was 37.5 per cent., but after making allowance 
for imperfect diagnosis and treatment, Barnard concludes that the 
mortality should be 16 per cent. 
Treatment is purely surgical. 
Subphrenic Pyopneumothorax.-The peculiarity of this form of 
subphrenic abscess is that at the bedside it imitates an ordinary pneumo- 
thorax or pyopneumothorax. The existence of a gaseous abscess under- 
neath the diaphragm was first diagnosed during life as a logical 
deduction from the physical signs by G. H. Barlow1 as far back as 1845, 
but it was not until Leyden's2 article, in 1880, that it became generally 
recognized and the subject of numerous papers. It seems that since 
perforated gastric ulcers have been treated by immediate operation this 
form of subphrenic abscess has become less common. 
Etiology.-The causes of a gaseous subphrenic abscess are less numerous 
than those of a simple subphrenic abscess. Perforation of a gastric 
ulcer is the most important cause. In the sixty years, 1846 to 1906, 
there were about 26,000 autopsies at St. George's Hospital, among 
which Wahby found 32 gaseous subphrenic abscesses, 25 (21 females, 4 
males) of which, or 78.1 per cent., were due to perforated gastric ulcer. 
In order that the resulting peritonitis should be localized, certain con- 
ditions are necessary; thus preexisting adhesions which prevent the gastric 
contents from spreading widely over the peritoneum are of great impor- 
tance. It is, however, highly probable that in certain circumstances 
perforation of the stomach may lead to a localized abscess even in the 
absence of these adhesions; the occurrence of perforation in a stomach 
containing but little food, in a patient in the supine position, so that 
only a small quantity of the gastric contents escapes and does not 
travel far into the peritoneal cavity, and then mainly into the upper 
part, gives a combination of circumstances in which the inflammatory 
process may become circumscribed instead of generalized. The position 
of the perforation is another factor of importance: if on the posterior 
surface, a localized abscess is likely to follow, while if it is on the anterior 
surface, general infection of the peritoneum is apt to occur. Perforation 
of an ulcer close to the pylorus may lead to a localized abscess in the 
right kidney-pouch. Perforation of the stomach due to carcinoma is a 
rare cause of a gaseous abscess. 
Perforation of a duodenal ulcer usually gives rise to general peritonitis, 
but in a small minority of the cases a subphrenic pyopneumothorax on 
the right side results. As long ago as 1862, Bouchard recorded a case. 
Out of 32 gaseous subphrenic abscesses at St. George's Hospital, 6 (3 
males, 3 females), or 19 per cent., were due to perforation of a duodenal 
ulcer. 
An abscess in the neighborhood of the stomach or duodenum has in 
rare instances perforated (exogenous ulceration) into the alimentary 
1 London Medical Gazette, 1845, i, 13. 
2 Zeit. f. klin, Med., 1880, i, 320. DISEASES OF THE PERITONEUM 
711 
canal, with the result that a gaseous subphrenic abscess is produced. 
A suppurating hydatid cyst of the liver may rupture into the alimentary 
canal and become gaseous, but this condition, of which Deve1 has collected 
7 examples, is not the same as an ordinary subphrenic pyopneumothorax. 
A suppurating hydatid of the liver, from infection with anaerobic Organ- 
isms, may contain gas, and in rare instances, by rupturing into the 
space between the liver and the diaphragm, may produce a subphrenic 
pyopneumothorax on the right or left side, according to the position 
of the cyst in the right or left lobe of the liver. In Maydl's2 collection 
of 179 cases of subphrenic abscess there were 3 of gaseous subphrenic 
abscess due to hydatid cysts of the liver. Perforation of an ulcer in 
the colon very seldom produces a gaseous abscess. 
An appendicular abscess, although usually simple, may be gaseous; 
this was so in 15 per cent, of the 73 cases of subphrenic abscess due to 
appendicular infection analyzed by Elsberg.3 The presence of gas in 
these abscesses was at first considered to be due to secondary com- 
munication with some air-containing viscus, but it is, in many instances 
at least, of bacterial origin. 
Morbid Anatomy.-The situation and boundaries of subphrenic 
abscesses have been described. In contrast to simple subphrenic 
abscesses, which are much commoner on the right side, gas-containing 
subphrenic abscesses are in the great majority of cases on the left side. 
This is due to the preponderating influence of perforated gastric ulcers 
as the causal factor. 
The diaphragm is pushed up so as greatly to encroach on the cavity 
of the thorax. The perforation in the stomach or duodenum is usually 
open, but in some instances becomes closed with fibrin. The size of 
the cavity may vary considerably; sometimes these abscesses are very 
large, and have been known to contain in addition to gas a quart of 
purulent fluid with an admixture of gastric contents of an extremely 
offensive character. The abscess may erode the substance of the spleen. 
Perforation into the general cavity of the peritoneum occurs in a few 
cases. The inflammatory process readily spreads through the diaphragm 
and sets up pleurisy with effusion and collapse of the lower lobe of the 
lung. The effusion is usually serous or serofibrinous, but may be purulent, 
and in this even the lung may be disorganized by multiple abscesses. 
Perforation of the diaphragm may be followed by a true pyopneumo- 
thorax or, when the lower lobe of the lung is already adherent to the 
diaphragm, by suppurative destruction of the lung or gangrenous pneu- 
monia; or the abscess may rupture into the bronchi. Pericarditis may 
be found, but is not so frequent as pericardial friction during life. 
Age and Sex.-As most cases are due to perforation of a gastric ulcer, 
the patients are chiefly young women. In the 32 cases at St. George's 
Hospital the average age was thirty-three years, being thirty years in 
the 24 females and forty-two years in the 8 males. Vanlair recorded 
a gaseous subphrenic abscess in a boy six years of age. 
1 Rev. de chir., Paris, 1907, xxxv, 529. 
2 Ueber subphrenische Abscesse, 1894, Vienna. 
3 Annals of Surgery, 1901, xxxiv, 729. 712 
DISEASES OF THE DIGESTIVE SYSTEM 
Symptoms.-The onset is usually sudden, with very severe pain, 
due to perforation of the stomach; in this respect it differs from the 
simple subphrenic abscesses in which the onset is often insidious. In some 
cases, however, the leakage from the stomach is quite latent. The 
patient's history often shows indications of gastric ulcer. The pain, 
which is agonizing and may be accompanied by collapse, is situated in 
the upper part of the abdomen, usually on the left side. The onset may 
be accompanied by vomiting, which may or may not persist afterward; 
the vomited matters may contain blood and bile. It is important to 
realize that vomiting may occur after perforation of a gastric ulcer, 
and that this event does not seriously militate against that accident. 
Directly after the onset the abdomen becomes extremely tender, so 
that accurate examination may be impossible at first; as a rule, it rapidly 
becomes distended, although in men it may be rigidly contracted, 
tympanitic, and does not move on respiration. The temperature 
becomes raised, the pulse and respiration rates are rapid, rigors may 
occur, leukocytosis is present, there is nocturnal sweating, and the 
patient has the general appearance of suppuration with abdominal 
pain and some respiratory embarrassment. 
The physical signs may very closely resemble those of a true pneumo- 
thorax or pyopneumothorax. There is a tympanitic note on percussion 
over an area of distension in the upper part of the abdomen; the altered 
note extends up into the thorax for a considerable distance, but not 
to the extreme apex. On the right side the diaphragm may be displaced 
as high as the second rib, but the presence of the heart prevents the 
same amount of upward displacement on the left side. The tympanitic 
note may be mainly behind the sternum. There is dulness posteriorly 
on the affected side when the patient is lying on his back, and wThen 
turned on his side the positions of the dull and tympanitic areas alter 
as in a pyopneumothorax. A bell or coin percussion note, amphoric 
breathing, succussion, and metallic tinkling may be heard over the 
swelling and part of the chest. When the left side is affected the heart 
is displaced upward, but only slightly to the other side, thus differing 
from what occurs in a true pneumothorax. When the abscess is on the 
right side the liver may be greatly displaced downward and be palpable 
below the umbilicus; the hepatic dulness will then be absent from its 
normal position. The costal margin is pushed out and the lower inter- 
costal spaces may bulge as in pneumothorax. 
Thoracic complications are almost constant. Signs of pleurisy rapidly 
come on, but in some instances the signs are those of pneumonia of the 
base of the lung on the corresponding side. The effusion is usually serous 
at first, but may subsequently become purulent. A pleuropericardial 
or pericardial friction rub is not uncommon. Secondary parotitis occa- 
sionally occurs, and if suppuration supervenes may prove very serious. 
In rare instances subcutaneous emphysema has appeared. 
Diagnosis.-The common error is to regard as a pyopneumothorax 
a gaseous abscess which is below the diaphragm. While the history 
and mode of onset frequently point to the abdomen rather than to the 
thorax, the signs suggest a pyopneumothorax from which it can be DISEASES OF THE PERITONEUM 
713 
most certainly distinguished by a skiagram showing the position of 
the diaphragm. 
The physical signs in favor of a gaseous subphrenic abscess are that 
the pneumothorax appears to be partial, not universal, as shown by the 
presence of normal breathing over the upper part and apex of the lung; 
that the heart's apex is displaced upward and but little to the opposite 
side; that a bell note and other signs of an air-containing cavity can be 
obtained well below the limits of the thoracic cavity, for example, below 
the left costal margin; and that cough and expectoration are late in 
appearing, or insignificant. 
A subphrenic pyopneumothorax is often complicated by a pleural 
effusion-serous or purulent; the diagnosis of these two concomitant 
conditions may be greatly aided by the withdrawal of pus and gas from 
one interspace, and of serum or pus of a different character from a higher 
interspace. The fluid from a subphrenic abscess comes out more freely 
during inspiration, while in a pleural effusion its exit is accelerated during 
expiration. It must be remembered, however, that puncture of the 
chest, although often desirable to determine whether, and if so where, 
operative procedures should be carried out, may spread infection from 
the pleura to the peritoneum or vice versa. 
The diagnosis from a pleural effusion rests on the detection of the 
signs of a cavity containing fluid and gas, on the changing dulness in 
a gaseous subphrenic abscess, and on the absence of this change in a 
pleural effusion (Godlee), on the lateral displacement of the heart in a 
pleural effusion, and upon its upward displacement in a subphrenic 
gaseous abscess. 
Abdominal distension due to flatulence may be accompanied by dis- 
appearance of the normal liver dulness and by a bell note, but the liver 
cannot be felt to be displaced downward. 
A diaphragmatic hernia on the left side which contains the stomach 
gives rise to signs resembling in many respects those of a pyopneumo- 
thorax, but the abdomen falls in instead of being distended, and the 
heart is pushed over to the right side very much more than in a subphrenic 
pyopneumothorax. In making a diagnosis the arrays should be employed, 
and a metal probe passed into the stomach and its position noted. 
Prognosis.-In subphrenic pyopneumothorax this is always grave, 
partly because the extension of inflammation to the pleura and lung is 
a frequent and serious complication, and partly because the large abscess 
cavity may not close and the patient dies from toxic absorption. 
Treatment is surgical, and consists in opening and draining the abscess. 
SIMPLE CHRONIC PERITONITIS 
This condition may for convenience be divided into (1) circumscribed 
or localized areas of chronic peritonitis, and (2) diffuse chronic peritonitis. 
There are necessarily transitional cases in which the chronic peritoneal 
change is, on the one hand, not sufficiently localized to be included in 
the first category, and, on the other hand, is far from implicating the 714 
DISEASES OF THE DIGESTIVE SYSTEM 
whole of the peritoneal cavity. As a matter of fact, chronic peritonitis 
is seldom universal and equally well-marked over the entire abdominal 
cavity. The change may be advanced in the upper part of the abdomen 
over the liver, spleen, and omentum, and slight in the pelvis. 
Localized Chronic Peritonitis.-The adhesions due to a past acute 
peritonitis must be distinguished from the progressive or chronic inflam- 
matory process which alone deserves the name of chronic peritonitis. 
The causes of localized chronic peritonitis are numerous. The female 
genital organs very commonly give rise to chronic pelvic peritonitis 
which produces dense adhesions around the Fallopian tubes, ovaries, 
and uterus. The vermiform appendix and the broad ligament may 
become so matted together that even after death it is extremely difficult 
to determine in which of these structures the inflammatory process 
originated. The main cases of chronic perimetritis and pelvic peritonitis 
are gonococcic and puerperal infections. It is highly probable that 
hemorrhages from the Fallopian tubes may, as the result of subsequent 
microbic activity, be responsible for chronic pelvic peritonitis. A chronic 
gastric or duodenal ulcer may produce progressive localized peritonitis 
in the immediate vicinity. The contraction of the thickened peritoneum 
may play a part in producing hour-glass contraction of the stomach, 
duodenal stenosis, or even stricture of the common bile duct. Appen- 
dicitis is an important cause of localized chronic peritonitis in the right 
iliac fossa. Chronic peritonitis may also be limited to the orifice of, 
hernial sacs, to the surface of the intestines in chronic intussusception, 
and occasionally, it is said, to the flexures of the colon in chronic stasis. 
Chronic cholecystitis, especially when associated with gall-stones, may 
set up very marked local peritonitis which unites the gall-bladder to 
the neighboring viscera, especially the pylorus. 
In hydatid or other cysts, such as ovarian, there may be such thicken- 
ing of the overlying peritoneum that the condition resembles a lamellar 
or corneal fibroma. As the result of friction or pressure, chronic capsulitis 
of the spleen and liver may occur. Localized thickenings, white in 
color, raised above the surface of the capsule of the spleen, are common 
in splenomegaly; they are composed of dense white fibrous tissue and 
are spoken of as lamellar or corneal fibromas. Much less commonly 
similar masses are found on the surface of the liver. 
Clinically, the results of localized chronic peritonitis are variable. The 
lamellar fibromas of the spleen do not give rise to symptoms. Adhesions 
and indurations around the stomach and flexures of the colon and else- 
where may interfere with the natural movements of the viscera. Thus 
in the case of the stomach there may be persistent pain after food, or 
"adhesion dyspepsia;" this is not uncommon in women formerly the 
subjects of gastric ulcer, and may be thought to be due to a relapse of 
that disease. As a very rare result of perigastric chronic peritonitis 
there may be compression of the common bile duct and jaundice. In 
one example of this, secondary to a chronic ulcer near the pylorus, there 
was such extensive fibrosis that a tumor, regarded as malignant during 
life, could be felt. Chronic peritonitis around the gall-bladder may lead 
to pyloric obstruction and dilatation of the stomach. DISEASES OF THE PERITONEUM 
715 
Chronic peritonitis around the colon, especially the flexures, may 
give rise to constipation and pain, especially after defecation; according 
to the position of the lesion, the condition may imitate appendicitis 
or malignant disease of the colon. The peritoneal bands in connection 
with the ascending and transverse colon described by Lane,1 as the 
result of intestinal stasis and due to "crystallization of lines of strain" 
and by Jackson2 as due to membranous pericolitis, are by others regarded 
as congenital and not pathological in origin (Flint,3 Gray and Anderson4). 
Patients vary much in the way in which they feel such pain; some are 
martyrs to these painful peritoneal adhesions, while in others-probably 
in the great majority-there is little or no inconvenience. The adhesions 
may produce acute intestinal obstruction by kinking and strangulation 
of the intestine. In some instances the persistent pain suggesting chronic 
appendicitis may justify laparotomy. Short of this, the treatment 
should be directed to diet, prevention of constipation, local measures 
for the relief of pain, and to improvement of the general health. 
Chronic peritonitis involving the sigmoid mesocolon (perimesosigmoiditis) 
and the mesentery of the lower part of the ileum (chronic mesenteric 
peritonitis) was described by Riedel as the result of constipation. But 
Kiiss5 has insisted on the spread of infection from the pelvic organs, 
especially of females in whom the condition is much commoner than 
in males, and on the production of stenosis of the sigmoid and rectum by 
the cicatrizing pericolitis. There is a radiating thickening of the meso- 
colon which has been regarded as an important factor in the production 
of volvulus of the sigmoid flexure. The symptoms of pericolitic stenosis 
of the sigmoid and rectum are those of carcinomatous stricture. In 
one case the dense fibrosis, due to salpingitis, so compressed the ureters 
as to cause fatal uremia. 
Chronic hyperplastic tuberculosis of the intestine usually takes the 
submucous form, but in a few instances, of which Kidd6 has collected 
6 examples, it is subserous and in at least 3 cases has attacked the sigmoid 
flexure; it is not improbable that some cases described as subserous 
fibromas were in reality of this nature. 
Diffuse Chronic Peritonitis.-Under this heading it is convenient 
to consider cases which have in common a diffuse peritoneal inflammation 
of chronic and progressive character, not manifestly due to tuberculosis 
or new growth. It is sometimes called simple chronic peritonitis to 
distinguish it from the two forms just mentioned. Chronic proliferative 
and chronic indurative peritonitis are synonyms sometimes employed, 
and since ascites is extremely common, the name chronic exudative 
peritonitis is almost as applicable. 
Etiology.-There is considerable difference of opinion as to the relative 
importance of the causal factors. The classification of chronic peritonitis 
here adopted is: (1) When associated with varying degrees of chronic 
1 Lancet, London, 1903, i, 153; Surg., Gyn., and Obst., 1908, vi, 115 
2 Surg., Gyn., and Obst., 1909, viii, 324. 
3 Johns Hopkins Hosp. Bull., Baltimore, 1912, xxiii, 302. 
4 Lancet, London, 1913, i, 1300. 
5 Rev. de chir., Paris, 1910, xli, 190, 503, 688. 
6 Lancet, London, 1907, i, 9. 716 
DISEASES OF THE DIGESTIVE SYSTEM 
inflammation of the pericardium and pleurae. (2) When associated 
with arteriosclerosis and granular kidneys. (3) When associated with 
other conditions. The first two categories are the most important. 
1. Simple chronic peritonitis may be combined with inflammatory 
changes in the pericardium and pleurae. The association of similar 
inflammatory changes, whether acute or chronic, in two or more serous 
cavities has been called polyserositis and polyorrhomenitis.1 When 
the condition is chronic it has also been termed multiple progressive 
hyaloserositis or Concato's disease. The chronic inflammatory changes 
in the thorax that may be found in association with simple chronic 
peritonitis vary in extent and intensity; thus there may be chronic 
indurative mediastinopericarditis with obliteration of both pleurae, 
chronic mediastinitis alone, or adherent pericardium. Cases associated 
with adherent pericardium are the most usual. In some cases of long 
standing the thickened and adherent pericardium may be calcified; 
the peritoneal change is then advanced and the liver may be cirrhotic, 
thus differing from its usual condition of that organ-chronic venous 
engorgement and fatty change-in chronic peritonitis. It is generally 
considered that when chronic intrathoracic and peritoneal serositis are 
associated, the primary focus is more often intrathoracic; but it must 
be remembered that infection spreads more rapidly from the abdomen 
to the thorax than vice versa. 
The original starting-point of the inflammation may thus be on either 
the upper or under surface of the diaphragm; when there is an adherent 
pericardium, especially if it be calcified, it is probable that the original 
focus was in this position. The original lesion may be an acute pericar- 
ditis or perihepatitis, or there may be recurrent attacks. But on whichever 
side it starts it spreads through the diaphragm, the constant movements 
of which interfere with the natural cure of the morbid process, and so 
induce the chronic inflammatory process which is most marked on each 
side of the diaphragm and fades off in the more distant parts of the 
adjacent serous membranes. The chronic peritonitis is, therefore, most 
advanced over the liver and spleen. 
The pericardial pseudocirrhosis described by Pick2 is probably allied 
to this form of chronic peritonitis; Pick, however, believed that a latent 
adherent pericardium gives rise to circulatory disturbance in the liver, 
hepatic fibrosis, ascites, and that chronic peritonitis, although it 
might result from the ascites and repeated tappings, was a more or less 
accidental and secondary event. Nicholls3 and Kelly4 drew special 
attention to the association of chronic peritonitis with similar intra- 
thoracic changes. 
2. The association with arteriosclerosis and granular (arteriosclerotic) 
kidneys was insisted on by Hale White,5 who found it in 19 out of 22 
cases of universal perihepatitis and peritonitis, but some observers 
do not attach much importance to its etiological influence. 
1 Vide F. Taylor, Brit. Med. Jour., 1900, ii, 1693. 
2 Ztschr. f. klin. Med., Berlin, 1896, xxix, 385. 
3 Studies from the Royal Victoria Hospital, Montreal, 1902, i, No. 3. 
4 Amer. Jour. Med. Sci., 1903. cxxv, 116. 
6 Transactions of the Clinical Society of London, 1888, xxi, 219. DISEASES OF THE PERITONEUM 
717 
3. Simple chronic peritonitis may occur in combination with various 
intra-abdominal lesions, or its starting-point may be quite obscure. 
The associated lesion, such as syphilis of the liver, may reduce the 
resistance of the peritoneum, or, as in the case of chronic duodenal 
ulcer or cholecystitis, may provide a local focus for infection. In such 
cases a widespread chronic inflammatory process results instead of the 
local reaction which would be expected; this may be compared with 
the formation of large cheloids after minute injuries, and possibly the 
excessive reaction may depend on a low resistance, inherent or acquired, 
of the peritoneum in that individual. 
Alcoholism has been regarded as a factor, and would reduce the 
resistance of the peritoneum and by setting up gastro-intestinal inflam- 
mation favor infection. The chronic venous engorgement due to heart 
and other obstructive diseases would act in much the same manner. 
The relation of ascites to the chronic peritonitis is usually considered 
to be that the chronic peritonitis causes the ascites, but it is, conceivable 
that in some circumstances the reverse may hold good; thus, in chronic 
ascites due to backward pressure of heart disease, repeated tappings 
may favor a low form of infection, which is not necessarily'introduced 
from without but may be carried by the blood-stream. In some cases 
trauma appears to be the exciting factor, and it is quite conceivable that 
by damaging the viscera it would allow of a low form of infection of 
the peritoneum. Lastly, no obvious cause may be forthcoming. 
Pathogeny.-Since the process is evidently a chronic and progressive 
form of inflammation, it has naturally been surmised that it is the result 
of infection with microorganisms of a low grade of virulence. Nicholls 
suggests the Bacillus tuberculosis, B. coli, and B. typhosus. Louis (1825) 
regarded chronic peritonitis as always tuberculous; in modern times 
Picchini (1891) argues that subacute and chronic polyorrhomenitis is 
practically always tuberculous. The recognition in recent years of a 
special form of tuberculosis, the chronic hyperplastic, which is best 
known in connection with the ileocecal part of the intestine, suggests 
that there may be a chronic hyperplastic tuberculous peritonitis which 
bears the same relation to ordinary tuberculous peritonitis that chronic 
hyperplastic tuberculosis of the intestine does to ordinary intestinal 
tuberculosis. As bearing on this view, it may be pointed out that tubercle 
bacilli are now found in many cases of ascites which do not otherwise 
suggest peritoneal tuberculosis, and that tuberculosis with fibrotic 
changes is a not uncommon complication of arteriosclerosis. The last 
point may help to explain the association of arteriosclerosis and granular 
kidney with simple chronic peritonitis. 
Morbid Anatomy.-The appearances vary considerably from the 
more marked changes of the "iced" organs to a general slight opacity 
of the peritoneum. In a well-marked case the peritoneum is covered 
by a thick membrane which resembles a thin layer of cartilage; it is dull 
white or glistening and pearly in color, and may show pigmentation. 
This dense layer, especially over solid organs, such as the liver and 
spleen, for which it forms a firm casing, may show a few depressions like 
the pitting of sand by rain drops. It is possible that these deficiencies 718 
DISEASES OF THE DIGESTIVE SYSTEM 
are the result of rupture of the dense fibrous tissue induced by its own 
contraction. On the other hand the thick membrane may be locally 
accentuated in the form of fibrous elevations or nodules, perhaps more 
often seen on the parietal peritoneum; to this condition the name "peri- 
tonitis fibrosa" has been applied; these fibrotic elevations when small 
may closely resemble miliary tubercles, or when large, nodules of dissemi- 
nated malignant disease. 
The thick membrane, which may be even one-quarter of an inch in 
depth, can usually be peeled off the liver and spleen, leaving their capsules 
in a fairly normal condition. From its marked tendency to cicatricial 
contraction it squeezes the organs and leads to atrophy; in extreme 
instances these organs may therefore become so atrophied as to be 
isolated in the abdominal cavity and lose their normal relations. The 
omentum becomes shortened and rolled up into a firm cord, often in 
irregular knots, running transversely across the abdomen; in some 
instances hardly a trace of the omentum is left. In like manner the 
mesentery becomes retracted, so that the small intestines are anchored 
to the spine and cannot float in the ascitic fluid, "and, if a hernia has 
existed, it'will sometimes be found to have been completely reduced" 
(Hodgkin1). At the same time there may be such considerable diminu- 
tion in both the length and diameter of the alimentary canal that the 
valvulse conniventes become very closely placed-Prof. W. H. Welch 
has shown me a specimen in which the longitudinal section of the intestine 
looked like a comb-and the colon may be no larger than the small 
intestine. This gives rise to impaired absorption. The condition has 
been called "peritonitis deformans." Subacute or acute peritonitis 
may supervene. 
Adhesions are often present, but their extent varies greatly. They 
are more often seen over the solid and relatively fixed organs, since the 
peristalsis of the intestines interferes with their formation and may 
rupture them when formed. The remains of adhesions may be seen 
as filamentous or villous tags on the small intestine, and sometimes 
resemble miliary tubercles. Adhesions are not uncommon between the 
liver or spleen and the diaphragm, and may be dense or delicate. Acute 
strangulation of the intestine due to bands is very rare in this form of 
chronic peritonitis. When there are sufficient adhesions the ascitic 
fluid may become encysted, and when the adhesions are so numerous as 
to obliterate a large area of the peritoneal cavity the fluid effusion may 
be slight. 
The liver and spleen are often described as "iced," or as showing 
universal chronic capsulitis, and in the case of the liver as " Zucker- 
gussleber" (Curschmann2). This condition, also called universal chronic 
perihepatitis, was formerly regarded as a distinct morbid entity, and 
many cases of chronic ascites, in reality due to chronic peritonitis, were 
regarded as the result of chronic perihepatitis, the existence of the more 
widespread peritoneal change being ignored or regarded as a secondary 
1 Lectures on the Morbid Anatomy of the Serous and Mucous Membranes, i, p. 152, 
London, 1836. 
2 Deutsche Med. Wchnschr., 1884, x, 564, DISEASES OF THE PERITONEUM 
719 
result of the recurrent ascites and consequent tappings. From the 
frequency of ascites in hepatic cirrhosis the liver was considered the 
important factor in the production of ascites, and disease of its capsule 
was therefore accepted as a sufficient cause of ascites without any 
reference to the peritoneal change. The thickness of the membrane 
varies in different parts; it modifies the shape of the viscera, rounds off 
the edges, and covers up natural depressions. The gall-bladder may be 
almost buried, and is usually collapsed, but constriction of the bile 
duct or portal vein is very rare. In a case at one time under my care 
prevertebral chronic peritonitis leading to obstruction of the lymphatics 
and so to elephantiasis was found at the autopsy.1 The organs usually 
show chronic venous engorgement, but any considerable extension of 
fibrosis from the capsule into the substance of the organs is very rare. 
Microscopically there is extremely dense fibrous tissue laid down in 
parallel lamellae, with a few nuclei between. The fibrous tissue is prone 
.to undergo hyaline change, hence the condition has been called hyalo- 
serositis (Nicholls). The deeper layers of the membrane show bloodvessels 
with collections of leukocytes and mast cells. Nicholls was unable to 
find any evidence of fibrin. As the wrinkled peritoneum can be seen 
underneath, the formation of the membrane is due to organization of 
exudation, and not to hyperplasia of the peritoneum. 
Clinical Picture.-The condition most commonly occurs in middle 
life, but it may be seen in children; the sex incidence is about equal. 
The cases may present different manifestations, but the characteristic 
result is chronic ascites, which requires numerous tappings and recurs 
with remarkable persistence. The interval between successive tappings 
may diminish in progressive cases so that paracentesis may become 
necessary every week; more than 100 tappings may be required. After 
tapping, the rolled up omentum may be clearly felt running across the 
abdomen, and is often more distinctly palpable toward the left hypo- 
chondrium. The other signs of ascites will be found. The distended 
abdomen may be almost uniformly dull, since from retraction of the 
mesentery the small intestines are tethered to the spine and unable to 
reach the abdominal wall. In rare instances friction is audible. In 
some cases the fluid is encysted and the abdomen is irregular, so that 
the diagnosis may be very difficult. Signs of concomitant disease, such 
as adherent pericardium, valvular disease of the heart, pleural effusion, 
or renal disease, may be present. The urine is somewhat scanty and 
may present the characteristics of granular kidney. Jaundice is very 
rare, and when present is due to some complication. 
Symptoms.-The onset is, as a rule, gradual; but symptoms may 
date from a febrile attack, and are usually vague. The first thing noticed 
is swelling of the abdomen followed by abdominal uneasiness and a 
sense of fulness and weight, but pain is absent or slight and only brought 
on by movement. There is naturally some loss of strength, and the 
muscles are flabby, but emaciation is slow in appearing. Patients may 
feel well and, except for the abdominal embarrassment, able to be up. 
1 Brit. Med. Jour., 1907, i, 617. 720 
DISEASES OF THE DIGESTIVE SYSTEM 
Respiration may be somewhat hampered, constipation is usual and no 
doubt in part depends on the weakened state of the abdominal muscles, 
and there may be some flatulency and dyspepsia. Gastro-intestinal 
hemorrhage does not occur. In the later stages considerable wasting 
and oedema of the feet supervene. It is noteworthy that oedema of the 
feet occurs long after ascites has been well established. 
The fluid varies to some extent in its characters. Usually it is like 
serum, of a citron color, and of a specific gravity of 1.015 or more. It 
may clot and form threads of fibrin or large flocculi. In some instances, 
in which subacute inflammation has supervened, it becomes turbid. 
It may be milky or chyliform, and after tapping blood-stained. 
Diagnosis rests mainly on the presence of chronic and recurrent 
ascites, for which no other cause is forthcoming. It must be distinguished 
from other causes of ascites, such as tuberculous and malignant peri- 
tonitis and hepatic cirrhosis. 
Prognosis.-This should be guarded; recovery is rare, but the course 
is slow, and as many as 100 tappings may be required. Some cases of 
the recurrent ascites which are diagnosed as simple chronic peri- 
tonitis certainly recover after a number of tappings. Nicholls found 
that the duration varied between two and sixteen years. The average 
duration of Ramsbottom's 9 cases was 624 days.1 Death is generally 
due to intercurrent infection, such as pneumonia, but in cases associated 
with adherent pericardium and chronic mediastinitis it may be due to 
cardiac failure. 
Treatment should, in the first instance, be directed to the cause, such 
as renal disease, heart affections, or syphilis; otherwise it is palliative and 
symptomatic. No permanent good can be anticipated from laparotomy 
and the attempt to produce artificial adhesions on the lines of the Taima- 
Morison operation for the relief of the ascites of portal cirrhosis of the 
liver. Paracentesis should be performed when required; often this 
gradually becomes more frequent and may be necessary every week. 
Injection of adrenin in distilled water into the peritoneal cavity before 
the cannula is withdrawn is worth a trial. 
Diuretics, such as caffeine, may be employed from time to time, and 
tonics will usually be necessary. Good hygienic conditions and fresh 
air are desirable. It is not necessary for the patient to remain in bed in 
the earlier stages. Some relief to the feeling of weight in the distended 
abdomen may be obtained from the use of a binder or belt. 
TUBERCULOSIS OF THE PERITONEUM AND TUBERCULOUS 
PERITONITIS 
The ordinary clinical heading of tuberculous peritonitis covers cases 
with somewhat different morbid lesions; thus, although tuberculous 
inflammation confined to the peritoneum is, strictly speaking, all that is 
implied, it is customary to include cases having in addition tuberculous 
1 Medical Chronicle, Manchester, 1906, xlv, 7. DISEASES OF THE PERITONEUM 
721 
ulcers of the intestine and tuberculosis of the intra-abdominal lymphatic 
glands, since these conditions are commonly combined and often cannot 
be separated during life. 
The incidence of peritoneal infection in tuberculosis has been differently 
estimated. In 531 cases of pulmonary tuberculosis examined after death 
at the Brompton Hospital, there was tuberculous peritonitis in 22, or 
4.1 per cent. (Fowler and Godlee1). In 197 cases of tuberculosis at the 
Boston City Hospital the peritoneum was infected in 14, or 7.1 per 
cent. (Bottomley2). In 1393 cases of tuberculosis at Breslau there was 
tuberculous peritonitis in 226, or 16.2 per cent. (Borschke3). In 300 
cases of fatal tuberculosis of various parts of the body at St. George's 
Hospital the peritoneum was affected in 56, or 18.6 per cent. 
Etiology.-Age.-The disease may occur at any period of life, but it 
is rare in babies and in old age. Osler records a patient aged eighty-two 
years, while among 163 cases tabulated by Morley Fletcher,4 eight 
were under one year. It is most frequent between twenty and forty 
years of age. The belief that the disease is commoner in children is 
probably the result of confusion between chronic intestinal disturbance 
with a distended abdomen, formerly spoken of as " tabes mesenterica," 
and true peritoneal tuberculosis. In 306 cases of tuberculous peritonitis 
under the age of fifteen, nearly half were between the ages of three and 
seven years (Faludi5). 
Sex.-In children the sex incidence is equal (Faludi, Morley Fletcher). 
In adults there is a marked divergence between statistics obtained from 
postmortem records and those of operation. Postmortem records show 
that it is more frequent in males; in Konig's 107 cases, 89 were males. 
In operation cases females are greatly in excess; this depends on the 
frequency with which tuberculosis of the Fallopian tubes serves as 
the starting-point for peritoneal infection. 
Disposing Factors.-Cirrhosis of the liver shows a decided tendency 
to be complicated by peritoneal tuberculosis; thus in 584 cases of hepatic 
cirrhosis, tuberculous peritonitis occurred in 53, or 9 per cent. No 
doubt concomitant or antecedent alcoholism favors the incidence of 
tuberculosis generally, but the catarrh of the intestine and the portal 
obstruction probably play a part in localizing the infection. Injury 
has, in some cases, preceded the onset of symptoms. Pregnancy, accord- 
ing to H. Kelly,6 has a definite causal relation to tuberculous peritonitis; 
in 28 per cent, of his cases the illness was dated from childbirth or a 
miscarriage. Heredity would naturally be expected to be of some 
importance in the incidence of tuberculous peritonitis, but in 25 cases 
investigated by Bottomley there was a history of tuberculosis in 2 only. 
Bacteriology.-The bovine form of the tubercle bacillus was found 
by the English Commission on Tuberculosis (1911) in 14 out of 29 cases, 
and by the German Commission in 63 per cent, of the cases of abdominal 
1 Diseases of the Lungs, p. 358, London, 1898. 
2 Medical and Surgical Report, Boston City Hospital, 1900, p. 118. 
3 Virchows Archiv, 1892, cxxvii, 121. 
4 Diseases of Children (Garrod, Batten, Thursfield), p. 242, 1913, London. 
5 Jahr. f. Kinderh., 1905, Ixii, 304. 
6 Operative Gynecology, 1906, ii, 237. 722 
DISEASES OF THE DIGESTIVE SYSTEM 
tuberculosis investigated. In 71 cases in New York 44, or 62 per cent., 
were bovine; there were 12 adults with bovine tuberculosis in 3, or 25 
per cent.; and 41 of 59 children, 69 per cent, of whom were bovine (Iless1). 
Tubercle bacilli are comparatively seldom found in the peritoneal 
effusion by ordinary microscopic examination. Jousset's method of 
inoscopy is, however, more successful in leading to their detection. 
This scarcity of bacilli in the fluid, also seen in tuberculous pleural 
effusion, is thought to depend on adhesion of the bacilli to the serous 
membrane. Injection of the ascitic fluid into guinea-pigs proves that 
bacilli are present. 
Paths of Infection.-In generalized tuberculosis the miliary tubercles 
seen on the peritoneum are due to hemic infection, the bacilli reaching 
the peritoneum by the bloodvessels, but in these cases the peritoneum 
merely shares in the universal outburst of tubercles and is seldom 
inflamed. Tuberculous infection usually reaches the peritoneum through 
the lymphatics. The bacilli may be conveyed from the intestine and 
vermiform appendix, the lymphatic glands, the pleurae, the suprarenals, 
prostate, vesiculae seminales, and the testes. 
It is remarkable how often tuberculous ulceration of the intestine 
secondary to pulmonary tuberculosis is seen without diffuse tuberculous 
peritonitis. Thus, among 382 fatal cases of pulmonary tuberculosis 
at the Brompton Hospital, London, tuberculous ulcers were present in 
the intestine in 296, or 77.5 per cent., while tuberculous peritonitis 
occurred in 15 only, or 4 per cent. (Fowler and Godlee). The occurrence 
of tuberculous peritonitis secondary to primary intestinal tuberculosis 
is variously estimated. German statistics are to the effect that primary 
intestinal tuberculosis even in children is very rare, and it is therefore 
not surprising that among Borschke's 226 cases of tuberculous peritonitis 
not a single one was secondary to primary intestinal tuberculosis. British 
statistics give a percentage of primary intestinal tuberculosis in children 
ranging up to 28.1 per cent, of the cases of tuberculosis (Shennan2) 
and averaging 19 per cent, as against 4 per cent, in Germany and 3 
(Harbitz3) to 1.3 (Hess) per cent, in the United States. In women 
tuberculous disease of the Fallopian tubes is a prolific source of tuber- 
culous peritonitis. Primary tuberculosis of the peritoneum, in which 
there is no tuberculous focus elsewhere in the body, and in which the 
path by which bacilli have got into the peritoneum is not obvious, is 
rare. Borschke's series of 226 cases contained only 2. 
Morbid Anatomy.-A few words may first be devoted to localized 
tuberculosis of the peritoneum. Local tuberculosis is always present 
in the subserous tissues of tuberculous intestinal ulcers, and occasionally 
gives rise to localized peritonitis, as shown by tags of adhesions. There 
may be localized tuberculosis in the neighborhood of the vermiform 
appendix or Fallopian tubes. In some instances a hernial sac when 
operated upon has been found to show localized tuberculosis. 
In tuberculous peritonitis the morbid appearances vary considerably. 
1 Amer. Jour. Med. Sci., 1908, cxxxvi, 183. 
2 Edinburgh Hospital Report, 1900, vi, 130. 
3 Journal of Infectious Diseases, Chicago, 1905, ii, 189. DISEASES OF THE PERITONEUM 
723 
Strictly speaking, these distinct types of tuberculous peritonitis from 
a pathological point of view do not exist, for they overlap and one 
described form may be only the later stage of another. Dupre 
and Ribierre1 divide tuberculous peritonitis into (1) acute forms: (a) 
miliary, part of a generalized tuberculosis with abdominal pain, vomiting 
and tympanites; (6) miliary tuberculosis of the peritoneum and pleurae 
(c) miliary tuberculosis around the cecum resembling appendicitis. 
(2) Chronic forms-namely, those usually recognized in this country: 
(a) ascitic, due to miliary tubercles on the peritoneum; (6) caseous, 
ulcerating, or suppurative; (c) fibrous; (d) localized. 
The following method of dividing the anatomical lesions depends on 
the amount of adhesions present: (1) the ascitic; (2) the loculated, 
including (a) suppurative or ulcerous and (b) encysted ascites; and 
(3) obliterative, called chronic fibroid tuberculosis by Osler, fibrous 
or adhesive by others. 
1. In the ascitic form there are few or no adhesions, and the exudation 
is free in the peritoneum. There is miliary tuberculosis which may be 
acute, subacute, or chronic. In the more acute forms inflammation 
of the peritoneum is engrafted on to miliary tuberculosis. The small 
tubercles vary in size from that of a millet seed downward, are scattered 
over both layers of the peritoneum, mesenteries, and omentum, and 
are often more numerous over the diaphragm. In the chronic forms 
the tubercles are larger, fibrotic, and are often somewhat pigmented; 
the peritoneum is thickened and the naked-eye appearances may exactly 
imitate those of malignant disease. The omentum becomes rolled up 
into a hard mass, the mesentery is shortened from cicatricial contraction 
so that the intestines become tethered to the spinal column, and from a 
similar process the intestine becomes shortened in length. These changes 
resemble those in simple chronic peritonitis. 
Pseudotuberculosis is very rare. Deve2 described multiple granulomas 
on the peritoneum enclosing fragments of hydatid membrane and 
booklets in cases of rupture of a hydatid cyst; a similar appearance 
may be due to multiple minute cysts. Pseudotuberculosis due to the 
ova of a tape-worm has been recorded (Helbing). 
2. The loculated or encysted form of peritonitis may be (a) suppura- 
tive or ulcerated or (b) ascitic, (a) In the most characteristic and 
serious form the intestines are matted together by adhesions and enclose 
collections of serofibrinous, turbid, or purulent exudation. In this 
form the tubercles increase in size, become confluent masses of caseous 
material surrounded by fibrin and adhesions, and by softening give rise 
to suppurating foci among the adherent coils of intestine. There may 
thus be numbers of intraperitoneal abscesses, the pus of which may 
erode the walls of the intestine and eventually lead to perforation, and 
as a result a fecal fistula may form at the umbilicus. Purulent foci 
may also open into the vagina; in such cases the tubes were probably 
the original focus of infection. On attempting to unravel the intestines 
in such a case the bowel is easily torn, and it is sometimes difficult to. 
1 Nouveau traite de medecine (Brouardel, Gilbert, Thoinet) 1909, xviii, 175., 
2 Arch, de med. exper. et. d'anat. path., Paris, 1907, xix, 347. 724 
DISEASES OF THE DIGESTIVE SYSTEM 
be certain whether perforation was present during life or was made at 
the necropsy. The adhesions unite all the viscera; the omentum is 
thickened, contains caseous tubercles, and is usually rolled up into a firm 
cord. The mesenteric glands are enlarged and caseous; they may soften 
and give rise to a circumscribed abscess, which in a case seen by the 
writer imitated a pancreatic cyst. 
(6) In the ascitic form of loculated tuberculous peritonitis there is a 
transition between the ascitic and obliterative forms. 
3. The obliterative (chronic fibroid or adhesive) form may follow 
cure of the ascitic form or develop subacutely. The inflammatory process 
leads to universal adhesions which unite all the abdominal viscera 
inextricably to each other and to the abdominal wall; as a result there 
is no exudation. The tubercles tend to undergo fibrotic changes and 
show pigmentation. The matted intestines, the rolled up omentum, 
and masses of caseous glands embedded in adhesions give rise to the 
tumor-like masses felt through the abdominal wall. In exceptional 
instances large pendulous caseous masses, resembling "Perlsucht" in 
animals, have been described in man (Bizzozero,1 MacCallum2). 
Tuberculous peritonitis may, as already pointed out, be associated 
with cirrhosis of the liver; in the vast majority of cases the hepatic 
change is the older, but some cases of interstitial change due to tuber- 
culous infection of the liver may be secondary to tuberculous peritonitis. 
In some cases the serous membranes-pleurae and peritoneum-seem 
especially liable to tuberculous infection, and may be notably affected, 
although there is little evidence of tuberculosis elsewhere in the body. 
The lymphatic glands in the anterior mediastinum are infiltrated with 
tubercle as the result of infection from the abdomen., 
Symptoms.-These vary quite considerably according to the ana- 
tomical lesions present. In generalized miliary tuberculosis the infection 
of the peritoneum may be latent, and, there being no effusion, the 
peritoneal infection is not suspected during life unless there be abdominal 
pain or retention of urine and difficulty and pain in micturition. In 
local peritoneal tuberculosis there may be local pain and tenderness; 
this may be seen in the neighborhood of the vermiform appendix, and 
then suggests appendicitis. 
The anatomical forms into which diffuse tuberculous peritonitis has 
been divided may to some extent be correlated with corresponding 
groups of symptoms and physical signs. 
1. In the ascitic form, in which miliary tubercles are scattered over 
the peritoneum, the characteristic feature is the effusion. The onset is 
usually gradual and preceded by failing health, loss of appetite, strength, 
and weight, with some abdominal discomfort or pain. The abdomen 
becomes swollen and tumid, often mainly tympanitic at first, and in 
children the condition may resemble that of chronic intestinal catarrh. 
As the case progresses the distension is gradually seen to be not entirely 
tympanitic, and evidence of free fluid becomes obvious and more distinct. 
In some cases the onset of ascites is sudden. As a rule, the amount of 
1 Morgagni, 1867, ix. 2 Johns Hopkins Hospital ^'Uetin, 1901, xii, 293. DISEASES OF THE PERITONEUM 
725 
fluid is not extreme, and if removed reaccumulates slowly; but in adults 
with existing hepatic cirrhosis the ascitic distension may be indistinguish- 
able from that due to uncomplicated cirrhosis. The distended abdo- 
men is tender on pressure. The pressure of a large ascitic effusion on 
the inferior vena cava may cause some oedema of the feet and even 
a trace of albumin in the urine. The ascitic fluid may be clear, turbid, 
or even blood-stained, and may coagulate when removed. As pointed 
out elsewhere, the contained cells are mainly lymphocytes. The opsonic 
index of the effusion is lower than that of the blood serum. 
2. (a) The suppurative or ulcerative form of encysted tuberculous 
peritonitis is the most characteristic. The onset of abdominal symptoms 
is, as in the ascitic form, preceded by failing health and an irregular 
temperature. The abdomen becomes swollen and tumid, often first 
in the lower part, and there is a complaint of abdominal discomfort and 
tenderness, and of griping pains. The abdominal pain is made worse 
by walking and by jarring. The abdomen gradually becomes more 
distended, and the existence of fluid is suspected, but being more or less 
encysted is often difficult to determine. On palpation the abdomen 
feels doughy and tumor-like masses due to enlarged glands, adherent 
coils of intestine, or the rolled up omentum may be felt through the 
abdominal wall. The thickened omentum forms a characteristic hard 
cord running transversely across the upper part of the abdomen; there 
is usually resonance above it, which enables it to be distinguished from 
the margin of the liver. The tumors are usually fixed, tender on pressure 
and usually dull on percussion. The amount of distension and the 
distinctness with which these pseudotumors can be felt vary from time 
to time. This depends on changes in the amount of exudation and in 
the quantity of gas in the intestines. In advanced cases the umbilicus 
may become indurated and inflamed from an abscess pointing there; 
although this should always suggest the possibility of tuberculous peri- 
tonitis, it is not pathognomonic, for a localized pneumococcic abscess 
may discharge at the umbilicus, and so may an abscess in puerperal 
infection. Percussion is painful and shows irregular areas of resonance, 
due to tympanitic distension of intestinal coils, and of dulness due to 
localized exudation. Rectal or vaginal examination may reveal the 
presence of tumors due to glands, matted coils of intestine, or salpingitis. 
(6) In the ascitic form of encysted peritonitis the collection of serous 
fluid may simulate an abdominal cyst, especially in women. 
3. In the obliterative form the clinical manifestations are often vague. 
They may be mainly those due to interference with the functional 
activity of the alimentary canal, dyspepsia, flatulence, constipation, and 
pain; or there may be palpable tumors. Some cases with universal 
adhesions may not present any symptoms, but in others the intestinal 
movements may be so interfered with as to give rise to chronic obstruc- 
tion. Symptoms of chronic intestinal obstruction may be brought 
about by peritoneal adhesions at one point; or in rare instances 
numerous peritoneal adhesions, no one of which produces definite 
obstruction, may so obstruct the intestines as to give rise to chronic 
obstruction; in such a case in a child the visible contracting coils of 726 
DISEASES OF THE DIGESTIVE SYSTEM 
intestine may be seen through the abdominal wall. We will pass to a 
more general consideration of the manifestations that may occur in the 
anatomical forms of tuberculous peritonitis: 
The spleen and less often the liver may be enlarged. Very considerable 
hepatic enlargement may be due to fatty change, or to concomitant 
backward pressure. In boys with a patent funicular process between 
the peritoneal cavity and the tunica vaginalis testis tuberculous thicken- 
ing may spread down the cord, and hydrocele may result. 
The abdominal walls may show prominent subcutaneous veins, and 
the skin may become harsh, dry, and lose its elasticity. But with 
abdominal distension it may become shiny; in some instances it is 
pigmented, and sometimes pigmentation is also seen on the face and 
may be regarded as indicating some degree of suprarenal insufficiency. 
There is often a drawn expression, and the face shows signs of grave illness. 
The condition of the tongue varies; it may be red, irritable, and denuded 
of epithelium, or furred. Nausea, vomiting, and hiccough are rare. 
The stools may be colorless and fatty, especially in children, but 
this change occurs in other cachectic conditions. The temperature is 
raised in acute and suppurative cases, and may touch 104° F. In many 
cases there is but slight fever, and in the chronic forms there may be 
none. From abdominal distension and upward displacement of the 
diaphragm respiration is embarrassed, and the respiratory movements 
are rapid, shallow, and mainly costal. The pulse becomes rapid in acute 
cases, but in the chronic forms is not affected. 
The urine does not contain the large quantities of indican seen in 
acute peritonitis. Ehrlich's diazo reaction may be present, but in 55 
cases it was absent in 62 per cent. (Hamman1). The urine is high-colored. 
Albuminuria is not generally considered to be frequent, but Hamman 
found it in 81 out of 133 cases. Micturition may be painful. In females 
tubercle bacilli may be found in the vaginal discharge. 
The blood shows a moderate secondary anemia, but from concentration 
of the blood due to ascites or purging there may be an apparent poly- 
cythemia. Leukocytosis is not part of the blood-picture of the disease, 
but it occurs in a certain number of the cases (40 per cent., Emerson; 
30 per cent., Shattuck; and 23 per cent., Cabot); and is the result of 
some complication or secondary infection. A high leukocyte count is 
more often seen in children; thus the average count in 23 children was 
16,435 (Botch2). 
Jaundice from compression of the ducts by adhesions has been recorded 
(Dujon3), and may also be due to the pressure exerted by tuberculous 
glands in the portal fissure, but even this is rare. Ulceration of a tuber- 
culous gland into the hepatic artery has been known to produce an 
aneurism (Birkhardt and Schumann4). 
Complications.-Extensive tuberculous ulceration of the intestine, 
especially of the colon, may be suspected when there is diarrhoea with 
1 Johns Hopkins Hosp. Bull., Baltimore, 1908, xix, 256. 
2 Jour. Amer. Med. Assn., 1903, xl, 69. 
3 Proces-verbaux. XIX Congres de chir., 1906, 166. 
4 Deut. Arch. f. Idin. Med., Leipsic, 1907, xc, 288. DISEASES OF THE PERITONEUM 
727 
offensive stools and blood; bacteriological examination will show tubercle 
bacilli in the feces. Acute or subacute symptoms suggesting appendicitis, 
cholecystitis, or pelvic peritonitis may be due to an eruption of miliary 
tubercles over the peritoneum without any ascites (Armand-Delille1)- 
Acute peritonitis may supervene as the result of rupture of a suppurating 
gland or from perforation of a tuberculous intestinal ulcer. Acute 
obstruction may be due to a band, or possibly to thrombosis in the 
tributaries of the mesenteric vessels and paralysis of the corresponding 
segment of intestine (Johnson2). 
The thoracic complications are pulmonary tuberculosis and pleurisy, 
which may be bilateral. A tuberculous pleurisy may exist at the same 
time as an active tuberculous peritonitis, precede it, or come on when 
the peritoneal lesion has ceased to be clinically manifest. Symptoms 
suggesting subacute intestinal obstruction-namely, constipation and 
vomiting-may be in reality due to the onset of tuberculous meningitis. 
Diagnosis.-The presence of tuberculosis elsewhere is an important 
factor. In children tuberculous infection of the peritoneum is much 
the commonest cause of ascites. In women the association of disease 
of the uterine adnexa should always suggest a tuberculous origin for 
ascites or chronic peritonitis. 
In some rather rare cases there may for a time be a very considerable 
resemblance to typhoid fever. The most certain means of distinguishing 
between these two conditions is by a blood-culture or by the agglutination 
reaction. When tuberculous peritonitis comes on acutely there may 
be very great difficulty in deciding whether the condition is due to 
pneumococcic or tuberculous infection. 
It may be very difficult to avoid mistakes in the diagnosis between 
the ascites of tuberculous peritonitis and that of hepatic cirrhosis. In 
children hepatic cirrhosis is rare, and when it gives rise to ascites tuber- 
culous peritonitis is very likely to be diagnosed. In adults the diag- 
nosis is not so difficult, as help is obtained from a history pointing to 
alcoholism or from the presence of tuberculosis elsewhere. But alcoholism 
disposes both to cirrhosis and to tuberculosis, and pulmonary tuberculosis 
is not uncommon in cirrhosis. Further, tuberculous peritonitis may 
supervene in the course of hepatic cirrhosis, and when this occurs the 
true nature of the ascites is not likely to be suspected until the fluid 
is examined. (For cytological diagnosis see pages 529 and 666.) 
In simple chronic peritonitis there is an absence of fever, there is less 
pain, and examination of the fluid after tapping should enable a diagnosis 
to be made. Some assistance may be obtained by estimation of the 
opsonic index before and after abdominal massage, a considerable rise 
in the index pointing to tuberculosis. 
Difficulty sometimes arises in deciding whether abdominal distension 
with fluid and the presence of tumors-omental and glandular-are 
due to tuberculosis or to malignant disease. In some cases a diagnosis 
is only made by opening the abdomen. As a rule, an irregular tem- 
perature and a history pointing to tuberculosis favor tuberculous 
1 Presse med., Paris, 1912, xxi, 397. 
2 Practitioner, 1906, Ixxvi, 332. 728 
DISEASES OF THE DIGESTIVE SYSTEM 
infection, which in children is of course much commoner than is 
intra-abdominal sarcoma. In adults the presence of multiple tumors 
is more probably evidence of malignant disease. Cases of chronic 
intussusception in children have been regarded as tuberculous peritonitis. 
Prognosis.-This may be considered from several points of view: 
(a) as to immediate recovery; (6) as to relapses of the peritoneal infec- 
tion; (c) as to complications and remote mechanical effects of adhesions. 
(a) As to immediate recovery. The prognosis is different in the various 
forms of peritoneal tuberculosis. The disease may become arrested 
and the symptoms disappear without any manifest cause. The improve- 
ment may be permanent or only temporary. The prognosis is best in 
the discrete miliary form with ascites when uncomplicated, and worse 
in the form with numerous localized foci of purulent exudation. Accord- 
ing to F. Taylor, tuberculous peritonitis is probably fatal in more than 
half the cases, but the general impression is that the outlook is more 
hopeful than this and that cure occurs in 50 per cent. In estimating 
the outlook in an individual case, the condition of the general nutrition, 
the evidence of tuberculosis elsewhere, as in the lungs, the presence of 
diarrhoea and of a raised temperature must be taken into account. 
An increased excretion of chlorides in the urine is said to be a sign of 
improvement. Wasting diarrhoea and persistent fever are bad signs. 
The prognosis is bad in the presence of complications such as extensive 
ulceration of the intestines, well-established pulmonary tuberculosis, 
generalized tuberculosis, meningitis, and evidence suggesting rupture 
of a suppurating mesenteric gland into the peritoneal cavity. It is said 
that the presence of pleurisy does not make the prognosis worse. An 
abdominal abscess is a grave sign, but recovery may follow discharge 
of pus from the umbilicus; a fecal fistula is nearly always fatal. 
(5) Recurrence occurs in a certain number of cases. This probably 
depends on the presence of some source of reinfection in the abdominal 
cavity-namely, in the intestine, lymphatic glands, vermiform appendix 
or the Fallopian tubes. The importance of removing the local focus 
whenever possible has been shown by W. Mayo.1 On the other hand, in 
122 cases of tuberculous peritonitis at all ages, Stone2 did not find a 
primary focus in the Fallopian tubes or the vermiform appendix in any 
case. But the Fallopian tubes are often infected from the peritoneum. 
(c) Generalized tuberculosis occurs in a considerable proportion of the 
fatal cases in children; in 26 fatal cases this was noted in 13 (Rolleston3). 
The remote mechanical effects are due to peritoneal adhesions which 
may give rise to internal strangulation of the intestine and acute obstruc- 
tion. Undoubtedly a considerable proportion of the cases of strangulation 
by bands occur in patients who have suffered from tuberculous peri- 
tonitis, but the number of cases of tuberculous peritonitis in which acute 
obstruction is due to a band must be small. Since tubercles and peri- 
toneal adhesions may completely disappear, the persistence of adhesions 
probably depends on a particularly severe form of peritonitis or, more 
1 Jour. Amer. Med. Assn., 1904, xliv, 1157. 
2 Boston Med. and Surg. Jour., 1908, clviii, 705. 
3 Brit. Med. Jour., 1911, ii, 473. DISEASES OF THE PERI TON EV M 
729 
probably, on the persistence of a tuberculous focus in the peritoneal 
cavity. 
Treatment may be divided into (1) medical, (2) by injection of vac- 
cines, (3) hygienic measures, and (4) by surgical means. 
Medical.-The patient should be kept in bed in a well-lighted and 
airy room. The bowels should be regulated, any tendency to diarrhoea 
controlled, and constipation obviated. Offensive stools should be 
treated by guaiacol, which is less irritating than creosote, or if offensive 
and loose, by salicylate of bismuth. Cod-liver oil and the syrup of the 
iodide of iron may be given with advantage, but the dose of cod-liver 
oil should be small at first and the stools should be examined to see that 
it is being assimilated. Iodine in solution has also been injected under 
the skin, and good results have been recorded. Mercurial or iodoform 
ointment, or guaiacol (3j) in anhydrous lanolin (gj) maybe rubbed into 
the skin of the abdomen, which is then covered by a flannel binder. 
Good results, however, have been reported simply from bandaging. 
Vaccine.-Treatment is sometimes very successful. Tubercle vaccine 
(Koch's new tuberculin; T.R.) in doses of ytto mg. °f the powdered 
vaccine is given hypodermically, and is not increased above mg. 
Riviere1 advises tto'W t° woo mg- f°r a child of one year, mg. 
for a child of five years, and mg. for children of ten to twelve years. 
If human tuberculin fails a trial may be given to bovine tuberculin. 
Hygienic Treatment.-Very satisfactory results follow moving the 
patient in the early stages into the country and especially to the seaside, 
with the adoption of open-air treatment. This should be adopted as early 
as possible, and continued until recovery has been established. 
Surgical Treatment.--Laparotomy is contra-indicated in widespread 
tuberculosis, in infants under a year old and in the presence of pul- 
monary tuberculosis. It is necessary when an abscess forms or when 
acute intestinal obstruction occurs; and it is useless in the obliterative 
and adhesive form. The question of operative interference, therefore, 
mainly concerns the ascitic form. The operative treatment really dates 
from 1862, when Sir Spencer Wells opened the abdomen of a woman 
twenty-two years of age, but instead of an ovarian cystadenoma, as 
had been anticipated, found widespread peritoneal tuberculosis; the 
abdomen was emptied, and after a sharp attack of peritonitis the patient 
got well and remained so. Treatment by laparotomy with simple evacua- 
tion of the ascitic fluid was thus started, and in 1890 Konig published 
131 cases, with 84 recoveries. It was supposed that operation reduced 
the rather feeble vitality of the peritoneal tubercles, and thus led to 
their death. The way in which the withdrawal of fluid acts is now 
explained in the following manner: peritoneal tuberculosis, being a 
local infection, the opsonic index of the ascitic fluid is lower than that 
of the blood-plasma; hence, if the ascitic fluid be removed, it enables a 
fresh effusion from the blood to occur; the opsonic index of this recurrent 
effusion is higher than that of the original one, and therefore exerts a 
curative effect on the local tuberculous process. If this were the only 
1 Brit. Med. Jour., 1907, ii, 1131; and Tuberculin Treatment, 1913, Oxford. 730 
DISEASES OF THE DIGESTIVE SYSTEM 
object to be aimed at, simple paracentesis should be equally effective. 
Cures have indeed followed paracentesis alone, or followed by the injec- 
tion of an emulsion of iodoform (Schumann1) or of oxygen (Schulze2) 
into the peritoneum. The utility of laparotomy is, however, by no 
means confined to removal of the ascites; it is important to take away, 
when possible, the primary focus of tuberculous infection, such as the 
Fallopian tubes or the vermiform appendix, so as to prevent continued 
infection and a relapse. The question whether laparotomy gives better 
results than medical treatment has been extensively discussed, and 
numerous statistics have been brought forward by surgeons and phy- 
sicians to support their respective lines of treatment. At the present 
time opinion is still somewhat divided between these two views. 
Patients to be submitted to laparotomy should be selected; and as 
they are therefore those in which the prognosis of a spontaneous cure 
is favorable, the question has naturally been much debated whether 
laparotomy really exerts a beneficial influence. It is probable that when 
employed in suitable cases laparotomy does accelerate a cure. Medical 
and hygienic treatment should be tried first, and if improvement follows 
should be persisted in. If improvement does not occur in four or six 
weeks operation is indicated, unless there be some reason to the contrary. 
Any sign of increase in the activity of the disease should lead to earlier 
operation. 
TUMORS OF THE PERITONEUM 
The subject of new-growths of the peritoneum will be considered 
under the following heads: 
1. Non-malignant tumors, (a) Solid. (6) Cystic. 
2. Malignant growths, (a) Primary. (6) Secondary. 
Non-malignant Tumors 
These are not so rare as primary malignant tumors of the peritoneum, 
but this is mainly due to the inclusion, among innocent tumors, of cysts 
which are commoner than the solid innocent growths. 
Solid Non-malignant Tumors.-Fibromas, Fibromyomas, and Myomas.- 
In the first place circumscribed thickenings of the peritoneum due to 
attrition, such as the lamellar fibromas on the surface of an enlarged 
spleen, or those due to chronic inflammation, such as the fibrous plaques 
sometimes present in chronic peritonitis, fibrosed tubercles, and pseudo- 
tubercles must be excluded from consideration. A lamellar fibroma has 
been known to form around a piece of steel (Shattock3). 
Although not intraperitoneal tumors, attention may be directed to the 
fibrous desmoid tumors of the anterior abdominal wall, which, although 
innocent, are sometimes erroneously described as fibrosarcomas. They 
occur mainly in women, especially in multiparse and during pregnancy, 
1 Zentralbl. f. Chir., Leipsic, 1904, xxxi, 1409, Orig. 
2 Mitt. a. d. Gremgeb. Med. u. Chir., Jena, 1907, xviii, 180. 
3 Transations of the. Pathological Society of London, 1893, xliv, 151. DISEASES OF THE PERITONEUM 
731 
and it has been said that the protuberance of the abdomen favors their 
development. They are more often below than above the umbilicus; 
they are equally common on the right and left sides. They arise from 
the sheath of the rectus muscle, from the neighboring aponeuroses, from 
the iliac crest (Nelaton), from tendons (Doran), or possibly from the 
round ligament of the uterus. They may be multiple. In 400 cases 
of connective-tissue tumors of the abdominal wall collected by Pfeiffer,1 
87 per cent, were in women. 
Pure fibromas are rare, they are usually single and of considerable 
size, and are found in connection with the mesentery, omentum, or the 
retroperitoneal space. They probably arise from proliferation of pre- 
existing fibrous tissue in these positions, but Belkowsky2 described a 
hard fibroma which he believed was derived from an appendix epiploica. 
Whitney3 described a special group of fibromas arising from the sub- 
peritoneal tissues of the true pelvis. The tumors are composed of 
cedematous fibrous tissue enclosing some endothelial cells, and may 
produce hernial protrusions in the perineum, ischiorectal region, labium, 
or scrotum. Of Whitney's 19 cases, 15 were females and 4 males. They 
may reach a very considerable size. 
Some apparently fibrous tumors growing from the retroperitoneal 
space and from the root of the mesentery contain smooth muscular fibres, 
which may be derived from Treitz's muscle in the root of the mesentery, 
and are really fibromyomas. The tumor may pass between the layers 
of the mesentery and form a solid mesenteric tumor. In 32 cases of 
fibroma, fibromyomas, or myoma of the mesentery, collected by Greer,4 
11 were in females, thus disproving the view that these tumors are 
necessarily of uterine or broad ligament origin. Fibromas and fibro- 
myomas are encapsulated and shell out readily; they may show mucoid 
degeneration with the formation of spaces in their substance, and so 
resemble cystic fibromyomas of the uterus. Fibromyomas, or possibly 
in rare instances myomas, of retroperitoneal origin may be multiple. 
The clinical aspects depend upon the position of the tumor. The 
special feature of the fibromas arising in the true pelvis-viz., the ten- 
dency to give rise to hernial protrusions-has already been referred to. 
The symptoms come on slowly, pain is absent in most instances, and 
intestinal obstruction, which is not uncommonly brought about by 
mesenteric cysts, does not seem to occur. The correct diagnosis is 
very difficult, and these tumors are very likely to be regarded as ovarian 
cysts or uterine fibromyomas. 
The treatment is surgical, and consists in removal. Of 27 fibromas 
or fibromyomas of the mesentery removed by operation, 20 recovered 
(Greer). A ganglionated neuroma derived from the sympathetic has 
been found in the mesentery (McNaughton Jones5) and a neuromyoma 
of the mesentery has been described (Paterson6). 
1 Beitr. z. klin. Chir., Tubingen, 1904, xliv, 334. 
2 Rev. med. de la Suisse Romande, Geneva, 1893, 431. 
3 Annals of Surgery, 1905, xli, 823. 
4 Brit. Med. Jour., 1911, ii, 1085. 
6 Proc. Roy. Soc. Med., 1912, v, (Obst. and Gyn. Sect.), 287. 
6 Lancet, London, 1913, ii, 997. 732 
DISEASES OF THE DIGESTIVE SYSTEM 
Lipomas may arise in the abdominal cavity (1) in connection 
with hernial orifices, the inguinal, femoral, or obturator rings, and in 
weak spots or defects in the linea alba. Overgrowth of fat in these 
positions may exert traction and so pull out a process of the parietal 
peritoneum and thus give rise to hernia. They may cause pain and 
vomiting, which, unless their presence is detected, are difficult to explain 
(Anderson1). (2) In rare instances they arise from giant-growth of an 
appendix epiploica; Gruber2 recorded a large pedunculated lipoma 
which formed the only content of a left scrotal hernia. (3) From the 
fat around the kidneys and in the iliac fossae; they lie under the prerenal 
fascia which separates them from the colon, intestines, and pancreas. 
These lipomas are rather more common on the right side and may remain 
retroperitoneal, or may work their way between the layers of the mesen- 
tery, mesocolon, omentum, or, in very rare instances, of the broad 
ligament (Middelshulte,3 Peyrot,4 Treves,5 Borrmann6), and so become 
more or less pedunculated. The transverse colon may become surrounded 
by the adipose growth. They are usually single, but may show signs of 
fusion of separate tumors. They may be composed of fat only or of 
fat mixed with fibrous tissue, show myxomatous degeneration, calcareous 
infiltration, or very rarely contain cartilage. Very exceptionally sar- 
comatous change has supervened. They may be encapsuled, or shade 
off into the retroperitoneal fat from which they arise. Most of the 
recorded instances have weighed over twenty pounds, and about 6 
have been more than fifty pounds. In Buckner's7 case, a fibrolipoma 
arising in the subperitoneal tissue of the true pelvis weighed 268 pounds. 
Etiology.-The large lipomas, which are decidedly rare, are more 
frequent in women than in men; thus, out of 84 cases 61, or 73 per cent., 
were in females, and 23, or 27 per cent, in males (Proust and Treves8). 
The usual age is between thirty and fifty years, but isolated examples 
have been recorded in children (Lauwers). They are not necessarilv 
associated with general obesity. Of Proust and Treves' 89 collected 
cases, 14 were parietal, 38 perirenal, and 37 mesenteric. Ten were 
multiple and the remainder single tumors. 
Physical Signs- Unless of a large size, they are not likely to be 
detected, as from their soft consistency they are difficult to feel. They 
grow slowly, so that the increase in size of the abdomen is gradual. 
When palpable, the tumor is soft, smooth, free from tenderness, and 
semifluctuating, so that ascites, either general or encysted, is commonly 
suspected, although ovarian or hydatid cysts have been diagnosed. 
As growth proceeds, the abdominal distension, which is mainly in the 
anteroposterior diameter, increases, the diaphragm is pushed up and 
the contents of the thorax pressed upon. The later stages are attended 
1 Brit. Med. Jour., 1896, ii, 1087. 
2 Virchows Archiv, 1885, cii, 541. 
3 Inaug. Diss., Griefswald, 1884. 
4 Bull. Soc. anal., Paris, 1875, 3s., x, 178. 
6 Transactions of the Clinical Society of London, 1893, xxvi, 101. 
6 Vichows Archiv, 1907, clxxxix, 436. 
7 Quoted by Whit ney, Annals of Surgery, 1905, xli, 823. 
8 Rev. gyn. et de chir. abdom., 1908, xii, 93. DISEASES OF THE PERITONEUM 
733 
with general wasting and oedema of the feet; malignant disease may 
then appear probable. 
Symptoms.-The progress of the disease is slow, the general health 
and nutrition are well maintained, and symptoms do not appear for 
a long time. They include a feeling of weight, fulness, and discomfort 
from abdominal distension, sometimes gastro-intestinal symptoms from 
pressure on the stomach and intestines, inconvenience from pressure 
on the urinary bladder, and sooner or later dyspnoea from the upward 
displacement of the diaphragm. 
Diagnosis from ascites is extremely difficult, as such a rare condition 
as a lipoma is only likely to be suspected after the abdomen has been 
unsuccessfully tapped. From malignant disease their slow course is 
the main distinction. From ovarian and hydatid cysts they differ in 
their softness and indefinite outlines. Difficulty has occurred in distin- 
guishing them from large lipomas of the abdominal wall. 
Prognosis.-This depends upon their being operated upon before 
they have reached a very large size, for if left alone the patients gradually 
emaciate and die. In 26 cases in which the tumor was wholly or partially 
removed, recovery followed in 12, with recurrence in one (Adami1). 
Treatment.-The only radical method is surgical, but the results of 
removal differ in those that are entirely retroperitoneal and in those 
that are pedunculated or situated in the omentum. Removal of a 
retroperitoneal lipoma has, in some cases, deprived a considerable 
extent of the intestine of its blood-supply, and so led to gangrene or 
necessitated resection of part of the intestine. In 31 retroperitoneal 
lipomas operated on the mortality was 51.6 per cent. (Reynolds and 
Wadsworth2). 
Angioma is very rare, but the line dividing them from angiosarcoma 
is rather thin. In Julliard's3 case a cavernous angioma of the mesentery 
was as large as an adult's head, and produced intestinal obstruction. 
A cavernous angioma of the transverse mesocolon was diagnosed 
as a twisted mesenteric cyst (Wagener4). Lane5 successfully removed 
a large degenerating cavernous angioma from the peritoneum of a child 
aged seven years. 
Myxoma.-Myxomatous degeneration, of course, occurs in fibromas, 
myomas, and lipomas, and in some instances the condition may be so 
advanced as to appear to be a pure myxoma. 
Cysts.-Parasitic. Hydatids, cysticercus. 
Non-parasitic.-Mesenteric, omental, sanguineous, retroperitoneal 
hematoma, dermoid, retroperitoneal, urachal, conditions simulating 
cysts. 
Hydatid Disease of the Peritoneum.-Infection of the peritoneum with 
the cystic or bladder stage of the Taenia echinococcus, although very 
striking, is not common; thus, in 1897 cases of hydatid disease, tabulated 
1 Montreal Med. Jour., 1897, xxv, 620- 
2 Annals of Surgery, 1906, xli, 61. 
3 Rev. de gyn. et de chir. abdom., 1904, viii, 229. 
4 Zentralbl. f. Gynak., Leipsic, 1904, xxviii, 1600. 
5 Transactions of the Clinical Society of London, 1893, xxvi, 5. 734 
DISEASES OF THE DICESTIVE SYSTEM 
by Davies Thomas,1 the peritoneum, omentum, and mesentery were 
affected primarily in 26, or 1.4 per cent., only. From a review of 2727 
cases Deve2 concludes that peritoneal hydatidosis is always secondary. 
No statistics exist to show that hydatid disease of the peritoneum was 
commoner in the early part of the last century when Bright gave such 
a graphic account of its clinical features, but the practice then in vogue 
of tapping these cysts through the abdominal walls with a trocar offered 
great facilities for infection of the peritoneal cavity. 
The method by which infection of the peritoneum with hydatid cysts 
takes place is probably not always the same. In cases with a large 
number of cysts implanted on the peritoneum the most probable explana- 
tion is that rupture or leakage from a single and primary cyst, usually 
in the liver, has infected the peritoneum. It appears to take about 
two years for cysts thus implanted on the peritoneum to become suffi- 
ciently large to give rise to signs and symptoms. Admixture of bile 
with ascitic fluid does not prevent secondary infection of the peritoneum 
with hydatid cysts (Deve3). On the other hand, in instances in which a 
single cyst or only a few cysts occur in the retroperitoneal tissue, a 
very common position being between the prostate and the rectovesical 
fascia, the embryo may have burrowed from the bowel or from the 
bloodvessels in the neighborhood toward the peritoneum. Cranwell,4 
who has collected 56 examples of retrovesical hydatid cysts in males, 
believes that most of the retrovesical cysts are due to peritoneal infection. 
Morbid Anatomy.-The number of cysts may be enormous when the 
infection is secondary to rupture of a preexisting cyst; the omentum, 
mesentery, and visceral peritoneum may be almost universally affected, 
but the omentum and pelvis are the most frequent sites. The cysts 
may be of almost any size, from a pinhead upward; when single or few, 
the cysts tend to be bigger than when large numbers are present. The 
cysts may project from the surface of the viscera, be sessile on the 
peritoneum, especially on the omentum, mesentery, and pelvis, be 
pedunculated, and in rare instances a cyst may lie free in the abdominal 
cavity. Pedunculated hydatids may be sterile, probably from a deficient 
nourishment. The cysts may be separate or crowded together. Accord- 
ing to Stirling and Verco,5 adhesions around uninflamed cysts occur only 
after injury or operative interference. Chronic peritonitis may be set 
up by mechanical irritation, and may lead to the formation of a thick 
fibrous capsule over dependent or other cysts, such as those in Douglas' 
pouch, exposed to friction; calcification may subsequently occur. A rare 
condition of "pseudotuberculosis" of the peritoneum may follow rupture 
of a cyst, and consists of (1) minute developing cysts and (2) of small 
nodular granulomas containing booklets or pieces of hydatid membrane 
scattered over the surface of the peritoneum. 
Suppuration may take place in one or more of the cysts and set up 
1 Hydatid Disease, Adelaide, 1884. 
2 Compt. rend. Soc. biol., Paris, 1913, Ixxiv, 735. 
3 Compt. rend. Soc. biol., Paris, 1903, Iv, 75. 
4 Rev. de gyn. et de chir. abdom., Paris, 1907, xi, 606. 
5 System of Medicine (Allbutt and Rolleston), 1907, vol. ii, Part 2, p. 999. DISEASES OF THE PERITONEUM 
735 
a localized abscess, general peritonitis, or pylephlebitis and multiple 
abscesses in the liver (Ogle1). 
Clinical Aspect.-The enlargement of the abdomen is gradual, and 
may continue for years; in one of Bright's2 cases it had lasted for at 
least ten years. There may be either a diffuse swelling, or separate cysts 
can be made out, not only by palpation, but with the eye. The cystic 
tumors are often so firm as to suggest solid growths, they are freely 
movable, alter their position with that of the body, and are not obviously 
connected with any of the abdominal viscera. A hydatid thrill is rare, 
and as it may be present over other cysts, such as ovarian or mesenteric, 
and even in ascites, too much stress must not be laid on it. When the 
abdomen becomes very greatly distended the diaphragm is pressed up 
and respiration is much embarrassed, while pressure on the stomach 
and intestines may lead to dyspepsia, constipation, or, in very rare 
instances, to intestinal obstruction (Hutchinson3). As the result of 
pressure on the inferior vena cava, the superficial abdominal veins may 
become very prominent and the urine scanty and high-colored. A retro- 
vesical cyst in the pelvis may press on the rectum, bladder, and ureters, 
and may thus imitate a hypertrophied prostate, or lead to hydronephrosis, 
consecutive kidney disease, and pyelonephritis. Out of 24 autopsies 
on such cases, the ureters were dilated in 11 (Cranwell). There is vesical 
pain, frequent micturition, constipation, and a feeling of weight in the 
perineum. 
Diagnosis.-If multiple cystic tumors can be felt, the true solution 
is not difficult, but when the patient is a woman and one or two cysts 
only are palpable, the disease may be thought to be ovarian cystadenomas 
or even uterine fibromyomas. The history that a hydatid cyst of the 
liver has existed or has been tapped would be strongly in favor of hydatid 
infection of the peritoneum. From multiple abdominal malignant 
disease the slow course and evidence that the tumors are cystic should 
distinguish it. Exploratory puncture is dangerous, as anaphylactic 
symptoms and even death may follow escape of hydatid fluid 
into the peritoneal cavity. If it be done, the discovery of scolices, 
booklets, or of the characteristic laminated ectocyst, will make it certain 
that a hydatid had been aspirated; chemical analysis, however, does 
not settle the question, for some hydronephroses contain fluid of a very 
similar composition (Stirling and Verco). Eosinophilia, a specific 
precipitin reaction, and fixation of the complement when positive points 
to hydatid infection, but a negative result is inconclusive. 
Treatment.-A single cyst should be fully exposed and dealt with 
surgically; when the cysts are manifestly multiple, operation is still 
the only available means of treatment, but the result is not likely to be 
so satisfactory as with a single cyst. Deve4 urges that large sessile cysts 
should be injected with formol (2 per cent.) and the contents removed, 
and that small sessile cysts should be injected with formol only. In no 
1 St. George's Hospital Reports, 1867, ii, 347. 
2 Clinical Memoirs on Abdominal Tumors. New Sydenham Society. 
3 Med.-Chir. Trans., London, 1894, Ixxvii, 133. 
4 Normandie Med., Rouen, 1912. 736 
DISEASES OF THE DIGESTIVE SYSTEM 
case should a cyst be tapped through the abdominal wall. A single cyst 
in the pelvis may be opened through the perineum or vagina, but 
Cranwell recommends Tuffier's median incision above the pubes. The 
outlook in these retrovesical cysts is grave, as of 56 cases 25 proved 
fatal (Cranwell). 
Cysticercus cellulosae is, in rare instances, met with in great numbers 
inside the abdomen, chiefly in the mesentery, but this condition gives 
rise either to insignificant or to no clinical symptoms. 
Mesenteric Cysts.-This term has sometimes been applied to cysts 
in the omentum and mesocolon, but it is better to limit it to cysts in 
the mesentery of the small intestine and to employ it solely as descriptive 
of the position of the cyst. 
Pathogeny- Proust and Monod1 describe the following forms of 
mesenteric cyst: (1) Derived from the remains of embryonic epithelium 
(a) of intestinal origin; Terrier and Lecene2 collected 18 "enteroid" or 
juxta-intestinal cysts which they regard as derived 'from the remains of 
Meckel's diverticulum. Multiple cysts near the commencement of 
the jejunum may be the result of sequestrations from the intestine; 
Carnot3 showed experimentally that pieces of mucosa of the stomach 
and gall-bladder when implanted on the intestine formed cysts, and 
Walker-Hall4 described a mesenteric cyst lined by gastric mucosa with 
parietal cells. (5) From the remains of the Wolffian body, (c) Dermoid 
cysts are infrequent; they may lie between the layers of the mesentery 
or be attached to its surface and be pedunculated. (2) Serous cysts, 
lined by endothelium and due to distension of closed peritoneal pouches; 
they are very rare in the mesentery of the small intestine. (3) Lymphatic 
cysts may be simple or chylous. The latter contain lymphoid tissue in 
their walls, and constitute the most important group of mesenteric 
cysts. Brinsmeade5 found the sex incidence equal in 44 chylous cysts, 
and states that they may be congenital or occur late in life. 
Morbid Anatomy.-Usually unilocular these cysts are occasionally 
multilocular. The cysts may project from the free border of the intestine 
or from its mesenteric border and may then pass between the layers of 
the mesentery. Cysts may be embedded in the layers of the mesentery 
without any direct connection with the intestine. Their surface is 
covered by peritoneum and their walls are composed of fibrous tissue; 
they may contain smooth muscular fibres very irregularly arranged, 
and some fat. There may be no layer of epithelium on the interior of 
the cysts, which may be lined by granulation tissue. 
The contents may be clear and serous, containing albumin and choles- 
terin; turbid, viscid, with mucin; chylous, with the chemical composition 
of chyle. Timball6 collected 49 cases of mesenteric cysts with hemor- 
rhagic contents. Turnure7 has collected 50 cases of gaseous cysts in 
1 Rev. de gyn. et de chir. abdom., Paris, 1912, xix, 225. 
2 Rev. de chir., Paris, 1904, xxix, 161. 
3 Arch, de med. exper. et d'anat. path., Paris, 1905, xvii, 273. 
4 Jour. Path, and Bacteriol., Cambridge, 1908, xii, 128. 
8 Annals of Surgery, 1908, xlviii, 565. 
6 Rev. de chir., Paris, 1910, xli, 45. 
7 Ann. Surg., Phila., 1913, Ivii, 811. DISEASES OF THE PERITONEUM 
737 
connection with the intestine; they have been regarded (1) as true neo- 
plasms which secrete gas from the blood, and in this respect comparable 
with the air bladders of fishes (Mair1), (2) as due to bacteria, or (3) as 
purely mechanical. Skiagraphy shows marked luminosity of the abdomen. 
Physical Signs.-The cyst is round, well-defined, tense, elastic, 
movable, is usually on the right side of the abdomen a little below the 
umbilicus, and is not connected with any of the viscera except the 
intestines. It is dull on percussion, is surrounded by resonant intestine, 
and there may be a band of resonance due to the attached piece of 
intestine running across it. 
Symptoms.-A sudden attack of abdominal pain is usually the first 
indication of the existence of a mesenteric cyst; there may be recurrent 
attacks of colic and vomiting; while in a number of the instances acute 
intestinal obstruction has resulted from kinking of the intestine. On 
the other hand the symptoms may be those of gastro-enteritis. 
Diagnosis is often difficult, and when the cyst is detected, must be 
made from a distended gall-bladder, hydatid cysts hanging down from 
the liver or in the peritoneum, floating kidney, ovarian or parovarian 
cysts of small size with a long pedicle, solid tumors of the mesentery 
or omentum, pancreatic cysts which are much larger, and even an 
appendicular abscess. No exploratory tapping is permissible. 
Treatment is surgical, and consists in the enucleation of the cyst when 
this is possible, if not in drainage. These cysts should be operated upon 
without waiting for urgent symptoms. 
Omental Cysts.-The omentum may be the seat of cysts of various 
kinds, such as hydatid and "dermoid," which are referred to elsewhere. 
Hasbrouck2 distinguished (1) true cysts inside the omentum of which 
he has collected 20 examples from (2) cysts attached to the omentum, 
of which he collected 12. Multiple cysts possibly due to lymphatic 
obstruction have been recorded. Gairdner,3 Braithwaite,4 Mathews5 and 
others have described large single cysts with clear contents, possibly 
cystic lymphangiomas. Hemorrhage may take place into these omental 
cysts (Jacobi6). They have naturally been regarded as due to congenital 
aberrations; possibly some are, like the retroperitoneal cysts, derived 
from the Wolffian body, but Firket7 believes that proliferation of the 
peritoneal epithelium may form multiple small cysts. Of 22 cases quoted 
by Fort,8 50 per cent, were under ten years of age, and three-fourths 
were females. 
The condition does not appear ever to have been definitely diag- 
nosed before the abdomen was opened. Symptoms are not prominent 
in the early stages of growth, and pain usually leads to examination of 
the abdomen and the detection of a cyst which is superficial in position 
and usually movable to a limited extent. 
1 Journal of Pathology and Bacteriology, Cambridge, 1908, xii, 433. 
2 Annals of Surgery, Philadelphia, 1908, xlviii, 206. 
3 Transactions of the Pathological Society of London, 1852, iii, 374. 
4 Lancet, London, 1898, ii, 1472. 5 Brit. Med. Jour., 1905, ii, 1642. 
6 Transactions of the Association of American Physicians, 1901, xvi, 232. 
7 Arch, de med. exper. et d'anat. path., Paris, 1912, xxiv, 697. 
8 Annals of Surgery, 1907, xlv, 382. 
vol. in-47 738 
DISEASES OF THE DIGESTIVE SYSTEM 
Diagnosis.-Lipomas are the only solid tumors likely to be confused 
with omental cysts. The large omental cysts may imitate localized 
tuberculous peritonitis, or ovarian cysts with a long pedicle. 
Peritoneal Sanguineous Cysts.-Intra-abdominal cysts containing 
blood may be of various kinds. Thus, hemorrhage may take place 
into preexisting cysts, for example, as the result of twisting of the pedicle 
of an ovarian cystadenoma, or into a mesenteric cyst. Hemorrhage 
may occur into a soft sarcoma, and malignant hypernephromas may 
contain more blood than growth. Collections of blood in the female 
pelvis, which are generally ectopic gestations, ruptured aneurisms, 
and angiomas, need only be mentioned in order to be distinguished 
from a fairly definite group of cases, the peritoneal sanguineous cysts 
(Fisher1). Many so-called pancreatic cysts with blood-stained contents 
are the same as the sanguineous cysts found elsewhere in the peritoneal 
cavity, and are hemorrhagic effusions into the lesser sac of the peritoneum 
and therefore peripancreatic, not pancreatic. 
Morbid Anatomy.-1These cysts may also be found in the great and 
gastrohepatic omentum, mesentery, mesocolon, or project from the peri- 
toneum lining the back of the abdomen. The writer examined a san- 
guineous cyst arising in the pelvis in a man. The walls of the cysts 
are composed of well-formed fibrous tissue and may contain some 
patches of blood pigment. They are usually lined by adherent shaggy 
fibrin. The fluid is reddish brown and contains blood corpuscles and in 
some instances cholesterin. In cysts in contact with the pancreas the 
fluid contains pancreatic ferments. Blood-clot in various stages of change 
may be found in these cysts. Large nucleated cells-probably endo- 
thelial and derived from the peritoneum-also occur in the fluid. 
Pathology.-These cysts are probably the result of traumatic hema- 
tomas, but as the cyst may not become manifest until some time has 
elapsed since the injury, it has been suggested that local peritonitis 
first occurs and later hemorrhage from the newly formed vessels. 
Clinical Features.-The cyst is much commoner in the upper than 
in the lower half of the abdomen, and is usually in the middle line. 
It forms a large, tense tumor, may have pulsation conducted to it from 
the aorta and can be shown by percussion to be distinct from the liver. 
Symptoms are less marked than in pancreatic cysts, and after reaching 
a considerable size the tumor may remain unaltered for years. 
Diagnosis of peritoneal sanguineous cysts other than those around 
the pancreas is very difficult. This is mainly due to their rarity. 
Treatment is surgical and consists in draining the cyst. Excision is 
rarely possible, as the walls are so often part of the peritoneum forming 
the mesentery, lesser omentum, or mesocolon. Cure has followed 
tapping, but it is dangerous and should not be attempted until the 
cyst is exposed by laparotomy. 
Retroperitoneal hematomas are rare; they may be due to trauma, such 
as rupture of the kidney, bursting of an abdominal aneurism, or leakage 
from a hemorrhagic retroperitoneal or renal sarcoma. In some instances 
1 Guy's Hospital Reports, 1893, xlix, 275. DISEASES OF THE PERITONEUM 
739 
the source of the blood is not clear. The blood tracks down behind the 
peritoneum toward the pelvis, and may form a distinct tumor accom- 
panied by pain. On the right side such a tumor may suggest appendicitis. 
The symptoms may be those of acute intestinal obstruction. 
Dermoid cysts in rare instances occur in the peritoneum without any 
evidence that they were directly derived from the ovaries. Thus, 
Pakowski1 collected 74 of these dermoid cysts, 31 of which were connected 
with the mesentery of the small intestine. These cysts may be simple 
or composed of skin only, or composite or embryomas. They are usually 
found in females, but Pakowski collected 6 dermoids of the mesentery 
in males. They may occur between the layers of the mesentery, omen- 
tum, and transverse mesocolon, or in the retroperitoneal space. In 
some instances, however, a "dermoid" cyst originating in the ovary 
may become detached and subsequently contract adhesions elsewhere. 
Multiple "dermoid" cysts may be due to rupture of an ovarian embryoma 
with the resulting implantation of fragments over the peritoneum; the 
multiple growths are not malignant, but resemble the implantations 
sometimes associated with ovarian papillomas. Suppuration occasionally 
occurs in these cysts, and in rare instances, of which Montgomery2 
has collected 10 cases, the teratomas become malignant. 
Retroperitoneal Cysts.-Cysts manifestly arising in viscera behind the 
peritoneum, the kidneys, adrenals, and pancreas, are not included in 
this category. Although far from common, cysts of various kinds may 
be found in the subperitoneal connective tissue; for example, hydatids. 
A multilocular cyst, structurally resembling an ovarian cystadenoma, 
may occur in the retroperitoneal tissues of men as well as of women. 
These cysts may arise close to the kidney and be mistaken for a floating 
kidney, a hydronephrosis, or on the left side for a primary neoplasm 
of the tail of the pancreas. Severe attacks of pain, simulating Dietl's 
crises or those of appendicitis (Elder3), may occur. The cysts may pass 
between the layers of the mesentery, omentum, mesocolon, or meso- 
rectum, and in all probability are derived from sequestrations of the 
Wolffian body. They may contain several pints of fluid. The multi- 
locular cysts may become malignant and give rise to metastases. 
Among rare conditions cystic dilatation of the receptaculum chyli 
and collection of fluid in a subcecal pouch, the mouth of which has been 
closed, may be mentioned. 
Urachal Cysts.-The urachus may be partially pervious; thus minute 
cystic dilatations were found in 24 out of 74 cases specially examined 
by' Wutz? In rare cases there are cysts containing many pints of fluid. 
In some instances the cysts communicate with the bladder; infection 
may then spread into the cyst; in other instances the cyst and the urinary 
bladder are connected by an impervious cord. The contents may be 
clear, turbid, blood-stained, or purulent. The cysts are usually in front 
of the peritoneum and adherent to the umbilicus and anterior abdominal 
1 Arch. gen. de chir., Paris, 1912, vi, 1029. 
2 Jour. Exper. Med., 1898, iii, 259. 
3 Montreal Medical Journal, 1905, xxxiv, 891. 
4 Virchows Archiv, 1883, xcii, 387, 740 
DISEASES OF THE DIGESTIVE SYSTEM 
wall, but may be intraperitoneal; the latter position is explained by a 
persistence of the fetal mesentery of the urachus (Delore and Cotte1). 
The wall contains smooth muscular, elastic and fibrous tissue, and may 
show epithelium resembling that of the bladder, but this may be detached. 
The cysts are usually unilocular, but in Doran's2 case there were two 
cysts. Weiser3 tabulated 89 cases, but included 19 "allantoic" cysts 
(see infra), so that the number of authentic cases on record is not so 
great. They occur chiefly in women, but have been met with in men 
and in children. A case in a man, in St. George's Hospital, was diag- 
nosed correctly before operation. In Weiser's 89 cases females were 
about three times more often affected than males. The cysts are in 
the middle line between the umbilicus and the pubes; they may be soft 
and fluctuating, resembling a distended urinary bladder, or firm and 
apparently solid. There may be pain in the lower part of the abdomen, 
probably from associated local peritonitis. They may imitate encysted 
peritonitis, especially of tuberculous origin, and ovarian cystadenomas. 
The treatment of urachal cysts is surgical. In some instances they 
can be dissected out, in others the only available course is drainage. 
It is important that the relation of the cyst to the bladder and the 
possibility of a communication between the two should be borne in mind, 
otherwise a urinary fistula may follow operation. Tapping the cysts is 
only a palliative measure, as the fluid is prone to accumulate again. 
Conditions Simulating Peritoneal Cysts.-Encysted peritonitis may 
simulate a true cyst. Kelly and Hurdon4 figure cysts of this nature 
adherent to the tip of the vermiform appendix. The "allantoic" cysts 
described by Lawson Tait5 and B. Robinson6 in adult women are prob- 
ably examples of localized pelvic tuberculous peritonitis (Doran). 
Pseudomyxoma of the peritoneum consists in the presence of numerous 
encysted collections of gelatinous material in the peritoneum which 
follows rupture of an ovarian cystadenoma. In about 12 cases, chiefly 
in males, pseudomyxoma of the peritoneum has been due to the escape 
of the contents of a mucocele of the vermiform appendix. It may be 
confused with colloid cancer and with primary tumors derived from the 
Wolffian body which structurally resemble ovarian cystadenomas. 
Malignant Tumors 
Malignant growths are more often met with in the peritoneal cavity 
than innocent tumors, but this depends on the frequency of secondary 
infection of the peritoneum, for while primary malignant disease and 
innocent neoplasms of the peritoneum are both rare, primary malignant 
disease is the more exceptional of the two. 
Primary Malignant Diseases.-These may conceivably arise in several 
structures, such as (1) the endothelium of the serous membrane, of the 
1 Rev. de chir., Paris, 1906, 403. 
2 Medico-Chirurgical Transactions, London, 1898, Ixxxi, 301. 
3 Annals of Surgery, 1906, xliv, 529. 
4 The Vermiform Appendix and its Diseases, 1905, 311. 
5 British Journal of Gynecology, 1887, ii, 328. 
6 Annals of Surgery, 1891, xiv, 350. DISEASES OF THE PERITONEUM 
741 
lymphatics and bloodvessels; (2) the subserous connective tissues, 
especially around the spine and back of the abdomen, the periosteum 
of the spinal column and pelvis; and (3) the remains of the Wolffian 
bodies, Mullerian ducts, accessory adrenal bodies, or even from teratomas 
that have undergone malignant transformation. 
The tumor growth may occupy the omentum or, more rarely, the 
mesentery or the gastrohepatic omentum, and be thus to all intents 
and purposes intraperitoneal. In other cases the growth extends behind 
the peritoneum and to a slight extent displaces the abdominal con- 
tents forward; these are cases of retroperitoneal sarcoma. In some 
instances a growth at first definitely retroperitoneal passes forward, 
becomes pedunculated, and therefore partly intraperitoneal. Thus, 
although it might appear to be more logical to describe separately malig- 
nant disease (a) arising from the peritoneum itself, and (&) originating 
in the tissues (as apart from the organs) of the retroperitoneal space, 
any such distinction wTould in reality be artificial. 
Morbid Anatomy.-Primary malignant tumors of the peritoneum and 
retroperitoneal space belong to the group sarcoma or endothelioma. 
Formerly primary carcinoma of the peritoneum was commonly described; 
alveolar growths resembling carcinoma histologically undoubtedly occur, 
but are now regarded as endotheliomas and arising in endothelium, 
either of a lymphatic or bloodvessel or possibly of the surface of the 
serous membrane (Miller and Wynn1). The histological appearances 
of primary malignant growths of the peritoneum vary considerably; 
spindle-celled, round-celled, and irregular-celled, alveolar, fibrifying 
myxosarcoma and lymphosarcoma, endothelioma, and perithelioma 
(angiosarcoma) all occur. But of 16 primary sarcomas of the omentum 
11 were spindle-celled (Bonamy2). In some endotheliomas the micro- 
scopic appearances are confusing, in some parts resembling carcinoma, 
in others sarcoma. 
The shape of the tumors varies according to their position. Retro- 
peritoneal sarcoma and neoplasms originating between the layers of 
the great omentum are often flattened out so as to resemble a pancake. 
Retroperitoneal sarcomas may project forward into the peritoneal cavity 
and even become pedunculated. There may be multiple pedunculated- 
growths without any manifest primary growth. A primary malignant 
growth of the peritoneum may be rounded or lobulated. The tumors 
may reach a considerable size. A primary malignant growth of the great 
omentum recorded by J. W. Ogle3 weighed thirty pounds. The origin 
of primary malignant neoplasms is more rarely intraperitoneal than 
retroperitoneal. This depends on the presence behind the peritoneum 
of structures, such as lymphatic glands, connective tissue, and the 
remains of the Wolffian body and Mullerian duct, from which tumors 
may arise. As a rule, primary peritoneal and retroperitoneal tumors 
do not invade adjacent organs to any great degree. It may, however, 
be difficult to determine the exact origin of a malignant growth, and in 
1 Journal of Pathology and Bacteriology, Cambridge, 1908, xii, 267. 
2 Rev. de gynec., Paris, 1908, xii, 285. 
3 St. George's Hospital Reports, 1867, ii, 350. 742 
DISEASES OF THE DIGESTIVE SYSTEM 
some instances it must be left an open cpestion whether the growth 
arose in an organ and spread out of it or whether it started independently 
of a given viscus in question and subsequently infiltrated it. In such 
cases the histological appearance of the tumor is the best guide to its 
origin. 
The lymphatic glands and the connective tissues around the aorta and 
the periosteum of the vertebrae appear to be the commonest starting- 
points of retroperitoneal sarcoma. A malignant cystic tumor resembling 
an ovarian cystadenoma, and probably derived from the remains of the 
Wolffian body, may occur. 
Retroperitoneal sarcoma most often arises in the lumbar region and 
more frequently on the right side, but it may start in the middle line, 
in the iliac region, or in rare instances in the pelvis. There is frequently 
some local peritonitis with adhesions over the growth. The tumor is 
usually firm at first, but in a third of the cases it undergoes central 
necrosis and becomes cystic (Dutton Steele1). The contents may be 
hemorrhagic, myxomatous or purulent from infection. The pseudocyst 
has in rare instances opened into the intestine or peritoneum. Thus in 
a case under my care, a cystic, spindle-celled sarcoma arising near the 
right kidney opened into the duodenum. The growth may press on the 
inferior vena cava, the spinal nerves, or on the abdominal viscera. 
The fixed parts of the colon are more liable to be narrowed by retroperi- 
toneal growths. Tumors in the omentum, which may become cystic, 
may constrict the colon, and in primary sarcoma of the gastrohepatic 
omentum, of which Cobb2 has been able to collect three examples only, 
the stomach may be depressed downward (A. P. Gould3). Secondary 
growths occur in 33 per cent, of the cases, and are found in the liver, 
lungs, and peritoneum, and may give rise to ascites. 
Etiology.-Sex apparently has no influence. In retroperitoneal 
sarcoma, according to Dutton Steele, the first, fourth, fifth, and sixth 
decades are most often affected, and 53 per cent, occur between thirty 
and sixty years of age. Injury has been thought to be a causal factor. 
Clinical Picture.-The clinical manifestations vary considerably; most 
commonly there is a deep-seated abdominal tumor with somewhat 
variable gastro-intestinal symptoms, abdominal distension, and increas- 
ing weakness. Although usually fixed, the tumor is occasionally freely 
movable, especially in the early stages. It may be regular and smooth, 
or nodular, more or less firm, or may show various degrees of consistency; 
it may receive transmitted pulsation from the aorta; it is usually not 
tender on palpation, and is more often to the right of the middle line; 
a growth in the omentum may resemble a spleen dislocated by extensive 
deformity of the spine. Primary growths, especially in the omentum, 
may induce ascites and so imitate tuberculous peritonitis, while a flat 
retroperitoneal sarcoma, although not palpable, may by pressure on 
the spinal nerves give rise to severe pain in the back imitating that of 
aneurism, caries, or malignant disease of the spine, and by compressing 
1 Amer. Jour. Med. Sci., 1900, xcix, 311, and 1904, cxxvii, 939. 
2 Annals of Surgery, 1906, xliv, 16. 
3 Medico-Chirurgical Transactions, London, 1900, Ixxxiii, 257. DISEASES OF THE PERITONEUM 
743 
the inferior vena cava lead to oedema of the legs, genitals, and lower 
part of the abdomen with very noticeable enlargement of the subcuta- 
neous abdominal veins. There may be profound anemia before any 
tumor is palpable. On the other hand, malignant disease of the omentum 
may produce a large superficial mass forming a kind of shield in front 
of the intestines or may simulate enlargement of the liver. 
The progressive growth of the tumor usually causes pain and some- 
times vomiting, constipation, and even intestinal obstruction. The 
sudden onset of abdominal pain, probably due to extension of the growth 
setting up local peritonitis, may be the first symptom. The growth 
may then be sufficiently large to be easily detected. Although the 
tumor may be of considerable size, the general state of nutrition is less 
affected than in malignant growths of the stomach or liver of the same 
dimensions. When retroperitoneal it may be resonant from the presence 
of intestines, colon, or stomach in front of it. When ascites is present 
the fluid may be but is not necessarily blood-stained. The fluid may 
be remarkably viscid from the presence of a "mucoid" body. The course 
of the disease is somewhat rapid, the average duration of retroperitoneal 
sarcoma from the onset of symptoms being eight and a half months 
(Dutton Steele). Death is usually due to exhaustion, but in a few 
instances has been sudden and due to rupture of the growth and hemor- 
rhage into the peritoneal cavity. 
Diagnosis.-From the variable character of the symptoms this is 
very difficult and is usually arrived at only by a process of exclusion. 
Even although a peritoneal tumor be diagnosed, it is, except when 
there is definite evidence of other growths, impossible to be absolutely 
certain that it is malignant unless the abdomen has been opened. Even 
then removal of a piece of the growth for histological examination is 
necessary to be absolutely certain, for a considerable number of cases 
have been recorded in which the abdomen has been opened and closed 
on the discovery of an inoperable and apparently malignant tumor, and 
yet the tumor has subsequently disappeared (Greig Smith1). These 
"vanishing tumors" (Power2) may possibly, in spite of the absence of 
any naked-eye evidence, be inflammatory in nature; in some instances 
a foreign body which has perforated the intestine may be the cause 
(Bland-Sutton3), and it is conceivable that in some the condition was 
due to actinomycosis or pancreatitis (Bradford4). Malignant growths 
progress more rapidly, produce more marked constitutional symptoms, 
and give rise to pressure symptoms, such as pain and dilated abdominal 
veins, in a far greater degree than innocent tumors even though of great 
size. The differential diagnosis must be made from various conditions, 
such as pancreatic cysts, renal and suprarenal tumors, malignant disease of 
the liver (Sailer5), aneurism of the abdominal aorta which does not pulsate, 
retroperitoneal teratomas and innocent tumors, some cases of carcinoma 
of the colon with suppuration, uterine fibromyomas, and when there 
1 Medico-Chirurgical Transactions, London, 1894, Ixxvii, 139. 
2 Lancet, London, 1899, i, 583. 3 Ibid., 1903, ii, 1148. 
4 Clinical Journal, London, 1907, xxi, 76. 
5 Trans. Coll. Phys., Phila., 1912, xxxiv, 328. 744 
DISEASES OF THE DIGESTIVE SYSTEM 
is ascites from secondary malignant disease of the peritoneum and from 
tuberculous peritonitis. A horseshoe kidney, which is met with once 
in 1600 autopsies, has been mistaken for malignant disease. A nodular 
mass may resemble fecal accumulation, and enemas and purgatives may 
then be necessary to settle the diagnosis. 
Prognosis is extremely grave. Operative interference is impracticable 
in many cases, especially in extensive retroperitoneal sarcomas. Tumors 
in the omentum or mesentery are more amenable to removal. Removal 
of the tumor in an early stage, when it is more or less encapsulated, 
should lead to better results. In Williams'1 collection of 84 cases of 
retroperitoneal sarcoma, radical operations were performed in 12 cases, 
with recovery in 10. 
Treatment.-Except when removal is possible, treatment is palliative 
and symptomatic. 
Secondary Malignant Disease of the Peritoneum.-Synonym: 
Malignant peritonitis. Secondary infection with carcinoma or sarcoma 
is far commoner than primary malignant disease of the peritoneum. 
That it occurs more frequently in women than in men is in part accounted 
for by influence exerted by malignant disease of the female sexual organs, 
of the mamma} and of the gall-bladder. It chiefly occurs in or after 
middle life. 
Pathology.-The primary growth is usually in the abdominal organs. 
Malignant infection may also extend from the chest, either through the 
lymphatics of the deep fascia of the parietes from the mamma, described 
by Handley2 as " epigastric invasion" of the peritoneum, or less commonly 
from the cavity of the thorax as in primary carcinoma of the oesophagus. 
In primary malignant disease of the testes the lumbar glands may 
convey infection to the peritoneum. In some instances, as in generalized 
sarcoma, infection reaches the peritoneum by the blood-stream. Primary 
malignant disease inside the abdomen may spread to some extent by 
the lymphatics and bloodvessels, or to a limited degree by direct contact. 
But the chief means of dissemination is the liberation of infective cells, 
which become widely scattered over the abdominal cavity. 
Morbid Anatomy.-The tumors may be so minute and discrete as to 
imitate tuberculous peritonitis, and the condition may then be spoken 
of as miliary carcinomatosis; in other instances the secondary nodules, 
being larger and white in color, resemble caseous tubercles, while in 
some cases, especially of colloid carcinoma, the masses are very large 
indeed. In women the ovaries may become markedly infiltrated with 
secondary growth, and as they may form tumors much larger than the 
primary growth, this sometimes suggests that the original tumor growth 
started in both ovaries (Bland-Sutton3). The miliary growths are less 
translucent than miliary tubercles, when larger they are, as a rule, white, 
although they may be hemorrhagic, but they do not caseate and soften. 
The growths, which are generally sessile or more rarely pedunculated, 
may be umbilicated. The whole of the peritoneum may be infected, 
but the omentum, the mesentery, and Douglas' pouch are the regions 
1 Amer. Jour. Med. Sci., 1903, cxxvi, 269. 
2 Lancet, London, 1905, i, 1047. 3 Ibid., 1907, i, 1342. DISEASES OF THE PERITONEUM 
745 
most frequently affected. When the growths are miliary the peritoneum 
may be otherwise normal, but in most cases the peritoneum shows chronic 
fibrotic changes resembling tuberculous peritonitis, the white nodules 
being surrounded with fibrotic thickening and often outlined by a rim 
of pigmentation. From the resulting contraction the omentum may 
become rolled up and the mesentery markedly shortened. The intestinal 
tract may be much shortened, the intestinal walls thickened, and the 
lumen narrowed. The diaphragm may be much thickened from growth, 
and in these cases miliary carcinomatosis of the pleurae with effusion 
may result. Adhesions may give rise to loculated ascites. In some 
instances acute or subacute peritonitis is found at autopsy. From 
implication of the receptaculum chyli or of the thoracic duct the 
lacteals may be dilated, and from leakage true chylous ascites result; 
chyliform ascites is commoner. 
Occasionally large colloid growths are met with. More than one 
condition has been described as "colloid cancer" of the peritoneum; 
secondary growths due to a primary carcinoma of the stomach or colon 
are occasionally seen, but some of the cases formerly described as colloid 
cancer are probably primary retroperitoneal growths derived from the 
Wolffian bodies and are myxosarcomatous or endotheliomatous in nature. 
The histological character of the tumors will vary with that of the 
primary growth, spheroidal-celled carcinoma being the commonest form. 
Symptoms.-These come on gradually with loss of vigor, flesh, and 
appetite, and, except that they point to the abdomen, are somewhat 
indefinite. The symptoms vary since they are partly due to the primary 
growth, which is also usually in the abdomen, and partly to the peritoneal 
metastases; in fact, it is usually impossible to assign the symptoms 
exclusively to one or other cause. In addition to the progressive wasting 
and weakness there may be varying degrees of abdominal tenderness. 
Pain, on the one hand, may be almost absent, or, on the other hand, 
there may be colic from obstruction to the lumen of the colon, induced 
either by a primary carcinoma or by pressure or contraction exerted by 
secondary growths in the neighborhood. Tenderness and pain may be 
due to attacks of local peritonitis in connection with the growths. 
Physical Signs.-In most cases there is ascites which may obscure the 
existence of any growths. The fluid may be clear, turbid, blood-stained, 
chylous, or pseudochylous. The abdomen may be much distended. 
There may be prominent veins under the skin of the abdominal wall. 
The umbilicus may be infiltrated with secondary growth, and small 
nodules may be felt in the line of the falciform ligament; it should be 
remembered, however, that small masses of fat in this position may 
imitate nodules of secondary growth. As the result of distension the 
skin of the abdomen shows linese albicantes. Even when not previously 
stretched the skin may from loss of its elasticity be thrown into numerous 
wrinkles and become somewhat harsh and rough. In a case without 
ascites, under my care, numerous and extensive linese albicantes appeared 
on the back in the last ten days of life.1 
1 Brit. Med. Jour., 1908, i, 494. 746 
DISEASES OF THE DIGESTIVE SYSTEM 
Although there is usually emaciation, and to a greater degree than 
in primary malignant disease of the peritoneum, there is sometimes a 
very considerable amount of subcutaneous fat. Cutaneous pigmentation 
is not uncommon; and in very rare instances the skin of the abdomen 
shows a warty pigmented condition called acanthosis nigricans. (Edema 
of the feet, which may creep up the thighs to the abdomen, may be 
due to pressure on the inferior vena cava, or in the later stages depend 
on cardiac weakness. In some cases definite tumors can be felt through 
the abdominal wall; very frequently the omentum is rolled up and 
palpable as a hard tumor or transverse ridge, which must not be mistaken 
for the lower margin of the liver. There may be friction over the tumors. 
Often when ascites is considerable no growths can be detected until 
the abdomen has been tapped, and when the growths are small nothing 
may be felt even then. There may be concomitant pleural effusion on 
one or both sides due to intrathoracic infection. The duration of the 
disease is seldom more than six months and is often much less. 
Diagnosis.-When definite tumors can be felt in a patient who has 
malignant disease of the stomach, colon, etc., there can be no doubt. 
When tumors are palpable, but there is no history or definite evidence 
of malignant disease, the diagnosis must be made from tuberculous 
peritonitis, from fecal accumulation, and from the rather rare condition 
of multiple hydatids in the peritoneum. Tuberculous peritonitis is 
commoner in children and women, and may be accompanied by fever 
and by signs of suppuration about the umbilicus, while injection of the 
ascitic fluid into guinea-pigs would provide evidence of tuberculosis. 
Injection of tuberculin into the patient is another means of diagnosis. 
A blood-stained effusion is in favor of malignant disease. The discovery 
of multiple tumors in the abdomen should always suggest the possibility 
of fecal accumulation, and the effects of purgatives and repeated enemas 
on the position of the tumors should be tested. Multiple echinococcus 
cysts in the abdominal cavity run a slow course as contrasted with 
malignant disease, and may be definitely recognizable as cysts, while 
the history of a hydatid cyst in the liver makes the diagnosis of a similar 
condition in the peritoneum highly probable. In cases with marked 
ascites the presence or absence of tumors cannot be settled, and it may 
be impossible to decide whether the underlying condition is malignant 
disease or hepatic cirrhosis, simple chronic peritonitis, and other causes 
of ascites, such as portal thrombosis, until the abdomen is tapped. 
It should be remembered that the malignant growths in the peritoneum 
may be too small to be felt. In these cases enlarged glands in the groins 
or above the left clavicle, and to a lesser degree a blood-stained ascites, 
indicate malignant disease. 
Prognosis is, of course, hopeless. 
Treatment is purely palliative and in the direction of the relief of 
pain by opium, morphine, and external applications to the abdomen, 
in the alleviation of gastro-intestinal symptoms, and the removal of 
ascitic fluid by tapping. To prevent reaccumulation of fluid after 
tapping, the injection of a dram of adrenin (1 to 1000) diluted with 
water to half an ounce may be tried. CHAPTER X 
SPLANCHNOPTOSIS. VISCEROPTOSIS. ENTEROPTOSIS. 
GLENARD'S DISEASE 
THOMAS R. BROWN, M.D. 
The word enteroptosis, from the Greek -words and nrtoact;, 
although in reality meaning a falling or descension of the intestines, has 
been generally used to signify the descent of any or all of the abdominal 
viscera. The better word, however, is splanchnoptosis. In describing 
the displacement of the individual organs special terms are used, such 
as nephroptosis, to signify descent of the kidney; gastroptosis, of the 
stomach; splenoptosis, of the spleen; hepatoptosis, of the liver; coloptosis, 
of the colon; while some of the more modern writers on the subject use 
the term enteroptosis to mean descent of the intestines. The condition 
may be either partial or universal, and the different organs may be 
affected in varying degrees. It is also known as Glenard's disease, from 
the physician who first described it carefully. Etymologically speaking, 
all the terms are incorrect, and we should use nephroptosia, gastroptosia, 
etc., as A. Rose has specially insisted. 
One thing must be remembered in the discussion of this disease, and 
that is, that in the earlier days nephroptosis, being much more easily 
recognized, was regarded as the most important feature, and to it were 
ascribed the protean symptoms often met with, while later investigations 
with better methods of diagnosis have shown that the displacement of 
the kidneys is usually associated with the displacement of the stomach, 
intestines, etc., and that many of the symptoms originally ascribed to 
floating kidney are in reality referable to displacement of other organs. 
Anatomy and Embryology.-Before discussing the etiology of splanch- 
noptosis it will be advisable to call attention briefly to the anatomy and 
embryology of the abdominal organs. These viscera are held in their 
positions by a number of different forces: by the negative pressure of 
the thoracic cavity acting through the diaphragm; by ligamentous, 
vascular and peritoneal attachments; by the pressure of other abdominal 
organs; and by the supporting power of the abdominal muscles. Physi- 
ologically, no organ is absolutely fixed, but each is capable of a slight 
degree of movement, which may be caused by various factors, such as 
the position of the patient, the amount of food ingested, the passage of 
urine and feces, the respiratory and circulatory movements, and preg- 
nancy. Thus we must not consider the abdomen to be filled with viscera 
that are normally fixed in their positions, but rather of organs capable 
of a slight degree of movement under a variety of conditions, the only 
fixed area in the abdomen being the radix mesenterica. 
747 748 
DISEASES OF THE DIGESTIVE SYSTEM 
Embryologically the subject is interesting because of the fact that a 
number of authors regard splanchnoptosis as a reversion of the abdominal 
organs to the embryonic type, as Rosengart and Henle have shown. 
From the fetal position of the viscera the position found in normal 
children and adults is produced by gradual ascension of the various 
viscera, this being largely due to the fact that after respiration the liver 
rotates and rises into the dome of the diaphragm, and also undergoes a 
relative diminution in size. In advanced cases of splanchnoptosis the 
position of the abdominal organs very closely resembles that seen during 
embryonic life. 
Pathogenesis.-As regards the pathogenesis of splanchnoptosis diver- 
gent views are held, some believing that the condition is congenital, 
others that it is acquired, while others hold a middle ground. According 
to Glenard, the starting-point of the condition is the falling of the right 
colic flexure, due to a weakening of the hepatocolic ligament. This may 
follow injuries, pregnancies, strains, dyspepsia, typhoid fever, appen- 
dicitis, or localized peritonitis, but is primarily due to a constitutional 
defect as regards the strength and supporting power of the mesenteric 
tissues which is present in certain individuals. 
Stiller is another firm adherent of the congenital origin of splanch- 
noptosis, and he believes that this inherited tendency is shown by a con- 
stant organic type, a slender skeleton, a long thorax, soft, flabby muscles, 
and a diminution of the panniculus adiposus, and that in these patients 
may be found a neurasthenic stigma, the floating tenth rib. According 
to him the basis of the disease rests upon an embryological defect, and 
the numerous causes which many authors give for this condition are in 
reality not primary causes, but simply factors which bring about a 
condition to which the body is already embryologically committed. 
Fuhs is also a firm believer in the costal stigma, and calls attention to 
the frequency of splanchnoptosis among young unmarried Swedish girls 
who have never worn corsets and who have strong abdominal walls. 
The condition is also found frequently among Arab women, who also 
wear no constricting articles of clothing. Mathes believes that splanch- 
noptosis is a constitutional and hereditary anomaly of the entire organism, 
a lack of vital energy of all the vital tissues, while Harris, who has paid 
special attention to the etiology of nephroptosis, believes that this 
occurs in women with a particular body form, which can be expressed 
mathematically in terms of certain body diameters, and that practically 
all women with this body form have movable kidneys to a greater or 
less extent. 
Landau believes that the primary cause is a weakness of the abdominal 
wall, in many cases congenital, while according to Bouveret, neurasthenia 
is primary, splanchnoptosis secondary. Rosengart believes that in 
many cases there may be a real persistence of the fetal condition. Riegel, 
on the other hand, is a firm believer in the acquired nature of the disease, 
and thinks that any condition which either increases the pressure above 
the diaphragm or diminishes the pressure below may produce splanch- 
noptosis, such as pregnancy and parturition, wasting diseases, and the 
removal of abdominal tumors or ascitic fluid. SPLANCHNOPTOSIS, VISCEROPTOSIS, GLENARD'S DISEASE 
749 
Wolkow and Delitzen have carried out a number of interesting experi- 
ments in regard to the production of nephroptosis, and they conclude that 
the use of a belt may dislocate the kidney downward, may fix it, or may 
even move it upward according to the position of the belt. According to 
these investigators, nephroptosis is an infallible index of an existing 
alteration of the intra-abdominal equilibrium. Janovski, from his 
experimental studies, thoroughly agrees with these conclusions, while 
Longyear believes that the ligamentous union of kidney and colon is an 
even more important factor in the etiology of nephroptosis. 
Vietor believes that the fundamental cause of splanchnoptosis is the 
inability of the abdominal walls to resist the weight of the viscera, that 
this is an inevitable accompaniment of the upright position, and that 
anything which increases the instability of the body will tend to produce 
this condition, such as marked straightening of the thorax at its lower 
extremity, marked anterior convexity of the lumbothoracic segment 
of the spine, and marked tilting forward of the pelvis. 
Quincke gives three causes of splanchnoptosis: (1) Relaxation or 
stretching of the abdominal wall; (2) change in the form of the abdominal 
cavity; (3) stretching of one or more of the suspending ligaments; while 
Langerhans recognizes five causes: (1) Relaxation of the abdominal 
muscles; (2) hereditary predisposition; (3) pressure of clothing, as tight 
belts and corsets; (4) chlorosis; (5) nervous dyspepsia. 
The most valuable contribution to the pathogenesis of splanchnoptosis 
is that of Keith, who believes that the condition is the result of a vitiated 
method of respiration. According to him the organs within the thoracic 
and abdominal cavities are poised between the muscles of inspiration 
and expiration, two contending sets, which throughout the life of the 
individual strive for the mastery. The reason that the right kidney is 
so much more frequently displaced than the left is because the liver acts 
directly on the latter, while in the case of the former there is a safety 
valve in the shape of the splenic flexure of the colon, which may enter 
or leave the hypochondrium with the greatest freedom; also the left 
kidney is bound to the spleen, and the fundus of the stomach represents 
a much lighter hammer than the liver. The adhesion of the base of the 
pericardium to the diaphragm, peculiar to man and the anthropoids, 
is a most effective aid against ptosis. Briefly speaking, Keith's conclu- 
sions are as follows: (1) The contraction of the diaphragm is the factor 
which produces the displacement of the viscera in splanchnoptosis or 
Glenard's disease, and further, that of the various parts of the muscle, 
the crura are the most important agents in producing this result. (2) 
Before the displacement can be produced, either what he terms the 
thoracic supports of the diaphragm must have yielded, or the antagonistic 
abdominal muscles must have been hampered or weakened in their 
action, as, for example, by tight corsets. (3) The bonds which fix the 
viscera to the walls of the abdomen are of quite subsidiary importance. 
Thus the theories regarding the pathogenesis of splanchnoptosis may 
be broadly placed in three groups: (1) The condition is congenital, 
and is due to an inherent weakness of the tissues which support the 
abdominal viscera; such factors as clothing, trauma, disease, etc., are 750 
DISEASES GE THE DIGESTIVE SYSTEM 
not the primary causes, but simply contributory ones, which bring out 
or accentuate the inherited tendencies. (2) The condition is due to 
a number of conditions, each of which has as its result the weakening 
of the various visceral supports, due in some cases to pressure, in other 
cases to adhesions, in other cases to trauma, and in still other cases to 
a marked diminution of the supporting pow'er of the abdominal wall. 
(3) That each of the foregoing may be the primary cause of the condition; 
in other words, that there may be both an acquired and a congenital 
form of splanchnoptosis. 
In the great majority of instances, according to personal observations, 
the condition is due to a congenital defect, yet in some it may definitely 
be of the acquired type. 
Frequency.-In discussing the frequency of splanchnoptosis we will 
naturally and necessarily quote from the tables of the frequency of 
displaced kidney, displaced stomach, displaced liver, etc., because in 
the vast majority of cases the descension of one organ is associated with 
that of other organs as well, although for various reasons the one organ 
alone has been considered. Naturally the only tables of real value in 
this connection are those of recent years, when the condition has been 
well recognized, and when clinicians have been on the alert to diagnose 
it. Lawson Tait stated that there were no movable kidneys, and yet 
we have but to look at many of the older pictures, notably Botticelli's 
women and Memling's Eve, to realize that the condition has unquestion- 
ably been present for a long time, although it is highly probable that it 
is on the increase. The condition has been found in practically all the 
races in which it has been carefully looked for, and cases have been 
described quite frequently among the Arab women and other tribes 
among whom tight clothing is unknown. 
Glenard reported 148 among 1310 patients at Vichy; Stiller meets 
from 300 to 400 cases of splanchnoptosis in his private practice every 
year; while Kuttner found 100 cases of this condition among 4000 
patients in Ewald's clinic; Kuttner also states that he frequently found 
floating kidneys in children, which is also the writer's experience and 
that of Blum. Einhorn in one year saw 70 cases of splanchnoptosis 
among 1080 males, and 277 cases among 832 females. Of 240 cases of 
enteroptosis proper, 20 were in men and 220 in women, and in these cases 
movable kidney was met in 212, movable liver in 23 cases in association 
with movable kidney, and in 12 patients without movable kidney. 
Enteroptosis alone was met with in 15 patients, 1 male and 14 females, 
and movable kidney alone 57 times, 21 males and 36 females. Thus in 
Einhorn's practice, which is largely devoted to digestive disorders, and 
in which, therefore, the figures are extremely high, ptoses of the abdomi- 
nal viscera are met with in 6.5 per cent, of the males and 33.25 per cent, 
of the females. 
As regards the incidence of movable kidney the older anatomists and 
clinicians noted it but rarely;-thus, Ebstein found movable kidney only 
5 times in 3658 postmortems, while Landau reports only 4 cases among 
6999 hospital patients. 
The reports of later years, however, show the great incidence of this SPLANCHNOPTOSIS, VISCEROPTOSIS, GL^NARD'S DISEASE 
751 
condition, especially among women; thus, Lindner found that one out 
of every four women had displaced kidney; Mathieu found 85 cases 
among 306 patients; Larrabee reports 112 cases among 272 patients 
in the Out-patient Department of the Boston City Hospital; Glenard, 
in his statistics published in 1893, found 481 cases of floating kidney 
among 3788 patients, 2.7 per cent, in men and 22 per cent, in women; 
Wolkow and Delitzen found 66 cases among 221 women; Einhorn found 
nephroptosis in 1.81 per cent, of males and 20.6 per cent, of females. 
According to Burnam, who has carefully investigated the records of the 
Johns Hopkins Hospital, one out of every 5 women had a movable 
kidney, and one out of every 50 men, these figures agreeing absolutely 
with those of Tuffier. 
As regards the grade of displacement, Glenard describes four degrees: 
(1) When the lower portion of the kidney can be felt only during deep 
inspiration; (2) when the greater portion of the kidney can be felt, but 
the upper border cannot be made out; (3) when the whole kidney can 
be palpated during deep expiration; and (4) when the entire kidney 
can be palpated, and is capable of being moved about the abdominal 
cavity, this latter being the true floating kidney. According to Ewald 
and Kuttner, the degrees of displacement are: (1) The kidney shows a 
demonstrable respiratory movement without being dislocated to any 
extent; (2) the kidney shows a dislocation of the first degree, that is, we 
are able to palpate from one-third to two-thirds of the organ, which can 
be moved by means of the hand, and is more or less dislocated forward; 
(3) the kidney shows a dislocation of the second degree, that is, is palpable 
over its entire extent, is easily moved by the hands and during respiration, 
and lies near the anterior abdominal wall, or, at least, is easily brought 
there; and (4) the kidney is dislocated and fixed in an abnormal position. 
In Kuttner's and Ewald's series of 79 cases associated either with dilata- 
tion or displacement of the stomach, in 47 the right kidney was displaced, 
in 7 the left kidney, and in 25 both kidneys; 18 cases fell under the first 
grouping, 64 under the second, 19 under the third, and 3 under the 
fourth. 
As regards age, displaced kidney, as well as ptoses of the other viscera, 
is frequently met with in very young children, in several cases under 
three years of age. In Kuttner's series of 326 cases, 6 were found between 
one and ten years, 32 between ten and twenty, 82 between twenty and 
thirty, 123 between thirty and forty, 49 between forty and fifty, 26 
between fifty and sixty, and 8 between sixty and seventy; that is, the 
great majority of these patients when seen by the physician for the first 
time are between twenty and fifty years of age. Blum has recorded 
many cases among children, and we have noted the condition frequently 
in very young infants. 
As to the relation of pregnancy to floating kidney, in Kuttner's series 
of 94, 40 patients had never borne children, 10 had borne one child each, 
and 44 had borne two or more children each. In Landau's series, 31 of 
34, on whom notes were made, had borne no children, while in Lindner's 
series of 75 patients, 24 had never been pregnant, 12 had been pregnant 
once, 30 had been pregnant two or more times, while of the others no 752 
DISEASES OF THE DIGESTIVE SYSTEM 
notes were to be found. Of Drummond's 27 women patients 16 had 
borne children, while of Larrabee's 112 cases, 51 were nulliparous and 
50 multiparous. 
As regards the frequency with which right, left, and both kidneys are 
affected, in Kuttner's series of 727 cases, in 553 the right kidney alone 
was movable, in 81 the left kidney alone, and in 93 both kidneys. In 
Einhorn's series the right kidney alone was movable in 77.3 per cent, 
of the cases, the left kidney alone in 2.1 per cent., and both kidneys in 
20.6 per cent. 
As regards the incidence of gastroptosis, figures are of little value 
because, in the first place, the condition is generally overlooked unless 
associated with gastrectasis or unless special examination is made either 
by inflation or the use of the x-rays, and in the second place because 
many of the symptoms, which in reality were due to a displacement of 
the stomach, have been ascribed to displacement of the kidney and treated 
accordingly. Kuttner and Ewald report 100 cases of displaced kidney, 
94 in women, 6 in men, in 79 of which there was either a dilatation or 
displacement of the stomach. The writer's experience has been that in 
almost all the cases of splanchnoptosis the stomach is involved to a 
greater or less extent. The subject is still somewhat undecided because 
of the great difference of opinion as to the normal position of the stomach. 
Glenard has reported 51 cases of displaced liver, 32 being associated 
with movable kidney, and of these, 30 were women and 2 men. Einhorn 
reports 21 cases of displaced liver in 369 women, 9 cases in 439 men; a 
moderate degree of abdominal flaccidity was present in 16 of the 21 
women. Graham has collected 68 cases of displaced liver, 55 in women, 
13 in men, and Savelieff has recently collected 118 cases from the 
literature. 
Several isolated cases of floating spleen have been reported, although, 
unless the spleen is markedly displaced, a ptosis is difficult to determine, 
because of its position, which can only be determined by the most 
careful percussion and because of the absence of symptoms. The 
frequency of displacement of the pancreas, of the colon, and of the 
sigmoid flexure is difficult to determine. The displacement of the pan- 
creas is of interest because Glenard's corde colique transverse, which he 
believed to be the constricted transverse colon, Ewald regards as the 
pancreas. 
Cardioptosis, or the descension of the heart, has been described in a 
few cases. Einhorn found it 22 times in 926 patients, 18 men, 4 women, 
and in about one-half of these cases there was an associated hepatoptosis. 
He thinks the condition is probably due to the downward displacement 
of the diaphragm. Abnormal position of the oesophagus and cardio- 
spasm have been noted in a certain number of cases of gastroptosis. 
The association of displacements of the pelvic organs with splanchno- 
ptosis is a subject to which very little attention has been paid, and yet 
it is one of extreme importance, because retroflexion of the uterus is a 
very frequent accompaniment of displacement of various abdominal 
organs. Smithwick found that of 34 women with splanchnoptosis, 80 
per cent, had retroversion of the uterus generally in a marked degree. SPLANCHNOPTOSIS, VISCEROPTOSIS, GLENARD'S DISEASE 
753 
Symptoms.-We will discuss the symptomatology of splanchnoptosis 
in general, and later call attention to the symptoms especially referable 
to each of the displaced organs. In the first place, it must be insisted 
upon that there may be absolutely no symptoms whatsoever, and, in 
the second place, that the intensity of the general symptoms does not, 
as a rule, depend so much upon the extent of the displacement of the 
various viscera as upon the degree the nervous system is involved. In 
this connection we must not forget that all of these symptoms have been 
ascribed in turn to each of the viscera, according to whether kidney, 
stomach, liver, or intestines were the special object of study, and yet 
that in the vast majority the symptoms are referable to a displacement 
of all or most of the viscera, although the degree of displacement may be 
different. The usual picture of a case which presents symptoms is that 
of a thin, pale young woman or man of slight build, with dyspeptic and 
nervous complaints, a nervous expression, and thin, soft abdominal walls 
in which there is a marked lack of tone. Some have called attention 
especially to the juvenile expression of the face, others to the fact that 
the picture closely resembles that met with in phthisis. We may have 
symptoms of the most aggravated type of neurasthenia, to which are 
added various abdominal symptoms, such as indigestion, constipation, 
pain in various portions of the abdomen, a feeling of lack of abdominal 
support, frequent, sometimes painful, urination, backache, sideache, 
various respiratory symptoms, cardialgia, pain during or after meals, 
sometimes nausea and vomiting. All of these symptoms are aggravated 
by standing, walking, or exercise, while the prone position causes them 
to markedly diminish and sometimes to disappear for the time being. 
It is also noteworthy that the symptoms become less if the abdomen is 
lifted up either by an artificial support or by the hands of the physician 
as he stands behind the patient-the so-called "belt test" of Glenard- 
or after elevation of the foot of the bed. The greater the congenital 
anomaly, and the earlier the adjuvant factors act upon one so predisposed, 
the sooner will these symptoms make their appearance. Among the 
more important objective symptoms may be mentioned a flattened 
abdomen, often with hypoplastic walls, a bent spinal column, sometimes 
an abdomen flattened in the epigastric region but distended below the 
level of the umbilicus; sensitiveness to pressure near the tenth rib in 
some cases, a cord-like transverse colon (or displaced pancreas, according 
to Ewald), through which the pulsation of the aorta can be distinctly 
felt; while in some cases visible swellings can be seen in abnormal locations 
due to displacement of the various viscera. 
Glenard divided the symptoms into three special groups: hypostasis, 
or lack of tone of the abdominal walls, splanchnoptosis, and entero- 
stenosis. The first shows three special symptoms: deformity of the 
abdomen, flabbiness of the abdominal walls, and the ease with which 
the hypochondrium can be compressed. Splanchnoptosis shows four 
special signs: splashing sounds in the stomach, epigastric pulsation, 
floating kidney, and ptosis of the transverse colon. Enterostenosis has 
three special signs: palpable contracted band of the transverse colon, 
of the cecum, and of the sigmoid flexure. 754 
DISEASES OF THE DIGESTIVE SYSTEM 
Other symptoms of the most protean character have been ascribed 
to this condition. Meinert believes that chlorosis in young girls is some- 
times a crisis of splanchnoptosis, while Quincke puts stress upon'the 
respiratory symptoms, such as shortness of breath on standing or after 
exertion, cardiac oppression or distress, and sometimes dizziness or 
weakness. 
Glenard himself describes four forms of splanchnoptosis, the gastro- 
intestinal, the lithemic or hepatic, the neurasthenic, and the cachectic, 
and believes that in many cases the patient goes from one form into the 
other in the order named. Keith, who has paid so much attention to 
the respiratory phenomena of splanchnoptosis, calls special attention 
to the frequency with which cervical curvature or ewe-neck is met. 
He believes that from a clinical point of view the most important of 
the visceral bonds is the gastrohepatic omentum, and that more than 
half the results of ptosis of the liver and stomach are due to compression, 
straining or distortion of the bile, blood, nerve and lymph channels 
contained in this omentum, and that gall-stones are commonly present 
in cases of splanchnoptosis. 
As to the relationship between neurasthenia and splanchnoptosis, 
there is a marked difference in opinion, some holding that neurasthenia 
is primary and splanchnoptosis is secondary, others the reverse, while 
a third group holds, and probably rightly, that in most cases each 
represents a congenital fragility of tissue independent primarily of each 
other, but frequently associated and reacting very deleteriously upon 
each other. 
It must strike our gynecological brethren that the symptoms which 
they have ascribed to retroflexion of the uterus bear a striking resem- 
blance to those of splanchnoptosis, and this accentuates the fact already 
noted that in the vast majority of cases retroposition and retroflexion 
of the uterus are but associated signs of a general splanchnoptosis, and 
to expect relief by a ventral fixation of the uterus seems chimerical. 
Gastroptosis.-Gastroptosis, although one of the less frequently 
recognized of the visceral ptoses, is one of the most important as regards 
symptomatology. Undoubtedly many of the symptoms referred to dis- 
placement of kidney or liver are in reality due to an unrecognized dis- 
placement of the stomach. As to its frequency, it is being more and 
more recognized as it is being more carefully investigated. Meinert 
finds displacement of the stomach in 80 per cent, of the patients in his 
gynecological clinic, while Thompson, who has noted many cases, finds 
it six times more common in women than in men. 
In the downward dislocation of the stomach we have two main forms: 
First, the whole stomach may be dislocated downward, and second, the 
stomach may occupy a more vertical position, although, strictly speaking, 
the former is rare, due to the firm fixation of the cardiac end. The 
most frequent form is the subvertical, the next is the vertical, while the 
loop, crescent, or garland form is less common. The vertical or sub- 
vertical forms are peculiarly liable to dilatation, this being, of course, 
aided by a general weakness of the patient, frequent overloading of the 
stomach, relaxation of the abdominal wall, pregnancy and parturition, SPLANCHNOPTOSIS, VISCEROPTOSIS, GLENARD'S DISEASE 
755 
rapid loss of weight, and constriction due to corsets. As regards symp- 
toms, there may be none whatsoever; in fact, the symptoms directly 
referable to the stomach are largely dependent upon the associated 
dilatation of the motor or secretory anomalies. Steele and Francine 
found some dilatation of the pyloric extremity in each of 70 patients 
examined by them. We must, therefore, regard the symptoms met with 
in gastroptosis as largely due either to a perversion of the motor or the 
secretory powers of the stomach, or to a dilatation with its characteristic 
symptoms due to the retention and decomposition of food, and the 
associated toxemia. If the ptosis is marked, it is hard to see how it is 
possible to prevent difficulty in the propulsion of food, leading to increased 
fermentation in the stomach and subsequent distension and atony. 
So long as the stomach is not overtaxed there is little or no distress, for 
if the ptosis is not great the stomach is easily able to perform the addi- 
tional amount of labor. If, on the other hand, excessive work is thrown 
on the stomach, as after very large meals, rapid eating, the ingestion 
of much easily fermenting food, or the upright position after eating, 
the stomach is unable to do the excess of work, and dilatation occurs. 
The symptoms which are especially referable to the displacement of 
the stomach are distress and flatulence after meals, sometimes nausea 
and vomiting, tachycardia, anorexia, coated tongue, numbness and 
dizziness, pain, which may be due either to fermentation, associated 
catarrh, increased acidity, or the pressure of the displaced stomach on 
the solar plexus, and a feeling of lack of support, while in some cases 
the dread of gastric disturbances leads to slow starvation and cachexia. 
Many of these symptoms are, of course, in the main due to the associated 
dilatation or motor insufficiency, while in all cases the quantity of food 
seems to be of more importance than its quality in the production of 
symptoms. Rose believes that the condition is identical with atonia 
gastrica. A splashing or a rumbling sound in the stomach is frequently 
met with. Of course, it must be remembered that in many cases the 
symptoms are more referable to the neurasthenia so frequently asso- 
ciated with this condition than to the displacement of the organ per se. 
In gastroptosis, as in the other ptoses, the symptoms are usually lessened 
by the prone and increased by the upright position. 
As to the effect of ptosis upon the gastric secretion, subacidity is the 
rule as shown in patients examined by the writer; as the dilatation 
became more marked the free hydrochloric acid diminished, and was 
absent in most of the patients with very high grades of dilatation. 
Steele and Francine, from a study of 70 cases, also found that diminution 
of free hydrochloric acid was the rule. 
Nephroptosis.-Of all the divisions of splanchnoptosis, nephroptosis, 
or displaced kidney, has absorbed by far the greatest amount of attention 
and study, an unfortunate condition in many ways, because to it have 
been ascribed many of the symptoms which undoubtedly are referable 
to the displacement of other organs. Some, such as Israel, Litten, 
Morris, and Kuttner, believe that the so-called first degree of displace- 
ment of the kidney is not pathological. Harris, who is a firm believer in 
the congenital origin of nephroptosis, and who found a movable tenth 756 
DISEASES OF THE DIGESTIVE SYSTEM 
rib in 61 of 110 cases, believes that the characteristic sign is a peculiar 
body form, a marked contraction of the lower end of the middle zone 
of the body, with a diminution of the capacity of this portion of the body 
cavity. Becker and Lenhoff divide the distance from the suprasternal 
notch to the upper edge of the symphisis pubis by the least circumference 
of the abdomen, for the sake of convenience multiplying this by 100; 
the average index was 77, and they found that if it was above 77 the 
kidneys could usually be left, while if below 75, as a rule they could not 
be felt. Albarran, Sheldon, and others, have noted numerous cases in 
the same family. 
Among symptoms definitely referable to the kidneys themselves may 
be mentioned a feeling of lack of support in the back and flank, frequent 
urination, associated with burning sensations, which is sometimes 
diagnosed and treated as cystitis, and pain which may be either con- 
tinuous or intermittent, and which is often relieved by the patient 
lying down. There may be intermittent hydronephrosis with polyuria 
after the reduction of the kidney to its normal position, the so-called 
Dietl's crises, consisting of paroxysmal attacks of intense pain, nausea, 
and vomiting, according to some due to intermittent hydronephrosis, 
according to others to torsion of the renal vessels and nerves. Blood, 
albumin, and casts may occur in the urine. Some believe that the dis- 
placed kidney produces and maintains a congestion of the pelvic organs. 
Some patients complain of feeling a moving mass in the abdomen, 
others have definite symptoms of sciatica and crural and intercostal 
neuralgia. Intermittent hematuria and nephritis have been described, 
while in two cases of post-operative pyelitis examined by the writer 
the fact that the affected kidney was in each case the displaced organ 
suggests that its resistance is lowered by the displacement. 
Burnam, from his study of the cases of nephroptosis in the Johns 
Hopkins Hospital, finds that only one case in ten of movable kidney has 
marked local symptoms, the cardinal symptoms being pain in the side, 
gastric symptoms, and nervousness. The dragging dull pain in the 
flank is about three times as common as acute attacks of Dietl's crises. 
About one out of every eight cases with Dietl's crises shows a beginning 
hydronephrosis, about one out of every three cases shows marked gastric 
symptoms, and one out of every three cases shows pronounced nervous 
symptoms. Tuffier believes the gastric symptoms in nephroptosis are 
due to an atonic gastric dilatation, while of the paroxysmal pains in 
the renal region he describes two kinds: first, slight pain followed by 
the passage of much clear urine, and second, the pain associated with 
intermittent hydronephrosis, a renal tumor usually being made out 
during the paroxysm, while the amount of urine, which is markedly 
diminished with the onset of the pain, is often markedly increased with 
its subsidence, part of this increased flow being due to reflex stimulation 
of the healthy organ. Kelly, by catheterization of movable kidneys, 
has shown that a slight hydronephrosis is the rule, for he found the 
average capacity of the renal pelvis in 65 cases of nephroptosis to be 
between 12 and 13 cc., the normal capacity being 7 to 8 cc. 
The relationship between nephroptosis and dil ^tion of the stomach SPLANCHNOPTOSIS, VISCEROPTOSIS, GLENARD'S DISEASE 
757 
has not as yet been definitely determined. According to some the 
gastrectasia is definitely secondary to gastroptosis, while according to 
others the displaced kidney plays a very important part in the production 
of the dilatation. It seems probable that the dilation of the stomach 
so frequently met with in splanchnoptosis is in the vast majority of 
cases etiologically dependent upon the gastroptosis, and that there is no 
causal relationship between it and floating kidney except in very rare 
instances. There is no question but that chronic appendicitis is fre- 
quently associated with displaced right kidney. Many have also called 
attention to the relationship between floating kidney and obstruction 
of the common bile duct. 
Hepatoptosis.-Floating liver is frequently not diagnosed, due partly 
to the difficulty in making out a moderate degree of displacement, 
partly because it is frequently regarded as an enlarged liver and partly 
because by the vast majority of observers the kidney is the only organ 
carefully investigated in splanchnoptosis; yet the tables of Graham, 
Einhorn, Landau, and others show that the condition is not rare. The 
symptoms of the condition are rather indefinite. There may be sponta- 
neous pain, which is sometimes brought on by jumping, walking, raising 
the right arm, sneezing, coughing, and yawning, while sometimes parox- 
ysms of pain occur without apparent cause. In the writer's experience 
pain has been a very common symptom, usually relieved by making 
the patient lie on the back or on the right side, or by manual replacement 
of the organ. The pain is commonest in the right hypochondriac and 
epigastric regions, radiating thence toward the shoulder or the flank. 
Pressure, although rarely painful, often produces peculiar sensations 
in various portions of the body, especially the arms and shoulders. 
Many patients complain of digestive symptoms, meteorism, constipa- 
tion, or of feeling a movable body, colicky pains, respiratory disturbances, 
palpitation and jaundice. Keith believes that they are caused by the 
compression of the bile, blood, nerve, and lymph channels contained in 
the gastrohepatic omentum and that gall-stones are very commonly asso- 
ciated. Steele showed by experiments on a cadaver that biliary obstruc- 
tion is met with in floating liver, pressure in the common duct being 
between two and three times the normal. Landau describes three 
grades of hepatoptosis: (1) moderate descent with anteversion or retro- 
version; (2) marked descent either with lateral displacement toward 
the right, or with anteversion or retroversion; (3) vertical or oblique 
displacement, the left lobe descending into the abdominal cavity. 
Descent of the Intestines.-This is practically met with in every case 
of splanchnoptosis, but the difficulty of making a definite diagnosis 
has made most observers minimize its importance, yet the intestinal 
symptoms are many and diversified, and among them may be mentioned 
constipation, fermentative dyspepsia, mucous colitis, which is quite 
common, various symptoms due to stenosis of the intestines, marked 
fulness in the lower half of the abdomen, and peristaltic movements in 
the displaced intestines, often made out if the abdominal wall is thin. 
Ewald believes that the intestinal disturbances are due to the dragging 
of the bands on which the sections of intestines are hung, producing 758 
DISEASES OF THE DIGESTIVE SYSTEM 
reflex irritation of the intestines, disturbances in their circulation, 
their motor and secretory functions, while, due to the sinking of the 
transverse colon, the horizontal portion of the duodenum is pulled 
downward. It is possible that a low grade of peritonitis may develop 
from the persistent fecal stasis, and that this may be the cause of Lane's 
band, Jackson's veil, etc. The small intestines, containing liquid feces, 
are but slightly affected by ptosis, but in the large intestines, containing 
solid feces, a loop or kink is of much more serious importance and may 
produce marked constipation and possibly the symptoms of auto- 
intoxication. A kinked or a redundant sigmoid is often the cause of 
most intractable constipation. 
Descent of Spleen and Pancreas.-The descent of the spleen has been 
rarely described, because it is difficult/to recognize slight displacements 
and because symptoms are usually absent. In a few cases which have 
symptoms the patients complain of dragging, uneasy sensations in the 
back and side. All grades of splenic displacement have been described, 
while the fact that several cases have been found in members of the 
same family suggests a congenital origin. The organ is usually enlarged, 
while sometimes torsion of the pedicle may occur with gangrene. 
As regards the pancreas, we must remember that a segment of this 
organ is firmly bound to the radix mesenterica, and is, therefore, fixed, 
but Ewald believes that the other portion may undergo descension, and 
may be felt as a constricted cord, which Glenard believed to be the 
transverse colon. 
Diagnosis.-The diagnosis of splanchnoptosis should be easily made 
by all careful observers. It can often be made when the patient is first 
seen; the characteristic body form, the expression frequently described 
as juvenile, the evident neurasthenic tendency so frequently associated 
with splanchnoptosis should at once call our attention to the possibility 
of this condition. Harris, Becker, Lenhoff, and others have expressed 
this peculiar body form mathematically, and the measurements which 
can be made in a few moments are often very suggestive. Others insist 
on the importance of a floating tenth rib in this condition. In all cases 
the vague and protean symptom-complex of nervous and digestive dis- 
orders, inability to do hard mental or physical work, and the other 
symptoms which have been described should make us suspect the con- 
dition. We must remember, however, that many patients show no 
symptoms whatsoever, and in such the diagnosis can only be made 
by a careful physical examination. 
As regards the diagnosis of gastroptosis, splashing or succussion sounds 
are frequently heard, there is commonly a sinking in of the epigastrium, 
with a bulging in the region of the umbilicus or below it, while if the 
abdominal wall is thin peristaltic waves may occasionally be definitely 
seen. To exactly diagnose the form and position of the stomach we 
may attempt to percuss the organ, use auscultatory percussion, or we 
may with the stethoscope over the stomach determine the length of 
time it takes for fluid to pass from the mouth into this organ. All 
these methods, however, are inexact, and it is advisable to distend the 
stomach; make use of Turek's gyromele; Einhorn's method of gastric SPLANCHNOPTOSIS, VISCEROPTOSIS, GLENARD'S DISEASE 
759 
diaphany, an electric light being introduced into the stomach; or inflate 
the stomach with water. Recently much work has been done in using 
the .T-rays in diagnosing this condition. The fish-hook, vertical, cow- 
horn (crescent, half moon), and spasmodic hour-glass forms have been 
regarded as normal types. Certainly from z-ray examinations the 
position of the normal stomach and intestines is lower than that described 
by the anatomists, this in part, however, being due to the fact that 
most fluoroscopic examinations of the gastro-intestinal tract are made 
in the upright position. 
In nephroptosis sometimes the displaced kidney can be distinctly 
seen through the thin abdominal wall, while in many cases a sinking in 
of the flanks can be noted. The only satisfactory way to make the 
diagnosis, however, is by means of bimanual examination and palpation 
of the organ. The patient should be examined both in the standing 
position, lying on the back, and lying on either side, while it is extremely 
important in many cases to make the patient walk around, hop, jump, 
or support herself with both hands on the side of the bed before making 
the examination. Many mistakes have been made by examining patients 
in bed after a night's rest when the kidney has returned to its normal 
position. Glenard's procede de pouce, the lifting up of the kidney with 
the fingers and its palpation with the thumb is a simple and easy method 
of determining displacement of this organ. In the case of Dietl's crises 
a tumor in the lumbar region is frequently made out, which disappears 
on the cessation of pain. It is an unquestionable fact that too frequent 
or too severe palpation of the kidneys may harm these organs, and 
albumin, casts, and blood may be found after such an examination. 
In hepatoptosis we practically always find a tumor in the right side of 
the abdomen with its convex surface directed forward. In making the 
diagnosis we use both palpation and percussion. On percussion the 
liver dulness, instead of beginning at the fifth rib or fourth or fifth 
interspace in the mammillary line, is at a much lower level, often the 
costal margin, while the lower limit of dulness is correspondingly 
depressed. In place of the normal liver note in the hypochondrium and 
epigastrium, we meet a tympanitic note due to the ascent of coils of 
intestine. When the patient is made to lie on his back or his right side 
with the hips elevated, the liver usually falls back into its normal position, 
and the topographical percussion is normal. For this reason it is impor- 
tant to percuss first with the patient in the erect position. By bimanual 
palpation we can make out the characteristic tumor in the hypochondriac 
or lumbar region; the patient must be examined in both the prone and 
upright position, and an attempt must be made to replace the organ. 
Because of the rotation of the organ the liver always seems enlarged. 
Sometimes by inspection a slight bulging of the abdomen on the right 
side is made out. We must remember that sometimes replacement is 
impossible because of adhesions, while in all cases we must differentiate 
a displacement which is part of a general splanchnoptosis from that 
due to pleurisy with effusion, diaphragmatic abscess, or from enlargement 
or tumors of the liver. 
In diagnosing displacement of the intestines, by far the most satisfactory 760 
DISEASES OF THE DIGESTIVE SYSTEM 
method is the use of the arrays, bismuth being given either by mouth 
or by enema. Usually the cecum and the transverse colon can be palpated 
as cords, while inspection will sometimes show us peristaltic waves in 
the displaced coils. By distension through a rectal tube by air or nitrogen 
gas we can usually determine satisfactorily the position of the trans- 
verse portion of the colon. The pulsation of the abdominal aorta can 
usually be easily felt. The low position of the hepatic and the high posi- 
tion of the splenic flexure, and the fact that the contents appear to 
remain longer in the cecum than elsewhere have been specially noted 
in rr-ray examinations. 
The diagnosis of splenoptosis is usually easy, as by palpation the 
organ with its sharp edge and notch may be easily made out. If, how- 
ever, the organ is fixed in an abnormal position and deformed by adhe- 
sions the diagnosis is much more difficult. 
If we make use of the methods described above, the diagnosis of 
splanchnoptosis should be easily made. In women from a careless 
examination the condition is frequently regarded as a purely gynecological 
one, while in some cases gastroptosis with the cachexia sometimes 
associated with it has been mistaken for gastric ulcer or carcinoma. 
Among the conditions which may be mistaken for floating kidney are 
fecal tumors in the hepatic flexure or in a loop of the small intestine, 
a distended gall-bladder, a myoma of the uterus with a long, thin pedicle, 
or a small ovarian cyst or tumor. Among the conditions for which 
floating liver has been mistaken may be mentioned renal tumors and 
hydronephrosis, nephroptosis, and certain rare cases of thickened 
mesentery or omentum. The spleen has occasionally been mistaken 
for a uterine myoma, or an ovarian cyst or tumor. 
Prognosis.-It must be remembered, in the first place, that in many 
patients no symptoms are present and no treatment necessary. If 
they are seen early and are willing and able to carry out the prophylactic 
measures described, or in those cases in which the symptoms are almost 
exclusively referable to one displaced organ, real success may attend 
the treatment, be it medical or surgical; but in the majority of cases 
seen in adult life, when the organs show considerable displacement, 
the symptoms are marked and varied and the nervous system consider- 
ably involved, although the condition may be markedly relieved in 
many cases and in some the symptoms made to entirely disappear, yet 
there will be a large number in whom treatment is discouraging. 
Treatment.-The treatment is in the main rather unsatisfactory, 
particularly so if the symptoms have been present a long time and the 
displacement of the various viscera has reached a marked degree. To 
comprehend the proper treatment it is well to remember that in the 
majority of cases the condition in all probability depends on a congenital 
fragility of tissue, while in those so disposed numerous secondary factors 
may bring about the displacement of the various viscera. 
Prophylaxis.-To prevent marked manifestations of splanchnoptosis 
it is most important that the tendency should be recognized early and 
every possible method of prophylaxis carried out. Children with the 
characteristic body form, or with a slight displacement of any of the SPLANCHNOPTOSIS, VISCEROPTOSIS, GLENARD'S DISEASE 
761 
abdominal viscera, should be treated with the utmost care; they should 
be made to lie down during certain hours of the day, especially after 
meals; great care should be paid to their diet, and if they are extremely 
thin every effort made to fatten them; the strength of the diaphgram, 
the intercostals, and the abdominal muscles should be increased by 
carefully chosen exercises; they should be given breathing exercises, in 
hope of enlarging the lower thoracic zone; sometimes they should be 
made to wear abdominal bandages for a short period of time if their 
abdominal muscles show great lack of tone; abdominal massage should 
be given if possible, and everything should be done to put them and to 
keep them in the best possible physical condition. 
Attention should be paid to all persons, whether adults or children, 
during and after acute or chronic diseases associated with marked loss 
of weight or diminution of muscular tone, and one should be most 
careful about allowing such patients to get up from bed and go back 
to active occupations. Systematic overfeeding associated frequently 
with massage should be carried out to bring back body weight and 
muscle tone to normaf. Great care should be taken after rapid obesity 
cures, and it is probable that in this, as well as in a number of the other 
above conditions, wearing a bandage for a short period of time would 
be advisable. Too much care cannot be taken during the puerperium. 
The patient should not be allowed to get up too soon, and when she does 
she should be provided with a snug abdominal support until the 
mechanical conditions within the abdominal cavity approximate the 
normal again. Great care and practically the same precautions should 
be taken after the removal of large quantities of ascitic fluid, or of large 
abdominal tumors, for in these conditions, as in pregnancy, there occurs 
a sudden diminution of intra-abdominal pressure. It is essential that 
we as physicians should demonstrate to our patients the dangers from 
the use of tight corsets or tight belts, and if they insist upon their con- 
tinuance try to persuade them to wear the less unhealthful kind, that 
is, the straight front corset, in which the pressure is exerted upon the 
lower half of the abdomen. The great majority of patients with splanch- 
noptosis are deficient in body fat, and even when no symptoms are 
present we should advise such patients to so regulate their diet and mode 
of life that an increase in weight will take place. Patients with this 
tendency should systematically carry out breathing exercises and other 
exercises to improve the tone of their respiratory and abdominal muscles. 
General Treatment.-The diet in splanchnoptosis depends largely 
upon the degree to which the stomach and intestines are involved. 
Ample nutrition to increase the body weight is most important, and this 
is best obtained by following a simple mixed dietary with little fluids 
at meals, while often between meals raw eggs and milk are given; in 
other cases the patient may be put at first on an absolute milk diet 
associated with rest. By these methods weight can be added with 
practically always a marked improvement; we must, however, be 
extremely careful not to overload the stomach and not to increase the 
tendency toward dilatation. Often it is advisable to insist that the 
patient lie down for some time after each meal. 762 
DISEASES OF THE DIGESTIVE SYSTEM 
We should advise our patients, against wearing tight clothing, and 
especially against wearing anything that constricts the lower half of the 
thorax. Great benefit can be derived from carefully selected outdoor 
exercises and Swedish movements, although these must not be overdone; 
in fact, it is wise to begin very gently and to gradually increase as the tone 
of the abdominal muscles improves. Patients should be taught the proper 
mode of breathing and of standing. Both abdominal and general massage 
is of real value in this condition. Electricity has been recommended. 
It has been frequently observed that after rest in bed, especially 
with the foot of the bed elevated, these patients often show marked 
improvement, especially in cases of marked gastroptosis with some 
dilatation, and a strict rest cure often produces splendid results. In 
some cases during pregnancy the symptoms are markedly relieved. 
Hydrotherapy is often helpful both as regards the gastro-intestinal 
and the nervous symptoms, and the Scotch douche has been found 
specially beneficial. In cases of associated dilatation of the stomach 
lavage is sometimes indicated in association with a careful diet. 
Medicinal Treatment.-Medicine plays but a very small part in the 
treatment. For the constipation so frequently present we should first 
try massage, and perhaps electricity, exercise, diet, and hydrotherapy;- 
if these do not prove effectual, enemata may be given, especially those 
of oil, while if laxatives are necessary, we may use sodium sulphate 
and aloes, as suggested by Glenard, or Epsom or Rochelle salt, as sug- 
gested by Ewald, or any simple laxative. If anemia is present, iron 
and arsenic are indicated, although each must be used with care, because 
they may increase the gastro-intestinal symptoms. As a general tonic 
nothing is so good as strychnine in increasing doses. As regards water, 
but little should be taken with the meals, as a rule, but a considerable 
amount should be taken on waking, in the middle of the morning and 
afternoon, and at bedtime; the alkaline waters are especially satisfactory. 
We may give alkalis for hyperchlorhydria, hydrochloric acid and bitter 
stomachics in subacidity and anacidity. 
Treatment by Mechanical Supports.-In the hands of most clinicians 
the use of various mechanical supports in association with the measures 
already described has proved of great value. The object of the support 
is to lessen the volume of the lower half of the abdomen and to increase 
intra-abdominal pressure; to get satisfactory results it is essential that 
the corset or belt should be applied with the patient in the inclined 
dorsal position, so that the various viscera are in their positions of least 
descension. The support is dangerous if it is not well made or applied 
properly, because if the pressure is above any of the displaced viscera 
it increases the descension, and unless the patient carries out systematic 
abdominal exercises the use of the bandage is likely to decrease the tone 
of the abdominal muscles. As a rule, when its use is associated with 
the proper dietetic, hygienic, and medicinal measures, a disappearance 
of many of the symptoms results in the majority of cases. 
Many different kinds of bandages have been recommended: Glenard 
advises an elastic bandage with straps; Rose one made of adhesive 
plaster; Gallant a corset made to fit the patient and laced from below SPLANCHNOPTOSIS, VISCEROPTOSIS, GLENARD'S DISEASE 
763 
upward with the patient in the inclined dorsal position. Ewald and 
Kuttner use besides the bandage a pad in kidney displacements, Riegel 
a pad or bolster in gastroptosis, Enriguez a pneumatic pad. 
Operative Treatment.-It has always been a moot question whether 
splanchnoptosis is a medical or a surgical condition. It seems that in 
the vast majority of cases it is strictly medical, and only surgical when 
the symptoms are so definitely referable to one organ that suspension 
will offer a good chance of the disappearance of the symptoms; in every 
case hygienic, dietetic, and mechanical measures should be faithfully 
tried first. Among the indications for surgical interference may be 
mentioned those cases in which practically all the symptoms are referable 
to the displacement of one organ. In the case of the kidney, Dietl's 
crises, intermittent hydronephrosis, symptoms suggestive of renal or 
hepatic colic, more or less constant pain, symptoms due to pressure of 
the displaced kidney upon other organs, or upon the sympathetic or 
genitocrural nerves, are all indications for operative treatment; and 
also, as Kelly has shown, when the attacks of pain may be reproduced 
by injecting salt solution into the renal pelvis through a ureteral catheter. 
In the case of the liver, pain of a tearing, twisting character if frequent, 
attacks like hepatic colic, and symptoms due to pressure on other organs, 
in the case of the spleen, torsion of the pedicle with swelling and gangrene, 
in the case of the intestines, constipation which does not yield satisfactorily 
to any medicinal or mechanical treatment, are all indications for surgical 
measures. It seems also justifiable to try operative measures in those 
cases with marked symptoms when all other methods have failed. 
In operating upon the stomach various methods have been devised. 
Duret, in 1896, stitched the stomach to the abdominal wall; Lambotte 
attached by suture the splenic and hepatic flexures to the abdominal 
wall, thus lifting up the stomach; Webster resected the abdominal wall, 
bringing together the recti, which had undergone diastasis; Walker 
performed gastrojejunostomy; Eve operated by placing sutures through 
the lesser curvature, the lesser omentum, and the liver substance; 
Coffey by suspending the stomach in a hammock made by the great 
omentum; Blecher and Bier by shortening and folding the gastrohepatic 
ligament. Beyea passed sutures through the gastrohepatic and gastro- 
phrenic ligaments, the stomach by this method not being fixed, but 
elevated into its normal position without affecting its mobility; while 
in cases of gastroptosis with marked dilatation, gastro-enterostomy or 
perhaps in some cases pyloroplasty, may be performed. It must not be 
forgotten that in some of these cases fixation is followed by dilatation, 
persistent vomiting, and even by marked thinning of the stomach wall. 
As regards fixation of the kidney, many methods have been described, 
such as suture through the fatty capsule alone, through the fibrous capsule 
alone, through the kidney substance, splitting and dissecting the capsule 
and stitching it to the lumbar muscles, and packing with gauze, which 
is kept in until firm adhesions form. Most operators advocate suture of 
the parenchyma in addition to a free dissection of the fibrous and fatty 
capsule, while Kelly insists upon the Brodel stitch. Wehrmann and 
Harris believe that the tendency has been to stitch the kidney too high, 764 
DISEASES OF THE DIGESTIVE SYSTEM 
as the liver may again press upon the upper pole and bring about a 
recurrence of the condition. Relapses after nephropexy are due either to 
this or to insufficient fibrous union between the kidney and the lumbar 
muscles; in some cases the kidney is fixed in the wrong position and the 
function of ureter and bloodvessels markedly interfered with; in women 
a satisfactory nephropexy is peculiarly difficult because of the greater 
obliquity of the lower ribs. 
The mortality in nephropexy is practically nil. Burnam finds that 
the result of the anatomical fixing method is practically perfect, there 
being no failures if the operation is properly done. As to the results, he 
found that 90 per cent, were cured of pain, about the same number 
showed a relief of stomach symptoms, while 50 per cent, were improved 
nervously; the results where both kidneys were movable were practically 
the same as in the case of unilateral disease if both were suspended. 
Tuffier has found that the result of fixation of displaced kidneys when 
hydronephrosis is present is not so good as in cases in which it is absent, 
for while the operation relieves the pain, the distension if present for 
long has affected the integrity of the organ, and it never regains its 
normal tone. Treves believes from a study of 300 cases that suturing 
of the kidney should be a rare operation, as he believes as good, if not 
better, results are obtained by the use of mechanical supports. 
As regards fixation of the liver, hepatopexy, various operations have 
been devised and performed. Billroth and others have sutured the liver 
to the abdominal wall, Langenbech has selected the lower costal cartilages 
as the points of fixation, some have produced adhesions between the 
convexity of the liver and the diaphragm by irritation of their surfaces, 
while others have sutured the fundus of the gall-bladder to the parietal 
peritoneum. Rovsing has reported 18 hepatopexies with good results. 
In most cases movable spleen requires no special treatment, but with 
torsion of the pedicle and symptoms of stasis, or symptoms of pressure 
upon other organs, splenectomy has been done. 
In displacement of the intestines considerable surgical work has been 
done recently. In the case of the small intestines, filled with liquid 
feces, ptosis produces comparatively slight symptoms, but the presence 
of solid feces in the large intestines means that descension is frequently 
associated with persistent and intractable constipation, this being 
especially so in ptosis and kinking of the sigmoid. To counteract this, 
various operations have been performed, suspension of the sigmoid 
flexure (sigmoidopexy) and even resection of the sigmoid. Within the 
past few years resection of the colon as practised by Lane has been fre- 
quently done, while appendicostomy and cecostomy or colostomy, with 
subsequent lavage of the intestine for a long period through the new 
opening, have been done in the hope of relieving the toxic symptoms 
present in certain of the cases of very marked enteroptosis, especially 
those in which many adhesions are present. PART II 
DISEASES OF THE URINARY SYSTEM 
CHAPTER XI 
INTRODUCTION TO THE DISEASES OE THE KIDNEY 
JOHN McCRAE, M.D. (Tor.), M.R.C.P. (Lond.) 
Before considering in detail the diseased, states of the kidney, it is 
necessary to collate some of the most important facts relative to urinary 
excretion and the work performed by the several parts of the kidney. 
Some investigators exalt the importance of the glomerulus, others of 
the tubule; some believe that forces largely mechanical govern the 
excretion of urine, others that the vital powers and the selective ability 
of cells are more potent. As often happens in a discussion in which 
contraries are dogmatically asserted, there is some truth in both views: 
most physiologists believe that the urine is produced as the result of 
carefully coordinated work on the part of the vascular pressure, the 
secretory powers of the cells and osmotic influences at work between 
blood, lymph, cell-fluid, and urine. 
THE PHYSIOLOGY OF THE KIDNEY 
Since the days of Bright the importance of the kidney as a seat of 
disease has certainly not been underestimated, so that there are diseases 
with urinary manifestations, such as diabetes, in which it is difficult to 
keep the kidney out of the mental picture, innocent though it be. As 
an excretory organ, while it probably stands second to the alimentary 
tract, it certainly surpasses in importance the skin, whose total excretion 
of water it equals, and it greatly surpasses such subsidiary systems of 
excretion as the breath and the saliva. With excretion so large and so 
important, it is natural that it should be held responsible for much that 
merely goes past its portal; being dependent on other systems to a large 
extent, the abnormal products appearing in the urine are often not the 
product of disease of the kidney but of some other organ or system. 
The kidneys excrete and put the finishing touches upon the urinary fluid; 
they are acting at the end of the metabolic course both as active and as 
passive agents. There are some modifications of the excreted products 
over which they have control, and some over which they have none. 
765 766 
DISEASES OF THE URINARY SYSTEM 
The limits of such control are what we endeavor to determine by experi- 
mental work, and there is at our disposal evidence which tends to show 
that while to some extent the kidneys are mechanical contrivances, 
mere filters, so to speak, they are to a far greater degree active, specific 
glands.1 The daily performance of the healthy kidney is no doubt a 
combination of these mechanical and vital processes. Yet the more 
one follows the conflict of evidence and the varying results that have 
been obtained by the use of similar experiments on kidney functions, 
the more must it be realized that these functions need not be absolutely 
hard and fast, unalterable, specific rules of procedure. Glomerulus 
and tubule assist one another: in time of stress, one may compensate 
for failure of the other: if both fail together, their work may be tem- 
porarily performed, in some degree, by the adjuvant systems, the ali- 
mentary canal, the skin and the other lesser excretory organs. Witness 
in nephritis the excretion of urea in the saliva, of chlorides in the feces. 
It is obvious that the variations in experimental results, and the 
difficulty experienced in trying to lay down hard and fast rules as 
to kidney function arise from this very "give and take" between 
the different parts of the kidney, and between the kidney and its 
fellow-organs. 
The rules of function that can be fairly considered as settled are 
these: The glomeruli excrete water and salts, such as sulphates, phos- 
phates, and carbonates, especially when these are in excess; many foreign 
substances, such as sugar, peptone, egg albumen, and hemoglobin, if 
injected, are also excreted by the glomeruli; yet sugar is excreted by the 
tubules when the kidney is poisoned by phloridzin, and many pigments, 
when injected, have been found to be excreted by the tubules. Urea 
is so readily diffusible that it is hard to believe that it is not excreted 
by the glomeruli, yet urea and uric acid are generally credited to the 
tubules; uric acid, indeed, seems to be thrown out by the convoluted 
tubules and the ascending loop of Henle, while phloridzin, cantharidin, 
and perhaps mercury are excreted by the tubules. Apparent discrepancies 
as to the place of excretion of any substance arise not from mistaken 
observations, but because the adaptability of the kidney causes these 
substances to be excreted now in one way, now in another; in short, it 
seems as if the tubules can share almost every glomerular labor when 
the need arises. 
There is much reason to suppose that water and salts may be excreted 
by the tubular epithelium also. When, by reason of altered blood- 
pressure, the glomeruli cease their activity the tubular epithelium has 
been proved to take up their function, so that excretion goes on. Nor 
is this assistance confined to temporary embarrassments of the glomeruli. 
When by reason of disease many glomeruli are destroyed, as in advanced 
interstitial nephritis, the output of urinary water is often largely 
increased. This may be due to hypertrophy of the remaining glomeruli 
but the widening of tubules and the endothelial type of their regenerated 
1 The infiltration theory was enunciated by Ludwig, and was supported with 
modifications by Hans Meyer and Koranyi, while the secretory theory was upheld 
by Bowman, Heidenhain, and, again, with modifications, by Bartels. INTRODUCTION TO THE DISEASES OF THE KIDNEY 
767 
epithelium suggest that they have assumed the work of excreting water 
at the expense, it may be, of their original function. This illustrates 
compensation exerted by one part of an organ in favor of another. 
There is good reason to suppose that the action of the epithelium is 
not always supplementary to that of the glomeruli, but may be antag- 
onistic or at least exerted in a contrary direction: the tubular epithelium 
can absorb fluid from the stream passing down from the glomerulus. 
Its absorptive and secretory power can be exerted either from body 
fluid to urine or from urine to body fluid. Ludwig erroneously supposed 
that the tubule was given its vast length to act as a corrective upon the 
lavish glomerulus, which, like a filter, passed out urinary constituents 
in the same degree of concentration as that in which they existed in the 
blood, subsequent alterations being a function of the tubule. This 
much we may retain of his hypothesis, that the absorptive power of the 
tubular epithelium may be exerted in more than one direction. 
What function is to be credited to the glomerulus, then, if it be not a 
filter? There is much reason in Brodie's contention that its peculiar 
structure allows it to act as a "propulsor," driving the water out of the 
capsule by its quick expansion; this function is necessarily apart from 
its vital secreting action. Let us digress, at this point, to indicate some 
of the characters that the epithelium of the tuft and the epithelium of 
the tubules respectively possess. It has been shown that the somewhat 
flat epithelium of the tuft lies on the capillary directly, without the 
interposition of any lymph space. By its great superficial area it approxi- 
mates to the endothelial cell of the capillary, and thus, in the glomerulus, 
where mechanical forces (e. g., blood-pressure) are prominent, the urinary 
water has to pass through only two flat cells, the capillary wall on the 
inside, and the outer flattened epithelial cell, which latter, by its shape 
and absolute juxtaposition, can allow the fluid to pass as readily as the 
capillary cell. But, on the other hand, it preserves enough of its epithelial 
quality to remember its function. It is a kind of frontier customs officer; 
it possesses complete power of allowing substances to pass, but, in 
addition, it possesses the power of selecting and turning back the unde- 
sirable elements. This is the specific power in which it surpasses its 
humbler endothelial brother. The tubule cell, on the other hand, works 
in an entirely different way. Between it and its capillary is a minute 
lymph space, and the lymph bathes it on one side and the urinary water 
in the lumen on the other. Here the layer of lymph exists to allow the 
cell to work, not in response to mechanical but to osmotic forces. The 
blood and the lymph make their exchanges, and the lymph and the cell 
make theirs; the lymph thus becomes a kind of middleman, and while 
breaking the continuity of mechanical forces, substitutes the medium 
by which osmosis can proceed. This being the case, it is readily under- 
stood that the osmotic process can go on as well from the urinary water 
to the lymph, by way of the cell, as from the lymph to the urinary 
water. 
The Excretion of Water.-The most easily understood function of the 
kidney is the excretion of urinary water, mostly a glomerular but partly 
a tubular function; this varies in amount directly with the rapidity of 768 
DISEASES OF THE URINARY SYSTEM 
flow through the renal vessels, which rapidity may or may not be in- 
fluenced by a rise or fall in blood-pressure; a certain minimal blood- 
pressure is necessary, but, if this be obtained, the effect of transient 
rises or falls in pressure is less apparent than the results obtained from 
an increased or decreased rapidity of flow. 
Thus cardiovascular influences in general have their effect upon the 
excretion of urinary water, but the vasomotor influences exerted upon 
the kidney vessels themselves must be infinitely greater. Where these 
vasomotor stimuli arise and how they are conducted we do not know. 
Yet the results depending upon them are at times remarkable. What 
is the mechanism of hysterical polyuria, and why may a cannula inserted 
in the ureter cause anuria? Why does moderate venous interference 
lessen instead of increase the amount of water? Again, what is to be 
made of the immense increase of urinary water which may be found to 
follow the excision of large fractions of the kidney substance? Upon 
the answers to these questions we can only speculate, but, at least, they 
indicate how great is the elasticity of function in the matter of water 
excretion. While attention is directed to the importance of vasomotility, 
it must in addition be kept in mind that there is a cellular selective 
power in the epithelium and endothelium of the glomerular capillary, 
although we do not know whether the urinary water escapes through or 
between the cells or by both routes; whatever be the fact, the endothelium 
does possess a varying power of allowing fluid to pass, either by a shrink- 
ing of the cellular bulk and a consequent increase of the intercellular 
spaces, or by a distension of the vessel producing a flattening or thinning 
of the cells. It may be stated, however, as a probability that the excre- 
tion of urinary water is accomplished by a combination of several forces, 
acting together or separately, namely, the pressure and rapidity of the 
blood-stream, the personal power of the capsular epithelium and the 
endothelial cells of the capillary, and obscure influences on either or 
both of these brought about by nervous stimuli; all of these, again, 
being to a large extent under the dominance of local vasomotor nerves. 
The influences which act upon the output of urinary water are thus very 
far reaching, and are such as will react to many physiological, to say 
nothing of morbid changes; the difficulty of telling how far the kidney 
itself is at fault, or how far it is merely proving an adjuvant to some 
other system, is apparent. The kidney may act the last-named good 
part for the sake of some other organ, such as the heart, and it may do 
this so long and so continuously that it becomes a slave, and bears the 
brand of its master in a physical change which is indelible. 
The Excretion of Solids.-The separation of the solid substances of 
the urine forms the next function of the kidney, and these substances 
fall at once into two groups, inherently useful materials (which are in 
excess, such as sugar in alimentary glycosuria, or which have served 
their purpose, such as pigments), and substances that are inherently 
harmful. The latter class embraces many end products of metabolism 
which we are accustomed to consider as the normal constituents of 
urine, as well as incidental substances introduced from without and 
substances produced by pathogenic agents in the body. As has been INTRODUCTION TO THE DISEASES OF THE KIDNEY 
769 
indicated above, the power of excreting solids seems to be shared by the 
glomeruli with the tubular epithelium; in the glomeruli there is no doubt 
a certain degree of extrusion by mechanical force of substances in crystal- 
loid or soluble form in the blood which are permitted by the glomerular 
epithelium to pass. It seems wrong to deny to the glomerular endo- 
thelium a certain ability of selection, because we admit it for capillary 
walls elsewhere in the body, and, if there be no selective power in the 
endothelium, that of the epithelium must be exerted through the barrier 
of the capillary wall. Some substances no doubt escape through the 
intercellular spaces in the capillary wall and the glomerular epithelium, 
spaces which although of size varying with the degree of distension, are 
never large: it seems probable that colloid molecules like albumins 
are always too large to escape through these, while perfectly soluble 
substances like sugar can do so in minute quantity. If inflammation 
or other destructive process has been at work, the way may be clear for 
molecules of any size. The epithelium appears to be able to take up 
colloidal substances from the blood. The process here must be very 
complex-a combination of mechanical filtration, endothelial selection, 
more refined epithelial selection, and perhaps osmotic exchange as well. 
In the tubules, on the other hand (bearing in mind what has been said 
previously as to the insulation of the tubular cell by an infinitesimal 
layer of lymph), the process is reduced to a combination of selection and 
osmosis. Perhaps, after all, selection is but an expression of osmotic 
force. If we have any force other than osmosis, we must admit that it is 
exerted this time across the barrier of the lymph space and the basement 
membrane. Further, the renal epithelium has the power of synthesis, 
and forms complex substances that are not apparent as such in the 
blood or lymph, such as hippuric from benzoic acid, as well as the power 
of analysis, breaking down other substances, as creatin to form creatinin. 
These changes are due to the formation in the tubular cell of an enzyme 
which has been called histozyme, and it is a significant fact that it has 
an interchangeable action, changing benzoic acid and glycocol to hippuric 
acid, and the contrary. The bearing of this quality upon the supposition 
that the renal epithelium is free to exert its power toward absorption 
as well as toward excretion is obvious. 
Lastly, has the kidney an internal secretion in the sense in which we 
speak of the secretion of the thyroid, the pituitary, or the adrenal ? One 
is tempted to think so, although it must be admitted that we have no 
evidence that is undeniably certain; unfortunately, extirpation of the 
kidneys is followed by death from symptoms which are explicable on 
other grounds than the absence of a specific secretion; but in nephrec- 
tomized animals death can be postponed for a short time, but not averted, 
by the administration of the juice of the fresh organ. The administration 
of raw kidneys in case of renal insufficiency has not yet been so successful 
as to enable us to deduce that a specific internal secretion exists. 
In considering normal urinary excretion, it seems necessary, above 
all other things, to acknowledge the vast importance of the dependence 
of one part of the kidney mechanism on another, and the readiness with 
which one part takes up the work of another, remembering, at the same 770 
DISEASES OF THE URINARY SYSTEM 
time, that there is a high degree of individuality in the renal cells them- 
selves, so that the degree of functional activity or of implication by 
disease may vary greatly in different parts of the same organ. 
THE PATHOLOGICAL PHYSIOLOGY OF THE KIDNEY 
The Relation between the Blood and Kidney Excretion.-While 
the kidney has a specific power of secretion or excretion which may be 
reserved for special occasions, or, on the other hand, which may be 
doing subsidiary work all the time, there is yet a very important, 
quasi-mechanical excretion going on constantly by the glomeruli. 
This was naturally one of the earliest facts to be observed. The glom- 
erulus, a mere coil of capillary, was seen to have a large afferent and a 
small efferent vessel; the blood-pressure at the source of the renal artery 
is high, that at the mouth of the renal vein low; it was thought that the 
excretion of urine was the expression of the difference of force between 
these, plus the amount that was excreted in the secondary system by 
which the tubule is supplied. It will be remembered that the arteriae 
interlobulares carry most of the blood entering the kidney directly to 
the glomeruli (although some of it goes to the vessels in the intertubular 
spaces), and that the efferent glomerular vessels are distributed to the 
intertubular tissue to supply the tubules after the blood has gone through 
the glomerulus. The kidney thus resembles a compound engine, in that 
most of, if not all, the blood goes to the high-pressure glomerulus, as 
the steam goes to the high-pressure cylinder, thence much of it goes to 
the low-pressure tubular capillaries, just as the steam, deprived of much 
of its expansive force, goes to the low-pressure cylinder; in all this the 
mechanical advantage is evident. 
The result is that, ordinarily, the blood-stream is inflicting a certain 
wear and tear on the glomerulus; the wear and tear depends upon the 
amount of work that is being extorted from the mechanism, or, expressed 
differently, depends upon the persistence with which blood at high 
pressure is supplied to the glomeruli; the compound engine after a hard 
run is allowed rest, but the glomeruli have no such relief; in any middle- 
aged kidney, or a kidney that has experienced hard, continuous strain, 
there are the so-called hyaline glomeruli which have still the form but 
none of the functions of glomeruli; as the body has no means of supplying 
new glomeruli, the blood force is no longer expended on the high-pressure 
glomeruli, but falls direct, to a great extent, upon the low-pressure 
secondary circulation, which was never built for such high-pressure 
work; it is likely, then, that degeneration goes on here all the more 
quickly, and stress undoubtedly leads to a rapid fibrosis; it is not difficult 
to imagine that a degenerated glomerulus leads soon to a damaged or 
quite inefficient tubule, not only from the results of this stress but 
because the inefficiency of the glomerulus brings it about that the tubular 
cells are no longer thoroughly washed by the free flow of urinary water. 
Another factor, which seems no less important, is the quality of blood that 
is supplied to the entire capillary system. The blood brings deleterious INTRODUCTION TO THE DISEASES OF THE KIDNEY 
771 
substances which injure structures in their passage, and the structures 
also have to take their nutrition from this source; the more deleterious 
substances there are the worse is the cell food, and, therefore, the poorer 
the work done by the cell; the cumulative nature of such a bad state 
of affairs is easily apparent. Thus it is brought to pass that perfection 
of selective power is lost, and substances that were once held back are 
allowed to pass through, and, on the other hand, substances whose 
appearance in the urine was dependent on kidney efficiency no longer 
appear there. In such circumstances water is excreted by skin and 
bowel; salts, such as chlorides, may escape by the intestine; nitrogen 
may, to a great extent, escape by the same way or even by the saliva 
in small amounts, and the well-being of the organism no longer depends 
on the kidney but on the excellence of the adjuvant systems. 
Tubular Functions and Disturbances.-The Functions of the Tubule and 
its Behavior when Irritated.-To the tubular epithelium we are in the 
habit of ascribing certain functions connected with the partial excretion 
of salts and other solids, as well as the synthesis of uric acid and the 
analysis of creatin and other bodies; but these are doubtless but a small 
part of the work of so complex a structure, and our knowledge of the 
actual secretory power of the tubular cells is gathered from sadly uncer- 
tain modes of investigation; the convoluted tubule and the ascending 
loops of Henle excrete uric acid; but what is to be said for the tubular 
areas that as yet, like brain areas, are "silent?" What mean the modifica- 
tions of epithelium in the various parts of the tubule? We can scarcely 
guess. One is tempted to indulge in the fancy that the tubule may some 
day be divided off as to function, in the same way as the alimentary 
tract is; that, just as there is a specialized process in each part of the 
latter, there may be in the former; also, that the processes of absorption 
and reabsorption that go on repeatedly as the intestinal contents pass 
down may, in some less degree, be repeated in the tubule. 
The convoluted parts of the tubules are those in which we mark most 
constantly the changes wrought by toxins; in fact, the strictly medullary 
parts of the tubules are as yet of but little use to us, so far as the micro- 
scopic determination of pathological change is concerned. Analogy 
leads us to suppose that if these last were concerned only in conduction 
we would have a less specialized lining for them. 
Experiments with pigments in the hands of Heidenhain, Adams, and 
many others, have proved useful in the determination of functions of 
different parts of the tubule; various pigments are put into the animal 
body, and when the animal is killed, after a shorter or longer period, the 
position of the pigment granules in the kidney cell is determined. The 
conclusions drawn therefrom are open to the objection that the position 
of pigment in the cell is not necessarily an indication of its route, but, 
if sufficient of such experiments be carried out, it is safe to assume that 
the distance (in the cell from the lining membrane) that the pigment 
has progressed in animals killed at various times after injection indicates 
whether the pigment is taken up from the blood or from the urine. It 
must be admitted, of course, that experimental animals are not exactly 
normal, and the very "give and take" of one part of the tubule and 772 
DISEASES OF THE URINARY SYSTEM 
another may perchance lead substances to be excreted in a way differing 
from that in the normal kidney. 
The tubular cell is prompt to suffer from the effect of even transitory 
toxicity of the blood and lymph. With reference to the lymph, indeed, 
we will do well to remember that the lymph which bathes the cells 
intercellularly probably acts precisely as does the blood with reference 
to excretion, save that, there being no high pressure in its current, it 
exchanges its constituents with the urine and the cell juice merely by 
osmotic variations of the fluids. To toxic lymph and blood the cell 
quickly reacts, entering the state of cloudy swelling; this is the peculiar 
"ground-glass" appearance that the individual cell takes when it is 
damaged, and the kidney of almost every infective or toxic case shows 
it so distinctly that it may be determined by the naked eye. It probably 
is often undergone by cells in the course of life, and from it the cell can 
recover entirely. Careful study of the cell with cloudy swelling indicates 
that there is a disturbance of the osmotic relations, by which the bulk 
of the cell becomes much greater; the Altmann granules, instead of being 
arranged in definite rows, appear to be dislocated from this arrangement 
and are seen in apparent disorder. The cell in this state is undoubtedly 
less efficient, and, as was pointed out earlier in this chapter, there is 
at once a less perfect excretion by the cell, and its own katabolism is 
increased. So the vicious process continues until the individual cell 
has gone on to the stages of granular, fatty, or hyaline degeneration, 
as the case may be, all of which are supposedly more extreme than 
cloudy swelling; it may well be imagined that the results upon excretion 
are to lessen its efficient performance. Such a condition may become 
the beginning of a permanent insufficiency, and the kidney tubule may 
not be able to regain its state of perfect health. 
When considering the damage wrought upon the kidney by toxins, 
it is essential, however, never to lose sight of the fact that there are 
two widely different classes of tissue involved, the parenchyma and the 
connective tissue. These differ widely in the extent of their reaction to 
irritation. The writer is in the habit of using a fanciful illustration for 
this: the parenchymatous cell represents the "professional man" in 
the community, specially trained, not to be replaced but by one of his 
own class, impressionable by even slight external stimuli, not prone to 
be physically hardy hor overgiven to reproduction. The supportive cell, 
on the other hand, is its "laboring-class" brother, not trained in any 
high, special task, whose supportive work can be replaced by any kind 
of tissue, even scar tissue, not readily impressionable, even by powerful, 
external stimuli, physically strong, and ready in reproduction. These 
two cells lie side by side in the kidney, exposed to the same toxic influ- 
ences, but reacting to them each in its own way. A toxin strong enough 
seriously to damage the high-class cell is only strong enough to irritate 
the low-class cell to reproduction. When the high-class cell is killed by 
toxin, in the absence of regeneration by the remaining tubular cells, 
it leaves no one of its kind in its stead, and its place is occupied, but its 
function is not performed, by the progeny of its laboring-class brother. 
If some such plan be kept in mind, one is prepared to collate the effects INTRODUCTION TO THE DISEASES OF THE KIDNEY 
773 
of toxin upon each kind of tissue, and so to form a right idea of the total 
result in the organ. When the condition of imperfect tubular excretion, 
referred to above, is prolonged, many cells die and are desquamated, 
and the toxins which sufficed to damage and even kill the cells are 
sufficiently potent to irritate the supportive structures to overgrowth; 
thus, hand in hand, the two processes go on until there is proliferated 
connective tissue where once was a tubule, and this is the process of 
fibrosis. The- work of every destroyed tubule must be thrown on its 
surviving fellows, and if the kidney continue to perform its work 
apparently perfectly, it is done, nevertheless, at a price; the price 
is stress, which will have to be paid for by shortened life of the other 
tubules. 
The Effects of Toxins.-What are the effective toxins? They are the 
toxins, so called, of the infective diseases, products of cell katabolism 
throughout the body, hemoglobin, many irritant exogenous poisons (of 
plant and animal origin), and perhaps many chemical products which 
we are accustomed to consider as the normal output of the kidney. This 
apparently brief narration includes a vast number of substances. The 
products of pathogenic bacteria are well known as having an irritant 
action on the kidney, but there are doubtless products of bacteria not 
known to be pathogenic which also irritate; the great numbers of bacteria 
in the alimentary canal are constantly producing substances with which 
the kidney has in part to reckon; and in constipation this responsibility 
is doubtless increased. Every cell that breaks down in the body has to 
be disposed of, and in cases of extensive damage, as burns, suppurations, 
and necroses, the kidney has to bear its large share of the excretion. 
With reference to exogenous substances, we have but to look at the belief 
that one food is better than another, that the red meats are harder on 
the kidneys than white meats, and a hundred other facts or fancies that 
make up our ideas upon diet; be they truths or errors, we have but to 
observe these to see that practitioners of medicine at least have given 
a large place to the responsibility of the end products of ingesta with 
regard to the kidneys. 
The Effects of Age.-The changes produced by age may be considered 
physiological, and doubtless are, but physiological in the sense of being 
processes which are always occurring, which cannot be obviated, however 
hurtful. Every "old" kidney shows certain changes which appear to 
be of the nature of replacement fibrosis such as we have previously 
described; they appear to coexist with changes in the arteries, and in 
the very old make up a well-defined entity. What, then, are the causative 
factors here ? If we knew the cause of arteriosclerosis the question would 
probably be answered: work, katabolism, stress, the hundred slight 
disturbances of all the tissues (whose katabolic effects must be disposed 
of) the fact that nothing lasts forever, the sudden jars, metabolic and 
chemical, of a blood-supply no longer perfectly cushioned by elastic 
arteries-these, and as many more, perhaps, go to make up the factors 
which cause the changes of age. The constant breaking down of cells 
is a strain on the kidney, the greater by so much as the kidney is older; 
but it must be said, on the contrary side, that the very fact that the 774 
DISEASES OF THE URINARY SYSTEM 
body is smaller and the cells fewer is of advantage to the kidney, because 
the output of such cells is less than in the body of full manhood; there 
is thus a kindly compensation in old age which tends relatively to 
lighten the renal labors. 
Nevertheless, it often appears that the "old" kidney is a very efficient 
one; and this compensation is a virtue not to be ascribed more to the 
kidney than to the circulation. As the arteries become old and inelastic, 
the heart can no longer depend upon them for the necessary contractions 
which tend to raise blood-pressure in localized areas, and must perforce 
work harder and adopt a higher general standard of minimum blood- 
pressure, which is accomplished by hypertrophy of the heart. From 
the time at which this raising of the minimum blood-pressure commences, 
the tissues, even when most at rest, are yet exposed to a strain greater 
than that to which they have been accustomed; with the increasing 
inelasticity the minimal blood-pressure continues to rise. The kidney 
shares to the full degree in bearing this strain, and the constant stimula- 
tion-mechanical if no other-leads to productive processes in the sup- 
portive structures. 
Parenchymatous Change in General.-Albuminuria and Casts.-As the 
kidney tubule is the unit of the kidney, and, so far as we can see, every 
tubule is built exactly like every other one, the parenchymatous derange- 
ments of the kidney can be narrowed down to the sum of the derange- 
ments of the single tubule, derangements that vary from cloudy swelling 
to complete disappearance and replacement. Slight changes often pass 
unnoticed, so far as any urinary sign is concerned, and, on the other hand, 
there are slight urinary changes, such as transitory albuminuria, with 
which we have not yet learned to coordinate the corresponding alteration 
in the kidney. Without entering into the question of albuminuria, it 
may be said that these transitory albuminurias must have a meaning; 
albumin has its place, and its place is not in the urine, so that " physio- 
logical," as a term applied to albuminuria, ought to mean not a normal 
process; but a process so little abnormal that experience has led us to know 
that its existence does not lead to more serious disturbance. Albuminuria 
can depend, too, upon causes which are not situated in the kidney itself; 
anything that prevents the exit of venous blood from the kidney may 
cause albuminuria; experimental temporary blocking of the renal artery 
may cause it, the upright position in some persons seems to cause it, or, 
to put it in another way, the recumbent position causes its cessation; 
also the distribution of increased pressure in pregnancy has been held 
to explain the existence of albuminuria. Under these circumstances, 
all or most of the albumin is excreted by the glomeruli. But in its 
occurrence, when there is disease of the kidney, the site of its output is 
uncertain, and may be tubular as well as glomerular. 
Here it is in place, also, to make reference to casts. The blood-cast 
is an evidence of rupture of a capillary or other vessel in the glandular 
part of the kidney. The source of the epithelial cast is equally obvious, 
although it is formed sometimes of the orginal tubular lining and some- 
times of epithelium that has been newly generated by the tubular cells; 
the histological nature of the cells concerned gives no accurate information INTRODUCTION TO THE DISEASES OF THE KIDNEY 
775 
as to the site of its formation, and in all cases it must be remembered 
that the cast, when seen in the tubule, may be on its way out, and is 
not necessarily at the site of its formation; epithelial casts can be formed, 
too, by agglomeration of cells, so that the juxtaposition of its individual 
members does not always mean that they occupied that place in life, 
although it generally does so. Some hyaline casts are also of epithelial 
origin, although it is not possible to say whether the hyalinization 
occurred in life or after the cells were detached. Whenever they can be 
recognized as epithelial, casts mean that the kidney substance is, to this 
extent, destroyed. It is true, that, normally, kidney cells are constantly 
paying their debt to nature by dying, and as such are being shed off, 
more or less altered. The appearance of single cells in the urine thus 
means nothing, but with aggregations of them it is different; if one may 
use a simile of a homely kind, the deaths of many men here and there 
in a community do no more than remind us of our mortality; but when 
a dozen members of one family circle die, we suspect a local cause. This 
is the state of affairs in the renal community when a cast appears; there 
is a local overturn of normal conditions where it originated. The state- 
ment has just been made that some hyaline casts are of epithelial origin; 
perhaps the majority are, but the subject has been the battleground of 
much controversy. It seems reasonable to suppose that hyaline casts 
can originate in three ways, from the epithelium itself, shed and altered; 
from coagulation of transuded plasma; and as an excretion of the tubular 
epithelium, or, better, as a separation of part of the tubular epithelium. 
These will be dealt with in their order. 
Langerhans demonstrated the colloid alteration that epithelial cells 
undergo, by which they become glassy and transparent. Ribbert has 
long championed the second theory of formation. He considers that 
casts are formed of albuminous transudate hyalinized by the acid reaction 
of the kidney. His experiments certainly seem to bear out the contention, 
but Saundby concludes from their rarity in functional albuminuria that 
this is not a common source. Some hyaline casts give the reactions of 
fibrin and some do not. The supporters of the third theory contend 
that hyaline casts may be formed by the shedding of material which may 
be either the cell substance itself, that has imbibed water and has swollen 
up, or is an excreted product of the cell. The material referred to can 
be seen in tubules of a kidney which is the seat of moderate nephritis, 
and consists of globules or masses of varying size, which look like irregular 
droplets, which appear to be able to fuse together, but which at times 
appear to be only the spaces between the meshes of the detritus that is 
seen in the lumina. Ribbert contends that these are normal. Where 
such are present, the epithelium is often found low and, as it were, 
lopped off; when the epithelium is not truncated, it may be that the 
material has descended from a higher part of the tubule. It will be at 
once evident that a growing vital part of the cell is yet left, and this may 
be the reason why a kidney can produce vast numbers of such casts 
through a series of years, without suffering greatly in the process. Oertel 
and Rovida long ago referred to these "plasma rings," and discussed 
their probable relationship to hyaline casts. Bartels considered that 776 
DISEASES OF THE URINARY SYSTEM 
the hyaline cast is generally formed from an excretion of the cells, while 
admitting the possibility of its formation from the coagulation of albumin. 
Councilman, who has carefully studied the kidney, will not venture 
an opinion upon the nature of these structures, but, on the other hand, 
admits the likelihood that fibrin can form casts. There is good reason 
to suppose that hyaline casts arise in all three ways, as Saundby stated 
some years ago. All of them indicate a pathological state of the secreting 
structures, and a hyaline cast, therefore, viewed in its most innocent 
1 ight, is an indicator of disease. Even when the cells are shed in numbers 
as casts, it is well to recall that kidney epithelium can be regenerated to 
a moderate extent over denuded areas. 
Changes in the Glomeruli.-The changes which are found in the 
glomerulus in different forms of disease are manifold, but it is hard to 
refrain from grouping them into those which signify acute disease and 
those which signify chronic change, although the boundary between 
the two is difficult to place. 
The Capsular Space.-Exudation of albuminous fluid and subsequent 
fibrin formation can occur, and this may either be absorbed, swept 
awTay, or may remain and become organized, so that partial or complete 
adhesion between the walls of the capsular space may occur, and, further, 
the glomerulus itself may become secondarily vascularized by new-formed 
vessels which run from the peripheral wall. Hemorrhage may occur 
into the capsular space. The lining epithelium may be so damaged as 
to become swollen, granular, and may be desquamated in a moderately 
undamaged or in a necrotic state, or in cases of less extensive damage it 
may actively proliferate. Degenerated cells pushed up from the tubules 
may appear in the capsular space, as was shown by Welch in the kidneys 
of cantharidin poisoning. In all this one may see, as has been suggested, 
the parallel that exists between the capsular cavity and the serous 
cavities, such as the pleura or the peritoneum (Cornil). It is not mere 
coincidence, but shows that the reaction to inflammatory, regressive, 
and progressive changes is everywhere in obedience to law. 
The Capillaries of the Glomerulus.-In the capillary branches may be 
found bacterial, fibrinous, or hyaline thrombi; leukocytes emigrating 
through the walls have been seen by Councilman, although the occurrence 
of this phenomenon had for long been denied; cells, evidently the pro- 
liferated endothelium, are seen, sometimes yet adherent, at other times 
desquamated and degenerated. An increase of the cells between the 
capillaries is at times to be seen, which cells may prove to be mainly 
leukocytes; this is, naturally, the result of the emigration spoken of 
above, and this infiltration may not be found elsewhere in the kidney, 
indicating clearly the existence of irritants whose "first choice" is the 
glomerulus. The entire glomerulus rarely may be converted into a 
granular, necrotic mass, in which no individual features can be distin- 
guished. Amyloid change of the capillary is familiarly known, and most 
common of all is the hyaline change which affects the vascular wall. 
Whether it occurs on its outer surface or its inner surface is uncertain, 
but the change begins in the distal parts of the loops and progresses 
until the lumen is partly or wholly occluded, and the entire tuft is 777 
INTRODUCTION TO THE DISEASES OF THE KIDNEY 
replaced by a hyaline mass, with an occasional narrowed blood-space 
in which the scattered nuclei of its lining cells still may be distinguished. 
Finally, the intercapillary connective tissue may be proliferated and the 
new-formed tissue ultimately shrink, pulling in the surface of the tuft by 
its contracting bands, just as happens in a "hepar lobatum;" this con- 
stitutes the lobulation that is at times so characteristic a mark of the 
damaged glomerulus. 
The effect of the above-mentioned chronic changes on the size and 
appearance of the glomerulus can be well imagined. Side by side with 
small, hyaline, useless glomeruli will be found others of great size, which 
by compensatory hypertrophy are capable of doing their own work and 
more; the excess of urine in cases of interstitial nephritis is probably 
partly due to the high efficiency of these hypertrophied glomeruli, at 
least so far as the excretion of water is concerned. 
Changes in the Tubule.-The alterations produced in the tubule are 
more simple than those in the glomerulus; we have here to consider only 
the changes that the individual cell may undergo. These are the various 
degenerations, cloudy, granular, hyaline, fatty, and "dropsical" (vesicu- 
lar, vacuolar); as a result of degeneration the cell may be desquamated 
individually, or with others as a cast; it may be thrown off and become 
cemented to others while in the tubule, again forming a cast; or it 
may become necrotic and disappear as quickly scattered debris. It may 
present variations of size and of shape, which variations in turn affect 
the capacity of the lumen of the tubule. Into the tubule may be thrown 
blood or the precursors of fibrin, with subsequent formation thereof. 
All degrees of variation of the size of the lumen are found from the narrow 
lumen of cloudy swelling to the cyst. All changes in the epithelial cell 
are but temporary, and must be considered as acute, in the sense that 
a cell will not live long in a damaged condition. When the cell dies, its 
neighbors may be able to generate a new cell to take its place, which, 
in its turn, may undergo similar changes; if no such substitute is formed, 
the tubule, as such, ceases to exist, or remains only as a space in the 
connective tissue; if its glomerulus also be destroyed, even the space 
ceases to exist, and solid fibrous tissue finally replaces it. 
The deleterious agents which affect the tubular epithelium may be in 
the blood or in the urine, and in either case the chances are that the 
glomerulus will have been first exposed to their action. 
Changes in the Interstitial Tissue.-Space need not be occupied in 
describing the changes that the connective-tissue stroma undergoes, for 
these are the same as are undergone elsewhere by supportive tissues. 
It may be the seat of a migration of leukocytes, of an active or a passive 
oedema, of a liquefying or a coagulation necrosis, or of any one of the 
many degrees of proliferation of its own elements with subsequent fibrosis. 
These changes do not always march shoulder to shoulder with changes 
in the connective tissue of the glomerulus, because the latter have 
peculiar opportunities for exposure to irritants. The capsule of the 
kidney is practically one with the stroma of the organ, and need not be 
separately considered. Variations in the size of the organ are assisted 
not only by the changes in the total mass of the interstitial tissue but 778 
DISEASES OF THE URINARY SYSTEM 
also by variations in the size of individual tubules and glomeruli, to say 
nothing of the variation in bulk of the blood and lymph vessels and 
their contents. 
NEPHRITIS 
Let us be thoroughly theoretical for a moment, and say that a nomen- 
clature of nephritis cannot be perfect until we describe every kidney in 
terms of the changes that exist in (1) the glomerulus, (2) the tubule, 
and (3) the interstitial tissue. Even now we are assuming that the 
tubule is a unit, whereas a fuller knowledge of its different parts may 
prove it to be divisible. The accurate description of a particular kidney 
ought to be denoted as follows: glomerulus, change of x degree, tubule, 
change of y degree, interstitial tissue, change of z degree; another kidney 
would show glomerulus, change of r degree, tubule, change of s degree, 
interstitial tissue, change of t degree. We have indicated a dozen varia- 
tions, temporary or permanent, in the glomerulus, any one of which may 
be accompanied by one or more of the variations to which the tubule 
is liable; combinations thus made by mathematical process are, to say 
the least, numerous; when we go farther, and find that every such 
combination may be again combined with any one of the variations in 
the interstitial tissue, the possibilities are legion. Such a nomenclature, 
alas, is quite impracticable; yet every classification of nephritic conditions 
which has been promulgated is an attempt to sort out this almost infinite 
series, and the classification that disposes of most is the best, but is 
equally certain to be the largest and most unwieldy. Most of us are 
content to use a working method of classification and nomenclature 
by which we name the lesion by the feature which happens to predom- 
inate. Yet two kidneys may present the same predominant feature, 
while the other characters may differ widely, and even the same pre- 
dominant feature may have been attained by widely different processes. 
Having pointed out the inexactness of the "nomenclature of the pre- 
dominant feature," we are inconsistent enough to fall back upon it. 
It is with an apology that one ventures upon the oft-trodden ground 
of Bright's disease, especially because the subject will be dealt with 
elsewhere. Bright's disease comprises acute and chronic parenchymatous 
nephritis, chronic interstitial nephritis, and that form of acute interstitial 
nephritis characterized by an infiltration of fibroblasts, but not by 
leukocytes (scarlatinal nephritis), all of which are toxic, not infective 
nephritides; that is, the bacteria are not pathogenically present in the 
kidney itself, as occurs in calculous, tuberculous, or other true infective 
acute nephritides. It is timely here to point out that those who make 
distinctions between chronic parenchymatous and chronic interstitial 
nephritis do so with the understanding that neither one ever exists 
alone; interstitial change never exists without an accompanying paren- 
chymatous change, undoubtedly brought about in successive generations 
of tubular cells by the same agent, and parenchymatous change cannot 
exist long without interstitial alteration following or accompanying it. 
Acute parenchymatous nephritis may be produced in a very short time, INTRODUCTION TO THE DISEASES OF THE KIDNEY 
779 
a matter of^iours, perhaps minutes, and obviously cannot be accompanied 
by an instantly produced fibrosis, for the nature of the latter process is 
that it can only be slowly produced. An observable acute parenchy- 
matous nephritis can, however, occur in any kidney, fibrosed though it 
be, provided enough tubules be left to enable us to see the change. We 
may go even farther than this, and say that the process we call chronic 
interstitial nephritis, strictly speaking, is no more than a series of slight 
consecutive acute attacks, each of which leaves a few more fibroblasts 
behind, and that in the intervals, although the results of previous acute 
attacks remain, the disease is at an absolute standstill. The "ups and 
downs" of a nephritic are familiar to us; the exacerbations referred to 
constitute the "downs." 
There are many terms constantly used to indicate the various types 
of kidney found in nephritics, and one hears of small white kidneys, 
large red kidneys, small red kidneys, large white kidneys, and yellow 
kidneys, until one may be forgiven if he becomes confused; we do well 
to remember the extreme uncertainty of predicting the kind of kidney 
from the clinical symptoms and signs, and the habit of referring certain 
clinical signs to a "large white kidney" or some other such kind is to 
be discouraged. It may appear from the foregoing that an attempt 
is made to array all inflammatory and quasi-inflammatory changes in 
the kidney under three or four headings, modelled upon the terminology 
of Bright. Such is not the intention. It is well known that there are 
diseased kidneys which do not conform to such types: some toxins affect 
largely or entirely the glomeruli; others cause a change that is almost 
entirely confined to a particular vascular area, such as that connected 
with the capsule: active and passive hyperemias lead to well defined 
changes that are not proved to be inflammatory, but which on the 
other hand are not purely nutritional. A large and important class is 
that of arteriosclerotic kidneys, which approximate to those of interstitial 
nephritis, yet with important differences. Obviously these various states 
cannot be classified under any such simple headings as those referred to. 
In the absence of a perfect classification, and in the absence of expectation 
of ever attaining a complete yet simple classification, it may yet be 
pointed out that a division into acute parenchymatous, chronic paren- 
chymatous, chronic interstitial and infective nephritides will embrace 
most of the lesions that are encountered, and will constitute a working 
basis for all but the experienced pathologist, who may safely be left to 
his own devices. 
The Varieties of Nephritic Kidney.-We have indicated above that 
the two main forms of chronic kidney damage go hand in hand; there 
is in reality a wide range of lesions, at the extremes of which stand, at 
one end, the kidney whose most prominent lesion is parenchymatous; 
at the other end, the kidney whose most outstanding character is inter- 
stitial change. Between lies every possible degree of combination. 
When we find a kidney which combines the characters of both to such 
a degree that neither is conspicuous over the other, we make a com- 
promise, and call it a mixed nephritis. 
The changes that specially mark parenchymatous change are that 780 
DISEASES OF THE URINARY SYSTEM 
the kidney is big, plump, firm, yet resilient, often "hog-backed," and 
it has a wide cortex, often swollen. Those that indicate the kidney of 
the interstitial type are that it is small, hard, nodular, with a large fatty 
pelvis and a narrow irregular cortex. The former kidney is generally 
red, the latter pale, and these two are the types called "large red" 
and "small white." Further color modifications of these may exist 
according to the more or less accidental amount of blood in the organ 
at the time of death, although it would not be correct to say that the 
presence or absence of excess of blood is a fortuitous circumstance. 
Anemia of the body causes pallor of the kidneys as of other organs, and 
hyperemia, active or passive, will give a dark red color; fatty change in 
the epithelium may be so extreme as to give a yellowish or dirty white 
color to the cortical structures,1 and a combination of this with hyper- 
emia is one of the sources of the so-called "mottled" kidney. 
Is there any relationship of these large and small kidneys one to the 
other? It has been known since the days of Bright that some large 
kidneys of the parenchymatous type progressed to become small ones 
of the interstitial variety. This is probably always so, provided the 
patient lives sufficiently long, but many succumb while the kidneys are 
yet large. There are, however, small granular kidneys that have never 
been larger than normal, that have, on the contrary, undergone a slow 
replacement fibrosis-the so-called primary renal cirrhosis or granular 
atrophy. The end result of this process does not markedly differ from 
the end result of interstitial nephritis, but it is presumably a process 
of quite different etiology. 
These interstitial changes in the kidney are intimately connected in 
many cases with hypertrophy of the heart, especially of the left ventricle, 
and with arteriosclerosis. We find that many people die with certain 
lesions of these three systems in whom one cannot lay the blame on one 
system rather than on another. Does the hypertrophied heart lay so 
much stress upon the vessels and the kidney as to damage them, or does 
the vascular change precede the others, or is the renal lesion the primary 
one, or is some widespread toxin responsible for all three at the same 
time? Speculation upon these questions is as yet unending, and so much 
has been brought forward in support of a positive answer to each one 
that no firm basis yet exists on which to make a decision. For purposes 
of demonstration to students, the writer is in the habit of indicating the 
combination diagrammatically by an equilateral triangle; at one angle 
is heart, at another vessels, and at the third kidney, thus: 
Heart 
Vessels 
Kidney 
Then having pointed out the intimate physiological relationship 
existing among the three, one may rotate the triangle, and it matters 
1 Kidneys of this color may fail to give the chemical reactions of fat. INTRODUCTION TO THE DISEASES OF THE KIDNEY 
781 
little which angle comes uppermost, as the three constitute a "triple 
alliance" which may fairly be said to represent an entity of disease. 
Changes in the stroma of the kidney, however extensive, are not of 
themselves reflected in the urine, but the accompanying parenchymatous 
alterations are, and it is the glomerular and tubular defects which give 
the urine its pathological characters. But we have, by long observation, 
been able to see that the parenchymatous and interstitial changes go 
together in such definite proportions that we are able to prognosticate 
the latter from the former. In a general way, a granular kidney is 
associated oftenest with much urine of low specific gravity and little 
albumin, whereas the large parenchymatous kidney is often associated 
with a more moderate amount of urine, with much greater albumin loss 
and more frequent casts. As for frequency of casts, we have to remember 
that their numbers must never be considered apart from the amount of 
urine, and that the degree of disease being equal, the kidney with most 
tubules will shed most casts. 
The uncertainty of prediction of the extent of disease from the obser- 
vation of the kind and number of the casts is very great. Max Brodel, 
of the Johns Hopkins Hospital, has compiled some interesting figures 
as to the number of tubules and glomeruli in the normal kidney. He 
has estimated that there are approximately 4,000,000 tubules and 
glomeruli in the two kidneys, aggregating about 75 miles in length. 
Based upon this calculation a tubule secretes between two and three 
drams of urine in a lifetime of seventy years. When we consider that 
a urinary examination takes cognizance of the production of casts or 
the shedding of epithelium from but an infinitesimally small part of 
this area, and that all forms of change resolve themselves into three or 
four different kinds of casts, it seems reasonable to make mental reserva- 
tions with any stated diagnosis which is based upon the number and the 
kind of casts present. 
The Functional Competence of the Kidneys.-Many an individual is 
at this moment the possessor of sadly damaged kidneys who yet enjoys 
relatively good health. Such a man has not the "margin of safety" 
possessed by a normal person, but nevertheless succeeds in weathering 
serious storms. Should the question of operation arise, the surgeon may 
be frightened by the amount of albumin or the number of casts to be 
found in the urine. It is obviously difficult from such observations 
to state how good or how bad the kidneys are. Is there any means by 
which a proper idea of the competence of the kidneys for their work 
can be obtained? Experimentally there are certain methods by which 
the functional capacity of the kidneys can be measured. Of these, the 
most serviceable is that known as the "phenolsulphonephthalein test" 
of Rowntree and Geraghty.1 
Phenolsulphonephthalein when injected subcutaneously, intramus- 
cularly or intravenously is excreted rapidly and practically quantita- 
tively in the urine, in which it can be determined by the addition of 
1 Jour, of Pharm. and Exper. Therap., 1910, i, 579; Jour. Amer. Med. Assoc., 1911, 
p. 811; Arch. Int. Med., 1912, ix, 284; Trans. Cong. Amer. Phys. andSurg., 1913, ix, 23. 782 
DISEASES OF THE URINARY SYSTEM 
alkali and comparison with a standard phthalein solution. After intra- 
muscular injection normally 50 to 65 per cent, is recovered in one and 
60 to 80 per cent, in two hours. Half an hour before administering the 
test the patient is given 200 to 400 cc. of water to drink in order to insure 
a free urinary secretion. One cc. of phenolsulphonephthalein solution 
containing 6 mg. of the dye is injected intramuscularly, preferably into 
a lumbar muscle. At the end of one hour and ten minutes and of two 
hours and ten minutes the bladder is emptied, a catheter being used 
when obstruction or inability to empty the bladder is known to be present 
or is suspected.1 
Each sample of urine is treated with sufficient 25 per cent. NaOH to 
elicit the maximum intensity of color and diluted with distilled water 
to one liter. The solutions are thoroughly mixed, small portions filtered 
off and compared in a calorimeter against a standard solution contain- 
ing 6 mg. of the sulphonephthalein diluted to one liter with the addi- 
tion of alkali. The calorimeters usually employed are Rowntree and 
Geraghty's modification of the Autenrieth Konigsberger calorimeter 
and the Duboscq, but when neither of these is available fairly accurate 
determinations can be obtained by means of two graduated cylinders 
of equal caliber, equal quantities of the standard and of the diluted 
urine being placed in the separate cylinders and the standard diluted 
until the colors in the two cylinders become identical when viewed 
transversely. 
The test is of great diagnostic and prognostic value in renal, cardio- 
renal, and cardiac diseases. In acute nephritis frequent repetitions of the 
test are necessary since marked renal functional changes occur with 
considerable rapidity. In mild chronic nephritis the excretion of the 
dye is but little reduced, while in severe nephritis it is markedly decreased 
or even suppressed. Marked diminution or suppression usually occurs 
in uremia, and impending uremia is frequently indicated, when routine 
clinical and urinary studies give no suggestion of it. Passive congestion 
only effects the phthalein output when of a severe grade and slight 
circulatory improvement is associated with prompt improvement in 
the phthalein excreted. The test is of great assistance in the interpreta- 
tion of cardio-renal cases, since it can reveal the relative responsibility 
of the heart and kidney. 
A marked decreased phthalein output always indicates severe functional 
involvement of the kidney, but a normal output does not mean a normal 
kidney, since in mild grades of chronic passive congestion and in some 
cases of chronic parenchymatous nephritis the phthalein output is not 
diminished. The test constitutes the most reliable individual test of 
renal function, other selected tests being used according to the nature 
of the case, e. g., studies of sodium chloride or water excretion in oedema, 
1 Following intramuscular injection the dye in health appears in the urine within 
ten minutes, while in disease it is usually delayed. In order to accurately determine 
the time of appearance a catheter is passed into the bladder and the bladder emptied 
immediately following injection. The urine is then allowed to drop from the catheter 
into a test tube containing a drop of NaOH and the time of the first appearance of the 
pink color noted. The urine is subsequently collected for one hour and two hours. INTRODUCTION TO THE DISEASES OF THE KIDNEY 
783 
of lactose excretion in mild congestion or nephritis, while for corrobo- 
rative evidence when the phthalein output is low in severe nephritis, 
the presence of cumulative phenomena should be determined, low freez- 
ing-point, increase in blood-urea, and total non-protein nitrogen. In 
any renal disease repetition of the test reveals whether the pathological 
process is progressive, stationary, or retrogressive. 
In patients with prostatic obstruction, a test of this kind guides the 
surgeon fairly accurately in selecting a time for operation when the 
kidneys are competent, better than the estimation of the urinary 
output, the total urinary solids, the urea, or the total nitrogen. It 
may be said, in general, that kidneys responding poorly to this test 
will probably behave badly subsequent to operation, if such be under- 
taken. 
Tests of like purpose are made by the use of methylene blue, indigo- 
carmine, rosaniline, and phloridzin. Ambard has devised a formula 
which depends upon the relative amounts of nitrogen in the urine and 
in the blood, which is used as an indication of the competence of the 
kidneys. Literature dealing with all these methods has appeared in 
great volume during the last three years. 
THE KIDNEYS AND FOOD AND DRINK 
The statement frequently made, "that more men die from overeating 
than from overdrinking," if true, refers no less to the kidneys than to 
the liver. Most articles of diet contain one or other of a long list of 
substances which are not easily excreted; they impose extra work upon 
the healthy kidney, and they are able to damage the unhealthy kidney. 
To restrict a healthy man's food because of a possible danger to his 
kidneys is not necessarily rational, even if it were possible; but we should 
adopt every means we can to spare the already diseased kidney, and the 
healthy kidney in times of stress, such as occur during the course of 
fever, of infections, and of intoxications. In these last the kidney may 
be so near the point of breaking down that injudicious diet may supply 
the necessary additional irritation to cause the breakdown. 
We have a preconceived idea that bland substances with a high pro- 
portion of water are kindly toward the kidney, while substances or fluids 
that are highly diuretic are considered to entail increased work upon the 
organ, and many condiments are thought to be actually injurious. These 
views appear in the main to be correct. In one sense, water is the best 
diuretic, and it is possible to wash the tissues as it is possible to wash 
the face, the ingestion of increased water and the consequent increased 
output of urine advancing the metabolic overturn in the whole body. 
But circumstances alter cases. We must agree with von Noorden and 
his school when they declare that there are times when the kidneys 
refuse to be washed; these observers have held with much reason that a 
kidney totally insufficient, that is, the kidney of anuria, is as unable 
to excrete water as anything else. Von Noorden even goes so far as 
to hold that to such a kidney water is as irritant as urea. Whether this 
be accurate or not, the kidney as persistently refuses to excrete the one 
as the other; restriction of fluids is therefore rational enough in this, 784 
DISEASES OF THE URINARY SYSTEM 
that when the blood-pressure tends to be high and oedema is occurring, 
it is useless, or worse, to add to both. As soon, however, as the kidney 
begins to express its readiness by a resumption of its water excreting 
function, the time has come when it will submit to washing. 
When kidney incompetence is evident, as in anuric or oliguric 
states, the withholding of food may be necessary; but in cases in 
which the physician is required to exercise supervision lest the kidney 
be damaged by an infective disease, when his work is really preventive 
rather than curative, what form of diet may he adopt? We must 
supply the body with food whose products are easily excreted, and we 
must avoid the use of drugs that are difficult of excretion. It is generally 
admitted that urea, creatin, hippuric acid, and phosphates are hard 
upon the kidneys. Urea is the result of ingestion of albuminous food; 
creatin exists largely in meat extracts and broths; meats and eggs are 
essentially protein, milk is moderately so, cream much less so than milk, 
starchy foods scarcely at all. Cereals, fresh vegetables, and boiled fruits 
are also innocent in this regard. Green vegetables, fruits containing 
kernels, and cranberries contain relatively large amounts of benzoic 
acid, which is synthetized to hippuric acid, which also is difficult of 
excretion; apples, pears, grapes and raspberries contain little of it. Phos- 
phates are largely present in meats, eggs, and milk; but von Noorden 
and others declare that the use of calcium carbonate with milk causes 
the excretion of much of the phosphoric acid by way of the alimentary 
tract, so that in this way the work entailed by a milk diet can be largely 
reduced; uric acid and the alloxuric bases come especially from meat 
glands, such as thymus, liver, and kidneys, and are moderately toxic 
to the kidneys; meats of all kinds contain extractives, and the so-called 
dark meats to a greater extent than the light meats. Adler, in a review 
of the subject, concludes that the prevalent idea that the subject of renal 
disease ought to eat light rather than dark meats is correct, and that 
these meats boiled contain the harmful factors less than when roasted. 
Condiments which are generally supposed to impose work upon the 
kidneys are pepper, curry, mustard, garlic, and nutmeg; and with refer- 
ence to drugs, one does well to remember the effects of cantharides, 
copaiba, turpentine, salicylates, carbolic acid, resorcin, lead, copper, 
silver, mercury, and boric acid, and even iodoform and tar preparations. 
Of all the articles of every-day diet, what is left to us to use that will 
not entail work upon the kidney? Judged by analysis, and supported 
by empirical knowledge, milk is a more suitable food than any other 
thing; but this is not meant to be a declaration in favor of "milk diet" 
as a routine treatment of renal insufficiency, because evil has been 
wrought by a slavish adherence to a milk diet, as if it were a rule. 
These statements are not made with any view to declaring a treatment 
for renal incompetence, or of forestalling the articles dealing with the 
renal diseases, but merely as a kind of working basis that one may keep 
in mind as an assistance in determining a diet in any case of illness in 
which the kidneys are specially liable to attack (as in scarlet fever), 
or in any case in which a damaged kidney leads one to be cautious lest 
the disease be aggravated. CHAPTER XII 
MALFORMATIONS OF THE KIDNEY, CIRCULATORY 
DISTURBANCES OF THE KIDNEY 
JOHN McCRAE, M.D. (Tor.), M.R.C.P. (Lond.) 
MALFORMATIONS OF THE KIDNEY 
The malformations of the kidney are of very slight clinical importance, 
especially to the physician; most of them, in fact, are but curiosities 
which lie undiscovered unless disclosed at autopsy. 
Absence.-Total absence of kidney tissue is generally combined with 
abnormalities of the sexual organs, and is not consistent with viability. 
There are in existence case reports professing the contrary, but they are 
not credible. 
Absence of one kidney, however, is fairly common, the writer having 
seen eight cases at autopsy. It is said, however, that in many so-called 
cases of absence of the kidney careful examination of the connective 
tissues of the region reveals that kidney substance may exist. No such 
microscopic examination was made in the eight cases to which reference 
is made. Once it was associated with a bicornuate, and once with a 
unicornuate uterus, and in many cases some anomaly of the sexual 
organs exists in association with it. The adrenal generally exists inde- 
pendent of the absence of the kidney, and sometimes a blind ureter 
opens to the bladder. The importance of this last fact is that the cysto- 
scopic finding of a ureteral orifice is not perfect evidence of the existence 
of a kidney. With the development of radiography, and its combina- 
tion with the use of the cystoscope, the clinical diagnosis of anomalies 
of kidney and ureter has become possible, and the recognition of such 
anomalies may assist the surgeon greatly.1 The blocking of a ureter 
by any cause becomes much more serious in a case of unilateral kidney 
than in a normal case, but this has a surgical rather than a medical 
bearing. Cases of unilateral kidney are generally provided with a normal 
or almost normal amount of kidney tissue, thanks to the hypertrophy 
or hyperplasia of the existing organ. The chief practical point in con- 
nection with unilateral absence of the kidney is that it gives a rational 
basis for the surgical rule that before a nephrectomy is performed the 
presence of the other kidney must be demonstrated. The writer was 
present on one occasion in which the surgeon's care in this respect pre- 
vented him from removing the only kidney. 
Failure of full renal development may be associated with a state 
1 Braasch, Ann. of Surg., 1912, Ivi, 726. 
785 786 
DISEASES OF THE URINARY SYSTEM 
called "renal infantilism,"1 occurring in ill-developed children and man- 
ifesting itself by polydipsia and polyuria. 
Anomalies of Shape and Position.-Persistence of the fetal lobulation 
of the kidney is at times observed but has no clinical importance, nor 
have those departures from the conventional shape of the organ which 
are often seen. Sometimes the kidney assumes a shape which bears no 
resemblance to the normal organ, but this is not generally associated 
with any reduction in quantity of the kidney tissue, and makes not the 
slightest difference to the possessor. Fusion of the kidneys is chiefly 
of anatomical interest, the most familiar form being the well-known 
horseshoe kidney, in which the lower poles of the two organs are joined 
by a bridge of kidney tissue. Disease arising in such a kidney may be 
difficult of recognition; it is stated that the mere existence of the anomaly 
may lead to abdominal pain centrally situated, relieved by the recumbent 
position.2 
Anomalies of the Renal Arteries.-The renal arteries may show 
varying irregularity in size, number, and position. In 1200 kidneys 
examined, 21 per cent, showed variation from the normal, a fact which 
is of interest to the surgeon, since the ligation of an aberrant branch may 
be overlooked.3 
Displacements.-The kidney may be fixed in almost any abnormal 
position on the posterior wall of the abdominal cavity, most frequently 
at the edge of the pelvis; an organ so situated may be at times palpated, 
and may cause confusion in diagnosis, but no rule can be laid down for 
the avoidance of a mistake. 
Mobility.-Gradations of mobility exist, from the kidney which is 
all but fixed to that which can be pushed into any corner of the abdom- 
inal cavity. The latter, although its dislocation is largely an acquired 
character, has probably a congenital laxity of fixation from the first. 
Anomalies of shape and site are not infrequently combined with undue 
mobility when the latter is of congenital origin. 
Congenital Cystic Kidney.-The condition known as cystic kidney is 
at times congenital. Both kidneys, more rarely one, may be composed 
of a number of thin-walled sacs, of varying size, containing usually clear, 
yellowish fluid; these cavities are sometimes lined with epithelium-like 
cells and are closed. The walls are fibrous and may contain islands of 
renal parenchyma. Such kidneys may be found in the fetus, sometimes 
so large as to impede labor, or in the infant, or, finally, in the adult past 
middle age. While these are found at an age past middle life, it by no 
means follows that they have developed in adult life; on the contrary 
it is generally conceded that they have a congenital basis. The statement 
that they are rarely found before fifty years of age may be due to the fact 
that the rest of the kidney substance is adequate until the time of the 
discovery, and that the renal competence of earlier years is sufficient 
to tide over the possessor of a cystic kidney until that age. In the light 
of our knowledge of cysts resulting from nephritis, it is not easy to imagine 
1 Miller and Parsons, Brit. Jour, of Children's Diseases, 1912, ix, 103 
2 Rovsing, Zeits. f. Urol., 1911, v, 585. 
3 Eisendrath and Strauss, Jour. Amer. Med. Assoc., 1910, Iv, 1375. MALFORMATIONS AND DISEASES OF THE KIDNEY 
787 
any other than a congenital beginning for those completely cystic kidneys 
that are observed in advanced life; it must be admitted that the sacs may 
have greatly increased in size as time progressed. 
The generally accepted view of the causation of congenital cysts of 
the kidney is that failure occurs m the accurate junction of the masses 
of nephrogenic tissue (later called the renal vesicles, which ultimately 
form the tubules proper) with the outgrowths from the Wolffian duct 
which form the pelvis of the kidney. 
A strange feature of this anomaly is that it has been found in several 
members of the same family, and mother and daughter have been observed 
similarly afflicted. It has been found, also, associated with cysts of the 
liver, and in a case from our own laboratory with cysts of the liver and 
pancreas. Professor Adami, discussing the latter case, thinks that the 
so-called cystic diathesis is rather a disposition to failure to overcome 
moderate obstruction of the ducts than a real liability to the formation 
of cysts. The cystic part of the kidney takes little or no part in urinary 
secretion, although it is conceivable that tubules might still remain in 
the walls of the cystic sacs; for all practical purposes the cystic part of 
the kidney has no influence for good or evil on the urine. Symptoms 
have been sometimes credited to a cystic kidney that really belonged to 
the other non-cystic organ. 
The special features of the condition in adult life are: (a) Renal tumor, 
general bilateral, the location of which is usually readily recognized; 
(6) the occurrence of hematuria, which may be present at long intervals 
over a period of years; and (c) the usual urinary findings of chronic 
interstitial nephritis with the common changes in the vascular system, 
arteriosclerosis and cardiac hypertrophy. Osler has noted the occurrence 
of marked pigmentation of the skin in some cases. The termination is 
usually from uremia or cardiac failure, rarely from complications which 
follow the rupture of a cyst. The treatment is that of chronic nephritis, 
except in the rare cases in which the condition is unilateral, when removal 
of the affected kidney is possible. 
CIRCULATORY DISTURBANCES IN THE KIDNEY 
Anemia.-Anemia or ischemia of the kidney may result as part of a 
general anemia, such as occurs in cancer, tuberculosis, or pernicious 
anemia, or may be caused by local agents of an organic kind which 
prevent ingress of blood to the kidney, or it may result from spasmodic 
contraction of the arterial wall. When there is a general anemia of all 
the tissues, the effect upon the kidney is that it undergoes a slow process 
of degeneration, produced by imperfect nutrition of the cells or imperfect 
removal of the waste products; this, however, is of little practical moment, 
as it is overshadowed by the effects of more important changes in other 
organs. The ultimate result may be an advanced stage of fatty degener- 
ation of the parenchyma. Local anemia of the kidney may be produced 
by narrowing of the lumen from disease of the arterial wall, by throm- 
bosis, or by the pressure of tumors or adhesions upon the artery; if severe 788 
DISEASES OF THE URINARY SYSTEM 
and long continued, the amount of the urine will be lessened, even to 
the extent of anuria; if the pressure be slight or temporary, its effects 
will scarcely be reflected in any urinary change. There are some cases of 
anuria, so-called hysterical, which are presumably due to anemia pro- 
duced by spasm of the arteries, and, also arising in the nervous system, 
instances in which anuria results in one kidney from injury or irritation 
of the other kidney or of its ureter. We shall not endeavor to recite 
the anatomical appearances found as a result of anemia pure and simple, 
because we rarely see them except in experimental animals; nor the 
clinical signs, because there are none (save lessening of the quantity of 
urine) which can be safely asserted to be the result of ischemia alone. 
Hyperemia.-The kidneys frequently become hyperemic, but the 
cases in which this happens are generally of such a kind that organs 
elsewhere in the body are more deeply concerned. Active hyperemia, 
such as occurs in inflammatory diseases, does not concern us here; 
passive hyperemia arises in two ways, either as part of a general venous 
stasis, or as the result of alterations of circulation which are local to the 
kidney. 
Considering venous stasis in general, it may be pointed out that the 
venous outflow from the kidney will be lessened when the blood cannot 
pass freely to the heart because of direct obstruction, or when the current 
is slowed because the arterial force (primarily the heart) is weak. In 
conditions of cardiac incompetence both of these factors may be at work, 
and the question which one is more effective is not of consequence. 
When the heart is incompetent and the arterial flow weak, the result is 
cortical and especially glomerular congestion, with excretion of albumin 
into the capsules. This much follows experimentation; the results of 
local venous stasis are felt first, on the contrary, in the medulla. If 
the two work together, the entire kidney is engorged, there is excre- 
tion of albumin, and the epithelium of the tubules suffers by reason of 
imperfect oxygenation, imperfect nutrition, inability to get rid of its 
excretions by way of the blood, or a combination of these. The result 
is its degeneration. Such a kidney, seen macroscopically, is large, firm, 
and dark red; its capsule strips readily leaving a smooth surface, its 
stellate veins are injected, its cut surface may be oedematous or even 
bloody, is of a deep-red color, and its glomeruli are prominent. This 
is the condition generally described as "cyanotic induration." Many 
authors consider that, should this state be long continued, a slowly pro- 
duced fibrosis is the result, which, although rarely great in degree, may 
yet suffice to produce contraction and consequent lessening of the size 
of the kidney. Oertel, however, in a recently studied series, does not 
find that venous stasis is followed by granular atrophy, and considers 
that such a change does not occur as the result of uncomplicated venous 
congestion, but from arteriosclerotic and other influences. Microscop- 
ically, the glomeruli are engorged and enlarged, and may lose their 
endothelium from pressure atrophy: the capsule of Bowman may be 
hyaline and stretched, and separation of fibres by oedema may be 
observed not only in the capsule but also in the intertubular connective 
tissue; the capillaries and lymphatics are dilated ne epithelium of the MALFORMATIONS AND DISEASES OF THE KIDNEY 
789 
tubules may show granular or fatty change, and some tendency to regen- 
eration. In all this, the signs of inflammation are absent. 
A passively congested kidney excretes a less amount of water than 
normal; the urine, therefore, is scanty, and for this reason of high specific 
gravity, highly colored, and readily precipitates its urates. Albumin 
is likely to be present in moderate quantity through the glomeruli, and 
casts in number commensurate with the destruction of epithelium; the 
latter being very gradual, casts are generally few. It is obvious that 
this condition is not easy to differentiate from an early nephritis; even 
the result of rest in a rapid clearing up of the signs and symptoms may 
not be sufficient to make the diagnosis plain; nevertheless, the recogni- 
tion of the existence of a cause for the congestion may assist. 
Thrombosis of the Renal Vessels and Infarct of the Kidney.- 
Thrombosis of the renal vessels, either artery or vein, or both, may occur. 
More than half a century ago it was recognized that the left renal vein 
of marantic infants was frequently the seat of thrombosis; the greater 
length of the left vein appeared to render it more prone to the process 
than the right. Thrombosis of the renal, as well as of other veins, was 
considered to be a sequence of a cachectic state, and today we can add 
little more to this than to point out the probability of its being the direct 
outcome of an infection that generally proves to be terminal. The 
appearance of a kidney with such a thrombosis, and the existence of 
symptoms or signs resulting therefrom, will depend largely upon the 
perfection of the collateral circulation; if the process does not prove 
fatal, the thrombosis will be found to have brought about a state of 
affairs not widely different from that found in passive hyperemia. 
Diminution of the urine, its high color, the presence in it of hemoglobin, 
and an icteroid tint of the skin are the external results that may be 
expected. 
Thrombosis of the renal artery may occur from trauma, infection, or 
from disease of the wall of the vessel, but is rarely found. If the entire 
vessel be occluded, complete and rapid necrosis of the kidney results. 
Much more commonly, embolism of a branch of the renal artery, with 
its resultant thrombosis, is seen. Emboli may be infective or non- 
infective, according to the nature of the original process from whose 
site the embolus is derived. In the former case there is a metastatic 
abscess set up in the area concerned; in the latter, the well-known 
infarct is formed. 
An infective embolus can and frequently does cause an infarct, but 
the rapid progression of the bacterial process causes the picture to be 
dominated by the features of abscess formation. When the embolus 
is non-infective, the case becomes one of infarction pure and simple. 
Such emboli are set free most often from thrombi or vegetations in the 
left side of the heart, but may happen when any foreign body, such as 
a mass of tumor cells, finds its way into the arterial circulation. What- 
ever be the appearance of such an infarct immediately after its forma- 
tion (and this is still a subject of debate), when seen the lesion is a yel- 
lowish, sometimes golden, roughly triangular area, edged by a hyperemic 
zone of kidney substance; if superficial, it usually projects slightly from 790 
DISEASES OF THE URINARY SYSTEM 
the level of the kidney, and is as prominent on the external as on the cut 
surface of the organ. Sometimes the cortex is infarcted in its entirety, 
the medulla and the contiguous layer of cortex being spared, since the 
thrombosis has occurred in the interlobular arteries. All but the largest 
infarcts become replaced by fibrosis and ultimately are represented 
by depressed scars on the outside and fibrosed areas in the substance 
of the kidney. 
Except in the case of the largest infarcts, there is usually no symptom 
or sign of their formation; a sudden pain in the kidney, with the appear- 
ance of blood or hemoglobin in the urine, in a patient prone to embolus, 
would justify the supposition that infarction had occurred; but usually, 
from the very fact that the primary disease is so serious, the existence of 
the renal infarct is unimportant; thus there is no need to deal with the 
question of prophylaxis or treatment, as these ends are served in the 
measures that are rationally adopted in the care of the primary disease. CHAPTER XIII 
ANOMALIES OF URINARY EXCRETION 
A. E. GARROD, M.D., F.R.C.P. (Lond.), F.R.S. 
The changes observed in the properties and composition of the urine 
in disease are almost infinite in their variety. Some are obvious to the 
most casual observer, gross deviations from the normal in tint, specific 
gravity, or volume. Others are readily detected by means of such simple 
tests as form part of the routine of clinical examination. Others, again, 
are only brought to light by elaborate chemical methods, or by the 
employment of instruments of delicacy and precision, for the use of 
which special training is required. Many have doubtless escaped 
detection up to the present time. 
When the kidneys are the seat of disease the impairment of their 
functions may be manifested by imperfect excretion of urinary ingre- 
dients, of inorganic salts, or of the end products of protein metabolism. 
The urinary water may be greatly diminished in quantity, or may be 
much in excess of the normal amount. The impairment of function 
may also be revealed by diminished molecular concentration of the 
urine, while that of the blood is increased to a corresponding extent. 
Diseased kidneys may allow passage to the normal proteins of the 
blood, which it is one of their chief functions to retain in the circulation 
while allowing passage to waste products. Hence, albuminuria comes 
to be one of the most important of the signs of renal disorders. Lastly, 
products of the breakdown of renal structure , such as epithelial cells and 
tube casts, may bear witness to profound changes in the kidneys. 
Such changes as the above, indicative of disease of the urinary organs, 
constitute only a small proportion of the deviations from the normal 
which are met with in disease. Anomalies due to metabolic derange- 
ments, in which the kidneys are in no way primarily concerned, are very 
numerous, and often quite as conspicuous. lienee the condition of the 
urine comes to reflect the state of the organism as a whole. 
CHANGES IN THE URINE DUE TO DISEASES OF THE KIDNEYS 
AND URINARY TRACT 
Polyuria and Ischuria.-Variations in the quantity of urine excreted 
are important signs in some varieties of renal disease. Diseases of the 
kidneys may give rise to polyuria on the one hand or to ischuria on 
the other. The ischuria, which may even amount to complete anuria, 
of acute nephritis may afford an even better indication of the degree 
791 792 
DISEASES OF THE URINARY SYSTEM 
to which the excretory function of the kidneys is impaired than do the 
amounts of albumin and blood which the urine contains. The polyuria 
of granular kidney is a familiar sign; and of scarcely less significance is 
the development of polyuria, with abundance of albumin, in cases of 
parenchymatous nephritis which are entering upon a chronic stage. 
Whereas, the destruction of one kidney or the blockage of its ureter 
does not profoundly or lastingly affect the volume of the urine, obstruc- 
tion of the second ureter, or the simultaneous blockage of both, causes 
a form of anuria of great interest, on account of the nature of the symp- 
toms which result, and of great clinical significance as urgently calling 
for surgical intervention. The intermittent passage of large quantities 
of urine, simultaneously with the disappearance of a renal tumor, is a 
valuable diagnostic sign in cases of unilateral hydronephrosis. 
Specific Gravity.-Just as inferences based upon the volume of the 
urine are of little value unless the specific gravity is taken into account, 
the information which the specific gravity affords needs to be supple- 
mented by a knowledge of the quantity excreted, in order that any 
satisfactory conclusions may be drawn from it. Moreover, seeing that 
the specific gravity varies widely at different periods of the day, it is 
important that the specimen tested should, if possible, be a sample from 
the day's total. The specific gravity affords a measure of the proportion 
of solids in solution, and deviations from the normal density of about 
1.020 may result from excessive or deficient excretion of water or from 
variations in the output of dissolved substances. 
Unless calculated for a normal volume of urine a low specific gravity 
does not imply a diminished output of solids in solution, for in association 
with polyuria there may be a daily output of excretory products which 
is in no way below the average, although, as in diabetes insipidus, the 
specific gravity may be very low. Even if the reading be low when 
corrected for a normal volume of 1500 cc. allowance must be made for 
the nature of the diet and the amount of protein which it contains. 
However, in renal cases the indications which the urinometer affords 
are often of much value, as, for example, when, apart from any increase 
in the volume of urine, the specific gravity tends to fall; as it often does 
before the onset of uremic symptoms. In this connection it must not 
be forgotten that in the late stages of many maladies of chronic course 
but in which the kidneys are not directly implicated, when death is 
approaching urine of low specific gravity and scanty in amount is wont 
to be excreted. 
Cryoscopy.-The method of cryoscopy, or determination of the freez- 
ing-point, recently applied to clinical purposes by A. von Koranji, owes 
its importance to the fact that the depression of the freezing-point 
of a solution supplies a measure of the osmotic pressure, and this again 
depends upon the number of molecules in solution. Thus, equimolecular 
solutions of two different substances will show a depression of the freezing- 
point of equal degree, and when two or more substances are in solution 
the depression will correspond to the total number of molecules, irrespec- 
tive of their nature. 
Tn dealing with an organic liquid such as blood or urine the conditions ANOMALIES OF URINARY EXCRETION 
793 
are not so simple. Salts, such as sodium chloride, are dissociated into 
their component ions, and each ion, which counts as a molecule for the 
purpose in hand, has an equal effect upon the freezing-point with a 
heavy protein molecule. In the case of the urine the most abundant 
constituents, and especially sodium chloride, are largely responsible for 
the observed depression. Moreover, in the complex mixture, molecular 
rearrangements occur after excretion, and these, as Koppe has shown, 
tend to diminish the number of effective molecules. The conversion 
of urea into ammonium carbonate will have a like effect, and therefore 
it would be desirable to make the determination with freshly passed 
urine, whereas the results will have little value unless a sample of the 
excretion of twenty-four hours be taken. Again, the total number of 
molecules in a sample specimen will be largely determined by the bulk 
of the urine in the day, so that an unusually high freezing-point may 
depend upon a copious excretion of water as well as upon a diminution 
of the solid constituents in solution. 
Accordingly, it is found that whereas the freezing-point of the blood 
of healthy persons deviates but little from -0.56° C., that of their 
urine varies between -1.3° and -2.2° C. Chiefly on this account the 
indications afforded by cryoscopy of the urine alone, in cases of bilateral 
renal disease, are apt to be inconclusive as to the functional competency 
of the kidneys. When the freezing-point of the blood can be compared 
with that of the urine in such cases the results obtained have a much 
greater value. The accumulation of excretory products in the blood 
lowers its freezing-point, whereas their comparatively scanty presence in 
the urine has an opposite effect, and the two figures tend to approximate. 
In extreme cases the freezing-point of the blood may be equal to, or even 
lower than, that of the urine. In acute nephritis, recovery is accompanied 
by a progressive fall of the freezing-point of the urine to normal figures. 
Electrical Conductivity.-The determination of the electrical conduc- 
tivity of the urine affords another means of determining the number 
of contained ions. Here again sodium chloride plays the most important 
part in causing variations in the resistance offered. Molecules which 
are not dissociated do not favor conduction, and a urine of high specific 
gravity due to contained sugar may, nevertheless, have a high resisting 
power. Hence the indications afforded by electrical conductivity are 
different from those afforded by the freezing-point. 
Reaction of the Urine.-This may afford valuable indications as to 
the condition of the urinary tract, but here again variations may equally 
result from conditions above the kidneys. Alkalinity due to the presence 
of ammonia and ammonium carbonate points to infection of the bladder 
or urinary passages, seeing that it is due to the decomposition of urea 
under the influence of bacteria. It is a prominent symptom of cystitis. 
It must be remembered, however, that certain microdrganisms"produce 
pyelitis or cystitis with acid urine. 
Ammoniacal urine may be recognized by its peculiarly offensive 
smell and by the change to blue of moistened red litmus paper held 
above the surface of the liquid. Alkaline urine of this character deposits 
abundant crystals of ammonio-magnesium phosphate, and since it is 794 
DISEASES OF THE URINARY SYSTEM 
usually associated with cystitis, many leukocytes are, as a rule, present 
in the sediment, and the urine may swann with bacteria. 
Albuminuria.-One of the most important of the renal functions is 
that of refusing passage to the proteins of the blood while allowing a 
free passage to the end products of metabolism. This function appears 
to be a highly specialized one, for proteins foreign to the blood, unless 
present in very small quantities, are not at all held back to the same 
extent, as witness the free excretion of hemoglobin in the paroxysms 
of hemoglobinuria, and of the Bence-Jones protein by kidneys which 
are not the seat of disease. 
With serum albumin, the blood globulin and fibrinogen the case is 
different, and although there are grounds for believing that minute 
quantities of these substances find their way even into normal urines, 
and that, occasionally, amounts appreciable by ordinary clinical tests 
pass through kidneys which are not seriously abnormal, in the conditions 
included under the name of functional albuminuria, the fact remains 
that the continuous excretion of appreciable quantities of albumin 
usually denotes renal disease, either primary or secondary to circulatory 
disturbances. Hence, albuminuria comes to be the most important of 
the urinary signs of disorders of the kidneys, and has a wholly different 
significance from the excretion of other protein substances in the urine. 
. Although it may be accepted as proved that the albumins of urine 
are actually blood-proteins which are not held back as they should be, 
the relative proportions of serum albumin and globulin are by no means 
those which prevail in the blood. Serum albumin usually preponderates 
greatly in the urine, but globulin is usually also present in varying 
amounts. Whereas, serum albumin alone may be present, this is hardly 
ever the case with globulin. The results of the investigations which 
have been carried out with a view to determining the significance of 
the relative proportions of the two proteins in albuminous urine have 
not proved of much clinical value. It would seem that a low proportion 
of globulin in cases of nephritis is a favorable indication. Haliburton 
suggests that, speaking generally, much globulin indicates a grave 
renal lesion. Further than this our knowledge does not allow us to go. 
Considerable interest attaches to that protein of urine which is pre- 
cipitated by the addition of dilute acetic acid to the diluted or undiluted 
urine in the cold. That this is not mucus, as was originally thought, 
was shown by the fact that when treated with mineral acids it yields 
no reducing substance, and for many years it was looked upon as nucleo- 
albumin. Morner arrived at the conclusion that this substance was 
in reality composed of compounds of serum albumin with chondroitin- 
sulphuric acid, nucleic acid, and, in cases of jaundice, with taurocholic 
acid. It has been stated by A. Oswald that the protein so precipitated 
from albuminous urine in cases of nephritis and of cyclic albuminuria 
is a mixture of euglobulin and fibrinogen. More recent work seems to 
prove that this substance is derived from the blood and is not a product 
of the diseased renal epithelium. Its presence has, therefore, a like 
significance to that of serum albumin and globulin. 
In considering the clinical significance of albuminuria it is necessary ANOMALIES OF URINARY EXCRETION 
795 
to draw a sharp distinction between the true renal forms and what has 
been styled accidental albuminuria. The mere presence of albumin in 
the urine does not necessarily imply a renal origin. In some cases it 
results from the admixture of vaginal discharge or of semen, in others 
it is due to disease of the urinary passages. Urine which contains blood 
or pus must always yield the reactions of albumin, and albumin is also 
present in chylous urines. 
Physiological or functional albuminuria offers a problem of no small 
difficulty, upon which the last word has by no means been said. It may 
be taken as proved that minute quantities of albumin, so minute that 
they escape the ordinary tests, are present in normal urines. Somewhat 
larger amounts are not uncommonly met with apart from any other 
signs of organic renal disease. As a rule the albumin present in cases 
of functional albuminuria is precipitated to a greater or less extent by 
acetic acid in the cold. Some subjects of functional albuminuria excrete 
albumin only after exertion, others after a cold bath, and others after 
mental or bodily strain. Severe and prolonged exertion will induce 
albuminuria in many persons. Often the functional albuminuria is 
profoundly influenced by position, and may only be present during the 
active hours. However, the influence of posture is also well marked in 
cases of albuminuria due to gross renal lesions. 
That the excretion of albumin in quantities easily detected is not 
strictly normal is an obvious truism, but the evidence is strong that it 
may be a symptom of no serious significance. Our interpretation of 
the observed facts will depend largely upon the views which we hold as 
to the limits of idiosyncrasy as distinguished from disease. A few such 
cases carefully watched from childhood to advanced life would throw 
more light upon the question than many investigations covering only 
brief periods. 
Albuminuria due to circulatory disturbances is a common symptom, 
well exemplified in cases of cardiac disease in which compensation fails 
and backward pressure leads to passive congestion in the kidneys. It 
is uncertain how far the increased pressure is directly responsible for 
the escape of albumin under such conditions, but it seems certain that 
the main cause is a secondary change in the renal epithelium due to 
deficient conveyance of oxygen to the part. When there is a complete 
obstruction of the renal vessels, as the result of embolism or thrombosis, 
the necrotic changes in the infarcted area amply account for the albu- 
minuria which results. The albuminuria of cholera has been ascribed 
to deficient blood-supply to the kidneys, but toxic influences probably 
play an important part. 
In the albuminuria of fevers, which constitutes a well-defined variety, 
circulatory disturbances may also come into play, but it is probable 
that a mild form of toxemic nephritis is often produced, and the cloudy 
swelling, so often seen at autopsy, bears witness to the changes in the 
renal parenchyma which fevers induce. This view gains in probability 
from the observation that the duration of the fever, rather than its 
intensity, is the most important factor in determining the excretion 
of albumin. 796 
DISEASES OF THE URINARY SYSTEM 
Albuminuria of slight degree is a common symptom in jaundice, and 
here also it is presumably toxic. Hyaline casts are usually present in 
considerable numbers, even in cases of jaundice in which no albumin is 
to be detected by the ordinary tests. Graver varieties of toxic nephritis 
are caused by various poisons, such as cantharides, turpentine, and 
carbolic acid. 
Special interest attaches to the albuminuria which is associated with 
nervous disturbances, the pathology of which is obscure. The temporary 
presence of albumin in the urine after epileptic fits, which has occa- 
sionally been observed, has been compared with that which is sometimes 
induced in healthy subjects by violent muscular exertion. 
The albuminuria which results from gross lesions of the kidneys is the 
most important of all. The quantities of albumin excreted vary quite 
widely from the conditions met with in acute parenchymatous nephritis, 
and in many chronic cases of the same disease, in which the urine becomes 
almost solid on boiling, to the no less significant presence of mere traces, 
in association with granular kidneys. However, in cases of granular 
kidney in which the heart is beginning to fail the amount of albumin 
in the urine may be very greatly increased. 
Detection of Albumin in Urine.-The tests most often employed in clini- 
cal work are the heat test and the cold nitric acid test. Although they 
are far from being the most delicate available it may safely be stated 
that any quantity of albumin which they fail to reveal may. for ordinary 
clinical purposes, be neglected. 
In performing the heat test the urine, if at all turbid, should be filtered, 
and the upper portion of the column in the test tube should be boiled. 
If a turbidity appears this may consist of albumin or of earthy phosphates 
thrown down as a result of a rearrangement of bases produced by boiling. 
On the addition of a drop or two of acetic acid the cloud will disappear, 
if it be due to phosphates, but if albuminous will persist or increase in 
density. When much albumin is present the coagulum will collect 
together and become flocculent when the acid is added. Urines contain- 
ing traces of albumin may show no turbidity on simple boiling, but if 
they be again boiled after the addition of acetic acid a cloud may appear. 
This second boiling should always be carried out. For the detection of 
slight turbidity the test tube should be held before a dark surface. 
In many albuminous urines, turbidity is produced when acetic acid 
is added in the cold, especially if the urine has been previously diluted 
with water. This is the precipitate of euglobulin and fibrinogen which 
has been referred to already. Precipitates of urates similarly produced 
will clear on warming; they will not appear after dilution of the urine. 
The advantage of the heat test lies in the fact that it is not yielded by 
other proteins than serum albumin and globulin. The only other urinary 
protein precipitated by heat is the Bence-Jones protein, but this is 
distinguished by the fact that coagulation begins at an unusually low 
temperature and that the liquid usually clears almost completely as the 
boiling-point is approached, especially if acetic acid has been added. 
The precipitate of earthy phosphates will hardly lead to mistakes, as 
acetic acid should always be added as a routine proceeding. ANOMALIES OF URINARY EXCRETION 
797 
Heller's test with cold nitric acid is best performed as a contact test. 
If albumin be present an opaque white ring, or rather disk, appears at 
the junction of the liquids. Beneath it a colored layer is often seen, 
due to oxidation of indican. When very minute traces of albumin are 
sought for it is well to employ a wide test tube or a small beaker. A 
faint, hazy ring above the junction of the liquids is due to the protein 
which was formerly spoken of as nucleo-albumin. In concentrated 
urine a ring of uric acid may form, which disappears on warming and 
is not obtained after dilution of the urine. After standing for a short 
time a crystalline ring of nitrate of urea is formed if the urine tested be 
very concentrated. Another possible source of error is the precipitation 
of resins, such as copaiba, in the urine of patients taking such drugs. 
Other proteins, such as the Bence-Jones albumin and albumoses yield 
this test as well as serum albumin and globulin. 
A number of different test solutions are also employed for the detection 
of proteins in urine. These all precipitate albumoses in addition to albu- 
min and globulin, but the albumose precipitates disappear on heating, 
to reappear when the liquid is cooled. Of such reagents, a saturated 
solution of picric acid is often used, either as a ring test or by the addition 
of the urine to the test solution. Care must be taken that the reagent 
is in excess. A solution of potassium ferrocyanide is widely employed, 
after acidification with acetic acid. Trichloracetic acid may also be 
mentioned, and salicyl-sulphonic acid, which is one of the most delicate 
and satisfactory of the precipitants of proteins; and only proteins are 
precipitated by this reagent. A few drops of a saturated solution of 
salicyl-sulphonic acid are added to the urine in the cold. If a turbidity 
results the liquid should be heated, when the turbidity, if due to an 
albumose, will disappear. The presence of globulin in considerable 
amount may be demonstrated by Sir William Roberts' test. The urine 
is allowed to fall, drop by drop, into a beaker of distilled water. If 
much globulin be present the path of each drop is made visible by a 
milky turbidity, for such proteins are insoluble in distilled water. 
A very rough notion of the proportion of albumin present in urine 
may be obtained by boiling a specimen in a test tube after the addition 
of a drop of acetic acid, and estimating the relative depth of the coagulum 
after it has had time to settle. By the use of Esbach's albuminometer 
a much more accurate notion may be obtained which suffices for ordinary 
clinical purposes, such as the estimation of the progressive diminution 
of albuminuria during recovery from acute nephritis. For accurate 
determinations, either of the total albumin or of serum albumin and 
globulin separately, it is necessary to proceed by laboratory methods, the 
proteins being isolated from the urine, dried and weighed. 
Sediments Indicative of Disease in the Urinary Tract.-The micro- 
scopic examination of urinary sediments often supplies important 
information as to the presence of morbid conditions in the kidneys or 
urinary tract. Normal urine is clear and limpid when passed, but on 
standing a slight cloud develops in the liquid, which is known as the 
nubecula; this may lie at the bottom or may hang suspended in the 
urine. The position is in part determined by the specific gravity of 798 
DISEASES OE THE URINARY SYSTEM 
the liquid and in part by the inclusion of air bubbles. The bulk of the 
nubecula consists of urinary mucoid, and in it are entangled a few 
epithelial cells, the sheddings of the surface layers of the mucous mem- 
brane, and also a few leukocytes. Seeing that, with the exception of 
bacteria, no cellular elements can pass the renal filter, any such which 
are present in the urine are derived from the kidneys themselves, or 
from the urinary passages, bladder, or generative organs. A few squam- 
ous epithelial cells may be looked upon as normal urinary constituents; 
only when the cells are numerous, and bear signs of coming from the 
deeper layers of the mucous membranes or from the renal tubules, can 
they be regarded as indicative of disease. 
Red-blood corpuscles afford the sole criteria of hematuria as distin- 
guished from hemoglobinuria, and their presence, even in small numbers, 
is evidence of hemorrhage from the kidneys or below. After soaking 
in urine they lose their hemoglobin and their biconcave form, and become 
globular or crenated. Leukocytes may be derived from vaginal secretion, 
and the presence of a few such cells has no serious import. In cystitis 
they may occur in any numbers, and when suppuration occurs in the 
kidneys or any other portion of the tract. The presence in them of 
gonococci is naturally of prime diagnostic importance. In alkaline 
urines they are apt to be swollen, globular, and hyaline, and their nuclei 
may only be demonstrable by the addition of acetic acid. When, as is 
sometimes the case, it is difficult to distinguish the leukocytes from 
cells from the renal tubules, the far deeper staining which iodine imparts 
to the former may be employed as a test. 
The epithelial cells which are met with in urine are of different shapes 
and sizes, and from their characters some indication may be obtained 
of the parts from which they are derived. However, even to the trained 
eye the exact determination of their place of origin presents no small 
difficulty, especially when, as is often the case, they exhibit degenerative 
changes which alter their appearance and forms. The cells shed from 
the surface layers are usually of the flat varieties. Exceptionally large 
squamous cells, often adherent into groups, are derived from the mucous 
membranes of the vulva, vagina, and prepuce. Of the true urinary 
epithelial cells those from the bladder are the largest. Tailed, pyriform, 
and oval cells are derived from the deeper layers and therefore suggest 
a more deep-reaching affection. They may come from the bladder, pros- 
tatic urethra, or pelvis of the kidneys. The small, rounded, or polygonal 
cells,with well-defined nuclei, which are derived from epithelium of the 
renal tubules, are the most important from a diagnostic standpoint, 
and if abundant they afford evidence of renal disease hardly less con- 
vincing than that derived from the presence of renal casts. Not merely 
the presence but also the condition of the epithelial cells is of importance. 
Some changes are merely due to their being soaked in the urine, but the 
presence of fat globules in their protoplasm may serve to give an idea 
of?the stage of the morbid process at their place of origin. 
Renal Casts.-These owe their importance to the fact that, being 
obviously formed in the renal tubules, their presence in any considerable 
numbers indicates that all is not well with the kidneys; and that when ANOMALIES OF URINARY EXCRETION 
799 
albumin or blood is also present the albuminuria or hematuria is of 
renal origin. The evidence of their renal origin is conclusive. In shape 
and size they correspond to the renal tubules, and they are often bedecked 
with epithelium which is obviously renal. Moreover, in sections of 
diseased kidneys they are frequently seen in situ. However, it cannot 
be inferred from the presence of a few hyaline or stippled casts in a 
centrifugalized deposit that anything serious is amiss with the kidneys. 
A few such objects may be found in some otherwise normal urines if 
the centrifuge be employed, and the almost constant presence of such 
casts in cases of jaundice suggest an irritant action of the bile constituents 
in the circulation upon the renal epithelium. Of renal diseases, it is in 
those which specially implicate the renal parenchyma that casts are 
most numerous, whereas in granular kidney they are scanty or absent. 
Hyaline casts are very delicate structures, so transparent that they 
may be difficult of detection in unstained specimens. Such casts vary 
greatly in length and often have broken ends, indicating that they origin- 
ally formed parts of longer specimens. It would seem that hyaline 
casts often indicate the slightest degree of renal mischief or the incipience 
of graver troubles. They are usually abundantly present in the early 
stages of acute nephritis, but even in the most chronic cases of paren- 
chymatous nephritis they are met with in association with casts of 
various other kinds. 
Epithelial casts are considerably larger than the hyaline, as is natural, 
seeing that the former correspond in size to the lumen of the renal tubule, 
whereas the latter represent the size of the tubule stripped of its epithelial 
lining. Every stage is met with, from a hyaline cast with a few cells 
from the tubal epithelium attached to it, to those which apparently 
consist wholly of epithelial cells, or from which a bare hyaline core 
may project at one end. Such objects are seen in their most perfect 
forms in the early days of an acute nephritis, and the cells with which 
they are clothed may have a cloudy or swollen appearance. Later on 
the condition of the epithelial cells may bear witness to a more advanced 
stage of disease; they may have a granular appearance, or may even 
contain highly refractive fat globules. 
The so-called amyloid or waxy casts, larger and less transparent than 
the hyaline, but homogeneous and often showing partial segmentation, 
are believed by many to be derived from those of the epithelial variety 
by degeneration and fusion of the constituent cells. Although they 
sometimes show the red coloration with methyl-violet and stain deeply 
with iodine, their presence affords no evidence that the kidneys from 
which they come are lardaceous. They indicate rather an advanced 
and chronic renal trouble, and are most often met with in cases of chronic 
parenchymatous nephritis of somewhat long standing. 
The casts which are grouped together under the name of granular 
differ considerably in appearance and size. Some are narrower and 
some broader; the component granules may be larger or smaller in size. 
They are opaque objects, and often have a brown tint. That they are 
friable is shown by the fact that they are usually short and often show 
broken ends. It is believed that the granules arise from the disintegration 800 
DISEASES OF THE UHINAHY SYSTEM 
of epithelial cells, and they are therefore held to indicate somewhat 
advanced renal lesions. They are met with in the urine in all varieties 
of nephritis and a few may be present in cases of granular kidneys. In 
cases of chronic parenchymatous nephritis a large proportion of the 
casts present are usually of this nature. Transitional stages between 
epithelial and granular casts are not infrequently met with. 
Fatty casts are held to denote an advanced degeneration of the renal 
epithelium. Fat granules, recognized by their high refractive power, 
are sometimes present in the cells of which epithelial casts are composed. 
In many granular casts some of the granules are composed of fat, and 
occasionally the casts are mainly composed of fat globules. Acicular 
crystals of fat or of fatty acids sometimes project from such casts, usually 
from one extremity, and impart a hedgehog appearance. 
Among other varieties, hyaline casts studded with red-blood corpuscles 
or crystals of calcium oxalate are sometimes seen. Casts richly beset 
with red corpuscles are common in the early stages of acute nephritis. 
Leukocyte or pus casts are much less common, as also are such as are 
composed of bacteria. 
The so-called cylindroids, long hyaline objects with tapering ends 
which often show a wavy outline and longitudinal striation, are threads 
of mucus which have no connection with true renal casts. Other objects 
which simulate renal casts are composed of amorphous urates or of 
hemoglobin debris which have assumed cast-like forms. 
Spermatozoa must also be mentioned among objects found in the 
sediment. Their presence will sometimes explain a slight albuminuria, 
and deprive it of any import as a sign of renal trouble. 
The presence in the sediment of the ova of Bilharzia hoematobia will 
afford conclusive evidence in cases of endemic hematuria. Within 
the oval envelope with its lateral or terminal spine the ciliated embryo 
is visible, and sometimes makes its escape from the shell under observa- 
tion. The presence of hydatid booklets which are easily recognized by 
their characteristic form, or of scolices, reveals the presence of hydatids 
in, or in connection with, the urinary tract; and the Filaria sanguinis 
hominis has sometimes been found in the urine. 
Hairs are usually accidental additions, but when a teratoma communi- 
cates with the tract hair is sometimes passed in considerable quantities, 
the phenomenon being known as pilimictia. 
Crystalline Sediments.-Although their presence is usually dependent 
upon processes behind the kidneys, they may afford valuable clues as to 
the nature of a calculus or gravel, the presence of which is indicated by 
other symptoms. The various crystals have very different degrees of 
diagnostic value. Thus, whereas the presence of hexagons of cystin is 
the diagnostic sign of cystinuria, and renders it almost certain that 
symptoms of calculus are due to cystin stone or stones, other crystals 
such as those of phosphates indicate little more than an abnormal reaction 
of the urine, and those of triple phosphate suggest ammoniacal decom- 
position. It is a matter of no small importance whether the crystals 
are already present in the urine when it is passed, or merely separate 
when it is allowed to stand. ANOMALIES OF URINARY EXCRETION 
801 
Uric acid crystals are the commonest of all those met with in urine. 
They are always tinted, although sometimes very faintly, by included 
urinary pigments. In carboluria the uric acid acquires a deep brown 
color, and the crystals appear black when seen in bulk. Those deposited 
from bile-stained urines are colored by the bile pigments, and when 
biliverdin is present are grouped into rosettes of greenish-yellow prisms. 
The exact conditions which determine the deposition of crystalline 
uric acid are not fully known. Klemperer assigns much importance 
to scantiness of urochrome; acidity certainly plays a part, as also does 
the amount of uric acid present, although excessive output of uric acid 
can by no means be assumed from the deposition of crystals. 
Crystals of ammonium urate are not infrequently deposited from 
feebly alkaline or amphoteric urines, often in company with those of 
ammonio-magnesium phosphate. Sometimes they assume the form 
of minute yellow dumb-bells or of the so-called "hedgehog crystals," 
small yellow .spherules with sharp excrescences. 
Calcium oxalate crystals are, next to those of uric acid, the commonest 
of all. They are often very minute, and form a snow-like layer on the 
top of the nubecula, or adhere to grease marks upon the sides of the 
containing glass. The commonest form is a flat octohedron which 
appears under the microscope in the semblance of a square envelope. 
Less common are cubical prisms with pyramidal ends. Twin crystals 
composed of interpenetrating octohedral forms are also seen. Imper- 
fectly crystalline forms are sometimes present, such as oval disks with 
deep central grooves upon their flat surfaces and more rarely true dumb- 
bells. When deposited from bile-stained urine, crystals of calcium 
oxalate are faintly tinted by bilirubin or biliverdin. 
Ammonio-magnesium or triple phosphate is deposited in crystalline 
form from arfy urine which is undergoing ammoniacal decomposition, 
and the presence of such crystals has no greater significance than this. 
They assume various forms, of which the most characteristic is the 
familiar "knife-rest" or "coffin-lid" shape. Feathery forms are also 
met with. When the urine is frankly alkaline they are usually surrounded 
by a deposit of amorphous earthy phosphates, which, with the crystals; 
are easily soluble in acetic acid. 
Neutral calcium phosphate or "stellar phosphate" forms crystals 
which are easily recognized and are not seldom seen in amphoteric 
urines and in those which owe their alkalinity to fixed alkalis. They 
form long, wedge-shaped prisms, with their broader ends cut off obliquely. 
They are usually grouped into stars, with their pointed ends toward the 
centre of the star. 
Magnesium Phosphate.-In some forms of gastric disorder treated 
by large doses of magnesium carbonate, tabular crystals of normal 
magnesium phosphate have been met with in the urine. 
Crystals of cystin are among the rarest of urinary sediments. They 
form colorless hexagonal plates the sides of which are often of unequal 
lengths, and groups of superposed hexagons are common. They may be 
distinguished by their ready solubility in ammonia and also in hydro- 
chloric acid. 802 
DISEASES OE THE URINARY SYSTEM 
Xanthin crystals, which arc always described among urinary sediments 
as lemon-shaped and yellow in tint, have been met with in only a single 
case, described by Vence-Jones many years ago, and were only present 
for a day or two. 
Calcium sulphate has been rarely met with as a sediment composed of 
long needles or tables with sloping ends; calcium carbonate is sometimes 
deposited from alkaline urines in small dumb-bells or spherules with 
concentric striation. Calcium and magnesium soaps in crystalline form, 
as needles resembling those of tyrosin, for which they may readily be 
mistaken, have been described by von Jaksch, and are sometimes seen 
adhering to and projecting from fatty casts. 
Bilirubin or hematoidin, in the form of minute brown acicular crystals, 
may be found in urines containing bile, and in some cases of malignant 
disease of the kidneys or urinary tract in which old extravasations of 
blood are breaking down. Crystals of these substances are indistin- 
guishable from each other and probably are chemically identical. 
Hippuric acid has been rarely seen as a urinary sediment composed 
of rhombic prisms. 
Indigo blue is found in amorphous particles in many alkaline urines, 
and rarely in the form of crystals. 
Crystals of tyrosin and leucin will be described elsewhere. 
In connection with disease in the urinary tract, deposits of crystalline 
cholesterin are of special interest, although they are very rare. The 
crystals may be very abundant, so that they appear as innumerable 
glistening particles when the urine is shaken. They have the charac- 
teristic form of rectangular plates each with one corner removed. The 
excretion of crystalline cholesterin has been observed in association 
with a variety of morbid conditions, all of which have this in common, 
that they are characterized by local lesions in the urinary tract. Thus, 
it has occurred in cases of congenital cystic disease of the kidneys, 
hydronephrosis, pyonephrosis, and chronic cystitis of long standing. 
Plaques of crystalline cholesterin have been found postmortem on the 
inner surface of the bladder and of the renal pelvis, and even in the sub- 
stance of the kidney. 
Lastly, calculi chiefly composed of cholesterin have occasionally been 
passed or removed from the bladder. These have usually been gall-stones 
which have found their way into the urinary passages through bilio- 
urinary fistuke, as was shown by the presence of bilirubin calcium, by 
facetting in some instances, or by the excretion of deeply bile-stained 
urine apart from any jaundice. No such explanation can be given, 
however, of a large calculus of almost pure cholesterin, described by 
Horbaczewski, which was removed by suprapubic lithotomy from the 
bladder of a little girl, and was mistaken for a cystin stone. 
Hematuria.-Among the symptoms which indicate disease of the 
kidneys or urinary tract hematuria claims an important place. In 
many cases the diagnosis of the place of origin of the admixed blood, 
and of the cause of hematuria, presents little difficulty; in others both 
are extremely obscure. Whether the blood conies only at the beginning 
of micturition, or only at its end, or whether it is intimately mixed with ANOMALIES OF URINARY EXCRETION 
803 
the urine, are points which afford valuable aid. Again, cystoscopic 
examination or the use of the separator is often of great use. 
The microscope not only supplies the only certain means of diagnos- 
ing hematuria from hemoglobinuria, a symptom of wholly different 
significance, but may also throw much light upon the origin of the 
blood. Thus the presence of numerous casts, and their characters, 
will serve to locate the lesion in the kidneys, and may show whether 
we have to do with an acute lesion or with one of a more chronic kind. 
Again, detached epithelial cells, if present in considerable numbers 
and of characteristic forms, may serve to indicate the situation of a 
lower lesion. The presence of crystals of certain kinds in considerable 
numbers lends color to the view that the hematuria is due to a calculus, 
whereas the presence of many crystals of calcium oxalate is equally 
compatible with that form of hematuria which results from the free 
consumption of rhubarb. The mere fact that red corpuscles are the 
only objects to be detected in the sediment is of no slight clinical value 
in particular cases, in excluding some of the causes of hematuria. 
Apart from the microscopic test, the tests for hematuria are mere 
indications of the presence of blood pigment as distinguished from 
blood. Urine containing blood necessarily yields the tests for albumin, 
and the negative results of such tests may exclude the presence of blood 
in cases in which the appearance of the urine suggests hematuria. On 
the other hand, the presence of an amount of albumin out of all proportion 
to the hemoglobin strongly suggests a renal origin. 
The color of the urine differs widely in different cases. It may resemble 
that of pure blood when the hemorrhage is copious, or a considerable 
sediment of blood may form on standing. When less blood is present 
it may impart a pink tint, or the urine may appear brown and smoky. 
The color may change from brown to pink on standing in contact with 
air. The browm tint is usually due to methemoglobin, but occasionally 
a deeply brown-stained sediment contains the pigment in a peculiar 
insoluble form, whereas the yellow supernatant liquid fails to yield the 
tests for hemoglobin. Alkaline urines containing blood have a peculiar 
livid tint in their deeper layers, shown by the spectroscope to be due to 
reduction of part of the dissolved hemoglobin. 
If the blood pigment in urine were always in the form of oxyhemoglobin 
the spectroscopic test would be a very delicate one, but the band in red 
of methemoglobin is not readily seen in very dilute solutions. In some 
cases of hematoporphyrinuria the pigment is in metallic combination, 
and shows absorption bands which may easily be mistaken for those 
of oxyhemoglobin. When such urines contain albumin in small amount, 
the risk of mistake is much greater than when they are albumin-free. 
Hellers' test, by boiling the urine with liquor potassee, is a delicate 
one, and when, after boiling, the color of the stained phosphate precipitate 
changes from brown to pink, and shows the spectroscopic bands of hemo- 
chromogen, the presence of blood pigment is placed beyond doubt. It 
must be remembered that chrysophanic acid, present in the urine of 
patients taking rhubarb and senna, also tints the phosphate sediment 
deeply, but sediments so tinted show no distinct absorption bands. 804 
DISEASES OF THE URINARY SYSTEM 
The guaiacuni and ozonic ether test is a very delicate one, provided 
that the reagents are fresly prepared. Under such conditions a negative 
result excludes the presence of blood pigment, and in practice the fact 
that other substances than blood cause the development of a similar 
blue color will seldom mislead. The most likely cause of error is an 
iodide, taken as a drug, but unless the iodide be present in very large 
amount the blue color appears much more slowly than in urine contain- 
ing more than minimal traces of hemoglobin. To the trained eye the 
appearance of the urine affords as delicate an indication as any of the 
presence of blood pigment but confirmatory tests are of course essential. 
The causes of hematuria are numerous. The blood may come from 
any part of the urinary tract, as the result of a variety of lesions. Thus, 
hemorrhage from the urethra may result from external injury, the 
passage of a calculus or gonorrhoea; the blood is passed at the commence- 
ment of micturition. Prostatic hemorrhage is not uncommon. Blood 
may come from the bladder in cystitis, when a calculus is present, or 
when its walls are the seat of tuberculous ulceration or of villous growths. 
In the vesical group may also be included the hematuria due to Bilharzia 
hcematobia, and that of chyluria. Hemorrhage from the ureters may 
result from the passage of a calculus or from tuberculous ulceration, 
and to the same causes, as also to new growths, may be due hemorrhage 
from the renal pelvis. 
Renal hematuria has many different causes. In acute nephritis 
blood is almost always found in the urine, and in unfavorable cases the 
hematuria persists into the chronic stage. Copious hematuria occa- 
sionally results from granular kidney. In lardaceous disease it is not a 
prominent symptom and is usually absent. Laceration of the kidney 
gives rise to copious renal hemorrhage. In renal tuberculosis hematuria 
is sometimes a prominent symptom, as also when the kidney is the 
seat of malignant growth. Infarction, if extensive, usually causes blood 
to appear in the urine. Among poisons, some, such as turpentine and 
cantharides, produce acute nephritis with hematuria. 
Hematuria may occur in such diseases as purpura hemorrhagica, 
leukemia, or scurvy, and also in the course of hemophilia. In infantile 
scurvy hematuria of slight degree is a very common symptom, and 
may be the first to attract attention. 
Certain less well recognized and more obscure varieties of hematuria 
call for special mention. Crystals appear to be capable of causing 
hemorrhage by the mechanical effect of their passage. Uric acid crystals 
may produce this result in young infants, and even in adults calcium 
oxalate crystals have this power. Ina not uncommon form of hematuria, 
which is alarming but without serious import. The excretion of blood and 
of numerous oxalate crustals is due to the copious eating of vegetables 
rich in oxalate. Of such rhubarb is the chief offender. 
Far more obscure are certain cases of renal hematuria, which may 
be so copious as actually to threaten the life of the patients, but which 
are due to none of the causes enumerated above. The blood usually 
comes from one kidney, as is shown by cystoscopic examination, and 
in some instances nephrotomy has been performed, the kidney split ANOMALIES OF URINARY EXCRETION 
805 
open and no lesion found; yet after the operation the hematuria has 
permanently ceased. It is to such cases that the terms "renal hemo- 
philia" and "renal epistaxis" have been applied. In some such cases 
Hurry Fenwick has observed a dilatation of the vessels of a single papilla, 
removal of which has cured the hematuria, and microscopic examination 
of the part removed has revealed localized interstitial change. 
Pyuria.-When accidental admixture can be excluded, the presence 
of pus in the urine affords important evidence of a lesion in or in con- 
nection with the urinary tract. The appearance of urine containing 
pus depends upon the quantity present and upon its reaction. From 
acid urine the pus tends to settle as a dense deposit of a yellowish or 
greenish hue, whereas the supernatant urine is clear. In alkaline urine 
the deposit is stringy and less circumscribed, and tends to cling to the 
sides of the containing vessel. Numerous epithelial cells accompany- 
ing the leukocytes may give an indication of the seat of the mischief. 
The time-honored teaching that pus in acid urine is usually of renal 
origin, whereas alkaline urine containing pus indicates a vesical lesion, 
often holds true, but the reaction of the urine is mainly dependent 
upon the nature of the infective organism at work in producing the 
pyuria; and whereas in cystitis due to Bacillus coli the urine tends to 
remain acid, the organisms of the proteus group may cause pyelitis by 
extension, and pyuria with alkaline urine. 
The pus present in the urine may have its origin in a purulent urethritis, 
usually gonococcal, but sometimes due to other organisms. Cystitis 
is always accompanied by pyuria, which may be of any degree from the 
presence of a few leukocytes upward. Tuberculous disease of the kidneys 
is an important cause of pyuria, and in such cases the urine is acid, unless 
there be a mixed infection. Pyelitis by extension and calculous pyelitis 
are also attended with pyuria. In pyonephrosis the discharge of pus 
is apt to be intermittent, and when an abscess in a neighboring part 
opens into the urinary passages there is usually a copious discharge of 
pus for a time, followed by a more or less rapid cessation of the pyuria. 
Urines which contain pus are necessarily albuminous, but the presence 
of an amount of albumin out of all proportion to the pus offers a strong 
presumption of a renal origin. 
Of the tests for pus in urine microscopic examination is the most 
conclusive. The ropy condition produced by the addition of a caustic 
alkali is often of value. When a layer of ozonic ether is poured upon 
the top of the urine in a test tube, and gently shaken with it, streams of 
oxygen bubbles rise through the etheral layer if the urine contains pus; 
but as Dixon Mann explains, this test fails to discriminate between true 
pyuria and mucus derived from the urinary mucous membranes. 
When purulent urine is passed through a filter paper the pus left 
upon the filter yields a blue color with tincture of guaiacum, without 
any addition of ozonic ether or other oxidizing agent. In performing 
this test care should be taken that the filter paper used does not itself 
yield a blue color with the reagent. 
Chyluria.-The passage of chylous urine indicates the opening of a 
lymphatic vessel into the urinary passages. This event is usually due 806 
DISEASES OF THE URINARY SYSTEM 
to the presence of the Filaria sanguinis hominis, but there are cases 
met with in patients who have never resided in a tropical climate, in 
whom the presence of chyluria cannot be ascribed to any parasitic cause. 
The excretion of the chylous urine is usually intermittent, and is 
determined by such causes as the taking of food and the posture of the 
body. The fat which imparts the milky appearance is in extremely 
fine division, the minute particles being far smaller than the fat globules 
in fresh milk. The microscopic appearances are more nearly imitated 
by mixing condensed milk and water. That the opacity is due to fat 
may be shown by shaking the urine with ether. The fat dissolves in 
and is separated by the ether, whereas the subjacent urine is left clear 
or only slightly turbid. 
Chylous urine sometimes sets into a jelly after it is passed, but after 
a short time liquefies once more. Occasionally the setting occurs in 
the urinary passages, with distressing results. Albumin and albuminoses 
also occur in chylous urines, and the presence of blood often imparts to 
it a pink tint. 
Fibrinuria.-In rare instances the urine has been observed to form 
jelly-like masses after it was passed, apart from the presence of chyluria. 
This phenomenon has sometimes been associated with grave forms of 
renal disease with highly albuminous urine. When hemorrhage occurs 
into the urinary passages fibrin is also, of necessity, excreted, and clots 
may form in the bladder or elsewhere. 
Pneumaturia.-The passage of gas bubbles with the urine, which is 
sometimes attended with a clearly audible sound, may arise from two 
wholly different causes. In some cases the gas finds its way into the 
bladder from the lower intestine, passing through a fistulous opening 
which is usually a result of a malignant growth with ulceration. Passage 
of fecal particles and debris per urethram will confirm the diagnosis of 
perforation. True pneumaturia, on the other hand, is a sign of infection 
of the bladder, and the liberation of large quantities of gas by bacterial 
action. If only a small quantity of gas be formed, it will be rapidly 
absorbed and will not pass as such. In the great majority of cases the 
symptom is associated with diabetes, and the gas expelled is carbon 
dioxide, liberated by the fermentation of glucose within the urinary 
tract. However, this is not always the case, and Adrian and Hann have 
described a class of cases in which glycosuria is absent, and the gas is 
formed by the action of bacteria of the colon group or Bacillus laclis 
aerogenes upon proteins in the urine of patients with cystitis. 
ABNORMALITIES OF THE URINE DUE TO DISORDERS 
BEHIND THE KIDNEY 
Almost any disturbance of the metabolic processes of which the body 
is the seat will induce deviations from the normal in the urine. Some 
such deviations are very inconspicuous and not easy of detection, others 
are obvious and do not require to be looked for. 
Polyuria and Ischuria.-Some variations in the quantity of urine 
excreted may be classed as physiological, such as the increase due to 807 
ANOMALIES OF URINARY EXCRETION 
copious drinking of liquids, and the decrease with profuse sweating; 
individual peculiarities play an important part in determining the volume 
of the urine or, more strictly speaking, the amount of liquid ingested. 
The influence of diuretic drugs and beverages must be taken into 
account, and the profound influence of the nervous system, which reaches 
its limits in the polyuria of fright on the one hand and hysterical anuria 
on the other. Among morbid conditions there call for special mention 
the ischuria of fevers and the polyuria which is a common symptom of 
convalescence from these, the polyuria which accompanies the absorp- 
tion of dropsical effusions, the ischuria of diarrhoea, and the excessive 
polyuria of diabetes mellitus and diabetes insipidus. The influence 
of renal disease upon the quantity of urine is discussed elsewhere. 
Color of the Urine.-This is the most obvious of its characters, and 
the changes which it undergoes in disease have been recognized as of 
diagnostic value since the days of Hippocrates and Galen. For clinical 
purposes urines may be conveniently classed as: (1) Yellow and orange; 
(2) pink and red; (3) brown and black; and (4) green and blue. Abnor- 
malities of tint may be due to changes in the relative amounts of the 
pigments which may be strictly classed as urinary, to the presence of 
body pigments which are not normally excreted by the kidneys, or to 
pigments derived from articles of food or drugs. 
Yellow and Orange Urine.-The yellow tint of normal urine, which varies 
in depth with its concentration and with the amount of pigment excreted, 
is due to urochrome, for the other normal pigments are present in quan- 
tities so minute that they have no obvious coloring effect. There is 
little doubt that the amount of urochrome is materially affected by 
disease, but we have no exact knowledge of these variations, nor, indeed, 
of where this pigment is formed. Urines rich in urobilin show the dark 
absorption band of that pigment situated near the solar F line, and 
have a richer orange tint than normal urine. Whereas, urochrome 
retains its yellow tint on dilution so long as any color remains visible, 
very dilute solutions of urobilin have a pink hue, and when urine rich 
in this pigment is examined in a conical glass, a pinkish tint is visible 
at the apex of the cone. Uro-erythrin in solution imparts a fiery orange 
tint, which may even suggest the presence of blood, whereas urate 
sediments colored by it are pink in color. 
Certain drugs modify the yellow color of urine. Chrysophanic acid, 
which is contained in rhubarb and senna, has this power, as also has 
santonin. In both instances the color of the urine is changed to pink 
by the addition of an alkali. A small admixture of bilirubin imparts 
a brownish-orange tint. 
Pink and Red Urines.-The commonest cause of a pink or red color 
of urine is the presence of oxyhemoglobin, but when the quantity of 
blood pigment is scanty it is usually changed to methemoglobin and 
imparts a smoky tint. In the condition known as hematoporphyrinuria, 
which will be discussed later, the color of the urine varies from that of 
port wine to absolute blackness, but the small amounts of hematopor- 
phyrin which are present in various morbid conditions, although they 
may greatly exceed the normal traces, do not appreciably modify the 808 
DISEASES OF THE URINARY SYSTEM 
color of the urine. Rosanilin, when administered as a drug, renders 
the urine pink, and eosin, contained in certain sweetmeats, also imparts 
a pink color, which is accompanied by a brilliant green fluorescence. To 
alkaline urine chrysophanic acid may impart a deep pink color. 
Brown and Black Urines.-Various causes may give rise to such colora- 
tion, and the associated conditions differ widely in gravity. Urines 
rich in bile pigment, and especially those in which some biliverdin is 
present, often approach to blackness, and the same is true of some 
which contain blood or hemoglobin. Methemoglobin, even in small 
amounts, imparts a brown or smoky hue, and it is probable that 
many of the black urines of early writers belonged to this class. Some 
were almost certainly passed by patients with paroxysmal hemoglobin- 
uria, and the name of " black-water fever" bears witness to the production 
of blackness by altered hemoglobin. In some cases of hematoporphy- 
rinuria also the urine may fairly be described as black. 
In some cases of indie anuria the urine darkens on standing, and 
becomes dark brown or even black. The color is not due to the indoxyl 
sulphates, which are colorless, but to higher oxidation products of indol. 
This variety of dark urine is not so well recognized as it should be, and 
it is probable that the condition in question has occasionally been mis- 
taken for melanuria. When such urines are warmed with nitric acid, 
blackening results; and when Jaffe's test for indican is carried out, 
chloroform takes up abundance of purple pigment, indigo blue and 
red, whereas the supernatant liquid remains as black as before. 
In true melanuria, indicative of widespread melanotic sarcoma, the 
urine is usually of normal color when passed, very seldom brown. On 
exposure to air it darkens from the surface downward, becoming first 
brown and later absolutely black. 
The darkening of alkapton urines on exposure to air follows a very 
similar course, but the two conditions are easily distinguished. 
Some drugs cause the secretion of urine which blackens on exposure 
to air; thus, carboluria is a familiar phenomenon which is ascribed to 
the excretion of hydroquinone, and among other drugs which produce 
like effect may be mentioned naphthalene, salol, creosote, thallin, and, 
to a less degree, salicylates. The leaves of uva ursi contain arbutin, 
from which hydroquinone is formed, and this may cause a conspicuous 
darkening of the urine of patients taking that drug. 
Green and Blue Urine.-Urines which contain bile pigment almost 
wholly in the form of biliverdin have a deep green color, but with this 
exception it may be stated that practically all green urines, as well as 
those which have a blue color, owe their tints to methylene blue. Anyone 
familiar with the reactions of such urines can easily convince himself 
of the nature of the coloration, but it is not always easy to ascertain how 
the methylene blue was introduced into the alimentary canal. Sometimes 
it has been administered as a drug, and the cause of the phenomenon is 
obvious; sometimes it has been taken in sweetmeats, and it should be 
mentioned that some white sweets contain it. Sometimes, again, one 
is driven to the conclusion that a pill of methylene blue has been intro- 
duced accidentally or otherwise among those of a different kind which 809 
ANOMALIES OF URINARY EXCRETION 
the patient is taking. This much is certain, that until coloration by 
methylene blue can be definitely excluded, speculation as to the nature 
of a green or blue urine is wasted. 
Hematoporphyrinuria.-Among conditions which are characterized 
by abnormal pigmentation of the urine this calls for special mention. 
It usually results as one of a group of toxic symptoms from the taking 
of sulphonal, much more rarely of trional, over long periods. Hemato- 
porphyrinuria may develop after a few doses of the drug, or only after 
it has been taken for several years in uniform nightly doses. It may 
even appear some days after the drug has been discontinued. Under 
any of these circumstances its prognostic significance is grave. 
It is a remarkable fact that, whereas the group of symptoms of which 
hematoporphyrinuria is one have been observed in a large number of 
female patients, it has very seldom been seen in males. It will be well 
to limit the application of the term to cases in which the urine assumes 
a deep red color like that of port wine, or is even nearly black, and is 
found to contain quantities of hematoporphyrin which are far in excess 
of those usually present in urine. Normal urines contain minute traces 
of hematoporphyrin in a variety of morbid conditions, and especially 
in chronic lead poisoning the normal traces are considerably exceeded, 
but the tint of the urine is not materially altered thereby. In cases of 
hematoporphyrinuria, in the restricted sense, the dark color of the 
urine is not due to the pigment in question, but, as Hammarsten pointed 
out, to other abnormal pigments which accompany it of which little 
is yet known. The color of such urine cannot be simulated by the ad- 
dition of hematoporphyrin, and when this pigment can be separated 
from the dark urines their color is not materially affected by its 
removal. 
The absorption spectra of hematoporphyrin are complex and very char- 
acteristic, and the bands are dark and sharply defined. Yet in these 
urines its detection by means of the spectroscope is by no means so easy 
as might be expected. The pigment often existing in them is the so-called 
"metallic" form, that is to say, in a combination in which it shows two 
bands which closely resemble those of oxyhemoglobin. 
The quantity present varies greatly, and it is sometimes necessary 
to precipitate the pigment before a certain diagnosis can be made. 
This may be done by the addition of calcium chloride and lime water, 
Salkowski's method. The precipitate, which carries down all the abnor- 
mal pigments, is extracted with alcohol to which sulphuric acid has been 
added, and the acid-alcoholic extract will show the spectrum of acid 
hematoporphyrin. 
Hematoporphyrinuria may be suspected when urine is excreted 
which resembles port wine in color, which shows absorption bands 
resembling those of hemoglobin, but contains no albumin and does not 
give the guaiacum test for blood. Sometimes the mere addition of an 
acid brings out the characteristic spectrum of acid hematoporphyrin. 
If the patient has recently taken sulphonal the condition is at once 
explained. The drug should be stopped, and sodium bicarbonate should 
be given in large doses. 810 
DISEASES OF THE URINARY SYSTEM 
Very rarely hematoporphyrinuria has been met with apart from the 
administration of sulphonal or its allies. Under such circumstances 
the symptom is of no such evil omen, and there is no special liability 
of the female sex. The symptom may persist for years, may recur at 
intervals, or may assume a paroxysmal form resembling paroxysmal 
hemoglobinuria, as in a case recorded by Pal. In some cases the urinary 
anomaly has recurred in association with attacks of hydroa cestivale. 
Urobilinuria.-Urobilin, which is recognized in urine by its dark 
absorption band near the solar F line, is mostly excreted in the form 
of a chromogen, which becomes converted into the pigment after it is 
excreted. Urobilin is mainly formed by the action of the intestinal 
bacteria upon bilirubin, and the bulk at least of the urobilin of urine is 
absorbed from the alimentary canal-whether there is not another 
source of the pigment within the body is a question which is not yet 
finally settled. The conditions which bring about an increased excretion 
of the pigment or its chromogen in the urine ar multiple, and this 
deprives its presence of much of the clinical significance which it would 
otherwise possess. Mere constipation may lead to urobilinuria. Ex- 
cessive hemolysis of moderate degree, with consequent pleochromia of 
the bile, is a well-recognized cause, and urobilinuria is to be expected in 
cases of pernicious anemia. In some cases an excessive urobilinuria has 
been observed as a result of the taking of trional, and in fevers of various 
kinds the urine frequently shows a strong urobilin band. 
The influence of the liver upon the excretion of urobilin is beyond 
question, and urobilinuria is common in association with hepatic disease, 
an association the nature of which is difficult of explanation. After 
an attack of obstructive jaundice, while the skin is still yellow, although 
bile is again entering the intestine, the bile pigment tends to be replaced 
in the urine by a copious excretion of urobilin, and the term urobilin 
jaundice has been frequently employed. It should be mentioned, 
however, that there is no evidence that pigmentation of the skin and 
other tissues is ever due to the presence in them of urobilin in place 
of the unaltered bile pigment. 
Uro-erythrinuria.-The frequency of pink urate sediments bears 
witness to the frequent presence of uro-erythrin in the urine in consider- 
able quantities. This very unstable pigment has a great power of 
coloration. Of the material from which it is formed and of its place 
in the classification of pigments nothing is known. It is probably not 
a constituent of strictly normal urines, but even a slight digestive dis- 
turbance may cause it to appear. In fevers it is common, but all the 
clinical evidence available connects its presence in the urine with func- 
tional derangements or organic disease of the liver. Patients whose 
urine deposits uratic sediments of a deep pink color almost invariably 
have some hepatic trouble which is manifested by other signs, whether 
it takes the form of cirrhosis or of malignant tumors, or of the nutmeg 
change which results from circulatory derangements with backward 
pressure and chronic congestion. When no uratic sediment falls, the 
pigment, if abundant, imparts to the urine a fiery orange color, which 
is changed to a dirty greenish tint by the addition of an alkali. ANOMALIES OF URINARY EXCRETION 
811 
Indicanuria.-Indoxyl is met with in urine mainly in combination 
with sulphuric acid, as the so-called urinary indican-a substance which is 
wholly different in nature from the indican of plants, which is a glucoside. 
A small fraction is in combination with glycuronic acid, and it is probably 
as the result of the spontaneous decomposition of indoxyl glycuronates 
that deposits of free indigo blue are sometimes formed in alkaline urines. 
Even in health the protective mechanisms which lead to the formation 
of such compounds, and so render the indoxyl harmless, are called into 
play to a small extent, and indoxyl-sulphates contribute to he normal 
quotum of aromatic sulphates. The parent substances of the urinary 
indican are the proteins of the food, which are in part decomposed in 
the intestine by bacteria. The particular portion of the protein molecule 
from which the indol is derived is the tryptophane fraction. 
In many morbid conditions, and in some which can hardly be called 
morbid, such as simple constipation, the formation o indol in the intestine 
and the excretion of indoxyl compounds in the urine is conspicuously 
increased, and such increase may be interpreted as a measure of bacterial 
decomposition in the alimentary canal. That in the great majority 
of cases the increased excretion has this significance seems certain, 
although we cannot be sure that some of the indol formed does not 
undergo further changes in the tissues, so that the excretion of indigo 
precursors does not necessarily afford an accurate measure of the process. 
Indicanuria has sometimes been observed in cases in which the cavities of 
the body contained fetid pus, as in fetid empyema, and such collections 
may afford other sources of indol. Indicanuria is a very marked feature 
in melancholia and malignant disease of the liver. 
In testing for indican it is essential that a freshly voided specimen of 
urine be used, as indican rapidly disappears on standing and so renders 
the results inconclusive. When urines containing indican are boiled 
with hydrochloric acid, to which a trace of nitric acid or of bleaching 
powder solution has been added, they undergo conspicuous darkening, 
and indigo pigments are formed. If hydrochloric acid be alone used 
indigo red is formed in excess; the oxidizing agents favor the formation 
of indigo blue. If they be added in too large quantities, isatin is formed 
and the result of the test may be deceptive. 
If, after cooling, the acid liquid be shaken with chloroform, the chloro- 
form acquires a deep purple color from admixture of the red and blue 
pigments, and with the spectroscope the absorption band in red, due 
to indigo blue, may be observed. If the chloroform be evaporated the 
two pigments may be separated by washing the residue with alcohol, 
which takes up the indigo red; whereas the indigo blue which remains 
undissolved forms a blue solution in chloroform. 
Melanuria.-The excretion of melanin, or rather of its chromogen 
melanogen, in the urine is a sign of great diagnostic value as indicating 
the presence of a disseminated melanotic growth. In cases in which 
the tumor is still limited to its primary seat no melanuria is observed. 
Only when secondary tumors are forming is melanogen excreted, and 
the occurrence and intensity of the melanuria appear to be chiefly 
determined by the invasion of the liver. 812 
DISEASES OF THE URINARY SYSTEM 
The urine has usually the normal color when fresh but quickly darkens 
on exposure to air and ultimately becomes black. Occasionally it has 
a brown color when passed. The addition of nitric acid in the cold 
causes immediate blackening, as also does that of a solution of ferric 
chloride. This latter reaction is the most satisfactory of all, for it is 
not obtained in any of the other conditions which simulate melanuria 
more or less closely. Unless it is obtained melanuria should never be 
diagnosed, but in the early stages* while the amount of melanogen 
excreted is small, the blackening may only be partial. Bromine water 
produces a yellow or chocolate-colored precipitate which rapidly blackens 
(Zeller's test). Von Jaksch has also pointed out that the urine in mel- 
anuria yields a deep Prussian-blue color when sodium nitroprusside 
and postassium hydrate are first added and acetic acid is afterward 
added in excess. However, this test is yielded by other than melanin 
urines, and even in the cases under discussion is not to be attributed to 
melanogen. 
Lithuria.-The deposition of amorphous sediments of urates as the 
urine cools is a very common event, and it cannot be too strongly insisted 
that this must not be interpreted as a sign that the daily output of uric 
acid is in any way above the normal limits. It often results from mere 
concentration of the individual specimen, due to excessive loss of water 
by the skin, as after violent exercise. Various factors contribute to the 
formation of such sediments, such as the degree of acidity of the urine, 
and an excessive output is one of these contributory factors. Even 
the temperature of the air has a potent effect, and uratic deposits are 
therefore more often seen in winter than in summer. Clinically, uratic 
deposits are common in the urine of patients with fevers and of sufferers 
from gout and various liver diseases. Their color varies from a pale 
yellow tint, due to included urochrome, to a deep pink, due to combined 
uro-ery thrin. 
This clinical association with gout has no relation to the excess of 
uric acid in the blood. The many investigations of recent years upon 
the urine of the gouty have failed to show any constant excess or decrease 
of the uric acid beyond the somewhat wide normal limits. Only just 
before the acute attack of gout has a diminished excretion been demon- 
strated, followed by an excessive output as the attack subsides. 
A diet rich in purin substances, as in thymus feeding, causes a con- 
spicuous increase of the excreted uric acid, and of morbid conditions the 
most obvious increase occurs in leukemia and is here attributed to the 
nuclein of the broken-down leukocytes. Even sufferers from chronic 
gout excrete more uric acid when fed with thymus, but the increase is 
proportionately less than in normal subjects. Nor is the deposition of 
crystalline uric acid necessarily due to excessive excretion. In leukemia 
it sometimes results from this cause, but many other factors are con- 
cerned, such as the degree of acidity, the proportions of salts and other 
constituents in solution, and, as Klemperer has shown, the amount of 
urochrome present. This observer finds that deficiency of urochrome 
has an important influence in favoring the deposition of uric acid. 
Here, again, apart from any excessive excretion of uric acid, there is a ANOMALIES OF URINARY EXCRETION 
813 
clinical association often observed between the deposition of uric acid 
sand, the formation of uric acid calculi, and the familiar phenomena of 
gout. The nature of this association is not yet clearly understood. 
In addition to uric acid the urine contains smaller quantities of the 
closely allied purin bases, xanthin, hypoxanthin, etc. These bases also 
are partly of exogenous and partly of endogenous origin; being more 
soluble they play little known part in pathology, but in very rare cases 
xanthin calculi have been formed in the kidneys or urinary passages. 
No idea of the amount of purin substances excreted can be obtained 
save by exact quantitative estimation of the daily totals. The estimation 
of uric acid can now be carried out without any special difficulty by 
Hopkins' method, while the purinometer of Walker Hall allows an 
estimate of the total purin output, both uric acid and xanthin bases, by 
a method so simple that it is available for clinical purposes. 
In conclusion, it may be mentioned that kidneys damaged by disease 
appear to exercise a less pronounced retentive effect upon the com- 
paratively insoluble uric acid than upon the very soluble urea. 
Creatinin Excretion.-Creatinin derived from the creatin of muscle 
is partly an exogenous and partly an endogenous urinary constituent 
to the amount of about 1 gram per diem. The exogenous excretion is 
derived from the meat taken as food. The endogenous excretion, which 
may be estimated by placing the patient on a creatinin-free diet, has 
been found to be increased during acute fevers, and, indeed, in any 
condition which is accompanied by an excessive breaking down of the 
muscular tissues. In cases with conspicuous splenic enlargement Macleod 
has found the endogenous creatinin much diminished, and in diseases 
in which chronic atrophy of muscles is a feature, such as progressive 
muscular atrophy and the myopathies, a diminished output is also 
observed, the total bulk of muscle tissue being in such cases much below 
the normal. The introduction of a new method of estimating creatinin 
in urine by Folin has led to a considerable increase in our knowledge 
of the variations in excretion of this substance in different diseases. 
The method consists in treating 10 cc. of urine with 15 cc. of a saturated 
solution of picric acid, and 5 cc. of 10 per cent, caustic soda solution, 
when a deep red color develops. The mixture after standing for five 
minutes is diluted up to 500 cc. with water, and the solution compared 
colorimetrically with a standard solution of potassium bichromate. 
Creatinin in the urine has a direct connection with the closely related 
chemical substance creatin occurring in the muscular system; but the 
exact nature of this relation is not definitely settled. Normally the 
amount of creatinin in the urine is independent of the amount of protein 
in the food or the total nitrogen in the urine and is a constant quantity 
for each individual. Creatin does not occur in normal urine, and appears 
only in minimal quantities after ingestion or subcutaneous injection 
of this substance. Under pathological conditions a rise in creatinin 
output is found in maniacal conditions, fever, acromegaly, and exoph- 
thalmic goitre. Diminished creatinin excretion is associated with 
depressed cellular activity as in the muscular dystrophies, lymphatic 
leukemia, and starvation. The excretion of creatin is distinctly 814 
DISEASES OF THE URINARY SYSTEM 
pathological, and is said to be associated with such conditions as acidosis 
in diabetes mellitus and cyclical vomiting, and more particularly in 
malignant disease of the liver. However, Greenwald, and Graham, and 
Poulton have shown that the presence of aceto-acetic acid in urine intro- 
duces serious errors into estimations of creatinin and creatin by the 
Folin method. It is, therefore, necessary that the question of the 
excretion of creatin in conditions associated with acetonuric should be 
investigated afresh. Small quantities of creatin are found during 
menstruation and throughout pregnancy. 
Phosphaturia.-The term phosphaturia as commonly applied is a 
misnomer, seeing that the deposition of amorphous phosphates in the 
urine is no indication of an abnormally great excretion of phosphoric 
acid, but merely of the abolition of its normally acid reaction. Such 
deposition occurs when the urine undergoes ammoniacal decomposition, 
but these cases are not spoken of as examples of phosphaturia. 
Alkalinity from fixed alkalis may be brought about in various ways, 
and its inevitable result is a separation of the earthy phosphates. Often 
it is a physiological event, and results from such simple causes as the 
taking of a diet rich in vegetables, or the drinking of alkaline mineral 
waters. Again, during the so-called "alkaline tide" which sets in some 
hours after a meal, the urine may become amphoteric or alkaline, not 
by the addition of alkali but by the withdrawal of acid in the secre- 
tion of the gastric juice. A like result may follow copious vomiting 
or lavage of the stomach. 
The excretion of alkaline urine as the result of none of these causes 
occurs as a definite pathological event which is often associated with 
neurasthenic symptoms and is apt to assume in the minds of the patients 
a gravity out of all proportion to its real importance. In a considerable 
class of cases such phosphaturia is associated with disorders of the 
sexual organs. The pathology of many of these cases is very obscure. 
In a certain class of case, which is especially common among children, 
the urinary anomaly is due to an excessive output of calcium in the 
urine. The excess of calcium combines with the phosphoric acid and 
causes a relative increase of insoluble basic phosphates and a relative 
decrease of the soluble acid phosphates to which the acidity of the 
urine is due. 
It is a well-known fact that in health the bulk of the calcium is excreted 
by way of the colon, and only a relatively small amount in the urine. 
Soetbeer, who has made a special study of the condition under con- 
sideration and whose results have been confirmed by Tobler and other 
observers, found that in association with the increase of calcium in the 
urine there is in these cases a diminution of its intestinal excretion. 
Soetbeer, therefore, places the seat of the morbid process in the mucous 
membrane of the colon, a species of colitis. It must not be supposed, 
however, that all cases of phosphaturia in children are of this nature. 
In cases of phosphaturia with increase of urinary calcium a regulation 
of diet, with substitution of food poor in calcium for those rich in salts 
of that metal, is indicated. In cases with nervous disturbances general 
tonic treatment usually proves the most useful. The administration ANOMALIES OF URINARY EXCRETION 
815 
of acids with a view to increasing the urinary acidity is very uncertain 
in its effects; but R. Hutchison has shown that acid sodium phosphate 
is more effectual than mineral acids, a result which agrees with what 
might be expected on theoretical grounds, viz., that an increase of 
phosphoric acid in the urine would rather tend to manifest itself by an 
increase of the acidity than by the production of the phenomenon 
commonly spoken of as phosph aturia. 
Oxaluria.-From the clinical stand-point, the importance of calcium 
oxalate as a urinary constituent is due to its sparing solubility and the 
frequency with which it is deposited in crystalline form, of even appears 
as concretions in the kidneys or bladder. Such deposition of calcium 
oxalate depends upon the interaction of a variety of causes of which 
excessive excretion is only one, although by no means unimportant. 
Of the small daily output of oxalic acid in human urine which, under 
normal conditions, does not exceed 1 or 2 mg., part is exogenous and 
derived from vegetable foods, and part is endogenous. Even upon an 
oxalate-free diet, such as pure milk, as also during abstinence from food, 
some oxalate continues to be excreted. Only a portion of the oxalate 
of the food finds its way in the urine; some is apparently decomposed 
in the alimentary canal rather than broken up in the tissues, seeing 
that injected soluble oxalates are excreted quantitatively. The admin- 
istration of hydrochloric acid has been shown to promote the absorption 
of calcium oxalate from the food and to increase the urinary output; 
and it is probable that in the cases described by Begbie and others as 
examples of an oxalic acid diathesis, attended with neurasthenic symp- 
toms, the deposition of oxalate crystals in the urine was, as Dunlop 
suggested, largely due to such increased absorption as the result of the 
acid dyspepsia which was a prominent phenomenon of the condition. 
In the older literature of the subject no clear distinction was drawn 
between the formation of crystals of calcium oxalate and an actual 
excessive excretion. Wide variations in daily output undoubtedly 
occur, some of which are due to the taking of vegetable foods rich in 
oxalate, such as rhubarb and spinach, as in the cases in which rhubarb 
freely eaten causes hematuria and the urine deposits crystals of calcium 
oxalate in great abundance. Increased excretion of oxalic acid has 
been observed in a variety of diseases, and especially in connection 
with jaundice and with diabetes; but in no disease is such excessive 
excretion found to be constant, nor is there any sufficient evidence of 
the occurrence of a metabolic error as the result of which an increased 
output of endogenous oxalate, as distinguished from the deposition of 
crystals, persists over long periods. The origin of the endogenous 
oxalic acid is still very obscure-some of it is probably of protein origin, 
some may be derived from purins, and it has been shown by Lommel 
that the administration of gelatin by the mouth is followed by an 
increased oxalate excretion; this suggests the gelatin of the tissues as 
one at least of its probable sources. 
In the present state of our knowledge, attempts to combat the tendency 
to deposit calcium oxalate from the urine may be directed along two 
separate lines. In the first place we may limit the output by eliminating 816 
DISEASES OF THE URINARY SYSTEM 
as far as possible from the diet articles containing oxalic acid. Many 
vegetables come into this category, and especially rhubarb, spinach, 
and tea, and on the basis of Lommel's observation gelatin should also 
be excluded. In the second place we may seek to produce the conditions 
best calculated to further the holding of calcium oxalate in solution. 
The acidity of the urine may be augmented by a meat diet, and following 
the lines suggested by Klemperer and Tritchler we may endeavor to 
diminish the calcium of the urine, and at the same time to increase the 
amount of magnesium present. The authors quoted have shown that 
whereas excess of calcium salts tends to further precipitation, excess 
of salts of magnesium tends to inhibit it. This object may be attained 
by the avoidance of foods rich in calcium, such as milk, eggs, etc., and 
the prescription of vegetable foods comparatively rich in magnesium, 
such as rice, farinaceous foods, peas, beans, and coffee. 
Leucin and Tyrosin in Urine.-The excretion of these amino-acids 
in the urine was first observed by Frerichs in a case of acute yellow 
atrophy of the liver, and it is with this disease that their excretion is 
especially associated and acquires considerable diagnostic importance. 
In cases of phosphorus poisoning also they are sometimes met with, but 
much less frequently, and as a rule in smaller quantities. 
In cirrhosis of the liver they have been sought for in vain, but Dixon 
Mann described their presence in the urine in some cases of nutmeg 
liver resulting from cardiac disease. In pernicious anemia they have 
occasionally been found. That these protein fractions are sometimes 
excreted unchanged by cystinurics is undoubted. Tyrosin is occasionally 
deposited from urines containing it as a sediment of delicate acicular 
crystals grouped into sheaves, whereas leucin is hardly ever thrown down 
spontaneously. Usually the crystallization of both substances occurs 
only after the urine has been concentrated, and when their presence 
is suspected the urine of twenty-four hours should be precipitated with 
lead acetate and filtered. After the excess of lead has been removed by 
a stream of sulphuretted hydrogen, and the lead sulphide filtered off, 
the filtrate is evaporated down to a syrup. From the residue the bulk 
of the urea may be removed by treatment with cold absolute alcohol, 
and what remains is extracted by boiling it with dilute ammoniacal 
alcohol. The filtered extract is once more evaporated to a small bulk 
and allowed to stand. Needles of tyrosin and greenish spherules of 
leucin may then be deposited. Care must be taken not to mistake 
spherules of ammonium urate for leucin. 
To insure certainty special tests for leucin and tyrosin should be 
employed, and Millon's test should at any rate be tried. All urines 
yield some pink color when heated with Millon's reagent, even in the 
cold. When much tyrosin is present the reaction is very intense on 
warming. When the urine gives no more coloration than does a control 
of normal urine the presence of any considerable quantity of tyrosin 
may be excluded. 
Since Jacoby showed that in aseptic autolysis of the liver leucin and 
tyrosin are abundantly formed by the action of the enzymes upon the 
proteins of the organ, the view has gained acceptance that their excretion ANOMALIES OF URINARY EXCRETION 
817 
is a result of an autolysis intra vitam, and receives support from the 
fact that in acute yellow atrophy these amino-acids are present in 
quantity in the liver, as well as in the blood and urine. On the other 
hand, Neuberg and Richter suggest that the destruction of the hepatic 
parenchyma, which certainly occurs, does not suffice as the source of 
the amounts of leucin and tyrosin sometimes found in the blood. 
It seems probable that the occasional excretion of leucin and tyrosin 
in cystinuria is due to a wholly different cause from that in liver disease, 
and is part of a widespread failure to deal with protein fractions. 
Alkaptonuria.-This is a very rare urinary anomaly, of which some 
40 or 50 cases are on record. Alkapton urine darkens on exposure to 
air, passing through shades of brown to absolute blackness. The dark- 
ening, which is accompanied by absorption of oxygen, is greatly hastened 
by the addition of an alkali. When the urine is heated with Fehling's 
solution, a deep brown color develops and a copious reduction occurs. 
An ammoniacal solution of silver nitrate is quickly reduced by it in the 
cold. When it is heated with Nylander's solution a darkening occurs, 
due to the action of the alkaline reagent upon the urine, but no black 
precipitate forms from reduction of bismuth salt. When a dilute solution 
of ferric chloride is added to the urine drop by drop a deep blue color 
appears for a moment as each drop falls, until oxidation is complete. 
The condition is usually detected during infancy by the staining of 
napkins as by photographic reagents, or in later life in consequence of 
the reducing action. In later life alkaptonuria individuals may have 
osteo-arthritic changes and show staining of cartilages and other tissues 
known as ochronosis. 
Alkaptonuria is not a disease but rather a "sport" of metabolism 
or chemical malformation. It is congenital, lifelong, and harmless, 
and apt to occur in families, not a few of whom are the offspring of 
consanguineous marriages. It is rarely directly inherited. The error 
consists in a failure to complete the katabolism of the aromatic fractions 
of proteins, tyrosin and phenylalanin, and the peculiar properties of 
the urine are due to the presence in it of an aromatic acid derived from 
these, homogentisic or hydroquinone-acetic acid. The statement that a 
second aromatic acid, uroleucic, is also present in some cases rests upon 
a misapprehension. 
Cystinuria.-The excretion of cystin in the urine is of considerable 
clinical importance, because this sparingly soluble substance is readily 
deposited, and cystinurics are very liable to develop renal or vesical 
calculi and to suffer from cystitis. The condition, which is rather less 
rare than alkaptonuria, is recognized by the formation of a sediment 
of very characteristic colorless hexagonal crystals, soluble in ammonia 
and in hydrochloric acid. Faintly tinted crystals of uric acid sometimes 
assume a somewhat similar shape, and starch granules and crystals of 
iodoform have been mistaken for those of cystin. If some of the sediment 
be dried upon a slide and some strong hydrochloric acid be allowed to 
flow over the crystals beneath a cover-glass, while the changes are watched 
through the microscope, beautiful prismatic crystals of cystin-hydro- 
chlorate are seen to grow out rapidly from each hexagonal crystal, and 818 
DISEASES OF THE URINARY SYSTEM 
to form a rosette which melts away as rapidly as it was formed on the 
addition of a drop of water. 
It was shown by Baumann and Udranszky that some cystinurics 
excreted the diamines cadaverin and putrescin in their urine and feces, 
and their observation has been repeatedly verified. However, in a 
number of recent cases they have not been found, and in others they 
have only been present at intervals, on isolated days or on several 
successive days. In the feces they have been comparatively seldom 
found. Cadaverin is much more frequently present than putrescin, but 
the two may occur in association. Still more rarely leucin and tyrosin 
have been found. 
PROTEINS IN URINE OTHER THAN NORMAL SERUM PROTEINS 
When a protein foreign to the blood plasma is present in it, in any 
but very small quantities, it is got rid of by excretion by the kidneys. 
Hence the presence of such proteins in the urine has a wholly different 
significance from albuminuria, and in no way implies damage to the 
kidney. Small quantities of foreign proteins, on the other hand, may 
continue to circulate in the blood until disposed of in other ways. 
Hemoglobinuria.-When hemolysis of moderate degree is in progress, 
as in pernicious anemia, the liberated blood pigment becomes converted 
into bile pigment, and the only effect upon the pigmentation of the 
urine is due to the presence of excess of urobilin, formed by the action 
upon the bilirubin of intestinal bacteria. When, however, a great and 
rapid hemolysis occurs from any cause unchanged blood pigment is 
excreted by the kidneys and hemoglobinuria results. Hemolysis of 
the necessary degree may be brought about by a variety of different 
causes. It is a well-recognized fact that transfusion of foreign blood, 
i. e., of the blood of an animal of different species, is followed by hemo- 
globinuria, and one may suppose that the corpuscles which are broken 
down are those of the foreign blood. A number of poisons exert powerful 
hemolytic actions, and of these potassium chlorate is the most impor- 
tant. Arseniuretted hydrogen and toluene-diamine also call for mention. 
Bacterial poisons of various kinds have like effects, as witness the 
hemoglobinuria which sometimes occurs in fevers. To this group prob- 
ably belongs the hemoglobinuria of new-born children which was first 
described by Winckler. The hemolytic action of malarial parasites is 
well known, and in the variety of malaria known as black-water fever 
hemoglobinuria is a prominent symptom. Hemoglobinuria may also 
follow extensive burns, and is sometimes seen in athletes and others 
after violent muscular exertion. 
The most remarkable of all the varieties is that known as paroxysmal 
hemoglobinuria, the pathology of which is still very obscure. In some 
cases this malady would appear to have a syphilitic origin and in others 
a malarial, but not unfrequently no such antecedent cause can be traced. 
The exciting cause of the individual paroxysm is, in the great majority 
of cases, exposure to cold, and this connection is so obvious that it may ANOMALIES OF URINARY EXCRETION 
819 
be predicted with certainty that an adequate exposure will precipitate 
an attack. In a few other cases muscular exertion or traumatism figures 
as the exciting cause. 
In association with a paroxysm of hemoglobinuria some of the symp- 
toms of peripheral asphyxia are almost invariably present, and in some 
cases the symptoms of Raynaud's disease are very pronounced. However, 
the association is a somewhat one-sided one, for in the majority of cases 
of Raynaud's disease, even of an extreme degree, hemoglobinuria does 
not occur. The symptoms develop shortly after the exciting exposure 
to cold, and after persisting for a few' hours gradually pass away, leaving 
the patient apparently well until the next exposure. In some cases anti- 
syphilitic treatment has appeared to work a cure, and in some quinine 
has been found beneficial. 
In appearance the urine of hemoglobinuria varies greatly. In the 
slighter degrees, such as are sometimes met with in fevers, it may be 
pink and transparent, and may show' the spectroscopic bands of oxyhemo- 
globin with great distinctness. In cases of poisoning by potassium 
chlorate the pigment set free is wholly or almost wholly in the form of 
methemoglobin. In paroxysmal hemoglobinuria the urine has a deep 
red or browm color approaching to blackness, and usually deposits a 
sediment of hemoglobin debris of a chocolate color. On spectroscopic 
examination the absorption band, in the red, of methemoglobin is usually 
clearly seen, as well as the bands of oxyhemoglobin. 
In all cases the diagnostic feature of hemoglobinuria, as distinguished 
from hematuria, is the absence of red corpuscles in the sediment. The 
particles of brownish debris are often seen to be grouped into cast-like 
forms. The presence of methemoglobin in the urine is in no w ay peculiar 
to hemoglobinuria, for the smoky urine of hematuria also contains the 
blood pigment in this form. In paroxysmal hemoglobinuria some 
albumin may persist in the urine for a time after the blood pigment 
has ceased to be excreted. 
The Bence-Jones Protein.-The excretion of this peculiar protein 
substance, which was first described by Bence-Jones in 1848, is one of 
the most remarkable of urinary anomalies. It is an albuminous sub- 
stance which is not known to be formed in the organism under normal 
conditions; and as a constituent foreign to the blood it is readily excreted 
even by intact kidneys and often in large quantities, up to as much as 
70 grams in the twenty-four hours. Although rare, the phenomenon is 
of great diagnostic importance, seeing that it may be the earliest recog- 
nized sign of an affection of the bone marrow known as multiple myeloma. 
The recognition of the substance presents no great difficulty when 
once its properties are knowm. It is distinguished from the ordinary 
proteins of albuminuria by its very low temperature of coagulation. 
The urine begins to show' turbidity wdien w'armed to 50° C., or even 
below' that point, and between 50° and 60° C. a bulky flocculent precipi- 
tate appears w7hich clings with great tenacity to the sides of the test 
tube and rises up in the froth which is abundantly formed. Further 
heating, especially after a few drops of acetic acid have been added, 
causes the precipitate to be redissolved, but some turbidity usually 820 
DISEASES DE THE URINARY SYSTEM 
persists. The degree of clearing which occurs as the boiling-point is 
approached varies and depends, as Magnus Levy has shown, rather 
upon the presence of other substances in solution than upon any inherent 
property of the protein itself. On cooling, the precipitate reappears, 
and by alternately heating and cooling the urine precipitation and 
re-solution may be indefinitely repeated. When the hot test tube is 
plunged into cold water the appearance of the precipitate showering 
down through the cooling liquid is very striking and characteristic. 
If the cold nitric acid test be alone employed the substance may easily 
be mistaken for albumin, as a similar white ring is formed. With salicyl- 
sulphonic acid, picric acid, and other reagents employed for the detecting 
of proteins, precipitates are formed which disappear more or less com- 
pletely on heating. With hydrochloric acid a dense precipitate is obtained. 
Albumosuria and Peptonuria.-Some confusion surrounds the use 
of the terms albumosuria and peptonuria. Whereas some confine the 
name albumosuria to the excretion of the Bence-Jones substance, which, 
as we have seen, is not really an albumose, and speak of the excretion 
of proto- and deutero-albumoses as peptonuria, others, employing the 
name peptone in Kuhne's more restricted sense as a designation for 
the only protein which is not precipitated by saturation of its solutions 
with ammonium sulphate, speak of the excretion of proto- and deutero- 
albumoses as albumosuria. It is only recently that Kuhne's peptone 
has been found in the urine by Ito. 
Although the excretion of proto- and deutero-albumoses is by no 
means rare it is not a conspicuous phenomenon from the clinical stand- 
point, and the quantities excreted are in no way comparable with those 
of the Bence-Jones protein found in cases of multiple myeloma. More- 
over, the characteristic reactions are frequently masked by the simul- 
taneous presence of albumin. Only comparatively rarely is a considerable 
quantity of albumose recognizable by the ordinary albumin tests. 
The albumoses are not precipitated by heating after the addition of 
a few drops of acetic acid. Many albumin test reagents precipitate 
them, and the precipitates formed are cleared by heating. The addition 
of nitric acid in the cold, of picric acid, and of potassium ferrocyanide 
and acetic acid produces precipitates which behave in this manner. 
When nitric acid is used error may arise by the formation, in a con- 
centrated urine, of a colorless precipitate of uric acid which is dissolved 
on heating and forms again on cooling; but any doubt may be cleared 
up by diluting the urine before the test is applied. 
Salicyl-sulphonic acid is a very satisfactory reagent for the detection 
of albumoses in the absence of albumin. The precipitate which forms 
when a few drops of a saturated solution of the acid are added to the 
urine in the cold is soluble on heating. The reaction is a very delicate 
one and this reagent only precipitates proteins. For the detection of 
small quantities of albumoses in the presence of albumin Devoto's 
method is perhaps the simplest. It is based upon the fact that when 
urine is saturated with ammonium sulphate, albumin and albumoses 
are alike precipitated. If, however, the saturated urine be boiled, the 
precipitate of albumin is thereby renderned inst. Joie in water, whereas ANOMALIES OF URINARY EXCRETION 
821 
that of an albumose is still soluble. The precipitate filtered off after 
boiling is therefore washed with water, and to the washings the tests 
for albumoses are applied. 
The biuret reaction is often recommended for the detection of albu- 
moses in urine, and may be conveniently applied as a ring test by gently 
pouring the urine upon the surface of a layer of cold Fehling's solution. 
If an albumose be present a pink ring will appear at the junction of the 
liquids, whereas an albumin yields a violet-colored ring. However, as 
Stockvis showed, this test is not reliable when it is applied to urine, 
since urobilin yields a similar pink tint. If the test be used care should 
at least be taken to exclude, by a preliminary spectroscopic examination, 
the presence of any considerable quantity of urobilin. 
Albumosuria is met with when considerable quantities of protein 
material are undergoing autolysis intra vitam, as, for example, in cases 
of acute yellow atrophy of the liver and of phosphorus poisoning and 
during the absorption of pneumonic exudates. During the rapid involu- 
tion of the uterus after parturition a physiological albumosuria occurs. 
The albumosuria of fevers, which is usually slight in degree, may be 
ascribed to the increased protein breakdown which accompanies the 
febrile state, and that which accompanies extensive ulcerative lesions 
of the intestine is usually set down to the permeation of the ulcerated 
surfaces by albumoses from the alimentary canal. 
True peptone was found in the urine by Ito, in association with other 
proteins, in cases of pneumonia and of tuberculous disease of the lungs. 
Nucleohiston has been found in the urine of patients suffering from 
pneumonia and from some other febrile maladies, and also in a case of 
lymphatic leukemia. 
Sugars in Urine.-The excretion of a sugar in the urine, even in quan- 
tity sufficient to yield the ordinary reduction tests, is not necessarily 
a morbid event. Any healthy individual will excrete glucose provided 
that a sufficient quantity be taken, in one dose, by the mouth. The 
quantity usually required to bring about this result is from 150 to 200 
grams, and in various morbid conditions the power of dealing with 
glucose is conspicuously lowered. Such alimentary glycosuria ex saccharo 
requires to be carefully distinguished from that which results from the 
free eating of starchy foods, glycosuria ex amylo, which is always a 
morbid event and represents the slightest degree of diabetes mellitus. 
In young infants who are upon an exclusive milk diet, alimentary 
lactosuria is not uncommon, and a five-carbon sugar appears in the 
urine when as much as a liter of a fruit syrup is taken, the power of 
dealing with sugars of this class being comparatively small. Apart 
from such conditions and the excretion of lactose by nursing women, 
the excretion of quantities of sugar readily appreciable by the tests in 
ordinary use must be classed as a sign of disease. 
Glucose.-The question of the causation and significance of glycosuria 
is intimately associated with the study of diabetes, and has been fully 
discussed under that head. 
Levulose.-After a sufficient dose has been taken by the mouth, 
levulose appears in the urine just as glucose does under like conditions. 822 
DISEASES OF THE URINARY SYSTEM 
However, the katabolism of levulose in the organism appears to follow 
a different path than that in which glucose is dealt with, and alimentary 
levulosuria has acquired a greatly enhanced clinical interest by the 
observations of H. Strauss and others, who have shown that the power 
of destroying this sugar is conspicuously impaired in various forms of 
hepatic disease. In this way a valuable test of the functional integrity 
of the liver is afforded. 
It is a recognized fact that many diabetic subjects can utilize levulose 
far better than glucose, but the excretion of greater or less quantities 
of levulose in association with dextrose appears not to be uncommon 
in diabetes, and the amount of levulose is in rare instances nearly as 
great as that of dextrose. In such cases administration of levulose by 
the mouth has not increased the output of levorotatory sugar, and in a 
case of mixed mellituria, investigated by Otto Neubauer, glucose given 
by mouth was excreted in part as such, and in part as levulose. 
To a quite different class belong the very rare cases in which levulose 
is excreted alone in the urine, one of which was most thoroughly studied 
by Otto Neubauer, who recovered the sugar in crystalline form. A 
diet free from carbohydrates caused disappearance of the sugar from 
the urine, but tolerance for starch, and even for glucose, was in no way 
diminished. Even inulin, which stands to levulose in the same relation 
as starch does to glucose, caused no obvious increase of the output, 
which wras wholly determined by the presence in the food of levulose 
as such, or in combination with glucose as cane sugar. Any adminis- 
tration of levulose was followed by its appearance in the urine, but 
whatever the quantity taken, from as little as 3.8 to as much as 50 grams, 
approximately the same fraction of the total, about 15 to 17 per cent., 
appeared in the urine unaltered. 
Lactose.-The excretion of lactose during lactation is a familiar event 
and attains its maximum when for any reason nursing is suddenly 
arrested. Again, as has already been mentioned, alimentary lactosuria 
is not uncommon in young infants. Lactosuria has no pathological 
significance, but is one of those harmless conditions which require to 
be borne in mind lest a wrong interpretation be put upon them. Laiose, 
maltose, and isomaltose have also been detected in urine, but their 
presence has no clinical importance so far as known. 
Pentoses.-The sugars which contain five carbon atoms in chain, 
instead of six, are abundantly present in plants, but it is only in recent 
years that members of the group have been recognized as constituents 
of animal tissues and rarely in the urine. Pentoses in considerable 
amounts may be introduced into the alimentary canal in vegetable 
foods, and as the power of the organism to destroy such sugars is much 
less than in the case of the members of the hexose group, they not infre- 
quently are excreted in appreciable quantities after the free eating of 
certain fruits, such as plums and cherries, when beer is freely used, or 
when quantities of prepared fruit juices are taken. Again, in some cases 
of diabetes traces of pentose have been detected in the urine, but the 
nature of the pentose present has not yet been determined. 
In certain rare cases the excretion of a pentose, racemic arabinose, to ANOMALIES OF URINARY EXCRETION 
823 
the amount of several grams per diem persists year in and year out, 
and perhaps throughout life, without any detriment to health. 
It is probable that pentosuria, which is a rare anomaly and apparently 
a harmless one occurring in families many of whom are of the Jewish 
race, should be classed with such sports of metabolism as alkaptonuria 
and cystinuria. Its clinical importance lies in the fact that those who 
exhibit the anomaly are usually looked upon as diabetics; dietary restric- 
tions are in these cases unnecessary and not called for. 
Glycuronic Acid.-Although not a sugar, glycuronic acid has such 
intimate chemical relationships with the members both of the hexose 
and pentose groups that it calls for mention among the reducing sub- 
stances which are met with in urine. It is excreted in combination 
with a variety of ingested substances, such excretion being the outcome 
of a protective mechanism by which the substances in question are 
rendered harmless and escorted out of the body. Thus the presence of 
a compound glycuronic acid is no more a pathological event than that 
of hippuric acid, in which glycocoll fulfils a similar function, and its 
explanation is to be sought in the excretion of the substance combined, 
rather than in any disturbance of metabolism. Whether or not glycuronic 
acid is a normal intermediate product in the katabolism of glucose is 
still an open question. It is derived from glucose by the oxidation of 
the alcohol grouping in the molecule, whereas the aldehyde grouping, 
to which the reducing power is due, remains unaffected. Emil Fischer 
is inclined to think that the noxious substance is primarily combined 
with glucose, and that the oxidation to glycuronic acid is effected later. 
Although the acid itself is dextrorotatory, the compound glycuronates 
met with in urine are levorotatory. They differ greatly in their stability; 
some, such as menthol glycuronic acid, undergo spontaneous decom- 
position in urine. Among substances the administration of which leads 
to the excretion of considerable amounts of the conjugated glycuronates 
are chloral, morphine, camphor, and copaiba, but even apart from drugs 
and foods the protective mechanism is called into play, and traces of 
indoxyl glycuronate, and perhaps others, are met with in normal urine. 
Recognition of Sugars in Urine.-The ordinary chemical tests merely 
afford evidence of the presence in the urine of a reducing substance which 
may or may not be a sugar. It is only by the employment of further 
methods that certainty upon the point may be obtained, and that the 
particular kind of sugar can be determined. 
In actual practice, if a conspicuous reduction occurs when hot Fehling's 
solution is added to hot urine, neither liquid actually boiling, there is 
little chance of error in making the diagnosis of glycosuria. When 
reduction is only obtained after boiling the mixture for some time, or 
when it is cooling, the evidence is not conclusive, especially if a pea- 
green opacity alone develops. Such a reaction may be, and often is, 
due to the presence of a small quantity of glucose, but it may also result 
from other causes, and confirmatory tests are necessary. In concentrated 
urine slight reduction may be brought about by uric acid and creatinin, 
or by salicyluric acid, when salicylates are taken as drugs. Sugars other 
than glucose may give rise to error and of these lactose is the commonest 824 
DISEASES OF THE URINARY SYSTEM 
With lactose the reduction is less prompt than with glucose, and does 
not occur below the boiling-point. 
Levulose cannot be distinguished from glucose by the copper tests. 
There is a consensus of opinion that in cases of pentosuria the reduction 
is usually delayed, and is apt to occur suddenly during cooling. However, 
Bial denies that this is a characteristic of fresh pentose urines, and has 
seen the reduction occur before the boiling-point is reached. As a rule, 
in pentosuria the reaction is as that yielded by 0.5 per cent, of glucose. 
The compound glycuronates reduce copper, but not all with equal 
readiness. Homogentisic acid reduces Fehling's solution readily, but 
to anyone familiar with alkaptonuria the darkening of the liquid when 
heated with the alkaline reagent, a change which precedes the reduction 
of the copper salt, at once suggests the true diagnosis. In carboluria 
a slight reduction occurs after boiling for some time, and is attributed 
to hydroquinone, which is excreted in combination with sulphuric acid, 
by which combination its characteristic reactions are masked. 
The 'polarimeter affords important information as to the presence 
and nature of sugars in urine. A strong dextrorotatory effect is highly 
suggestive of glucose, but lactose is also dextrorotatory. Levulose is, 
of course, levorotatory, and when present in association with glucose 
it counteracts to some extent, and may even completely balance, the 
dextrorotation due to the latter sugar. This fact renders the quantitative 
estimation of glucose in urine by means of the polarimeter uncertain, 
and may explain discrepancies between the results so obtained and 
those of the reduction methods. In a similar manner the rotatory effect 
of glucose may be partly masked by the presence in abundance of the 
levorotatory /3-oxybutyric acid, which plays so important a part in the 
causation of diabetic coma. 
The only sugar met with in urine which is actually optically inactive 
is the racemic arabinose of true pentosuria. The urine is also optically 
inactive in alkaptonuria. Glycuronic acid is dextrorotatory, but the 
compound glycuronates which are met with in urine have a levorotatory 
action. By boiling the urine with hydrochloric acid the compound 
glycuronates are broken up and the original levorotation is replaced 
by the dextrorotation of the freed glycuronic acid. 
To sum up, dextrorotation by a urine which contains a reducing 
substance indicates the presence of glucose, unless the conditions are 
such that lactosuria may be present. Levorotation may be due to 
levulose, or to compound glycuronates. If the urine be optically inactive 
there may be balancing quantities of glucose and levulose, or the sugar 
may be a pentose, or the reducing substance may not be a sugar at all. 
Further and most important information is supplied by the fermen- 
tation test. Whereas glucose and levulose are readily fermented by 
yeast, lactose, being a disaccharid, is not fermented until it has been 
split into dextrose and galactose, and no fermentation occurs within 
the twenty-four hours usually allowed for the test. The pentoses do 
not undergo fermentation, and the compound glycuronates also resist the 
action of yeast. In performing the test it should be remembered that 
the action of yeast is inhibited by exposure to too high a temperature. 825 
ANOMALIES OF URINARY EXCRETION 
A further means of discrimination is thus afforded. A levorotatory 
reducing substance which is removed by fermentation is presumably 
levulose, as the compound glycuronates are not destroyed by yeast. 
If a dextrorotatory urine becomes levorotatory after fermentation, the 
levorotation is probably due to /3-oxybutyric acid, the glucose having 
been destroyed. If the reducing power is absent after fermentation 
from a urine which was originally optically inactive, a balanced admixture 
of dextrose and levulose may be suspected. A dextrorotatory sugar 
which does not ferment is presumably lactose, and when dextrose and 
pentose are present in association the former will be destroyed by fermen- 
tation, and the urine which still retains the reducing power of the pentose 
will now be optically inactive. 
A reducing substance which is optically inactive and does not ferment 
may be pentose (racemic arabinose) or some of the reducing substances 
which are not sugars, of which the most potent is homogentisic acid. 
The phenylhydrazine test also supplies valuable indications which 
help in the differentiation of sugars. When a crystalline product is 
obtained it is practically significant of the presence of a sugar. It is 
true that glycuronic acid forms such a compound, but the conjugated 
glycuronates do not. However, some of the compound glycuronates, 
such as that of menthol, are very easily decomposed, and the possibility 
that the crystals obtained are formed by the liberated glycuronic acid 
cannot be wholly excluded. A few osazone crystals are not of great 
significance owing to the extreme delicacy of the test, which is capable 
of detecting traces of sugar within physiological limits. If the osazone 
obtained be purified by recrystallization, and its melting-point deter- 
mined, this affords important information as to the sugar present. 
Dextrose and levulose yield the same osazone which melts at 205° C. 
Lactose forms an osazone which melts at 200°, but owing to its greater 
solubility and the small amount of lactose which is usually present in 
urine, no crystalline product is usually obtained when the test is applied 
in cases of lactosuria. 
Pentosazones, which are easily obtained, may be recognized by their 
much lower melting-point, between 150° and 160° C., and the final 
diagnosis of pentosuria should not be made until a crystalline product 
of such a melting-point has been obtained. 
For the discrimination of special sugars certain substituted phenyl- 
hydrazines are of value. Thus, Neuberg obtained, by the use of methyl- 
phenylhydrazine, a compound with levulose which melted at 153° C., 
and the same observer has shown that, with parabromphenylhydrazine, 
glycuronic acid yields a crystalline compound which melts at 236° C. 
Special tests for certain sugars are also of value. Pentose and also 
glycuronic acid yield furfurol reactions. For the detection of pentoses 
Bial's modification of the orcin test is especially useful. The reagent 
is prepared by dissolving 1 gram of orcin in 500 cc. of hydrochloric acid 
of a specific gravity of 1.151; 20 to 30 drops of a 10 per cent, solution 
of ferric chloride are afterward added. The reagent should be kept in 
an amber glass bottle. In testing, 5 cc. of the reagent are heated to boiling 
in a test tube; after the tube has been removed from the flame, and 826 
DISEASES OF THE URINARY SYSTEM 
boiling has ceased, five drops of the urine to be tested are added from a 
pipette. If pentose is present a rich green color appears at the junction 
of the urine and reagent and spreads through the liquid when it is shaken. 
On examining with the spectroscope a dark absorption band is seen 
between the solar C and I) lines. A second band which is usually seen 
in the extreme red has no diagnostic importance. It is claimed for this 
test that when performed in the above manner it is yielded by no urines 
save those which contain pentose, and the writer's experience confirms 
this. If, however, the urine and reagent be boiled together, the green 
color and the characteristic absorption band appear if the urine contains 
a compound glycuronatc. Exact care in preparation of the reagent 
is necessary, and its efficiency should be tested with a solution of a 
pentose or with a pentose urine if such be available. 
Further evidence is afforded by the phloroglucin test, which is also 
yielded by glycuronic acid, and confirmation is obtained by preparing 
a crystalline osazone which, after recrystallization, melts at 150° to 
160° C. 
For the recognition of lactose Rubner's test may be employed. The 
urine is boiled for several minutes with an excess of neutral lead acetate; 
on addition of ammonia a red color develops and a cherry-red precipitate 
falls. 
Levulose differs from other sugars in yielding Seliwanoff's reaction. 
The test is carried out as follows: 10 cc. of urine are warmed with a 
little resorcin and 2 cc. of dilute hydrochloric acid. If levulose be present 
the liquid assumes a red color and deposits a precipitate which is soluble 
in alcohol, forming a rich red solution. 
Substances of the Acetone Group.-The substances grouped together 
under this name which appear in the urine, /3-oxybutyric acid, aceto- 
acetic acid, and acetone, are closely related and form a natural series. 
The most important cause of the formation of the acetone substances 
is apparently the withdrawal of carbohydrates from the food, or inability 
to burn carbohydrates, as in diabetes. Thus starvation or a carbo- 
hydrate-free diet excites acetonuria even in normal individuals, and 
in the cases of persistent vomiting in which it is a prominent symptom 
the acetonuria may be due to this same cause. In a variety of morbid 
conditions in which there is an abnormal tissue breakdown acetonuria 
is met with, such as fever, carcinoma, phosphorus poisoning; and cyclic 
vomiting, pernicious vomiting in pregnancy and delayed chloroform 
poisoning must be included among the conditions in which acetonuria 
plays an important part. In delayed chloroform poisoning, and also 
in fatal cases in children in which vomiting is almost the only other 
symptom save acidosis, advanced fatty changes have been met with 
in the liver by Guthrie, Langmead, and others. Speaking generally, 
acetonuria appears to be more easily induced in children than in adults, 
and is not uncommon in association with bronchopneumonia. 
It used to be held that the parent substances of the acetone group 
are the proteins of the body, but the investigations of Magnus Levy, 
who showed that the protein breakdown was quite unequal to explaining 
the enormous quantities of /S-oxybutyric acid sometimes excreted in ANOMALIES OF URINARY EXCRETION 
827 
the urine, and that the excretion of this acid in no way runs parallel 
with the total nitrogen output, proved that some other source must be 
looked for, namely, the fats. This has been confirmed by the demon- 
stration that a diet rich in fats causes an increased acetonuria, especially 
if the fatty acids present are oleic or other lower members of the fatty 
acid series. 
Still more recently the experiments of Embden and others on the 
production of acetone from certain amino-acids, leucin, tyrosin, and 
phenylalanin, when these were perfused through the liver, seem to 
indicate clearly that since acetone is formed from these protein fractions, 
the proteins of the food and tissues must be looked upon as contributing 
to the total yield of the substances of the acetone group. 
The most important member of the group, /3-oxybutyric acid, is the 
least easy of detection. A rough idea of the amount present may be 
obtained from the degree of levorotation which the urine exhibits after 
fermentation with yeast, but in order to obtain any accurate notion 
of the quantity present, it is necessary to extract the acid by methods 
which can hardly be classed as clinical; or to convert it into a-crotonic 
acid and to estimate it as such. Again, estimations of the urinary 
ammonia afford a rough indication of the amounts of /3-oxybutyric and 
aceto-acetic acids which are being excreted in combination with it. 
The presence of aceto-acetic acid is indicated by the well-known 
iron reaction, namely, the development of a deep red-brown color on 
the addition of a solution of ferric chloride. This test serves to indicate 
an increase of the substances of the group, and the presence of a higher 
member of the series than acetone. It therefore affords a very valuable 
indication that the morbid processes which result in the formation of 
these substances are actively at work. When patients are taking a 
salicylate or aspirin this reaction is, of course, masked by the iron reaction 
due to the drug. When doubt arises whether the color obtained is due 
to aceto-acetic acid, it may be dispelled by boiling the urine for a few 
minutes and repeating the test after it has cooled. As a result of such 
treatment aceto-acetic acid will be broken up into acetone and carbon 
dioxide and the reaction will no longer be obtained. Acetone as such is 
present in very small amounts in urine, and the tests supposed to detect 
its presence, such as that of Rothera, are in reality tests for aceto-acetic 
acid. In Rothera's test 5 cc. of urine are saturated with ammonium 
sulphate, 2 cc. of ammonia solution are added, and a few drops of a 
solution of sodium nitroprusside. If aceto-acetic acid be present a rich 
purple color gradually develops. 
Lipuria.-The excretion of fat in the urine in quantities which are 
appreciable to the eye is a decidedly uncommon symptom. In forms 
of renal disease in which the kidneys undergo a so-called fatty degenera- 
tion, such as chronic parenchymatous nephritis, the microscope shows 
fat globules in shed epithelial cells and in casts, and even free globules 
or crystals of fat may be present. In chyluria the milky appearance 
of the urine is due to the presence of minute fat particles. In cases in 
which malignant growths of the kidneys were breaking down larger 
quantities of fat have occasionally been detected in the urine. Apart 828 
DISEASES OF THE URINARY SYSTEM 
from these local forms of lipuria, there are others in which lipuria is 
an outward sign of lipemia, and in any condition in which there is an 
accumulation of fat in the blood it may find its way into the urine. 
The administration of large quantities of fat by the mouth may 
give rise to lipuria. During pregnancy the excretion of fat has 
been observed and a lipuria of moderate degree may be met with 
in cases of diabetes mellitus, phthisis, and other conditions attended 
by rapid wasting, acute yellow atrophy of the liver, and phosphorus 
poisoning. Fractures of long bones and the operation of osteotomy may 
be followed by the escape of fat into the blood, as is witnessed by the 
phenomenon of fat embolism, and may give rise to a considerable lipuria. 
In any case in which the urine is found to contain fat it is important 
to exclude accidental or intentional admixture, as by the use of an oiled 
catheter or the addition of milk to the urine after it has been passed. 
In true lipuria the fat may form an emulsion, as in chyluria, or may form 
a cloud suspended in the liquid, or an oily and transparent or an opaque 
layer upon its surface. By shaking the urine with ether the contained 
fat may be extracted, leaving the liquid clear and transparent when 
the layer of ether has separated from it. When a drop of the ethereal 
extract is allowed to evaporate on filter paper it leaves a translucent 
greasy mark. The minute globules in the sediment may be recognized 
with greater certainty by staining with osmic acid. 
Calculi composed of fats have, very rarely, been formed in the urinary 
passages. The suggestion that in such cases the fat has been introduced 
per urethram in the form of bougies or otherwise is certainly not tenable 
in all instances, and Horbaczewski's investigations suffice to establish 
the reality of urostealiths beyond all reasonable doubt. The fatty calculi 
have usually been coated with a layer of earthy phosphates. As to the 
significance of such calculi and the nature of the morbid processes in 
which they have their origin we are still completely in the dark. Not 
more than five or six such calculi are oh record. 
Choluria.-In cases of jaundice the bile pigment very early finds its 
way into the urine, and its presence therein may be recognized by the 
appropriate tests and by the color which it imparts. Uric acid crystals 
deposited from icteric urines have a leathery brown color when viewed 
in bulk, and under the microscope the individual crystals are seen to 
be modified both in tint and in form by the included bile pigment. 
Gmelin's test is best carried out by allowing the urine to flow gently 
on to nitric acid in a test-tube. A play of colors is seen at the junction 
of the liquids, and the whole of the layer of urine often acquires a lasting 
green tint. It is necessary that the green color of biliverdin should be 
obtained, as the chromogens of urine may yield pink or purple rings 
under the same conditions. Marechal's test is easily carried out and 
conclusive. Some tincture of iodine is allowed to flow upon the surface 
of the urine in a test tube, and a green ring colored by biliverdin appears 
at the junction layer if bile pigment be present. 
In some cases the amount of bile pigment is so small that the above 
tests yield inconclusive results. In such circumstances Huppert's test 
is of great value. Any required quantity of the urine may be precipitated ANOMALIES OF URINARY EXCRETION 
829 
by the addition of milk of lime or of barium chloride and hydrate. The 
precipitate, which carries down with it all the bile pigment present, is 
collected upon a filter and transferred to a beaker containing alcohol 
acidified with sulphuric acid. When the beaker is heated upon the water- 
bath the bile pigment is converted into biliverdin, which imparts to 
the acidulated alcohol a rich green color. 
Any condition which produces jaundice may cause the appearance of 
bile pigment in the urine, but the choluria may disappear while the 
skin is still conspicuously bile-stained. In a very few cases which may 
be classed as clinical curiosities the urine has been deeply bile-stained, 
although no jaundice existed. In such cases a fistulous communication 
has existed between the biliary and urinary passages. The bile salts 
are met with in the urine in jaundice, but far less constantly, usually 
only in the early days of the attack and in no large quantities. 
Pettenkofer's test is not applicable for the detection of the bile acids 
in urine, owing to the fact that indican and other constituents contribute 
to the production of a red color which closely simulates the true reaction. 
For clinical purposes the best test available is based upon the conspicuous 
lowering of surface tension which results from the presence of bile salts 
in solution. A finely divided, light powder, such as flowers of sulphur, 
is scattered upon the surface of the urine. Under ordinary conditions 
such a powder remains resting upon the surface of the liquid, but if 
bile salts be present it rapidly sinks to the bottom. CHAPTER XIV 
UREMIA 
A. E. GARROD, M.D., F.R.C.P. (Lond.)., F.R.S. 
The name uremia is used to designate a group of symptoms which 
usher in the fatal ending in a large proportion of cases of renal disease. 
The group embraces a large number of morbid manifestations of widely 
different characters, only a few of which are usually observed in any 
individual case, and which assume such diverse grouping that two cases 
which may, without hesitation, be designated uremic, may, in their 
superficial aspects, show little in common. The boundaries of the 
symptom-complex are somewhat ill defined, and whereas some authorities 
would limit the application of the term uremia to functional disturbances 
which appear to have a toxic origin, others would extend its signification 
to include a number of anatomical lesions such as ulceration of the 
stomach and intestines, stomatitis, and pericarditis; while others again 
regard as minor uremic phenomena the cardiovascular changes which 
play so conspicuous a part in chronic renal disease. 
Impairment of the renal functions, whatever may be its cause, may 
bring about a condition of uremia, provided always that both kidneys 
are implicated; but it is one of the most puzzling features of the condition, 
and one which opposes the chief obstacle to any satisfactory explanation 
of its pathology, that complete arrest of the excretory functions of the 
kidneys, although necessarily fatal unless relieved by surgical measures 
or otherwise, does not result in the more characteristic uremic symptoms. 
Unilateral renal disease, even though it result in such complete de- 
struction of the affected kidney as follows the permanent occlusion of 
one ureter by a calculus, does not give rise to uremia, provided always 
that the remaining kidney adequately performs its functions. 
On account of the protean aspects of uremia, an attempt to 
describe in detail the features of individual attacks entails needless 
repetitions, and it will, therefore, be more convenient to begin by con- 
sidering the various manifestations of the uremic state in turn, and to 
group them according to the several systems-nervous, alimentary, 
circulatory, and respiratory-to which they are referable. 
Pathology.-The Condition of the Urine.-In the majority of instances 
the onset of uremia is preceded by diminished excretion of urine, and 
if the scanty urine be of low specific gravity the danger of uremia is the 
more obvious. In some cases the quantity of urine passed is not below 
the normal, but when this is the case its specific gravity is usually low. 
Side by side with a fall of specific gravity goes an elevation of the freezing- 
point, both being dependent upon a decrease of solids in solution. 
830 UREMIA 
831 
Albumin is practically always present in the urine of uremic patients 
but the quantity varies greatly according to the nature of the primary 
renal lesion. Casts may or may not be present. The output of urea 
and of the total nitrogen of the urine has been found to be conspicuously 
diminished during the days preceding an attack, whereas during and 
immediately after the attack the excretion may be distinctly increased. 
An increased excretion of ammonia bears witness to some degree of 
acidosis 
The Blood.-In almost all cases uremia is accompanied by a noticeable 
increase of the molecular concentration of the blood. This is evidenced 
by a conspicuous depression of the freezing-point of the serum which, 
under ordinary conditions, is much more constant than that of the 
urine, and varies but little from -0.56° C. However, cases have been 
met with in which the molecular concentration was little marked, 
suggesting that the accumulation of waste products in bulk is by no 
means the only factor at work. On the other hand, a greatly increased 
molecular concentration of the blood may exist apart from the develop- 
ment of any uremic symptoms. 
The molecular concentration in the blood is mainly due to an accu- 
mulation of the nitrogenous products of the breaking down of proteins, 
as is shown by the conspicuous increase of residual nitrogen; that is to 
say, of nitrogen other than that contained in the blood proteins. This 
has been clearly brought out by the researches of H. Strauss1 carried 
out in Senator's clinic. At the same time no increase is apparent of 
inorganic salts, such as sodium chloride. The same lesson is taught by 
the more recent researches by physical methods; for the great depres- 
sion of the freezing-point of the blood, which is almost constant in 
association with uremia, is not attended by any increase of electrical 
conductivity such as would be observed if the molecular richness 
were due to an increase of dissociable molecules, such as those of salts. 
Urea is found in considerable quantities in various secretions and ex- 
cretions of uremic patients such as the gastric juice, intestinal contents, 
bile, saliva, and sweat, and in some cases the sweat as it evaporates 
leaves an efflorescence of crystals of urea upon the skin of the patients. 
Theories of Uremia.-In the earlier days of the study of uremia the 
symptoms grouped under that name were ascribed by Traube and others 
to such causes as oedema of the brain or disturbances of the cerebral 
circulation. Such views have met with little acceptance in recent 
years, and the characters of the uremic manifestations are so strongly 
suggestive of a toxic origin that investigators have, for the most part, 
sought to explain them as the results of the accumulation in the blood 
of a poison or poisons. The obvious association wThich exists between 
uremia and deficient functional activity of the kidneys naturally sug- 
gested that the toxic material might be found among the end products 
of metabolism, which it is the function of the kidneys to excrete; but 
in spite of the large amount of research which has been expended upon 
the problem, from the days of Bright and Addison to the present, no 
1 Die chronische Nierenentzundungen, Berlin, 1902. 832 
DISEASES OF THE URINARY SYSTEM 
solution yet proposed has met with general acceptance, and the cause 
still remains unknown. 
The very name uremia, which like so many other incorrect designa- 
tions has become so firmly established that to attempt to replace it 
would be alike futile and pedantic, is a legacy of the earliest of all the 
toxic theories, that which ascribed the train of symptoms to poisoning 
by urea. It was long ago clearly demonstrated that this theory was 
untenable, seeing that urea is almost devoid of toxic properties, and 
may be injected into animals in large doses without exciting any con- 
spicuous symptoms. A similar fate befell the well-known theory of 
Frerichs, who ascribed uremia not to urea itself but to ammonium 
carbonate formed from it within the organism by the action of a ferment; 
and Treitz's modification of that theory, according to which the change 
from urea to ammonium carbonate wTas brought about in the alimentary 
canal, for it was shown that an increase of ammonia in the blood is no 
constant or conspicuous feature of uremia. The theory of creatinemia 
also failed to win any general acceptance, nor has it been found that 
any one of the end products of protein katabolism fulfils the necessary 
requirements. 
In view of this failure to identify among the normal excretory products 
any single toxic agent capable of explaining the symptoms observed 
not a few physicians have been led to adopt the view that some inter- 
mediate product of metabolism may be responsible. Of such carbamic 
acid has most in its favor, in view of the phenomena observed in animals 
with an Eck fistula. Others again hold that the manifestations are 
rather the results of the retention of the excretory products generally 
than of the specific toxic action of any one of them. However, a great 
obstacle to the acceptance of this last view is the fact that the more 
characteristic symptoms are not seen in cases of complete anuria, in 
which the kidneys excrete no waste products at all. 
Among the older theories that of Bouchard, which was based upon 
the toxic effects which are observed when urine is injected into the 
circulation of animals, calls for special mention. The fatal effects of 
such injections, provided that enough urine be employed, are beyond 
question, and, in the light of more recent investigations, they appear 
to be largely due to the toxic action of potassium salts. Various organic 
constituents of urine, such as creatinin and the pigments, have been 
shown to be incapable of producing the observed toxic effects, at any 
rate in such quantities as are in the injected urine, whereas much of the 
toxic power is retained by the inorganic constituents of the ash. 
Bouchard found that the urine of patients with uremia was con- 
spicuously less toxic for rabbits than was normal human urine, and 
this observation supplied the strongest argument which could be adduced 
for the applicability of the results of toxicity experiments. He attributed 
the uremic symptoms mainly to organic toxic substances which are 
constituents of normal urine, but which he identified only by their 
physiological action, admitting that some portion of the poisonous 
effects of injected urine was due to potassium salts. Of the toxins, one 
induced convulsions, another depressed the temperature, another UREMIA 
833 
exerted a narcotic action, and yet another contracted the pupils. Bou- 
chard's urotoxins still remain theoretical substances, and his conclusions 
have failed to obtain acceptance from more recent investigators. 
The unquestioned toxicity of potassium salts formed the basis of the 
theory of Feltz and Ritter,1 who attributed uremia to their action. 
In support of their theory they brought forward a mass of valuable 
experimental results, which included demonstrations of the inability 
of various organic constituents of the urine to induce uremic symptoms. 
This theory has nevertheless shared the fate of so many others, and 
later investigators have failed to trace any direct relationship between 
accumulation of potassium salts in the blood and the development of 
uremia. Nor are the toxic effects of potassium salts at all strictly 
comparable with the phenomena of that condition. 
The failure which has hitherto attended all attempts to explain the 
phenomena by the toxic action of any one constituent of the urine, 
or any combination of excretory products, has led a number of more 
recent investigators to look for an explanation in other directions. 
Thus a physical theory has been propounded which attributes the 
effects to the mere accumulation of molecules in the blood, a molecular 
overcrowding, so to speak, rather than to any specific toxic action of 
particular molecules. The name of Lindemann is specially connected 
with this view. It would appear, however, that uremia occasionally 
develops apart from any excessive molecular concentration, and in cases 
in which the freezing-point of the blood is conspicuously depressed 
symptoms of uremia may be wholly absent. 
Some investigators have suggested that the kidneys produce an 
internal secretion which may play an important part in controlling 
metabolism. Thus Brown-Sequard found that animals succumbed 
more quickly after removal of the kidneys than after ligature of the 
ureters. Ascoli, who has confirmed this observation, ascribes the more 
rapid death to the loss of the internal secretion of the organs, and in 
support of this theory he adduces experiments in which the injection 
of the juice of normal kidneys into animals deprived of their kidneys 
prolonged life to the limit attained in animals with ligatured ureters. 
Rose Bradford's well-known experiments upon dogs suggest that the 
removal of renal substance within certain limits, as, for example, one 
kidney and part of the other, causes increased output of water and 
of the end products of protein metabolism such as urea, and that this 
may be ascribed to the diminution of a controlling influence exerted 
by the kidneys upon the metabolic processes, with the result that 
metabolism runs riot. This would naturally lead to an overloading of 
the blood with waste products beyond the accumulation resulting from 
mere retention. Moreover, Bradford has found that in cases of obstruc- 
tive suppression in which the internal renal secretion might be supposed 
to be still yielded, the accumulation of waste products in the blood was 
less than in ordinary cases of uremia. 
On the other hand, it must be mentioned that Bainbridge and Beddard, 
1 De Vuremie experimentale, Paris, 1881. 834 
DISEASES OF THE URINARY SYSTEM 
repeating Bradford's experiments with cats, did not constantly obtain 
an increased output of nitrogen, and regard the increase, when it occurs, 
as due to inanition, and of the same nature as that in starving animals. 
Another recent theory advocated by Ascoli1 and others is that which 
attributes uremia to nephrolysins. It has been shown that just as when 
bacteria find their way into the animal organism substances antagonistic 
to them are produced, so also when cells of a particular organ are injected 
sub cutem, or into the peritoneal cavity, substances antagonistic to the 
special cells injected are found in the organism. Of such products, 
which are collectively spoken of as cytolysins, those which are destructive 
of red-blood corpuscles, the hemolysins, have been most studied, but 
the nephrolysins have also attracted considerable attention. When 
broken-up renal substance is injected into animals, substances are 
found in the serum of the animals so treated which exert a destructive 
action upon the renal cells of other animals. When injected into a second 
animal such a serum sets up a nephritis and causes albuminuria, and 
the serum of the second animal, when injected into a third, has been 
found to excite a temporary albuminuria. 
It has been suggested that the tendency to chronicity in renal diseases 
is due to the establishment of a vicious circle, and that the nephrolysins 
formed as a result of the renal lesions aggravate the morbid condition 
in the kidneys. It has, indeed, been shown that when nephritis is set 
up in an animal, by chromic acid or otherwise, the serum of the animal 
contains nephrolysins which are capable of causing nephritis in a second 
animal, but it has not yet been conclusively proved that the nephrolysins 
so formed react upon the kidneys of the animal itself. However, it 
has been stated that injury to one kidney, such as follows ligature of a 
ureter, tends to excite disease in the second kidney, but clinical experi- 
ence of cases of unilateral obstruction by calculus does not appear to 
support this view. Ascoli records experiments which point to the produc- 
tion of antinephrolysins in animals which are protected by the injection 
of minor doses of nephrolytic sera. 
This observer and those who think with him believe that the phe- 
nomena of uremia may result from the action of nephrolysins upon the 
nerve centres. There is evidence to show that the effects of cytolysins 
are not confined to the special tissues to which they are antagonistic, 
but may be more widespread. Moreover, Ascoli found that the injection 
of normal rabbit serum into the subdural space of dogs produced no 
obvious effects, and even nephrolytic serum was sometimes equally 
innocuous; however, in some instances such sera excited general tonic 
and clonic convulsions and deep coma ending in death. 
Our knowledge of the nephrolysins, of their effects upon the kidneys 
of the animals in which they are primarily formed, as distinguished 
from those of other animals injected with the nephrolytic serum, and 
above all of the power of nephrolysins in the general circulation to excite 
the stormy symptoms of uremia, is still too incomplete for any theory 
in which they play the principal part to command acceptance. As 
1 Varies un gen uber Uraemie, Jena, 1903, UREMIA 
835 
Friedrich Muller has demonstrated, the renal diseases in which uremia 
is most apt to occur in its most pronounced forms are not always those 
in which the destruction of renal tissue is most extensive, and although 
in cases of obstructive suppression it may be that death results before 
the breakdown of renal substance is sufficient to cause the appearance 
of abundant nephrolysins in the circulation, such an explanation will 
not apply to the absence of convulsions and coma in cases of anuria 
from thrombosis of the renal arteries. 
Nevertheless, the theory in question calls for careful consideration, 
since it introduces new factors derived from a fresh field of study, and 
deals with classes of products which are still "seen through a glass 
darkly," the very existence of which was not even suspected until within 
recent years. Meanwhile the cause of uremia remains unknown. 
Symptoms.-Symptoms Referable to the Nervous System.-Convulsions. 
-These, of greater or less severity, are among the commonest and 
most conspicuous of the symptoms of uremia. They vary in degree 
from mere twitchings of muscles to fully developed epileptiform attacks. 
The latter bear a very close resemblance to true epileptic seizures, and 
present the ordinary sequence of tonic and clonic convulsive movements, 
followed often by a longer or shorter period of unconsciousness. Only 
by the antecedent symptoms, or by the evidences of renal disease, 
may it be possible to distinguish the condition from epilepsy. 
The onset may follow upon a period of chronic uremia, with headache, 
vomiting, and perhaps dimness of vision, of which the convulsion is 
merely the culmination. On the other hand, the antecedent symptoms 
may be very slight, such as headache of no severity, with or without 
nausea; or, again, the convulsions may set in with stormy suddenness 
in patients who are not conscious of any impairment of health sufficient 
to lead them to seek for medical advice, as is the case with not a few 
of the sufferers from granular kidney. 
Occasionally some subjective sensation or involuntary movement, 
such as is included among the recognized aura? of true epilepsy, precedes 
the convulsive seizure. Not infrequently the convulsions begin locally, 
as, for example, in the muscles of the face or of one limb, and they are 
usually more pronounced in half of the body. As in epilepsy an 
initial tonic stage, during which the embarrassment of respiration may 
cause pronounced cyanosis and turgidity of veins, following upon a stage 
of pallor, is succeeded by a clonic stage during which the tongue may 
be bitten. 
During the fit the pulse, which was previously of high tension in the 
majority of cases, may become small, rapid, and easily compressible; 
however, it sometimes happens that the tension is maintained throughout. 
The pupils are usually dilated and active, but they are in some instances 
contracted. Sir William Gowers states that nystagmus is sometimes 
observed, and lays special stress upon the implication of the facial 
muscles in uremic convulsions. The temperature is usually raised 
during the convulsive period, but this, like every other rule relating to 
uremia, is by no means absolute, and the record may be conspicuously 
subnormal. The fit may be followed by a period of somnolence, as in 836 
DISEASES OF THE URINARY SYSTEM 
epilepsy, or consciousness may not be recovered, the patient remaining 
in a state of coma, or, again, on recovery he may prove to be temporarily 
blind. The convulsions may follow each other at considerable intervals, 
or may recur so quickly that the patient's condition may be described 
as one of status epilepticus. Death may occur during a convulsion, 
and the first convulsion may prove fatal. 
Paralyses.-That local paralyses, usually of hemiplegic distribution, 
may occur in uremic conditions, in cases in which no gross cerebral 
lesions can be found postmortem other than oedema of the brain and 
its membranes, may be regarded as an established fact. Such paralyses 
have occasionally followed upon unilateral convulsions, but in some 
instances their onset has not been preceded by any epileptiform seizure, 
at any rate of a conspicuous kind. In some cases there has been right 
hemiplegia with aphasia, and aphasia has also been met with apart from 
any paralysis of the limbs. Hemianesthesia has occasionally been 
observed in association with hemiplegia. The duration of the paralytic 
symptoms varies greatly in different cases. 
Disorders of the Special Senses.-Sensory disturbances, and especially 
disorders of vision, are among the most noteworthy and remarkable of 
the symptoms of uremia. Doubtless, in some instances, impairment 
of vision is a result of albuminuric retinitis and of optic neuritis, but 
it is no less certain that complete amaurosis develops in association 
with uremic symptoms apart from any changes in the fundus of the eye 
which can be detected with the opthalmoscope. Moreover, the sudden 
onset and transient character of the amaurosis is hardly compatible 
with the presence of an organic lesion. 
Actual blindness may be preceded by a period of dimness of vision, or 
the stage of dimness may be at no time overstepped. Not infrequently 
the patient emerges from a convulsive attack completely amaurotic 
and unable to perceive even a bright light, or, again, the blindness may 
be, at least for a time, an isolated symptom of the uremic state. The 
loss of vision may last for a few hours or even less, or for a few days. 
In some, especially in puerperal cases, a more lasting blindness develops, 
which suggests that permanent damage has resulted from the lesion to 
which the amaurosis is due. As the sight is restored recovery is not 
always uniform over the field of vision, and large areas of blindness 
may persist for a time after other parts have regained their function. 
In uremic amaurosis the pupils usually, but not invariably, retain 
their activity. A central area of blindness for blue and yellow has been 
observed after recovery from uremic amaurosis, but, as Konig presents 
it and as C. Gerhardt1 has also shown, central blue blindness is some- 
times present in cases of granular kidney apart from any characteristic 
uremic symptoms, usually in association with albuminuric retinitis 
but also in cases in which there is little amiss detected with the ophthal- 
moscope. It would seem to be a renal rather than a uremic symptom. 
The affections of the sense of hearing met with in uremia are of several 
different kinds. Singing in the ears and noises of various kinds are 
1 Munchen. med. Wchnschr., 1900, xlvii, 1. 837 
UREMIA 
comparatively common. Partial deafness is less common and complete 
deafness is decidedly rare. Tinnitus may be accompanied by partial 
deafness, or impairment of hearing may be present apart from tinnitus. 
Dieulafoy1 described severe pain in the ears and face as an occasional 
accompaniment of impairment of hearing, but in some of the cases 
which he quotes definite aural lesions were present, such as perforation 
of the tympanic membrane, or injection along the handle of the malleus. 
Coma, Delirium, and Mania.-Drowsiness, apathy, and coma are 
conspicuous. The onset of coma is often gradual in chronic cases. It 
may be preceded by mental slowness or drowsiness lasting for weeks, 
and in favorable cases this stage may never be overstepped, restored 
functional activity of the kidneys being attended by a corresponding 
improvement of the mental state. On the other hand, it not infre- 
quently happens that a convulsion of sudden onset leaves the patient in 
a deeply comatose condition 
The unconscious patient may exhibit twitching of the limbs, or con- 
vulsive attacks may occur at intervals. The breathing may be stertorous, 
or may have the peculiar whiffing character upon which Addison laid 
special stress. Sometimes it assumes the Cheyne-Stokes rhythm. In 
some cases the cerebral disturbance assumes a more active form, and a 
muttering delirium may persist for days with incoherence of words and 
ideas. Delirium, which may be of all degrees of activity up to actual 
mania, may be an early symptom of uremia, and may replace coma as 
the sequal of a convulsive attack. 
Occasionally the patient exhibits delusions of persecution and endeav- 
ors to leave his bed and to escape from his imaginary persecutors. In 
other instances the mental derangement assumes a melancholic form, 
in others, again, it has a religious or erotic character, or there may be 
acute and violent maniacal outbreaks. The duration of such symptoms 
is very variable and in chronic cases may be for weeks or months. 
Headache and Giddiness.-Headache is one of the commonest symp- 
toms, and in chronic cases it is often the earliest of all. The headache 
has no constant character. In distribution it may be frontal, occipital, 
or general, and it sometimes has the unilateral distribution which is 
associated with migraine. It may be slight or of great severity. Giddi- 
ness, also, is a common early symptom. 
State of the Pupils.-This varies so greatly in different cases, and 
even in the same case at different periods, that it is of comparatively 
slight diagnostic value. In acute attacks the pupils tend to be dilated, 
but may be of normal size. In chronic uremia myosis is, on the other 
hand, by no means uncommon. During a period of amaurosis the 
pupils usually retain their activity. 
Symptoms Referable to the Alimentary Tract.-Scarcely inferior in 
clinical importance to the disturbances of the nervous system are those 
referable to the alimentary canal. These are seldom wholly absent, 
and in some cases dominate the clinical picture. Loss of appetite and 
nausea are usually complained of, and vomiting is a common symptom. 
1 Gazette Hebdom., 1878, xv, 49. 838 
DISEASES OF THE URINARY SYSTEM 
especially in cases of the more chronic kind, in which headache and 
vomiting usually precede and usher in the more alarming manifestations, 
and are often the sole evidences of uremia over considerable periods. 
Violent and persistent hiccough is of very evil omen, and usually precedes 
a fatal ending by a few days only. In some cases such hiccough is the 
earliest and most conspicuous uremic symptom in chronic renal disease, 
and perhaps most often in cases of granular kidney. Diarrhoea, although 
decidedly less common than vomiting, usually appears in the last stages 
of chronic renal diseases. The stools contain urea and ammonium car- 
bonate, may be watery or rich in mucus, and may contain material 
resembling frog's spawn. They are sometimes tinged with blood. 
The so-called uremic stomatitis has been specially studied by Lan- 
cereaux, Hirtz,1 and especially by Barie,2 who has published a monograph 
upon the subject. Barie distinguishes two varieties of such stomatitis; 
an erythemato-pultaceous and an ulcerative. In the first mentioned 
form there is at first merely injection and some swelling of the buccal 
mucous membrane; later, the tongue becomes coated with a grayish 
tenacious coating, of consistence like glue and of a sickly odor, and 
the gums and mucous membrane of the buccal cavity acquire a similar 
pultaceous covering. Beneath this coating the mucous membrane is 
dry and deeply injected, but is not ulcerated. When the sticky coating 
is removed it soon reforms. The saliva becomes scanty and tenacious, 
appetite is lost, and there is a loathing of food. Vomiting usually occurs 
and sometimes diarrhoea also. 
In the second or ulcerative variety, which is far less common, the symp- 
toms at first resemble those of the pultaceous stomatitis, but after a 
few days ulcers develop upon the gums and buccal surface of the lip 
and cheeks. In the centre of the ulcer there is often a caseous patch 
surrounded by a deeply injected zone. With the development of the 
ulcers the saliva, which has previously been scanty and tenacious, 
becomes very abundant and may amount to as much as 800 to 900 cc. 
in the twenty-four hours. In either form of stomatitis there may be a 
subjective sensation of heat in the mouth, but this is specially prominent 
in the ulcerative cases. 
Hemorrhagic erosions of the stomach have been described by Pineau 
and by Lancereaux. Ulceration of the intestines, although rare, has 
been met with in a sufficient number of cases to justify its inclusion 
among uremic, or perhaps to speak more accurately, among renal 
accidents. The colon, cecum, and lower portion of the ileum are the 
usual seats of such ulceration. 
Symptoms Referable to the Circulatory System.-It is probable that 
the cardiovascular changes which constitute so prominent a feature in 
chronic renal diseases have their origin in the presence of noxious 
materials in the circulating blood, and are themselves, in a sense, of 
uremic origin. There need be little hesitation in asserting that high 
arterial tension is a natural outcome of uremic poisoning. On the other 
hand, it is equally certain that high pulse tension is no constant feature 
1 Semaine Med., 1902, xxii, 109. 
2 Archiv. gen. de Med., 1889, clxiv, 415, 690. UREMIA 
839 
of the condition, and may be wholly wanting in the uremic state. The 
wide differences observed in the degree of arterial tension in undoubted 
cases are apparently due to the conflict of two factors, and it would 
seem that, in addition to the influence of the loaded condition of the 
blood in raising arterial tension, the enfeeblement of the heart, which 
is so often present, has a contrary influence which needs to be taken into 
account. Accordingly, as one or other of these factors predominate, 
so will the tension of the pulse be high, low, or intermediate in degree. 
If this be the true explanation of the clinical findings, it will be obvious 
that, given a condition of uremia, the absence of conspicuously high 
tension must be looked upon as a by no means favorable sign. 
The occurrence of cardiac failure in cases of renal disease is a suffi- 
ciently common phenomenon, and, in addition to the mechanical strain 
to which the heart is subjected in its endeavor to overcome peripheral 
obstruction, degenerat'on of its muscular walls plays no unimportant 
part in bringing about such failure. Indeed, experience in the post- 
mortem room teaches that a large proportion of sudden deaths among 
persons over forty years of age are due to myocardial degeneration in 
association with granular kidneys. The rate of the pulse also exhibits 
marked differences. Before the attack, and even during it, the pulse 
may be slow and irregular, but during the convulsive seizures it is more 
commonly small, soft, and rapid. 
The occurrence of pericarditis as a terminal symptom in renal cases, 
and especially in cases of granular kidney, has long been known and 
was observed by Bright. Such pericarditis is usually revealed by the 
development of a loud friction sound, but, as it is generally unaccom- 
panied by any precordial pain or by other symptoms which direct 
attention to the heart, it may easily be overlooked. 
Symptoms Referable to the Respiratory System.- Dyspnoea is a common 
symptom, but a study of the cases in which it is present shows that it 
may arise from several distinct causes. Often the respiratory disturbance 
is rather to be classed as renal or cardiac than uremic, and in chronic 
renal diseases there are several factors at work. 
The dyspnoea may be of pulmonary origin and due to emphysema, 
which is, in some degree, an almost constant concomitant of granular 
kidneys, and is occasionally so pronounced as to dominate the clinical 
picture. In other cases the dyspnoea is due to a complicating bronchitis, 
and in others, again, results from cardiac failure, as is evidenced by the 
state of the pulse and the presence of other signs of such failure. Again, 
an urgent form, met with in renal cases, may result from pulmonary 
oedema, and is attended by profuse, frothy expectoration which is apt 
to be blood-stained. This, again, although a renal rather than a uremic 
event, is not uncommonly met with in association with more strictly 
uremic phenomena. Pneumonia, hydrothorax, and hydropericardium 
must also be mentioned as causes of dyspnoea in renal cases, and the 
rarer oedema of the larynx which occasions urgent respiratory distress. 
To a different category from those so far mentioned belongs the con- 
dition known as "uremic asthma," which occurs in a paroxysmal manner; 
in this as in ordinary asthma, the dyspnoea is mainly expiratory. No 840 
DISEASES OF THE URINARY SYSTEM 
physical signs are to be detected apart from stridor. Such an attack 
is apt to supervene in the later stages of chronic renal disease, and in 
cases of granular kidney may be of sudden onset; it is not necessarily 
preceded by any serious indications of impairment of health. A great 
increase of pulse tension is characteristic of uremic asthma, and serves 
to distinguish the condition from other varieties of dyspnoea in the uremic 
state. This point is very clearly brought out by M. Weiss1 in his admira- 
ble description. In some instances the vasomotor storm is preceded by 
a stage of vascular relaxation with a resulting peripheral hyperemia, but 
upon this the stage of spasm quickly supervenes. 
Among the respiratory symptoms periodic breathing of the Cheyne- 
Stokes variety claims a place. The occurrence of Cheyne-Stokes breath- 
ing in uremia is by some attributed to cardiac failure, which is certainly 
one of the more common causes of such dyspnoea. However, there are 
difficulties in the way of accepting this explanation without qualification, 
and it is at least possible that when in an early symptom of uremia the 
sluggish response of the respiratory centre may have a toxic origin. 
Temperature.-In chronic uremia the body temperature tends to be 
subnormal. In some instances the fall is very conspicuous and subnormal 
readings are often continuously observed. On the other hand, febrile 
disturbance is usually present in association with acute attacks, 
and this, apart from any obvious complications such as pneumonia or 
pericarditis. The fever may even attain to hyperpyrexia. Strumpell, 
who attaches considerable prognostic importance to the state of the body 
temperature, regards exceptionally high or exceptionally low readings 
as of very unfavorable significance, whereas the outlook is decidedly 
better when the temperature does not depart very widely from the 
normal in either direction. This opinion is borne out by experience. 
Cutaneous Lesions.-Itching, which may be intense, is a not uncommon 
symptom, and, owing to the presence of urea in the sweat, the skin 
may be covered with a crystalline efflorescence of that material. With 
these exceptions, skin affections must be classed among the rarer mani- 
festations. However, there are strong reasons for including a form of 
erythematous eruption among the symptoms, for it has repeatedly been 
observed as a precursor of the more usual manifestations, or in asso- 
ciation with these, in cases which have shortly afterward ended fatally. 
Le Cronier Lancaster2 described this rash as first appearing in discrete 
maculse of a bright red color, usually upon the extensor surfaces of 
the hands, forearms, and legs. These quickly become papular, and 
fresh maculae and papules appear on all parts, including the face, palms, 
and soles. The mucous membranes are also affected and the throat 
becomes sore and congested. The papules tend to become confluent 
over large areas, especially on the back, arms, and thighs. After the 
lapse of three or four days the eruption may subside and extensive 
and free desquamation may follow, leaving the skin of a dull red tint 
and brawny, while some of the papules may become hemorrhagic. 
Sometimes the rash assumes an eczematous character, with the formation 
1 Zeitsche. f. Heilkunde, 1881, ii, 79. 
2 Clinical Society's Transactions, London, 1892, xxv, 49. 841 
UREMIA 
of scabs and crusts, and pustulation may occur. As a rule, itching is 
a prominent symptom. The prognostic significance of the erythema 
is decidedly evil and death usually follows within a few weeks. 
The Symptoms which Result from Anuria.-Whereas lesions of both 
kidneys which bring about conspicuous impairment of their functions 
usually result, sooner or later, in the development of uremia, it is a very 
remarkable fact that, when the excretory functions of both kidneys 
are completely suspended, the symptoms observed are not those of 
ordinary uremia, and are comparatively slight, although, if the anuria 
persist, a fatal ending is, after no long interval, inevitable. The cases in 
which such a condition is most often observed are those in which, one 
kidney having been previously rendered useless owing to obstruction 
of its ureter, a calculus lodges in the ureter of the remaining kidney. 
Less frequently both ureters are simultaneously obstructed by calculi 
or involved in a new growth. However, a similar result is brought 
about by thrombosis of both renal arteries. 
In a large proportion of cases of obstructive suppression some urine 
is passed at times, presumably because the pressure behind the obstacle 
reaches a level at which some of it is able to pass. Such urine is very 
pale, of low specific gravity, and contains little urea or other excretory 
products. It is sometimes blood-stained. The occasional passage of 
urine having the above characters affords little relief and does not long 
postpone the end. Obstructive suppression, unless it be relieved by 
the passage of a calculus or by surgical procedures, is necessarily fatal, 
but as many as seven or eight days may elapse before conspicuous 
symptoms develop. Although life may be prolonged for three weeks, 
death commonly supervenes in from nine to eleven days from the onset. 
During the earlier days the patient may exhibit hardly any symptoms 
suggestive of grave illness. Sleeplessness and gastric disturbance are 
usually present, but there may be no headache or vomiting. Progressive 
muscular weakness is common; the mind usually remains clear. Of the 
symptoms of the later days, dryness of the mouth and tongue, contraction 
of the pupils, and muscular twitching are among the most prominent 
and most constant. Convulsions are absent. The patient may become 
more and more drowsy and there may be some delirium, but coma is 
rare, and in not a few cases the patient remains fully conscious up to 
the moment of death. The appetite may be maintained up to within 
a few days of the end, but at the last usually fails completely. Curiously 
enough, the ammoniacal urinous odor which is so commonly noticed 
in uremia is wanting in cases of obstructive suppression. The breathing 
is slow and difficult. The pulse rate is little affected or is slightly quick- 
ened toward the end; the temperature tends to fall below the normal 
level during the later days. 
The Classification of Uremic Attacks.-Attacks of uremia may be 
classified according to their most prominent symptoms as nervous, 
alimentary, or respiratory, and so much is some special class of symptoms 
wont to predominate in individual cases that a classification upon such 
lines seldom presents any difficulty. More commonly the cases are 
grouped as acute, chronic, or latent, and the subdivision of the acute 842 
DISEASES OF THE URINARY SYSTEM 
cases into acute and fulminating, suggested by Rose Bradford, has a 
sound clinical basis. 
Fulminating uremia most commonly occurs in the course of chronic 
renal diseases. A patient with granular kidneys, who may not be con- 
scious of any serious impairment of health, is suddenly attacked with 
uremic convulsions, which may even prove fatal in the course of a few 
minutes, or by urgent uremic dyspnoea; again, a sufferer from that form 
of nephritis which is associated with contracted white kidneys develops 
acute uremic symptoms with little previous warning. In the acute 
form which may develop in cases of acute nephritis, and is also occa- 
sionally seen after operations upon the lower urinary tract, such as dilata- 
tion of a stricture, convulsions may occur after a short premonitory 
period in which headache, vomiting, dyspnoea, or delirium are the most 
prominent manifestations. 
Chronic uremia is best seen in cases of chronic parenchymatous 
nephritis, in which the minor symptoms of the condition, such as nausea, 
vomiting, and sometimes diarrhoea, may precede by a considerable 
period the onset of graver manifestations, and may persist for weeks. 
The name latent uremia is applied to the condition met with in cases 
of obstructive anuria, in which the more characteristic uremic symptoms 
may be absent up to the fatal ending. 
Diagnosis.-The diagnosis of uremia presents difficulties in not a few 
cases. Thus, when a patient is seen for the first time in a condition of 
coma, other varieties of coma have to be excluded. This is done by 
consideration of the state of the patient and by the history of his illness. 
The state of the pupils, as to equality, dilatation, or contraction, the 
odor of the breath, the presence or absence of albumin in the urine, the 
tension of the pulse and state of the arteries, and the presence or absence 
of evidences of paralysis of limbs, all need to be taken into account in 
arriving at a diagnosis. The history of a convulsion at the onset is very 
important, but it must not be forgotten that a series of convulsions 
followed by prolonged unconsciousness may occur in epilepsy and in 
the course of general paralysis of the insane, and that albuminuria may 
follow convulsive attacks. Difficulties of another kind may arise from 
the protean nature of the attacks, and the prominence of some particular 
symptom which may be one of the less common ones. Thus in one 
case vomiting may be almost the only symptom, in another hiccough. 
An attack may be ushered in by delirium which may even be maniacal, 
and Cheyne-Stokes breathing may be the earliest symptom. Hence, 
when any symptom of the uremic group is met with in patients suffering 
from renal disease its uremic origin is to be suspected. 
Prognosis.-This is always grave, and in connection with it two main 
points have to be considered-namely, the chance of recovery from 
the actual attack, and the likelihood of a recurrence of uremia at an 
early date. 
In acute nephritis with almost complete suppression of urine the 
patient may die during an attack of acute anuria, but, on the other 
hand, a patient who has exhibited grave uremic symptoms, such as 
convulsions followed by coma and amaurosis, may nevertheless make a 843 
UREMIA 
complete recovery, the danger of recurrence being wholly averted. On 
the other hand, in cases of chronic nephritis, even though the danger 
be averted for a time, a recurrence is highly probable, or, indeed, almost 
inevitable, at no very distant date, and in the great majority of cases 
the attack, if not at once fatal, marks the commencement of a rapid 
downward progress. The immediate prognosis of the attack depends 
in part upon the violence of the symptoms, for the fulminating attacks 
are usually fatal, and in part upon the response to our efforts to improve 
the working of the kidneys and to eliminate the poison by other paths. 
In latent uremia a fatal ending is inevitable unless it is possible to restore 
the functional activity of the kidneys. 
Treatment.-The methods which have met with general acceptance 
are, for the most part, based upon the assumption that the poison at 
work is a nitrogenous product which fails to be adequately excreted by 
the diseased kidneys. Thus the attempt is made, by restrictions of 
diet, to limit the formation of the end products of protein katabolism, 
and at the same time to reduce the accumulation of such products in 
the blood by venesection, and by encouraging their vicarious elimination 
by other channels than the kidneys. 
Many patients who develop uremia are already under treatment on 
account of the primary renal disease, and appropriate treatment of the 
nephritis offers the best chance of averting the onset of uremia. In cases 
of acute nephritis in which the output of urine is scanty, as also in cases 
of parenchymatous nephritis in which headache and vomiting or other 
symptoms of incipient uremia are beginning to manifest themselves, 
the application of dry cups to the loins will often prove of much service 
and is usually followed by a conspicuously increased output of urine. 
Copious diaphoresis is an important and well-established method of 
treatment. It has been objected that the quantity of excretory products, 
as measured by urea, which can be thus vicariously removed, is com- 
paratively small, and that profuse sweating will tend to increase their 
concentraction in the blood. However, clinical experience teaches us that 
hot water baths, and hot air or vapor baths, have a decidedly beneficial 
effect in uremic cases, and the pathology of the conditions is still so 
obscure that it would be very unwise to abandon a plan of treatment 
of proved utility for merely theoretical reasons. 
In acute cases, in which a prompt and copious diaphoresis is aimed 
at, the subcutaneous injection of nitrate of pilocarpine in doses of | 
grain (gm. 0.01) may be resorted to, but is now regarded with less favor 
than formerly. In connection with diaphoresis, as with other plans of 
treatment, the condition of the individual patient needs to be carefully 
considered, and especially the state of the heart and character of the 
pulse. The pulse should be carefully watched during the administration 
of the sweat bath, and stimulants should be given if necessary. 
Hydragogue cathartics are of undoubted service. In the more chronic 
cases saline purgatives or compound jalap powder, aided, if necessary, 
by enemata, will usually suffice, but in acute attacks more drastic 
cathartics, of which elaterium is most in favor, are called for. The 
utility of purgation is probably only in small part due to the 844 
DISEASES OF THE URINARY SYSTEM 
comparatively scanty elimination of waste products by the bowel. Vomit- 
ing, which is so common a symptom, aids the vicarious elimination, 
and lavage of the stomach has been recommended with the same object 
in view. Venesection, with the withdrawal of 12 to 20 ounces of blood, 
proves of great service in not a few cases, and is regarded by some 
physicians as by far the most important of all the therapeutic measures 
employed in uremia. Whether or not bleeding should be resorted to 
will be largely determined by the state of the pulse, and when a pulse 
of conspicuously high tension is a prominent feature, venesection will 
commend itself, rather than in cases in which a soft and feeble pulse 
affords evidence of a failing heart. The benefit which results is thought 
to be largely attributable to the withdrawal of a portion of the toxic 
material in the shed blood. Infusion of normal saline solution to replace 
the blood withdrawn is frequently practised, and in cases in which oedema 
is absent, as in acute uremia in connection with granular kidneys, saline 
infusions, apart from venesection, have been recommended. 
Removal of cerebrospinal fluid by lumbar puncture has recently been 
employed with benefit. 
For the reduction of excessive pulse tension, nitroglycerin, or in acute 
attacks the inhalation of nitrite of amyl, may be employed; but even 
in uremic dyspnoea, in which high tension plays so conspicuous a part, 
these drugs may afford but little relief. Digitalis is often of service in 
chronic cases, both in virtue of its action as a cardiac tonic and as a 
diuretic. Inhalation of oxygen, and especially its continuous inhalation, is 
of very real service in the treatment of uremic dyspnoea, and is strongly 
recommended by Samuel West as calming the distressing restlessness 
and even as modifying convulsive attacks. 
For the control of convulsions inhalation of chloroform is usually 
very effectual, and chloral and bromides may be administered either 
by the mouth or the rectum. Morphine, the use of which has been 
strongly recommended by Stephen Mackenzie, Osler, and others, often 
proves most valuable in the treatment of uremic states, and its judicious 
use has been shown to be unattended by the dangers which were formerly 
regarded as contra-indicating its employment. In renal dyspnoea it 
is said to afford more relief than any other therapeutic agent, and it 
also gives relief from restlessness, insomnia, and such conditions as 
the mental disturbances and Cheyne-Stokes dyspnoea which usher in 
the onset of uremia in some cases of granular kidney. CHAPTER XV 
NEPHRITIS: INTRODUCTION AND ETIOLOGY-ACUTE 
NEPHRITIS 
JAMES B. HERRICK, M.D. 
Introduction.-By nephritis is meant an inflammation of the kidney, 
and, as the term is commonly employed, a non-suppurative inflammation 
is implied. If other than the non-suppurative form is meant, a qualifying 
adjective, as "suppurative," "pyelo," etc., is prefixed. Non-suppurative 
nephritis is often spoken of as Bright's disease, or morbus Brightii, the 
terms nephritis and Bright's disease being used interchangeably. Strictly 
speaking, this is not correct. Bright described those inflammations of 
the kidney accompanied by albuminuria and dropsy, so that his descrip- 
tion did not include the group of nephritides in which there is no dropsy. 
So, too, in reality, it is not correct to speak of some of the diseased con- 
ditions commonly referred to as nephritis as inflammations of the kidney, 
i. e., as exudative and proliferative in character. The granular atrophy, 
for example, is, in the strict sense, not an inflammation. But until 
clinical and pathological differentiation is more sharply defined, the 
term nephritis, or Bright's disease, may conveniently be employed to 
designate the non-suppurative inflammations of the kidney, it being 
tacitly understood that some forms of "nephritis" are degenerative or 
atrophic in character rather than inflammatory, and that some con- 
ditions called Bright's disease are different from anything actually 
described by Bright. 
There is a quite general agreement as to the division of all cases of 
nephritis into the two classes of acute and chronic. Clinically and 
anatomically the distinction between acute and chronic is not always 
clear. Subdivisions of the acute class into varieties are occasionally 
attempted, sometimes on an etiological basis, e. g., malarial nephritis, 
or sometimes on a histological basis, e. g., glomerular or tubular nephritis, 
but such subdivisions will not be very satisfactory until etiological 
classification becomes possible. 
No serious, at least no successful, attempt has ever been made to 
classify cases of chronic nephritis from the stand-point of etiology. Morbid 
anatomists and pathologists are far from unanimous in their descriptions 
of the various types or groups of this disease. And physicians are not 
always able to make a differentiation that is satisfactory from the clinical 
point of view or that holds good in the light of postmortem revelations. 
Yet it is important that we have some working classification, even 
though it be somewhat faulty and largely artificial. 
From the time of Bright (1827) down to the present there has been 
845 846 
DISEASES OF THE URINARY SYSTEM 
more or less confusion of ideas concerning chronic nephritis. Rayer, 
a few years after Bright's first paper, made four varieties of chronic 
nephritis. In 1867 Rindfleisch declared that " the pathological anatomy 
of the kidney is certainly the subject which has stimulated the most 
investigation, and yet today it is the least complete chapter of the whole 
work." And Bartels,1 a little later, besides quoting with approbation 
the sentence from Rindfleisch, adds that "it is apparent that the doctrine 
of the diffuse renal diseases cannot be regarded as settled from any 
point of view." Senator,2 writing in 1901, says: "There is at present 
no detailed classification that has met with general approval and accept- 
ance." Bradford3 (1901) says: "Chronic Bright's disease, however, 
is the form in which the greatest diversity of opinion, as to its nature 
and forms, exists." 
At the meeting of the German Pathological Society in 1905 there was 
a general discussion on morbus Brightii. Ponfick,4 in a leading paper, 
emphasized the importance of further careful correlated clinical and 
anatomical study of cases, so that more order might be brought out of 
the present confusion. Friedrich Muller,5 in an inspiring and masterly 
critique of recent views concerning Bright's disease, admitted the unsat- 
isfactory nature of our knowledge concerning the true character of the 
lesions in the kidney, our loose methods of classification, the difficulties 
to be overcome before an exact etiological classification is possible, and 
our use of a terminology that is neither historically, clinically, nor 
anatomically correct. He even proposed the use of a new term, "neph- 
rosis," to include in a comprehensive way the degenerative lesions of 
the kidney that could not, strictly speaking, be called "nephritis." 
It may be stated that the kidney of congestion is, by common consent, 
ruled out of the category of the nephritides and Bright's disease. Amyloid . 
kidney is now rarely classed as a form of Bright's disease, or as an inflam- 
mation of the kidney, although it is recognized as occurring not infre- 
quently in connection with, or as a complication of, a true nephritis. 
There remain two groups of the chronic nephritides whose clinical 
features present such striking contrasts that, for purposes of description, 
one feels warranted in making separate classes of these groups. The 
justification of this seems apparent when one sees that corresponding 
to these two types, kidneys are found differing as markedly as do the 
clinical manifestations. To the one form, characterized by oedema with 
abundant albuminuria and cylindruria, the name chronic parenchymatous 
nephritis has been most often applied; to the other, with its marked 
cardiovascular changes, its relatively slight albuminuria and cylindruria, 
with its abundant urine of low specific gravity, its frequent uremia, the 
term chronic interstitial nephritis is given. As synonyms for the former 
may be mentioned large white kidney, large yellow' kidney, chronic 
desquamative and chronic tubal nephritis, etc.; for the latter, contracted 
1 Ziemssen's Encyclopedia, American edition, xv, 187. 
2 Die Erkrankungen der Nieren, Zweite Auflage, Berlin, 1902, p. 194. 
3 Diseases of the Kidneys in Gibson's Practice of Medicine, 1901, ii, 316. 
4 Verhandl. der deutsch. path. Gesells. Centrabl. f. ally. Path, und path. Anat., 1906, 
Band xvi, 49-64. 
6 Ibid., pp. 64-99. NEPHRITIS 
847 
kidney, cirrhosis, sclerosis, granular atrophy, gouty kidney, etc. The 
former is the "large white kidney." The kidney of the second class is 
the "contracted kidney." 
While these are types and while they are seen with all their classical 
text-book features, both at the bedside and on the autopsy table, great 
variations are frequently met with. Heubner rightly says that the 
majority of chronic kidney conditions are, according to generally accepted 
types, atypical. On close examination, it is seen that the names paren- 
chymatous and interstitial are in reality misnomers, for with every 
parenchymatous nephritis the interstitial tissue is involved, and paren- 
chymatous changes are seen in every case of chronic interstitial nephritis. 
The process is in reality a diffuse one-a chronic diffuse nephritis. In 
the one case the parenchyma is chiefly, and perhaps primarily, involved, 
and there is little or no induration or contraction; in the other, the 
interstitial structure shows the chief, perhaps the primary, change, and 
there is contraction or induration. Hence we have Senator's two classes 
of (1) chronic diffuse nephritis without induration; (2) chronic diffuse 
nephritis with induration. By diffuse is not meant that every part of 
the two kidneys-Bright's disease being a bilateral affection-is involved; 
as is well known, circumscribed foci of inflammation are often a striking 
figure in the kidney of nephritis, the "patchy" areas showing pathological 
change contrasting strongly with the healthier areas. By diffuse is 
meant diffuse in the sense that the parenchyma and interstitium are 
both involved. 
In practice the cases do not permit of such easy distribution into 
appropriate pigeon-holes as one might think. The pathologist often 
refuses to say more than that there is a chronic nephritis; and the clinical 
manifestations may be a mixture of the findings of the two classes. We 
must often be content with the diagnosis of chronic nephritis or chronic 
diffuse nephritis. This point deserves special emphasis, for much 
energy is wasted and much needless disappointment experienced in the 
attempt to make a given case fit into a classification that is largely 
artificial and necessarily imperfect. It is better for teacher, student, 
and practitioner to have a frank understanding and to realize that 
disease often refuses to conform to the picture of the classical type. 
In some cases the view of Frerichs and of Reinhardt that the contracted 
kidney is a later form of the parenchymatous seems to be confirmed. 
At the bedside this transformation of a chronic parenchymatous nephritis 
into the chronic interstitial is occasionally seen, and at postmortem a 
condition of secondary contraction is recognized. If we preserve the 
term chronic interstitial nephritis for the indurated or contracted kidney, 
it might be well to adopt the expressions secondary interstitial nephritis 
for this form and primary interstitial nephritis for the slowly developing, 
insidious, cardiovascular, typical contracted kidney. As a subhead under 
chronic interstitial nephritis should be placed the arteriosclerotic kidney 
or granular kidney, with its striking local vascular changes that are but 
a part of a more general arteriosclerosis. This can generally be recog- 
nized at autopsy, and may be suspected and permits of a probable 
diagnosis during life, particularly in the aged. 848 
DISEASES OF THE URINARY SYSTEM 
Tiie classification that seems the best is practically that of Senator: 
1. Chronic parenchymatous nephritis. (Chronic diffuse nephritis 
without induration.) 
2. Chronic interstitial nephritis. (Chronic diffuse nephritis with 
induration.) ' 
(a) Primary chronic interstitial nephritis. 
(&) Secondary chronic interstitial nephritis. 
(c) Arteriosclerotic kidney. 
3. Mixed type, a combination of 1 and 2, i. e., diffuse nephritis. 
ETIOLOGY OF NEPHRITIS 
In some instances the kidney is involved by a direct extension of 
inflammation from a neighboring structure. Such, for example, is the 
case in the ascending nephritis consecutive to pyelitis-pyelonephritis. 
But in the great majority of cases some substance carried by the 
blood to the kidney acts as the excitant of inflammatory or degenerative 
changes, acute or chronic, as the case may be, and the result is a nephritis 
or an atrophic process that in its results is akin to a true nephritis. These 
causes may for purposes of description be classified, although the dis- 
tinctions are here somewhat artificially made; and in reality the operating 
etiological factor in a given case is often not a simple one but a com- 
bination of two or more of the causes mentioned in these different groups. 
A working classification may be made as follows: 
1. The infectious diseases, acute and chronic. 
2. Chemical, i. e., toxic substances, acute or chronic in their action, 
(a) Exogenous. 
(6) Endogenous, (i) Gastro-intestinal, (ii) Metabolic products. 
3. Cold. Nephritis a frigore. 
4. Pregnancy. 
5. Heredity. 
1. The Infectious Diseases.-Infectious diseases may as a class be 
regarded as the cause of a large percentage of cases of acute nephritis. 
Many cases that at first sight seem to be due to causes that are not 
microbic, often on close analysis are found to have been preceded by 
definite symptoms of an infection, mild perhaps or even unheeded by 
the patient, but yet presumably the fons et origo of the later renal com- 
plication. An ambulatory scarlet fever, a comparatively insignificant 
angina, a mild rheumatism, a "cold" or supposedly trifling "la grippe" 
may be the precursor of a nephritis. In cases of obscure origin the cause 
may lie in an unsuspected pus focus in a tonsil, at the root of a tooth, 
in the gall-bladder, middle ear, urinary bladder, etc. The slow absorption 
of small amounts of toxins from these foci may have rendered the patient 
in a sense immune so that there are no very striking symptoms, either 
from the original source of the infection or in the kidney or other tissue 
that is secondarily involved; the process may rather be subacute. Such 
a patient may be said to have, as Dr. Kirk has well put it, the "toxin 
habit." lie has become accustomed to and tolerates fairly well the 
ordinary dose of toxin absorbed. NEPHRITIS 
849 
Among the infectious diseases attended or followed by acute nephritis 
scarlet fever stands preeminent. Even before the time of Bright, clinicians 
had noted the now well-recognized complication. Without stating it 
in figures, it is sufficient to know that experience the world over, in 
hospitals and in private practice, and with various kinds of treatment, 
has demonstrated the great frequency with which scarlet fever is accom- 
panied by acute inflammation of the kidneys. There would seem to be 
some selective action on the part of the infectious or toxic agent present 
in this disease for the kidney and even for one particular part of the 
kidney, viz., the glomerulus. Often the other clinical manifestations of 
scarlet fever are on the wane or have entirely disappeared; often the 
whole course of the illness has been mild, yet the nephritis occurs. Why 
the kidneys should be so peculiarly vulnerable in this malady is not 
known. Undoubtedly in some cases of scarlatinal nephritis there is a 
combination of operative causes. While the toxin must be regarded as 
the primary cause, exposure to cold, errors in diet, too short a period of 
rest in bed, constipation, or the use of alcohol may assist. 
Disregarding febrile albuminuria, acute nephritis is by no means as 
common in diphtheria as in scarlet fever. Acute nephritis in this disease 
is manifested in much the same manner as in scarlet fever, although it 
is more apt to make its appearance earlier. Since the use of antitoxin 
it is of rarer occurrence, it may be interesting to note that one of the 
earlier proofs that it was the toxin in many infectious diseases and not 
the organisms themselves that induced the nephritis was afforded by 
the injection of diphtheria toxin into animals, with the subsequent 
development of nephritis. 
Bright's disease as a complication of the other common infections of 
childhood is comparatively rare. Yet occasionally it is seen in measles, 
German measles, chicken-pox, whooping cough, and mumps. It may occur 
in epidemic cerebrospinal meningitis. 
A trace of albumin with a few casts is a common finding in typhoid 
fever, disappearing with the subsidence of the fever. True nephritis 
is rare, and Bartels1 saw but two instances in 1000 cases. The renal 
symptoms may appear early and for a time be the most striking feature 
of the case, constituting the so-called renal typhoid, or, it may be later, 
during the height of the disease or as convalescence sets in, that the 
kidney may become involved. In pneumonia casts and albumin can 
usually be found. In a series of consecutive cases the writer found in 
each instance at some time during the illness a trace or more of albumin 
and a few hyaline or granular casts. True nephritis is comparatively 
rare. It may appear during the height of the disease or during conva- 
lescence. In some of the cases of acute nephritis found in pneumonia, 
as in other infections, the renal trouble is merely an aggravation of a 
previously existing chronic nephritis, i. e., an acute exacerbation. 
With typhus fever and smallpox acute inflammation of the kidney is 
common. It has been seen in vaccinia. In cholera the scanty, bloody, 
and albuminous urine is found associated with an acute destructive 
1 Ziemssen's Encyclopedia, xv, 527. 850 
DISEASES OF THE URINARY SYSTEM 
degenerative change in the kidney. In yellow fever and acute yellow 
atrophy of the liver acute degenerative and inflammatory lesions are 
frequently found in the kidneys, and the symptoms of acute nephritis 
are present. In relapsing fever acute nephritis has been noted (Ponfick). 
Malaria often induces nephritis apart from the hemoglobinuria or 
black-water fever. Kelsch and Kiener insist upon the occurrence of 
malarial nephritis. Thayer analyzed the Baltimore cases and found 
acute nephritis in over 4 per cent, of the patients with estivo-autumnal 
infection. The so-called febrile albuminuria is found in a much larger 
percentage-probably one-half-of the cases of acute malaria. 
Considering the great frequency of rheumatic fever and chorea, nephritis 
must be regarded as a rare complication of these diseases, yet it is occa- 
sionally seen. If, however, we regard some of the anginas of obscure 
origin and some of the purpuras as rheumatic in character, rheumatism 
must be looked upon as a not infrequent cause of nephritis. It is not 
unusual to see a patient whose illness began with sore throat, joint pains, 
and purpuric manifestations, in whom oedema, albuminuria, hematuria, 
cylindruria, etc., give unmistakable evidence of an acute nephritis. In 
erythema nodosum, also, nephritis is reported. 
As has been already said, a tonsillitis1 or an every-day sore throat is 
in many instances the atrium for the entrance of toxic infectious agents 
that induce nephritis, and in all cases of obscure origin careful inquiry 
should be instituted as to recent throat or nose trouble. 
With erysipelas febrile albuminuria is common; true nephritis occurs, 
although not often. Nephritis has also been reported in dysentery. 
With septicemia and pyemia-due to a streptococcus, staphylococcus, 
pneumococcus, gonococcus, etc.-febrile albuminuria is the rule. True 
nephritis also is not uncommon. In some instances the nephritis is 
clearly metastatic, mycotic emboli from a thrombosed vein or from 
infected cardiac valves lighting up the nephritis or perhaps producing 
a suppurative nephritis or surgical kidney. But aside from the embolic 
variety, acute nephritis-"toxic infectious"-in the course of sepsis is 
frequently seen. Possibly some of the instances in which nephritis is 
recorded as due to a skin disease are in reality of the nature of "toxic- 
infectious" inflammations, the skin lesion being suppurative or furnishing 
a portal of entrance for germs. In a similar way alimentary disturbances 
may be microbic and the nephritis that perchance results might be classed 
under the head of infectious, although toxins are probably the direct 
exciting cause. 
Acute or subacute parenchymatous nephritis is often seen in tuber- 
culosis. Some of the supposed cases of nephritis with tuberculosis are 
amyloid. Perhaps, too, secondary infection with pyogenic microbes 
explains some of the cases of Bright's disease complicating tuberculosis. 
But whether one looks upon the tuberculous toxin as the cause of the 
complication, a view that has some experimental and clinical support, 
particularly from French observers, or regards the tuberculosis as merely 
a predisposing cause, and exposure to cold, use of drugs, overfeeding, 
1 Of, Morse, Archives of Pediatrics, 1904, xxi, 337. NEPHRITIS 
851 
use of alcohol, or a secondary infection as the real cause, certain it is 
that nephritis is quite common in tuberculosis. 
Influenza is also a cause of nephritis. During the epidemic in the 
nineties the unusually large number of cases of acute nephritis excited 
general comment among practitioners. 
Occasionally cases have been seen in which the question of the existence 
of some specific germ for acute nephritis has been raised. Saundby cites 
Fiesinger,1 who described what appeared like an epidemic of nephritis, no 
other localization of the infection than in the kidney being manifest. 
Black Milne2 raises the question as to the possible specific microbic 
origin in certain cases with a special tendency to localization in the 
kidney. 
The controversy concerning syphilis as a cause of nephritis has not 
yet quieted down. There are those who regard the inflammation of 
the kidneys in a syphilitic as due to the drugs employed, especially the 
mercury, to the influence of cold (Bradford), to accidental causes, such 
as alcoholism, to other infections, etc. Klieneberger,3 in Lichtheim's 
clinic, made a careful urinary study of 31 patients, some of whom were 
non-syphilitic, who were treated by mercurial inunctions. With great 
uniformity he found evidence of irritation of the kidney in the presence 
of albumin and casts, and while advocating the use of mercury in the 
treatment of syphilis, he feels that the remedy should be used cautiously 
and the effects on the kidney carefully noted, for, as he says, this is not 
an "indifferent" treatment. Wagner suggested that the angina often 
seen in syphilis might be the intermediate agent in producing nephritis 
by affording an avenue of admission for harmful germs. It is difficult to 
settle the question on the basis of clinical evidence alone. The writer's 
experience tallies with that of those who regard syphilis as a potent cause 
of acute nephritis, especially in the first two years after the initial lesion.4 
Of the influence of syphilis in producing chronic sclerotic changes in 
general, including such changes in the kidney, there is little question. 
The fact that an acute inflammation of the kidney accompanies or 
follows hard upon an infectious disease does not of necessity prove that 
the particular microorganism producing the infectious disease or its 
toxins is also causing the nephritis. While this is presumably so, it 
may often be that the infectious disease merely paves the way for some 
secondary and intercurrent microbic or toxic agent that acts upon the 
kidney under these, for the kidney, unfavorable conditions. Nothing 
definite is known that will explain why in one case of acute infectious 
disease the kidneys escape, while in another they are hard hit. Varia- 
tions in the amount of the toxin, its virulence, or the length of time it 
acts must be assumed to aid in the explanation. Differences in the 
make-up of the kidney and its resisting power or sensitiveness to harmful 
influences, and differences in the resisting power of the body as a whole, 
must be inferred. A once damaged kidney may be peculiarly liable to 
1 Rev. de Med., 1893, p. 404. 2 Brit. Med. Jour., 1892, ii, 1391. 
3 Zeitschr. f. klin. Med., 1906, Iviii. 
4 The subject of syphilitic nephritis has been treated by Josserand, Lyon Medical, 
November, 1904. Cf. Max Wagner, Munch. Med. Woch., 1902, Nos. 51 and 52, which 
contain numerous references. 852 
DISEASES OF THE URINARY SYSTEM 
become again seriously affected. Recovery may have ensued in a clinical 
or functional sense, yet a recovery with some permanent weakness or 
defect. But the entrance again into the body of microbes or the springing 
into activity of microorganisms that have long lain dormant and appar- 
ently harmless in the body-typhoid bacilli in the gall-bladder, gonococci 
in the prostate or Fallopian tubes, streptococci or staphylococci in the 
middle ear or in an ancient osteomyelitis or tonsillitis-may lead to a 
fresh acute outbreak in the kidney that had apparently recovered, but 
now shows itself peculiarly sensitive to even slight insults. 
A selective affinity of the toxins of certain diseases, e. g., scarlet fever, 
for the kidney may also be assumed to explain the unusual frequency 
of Bright's disease with some infections, its rarity with others. And 
the organisms, or rather their toxins, often display a selective affinity 
for certain parts of the kidney, one organism damaging particularly 
the glomeruli, another the tubular epithelium, or another the interstitial 
tissue. The lesions, too, are with some organisms chiefly exudative 
and proliferative i. e., truly inflammatory, with others degenerative 
or again often characterized by hemorrhages or interstitial cellular 
accumulations. More experimental, histological and clinical observation 
is still needed in order to clarify our knowledge of the anatomical changes, 
the perversion of function and the clinical manifestations due to acute 
nephritis as produced by particular kinds of organisms. 
2. Toxic Agents.-While the true nature of the poisons that produce 
nephritis in the case of the infectious diseases is not known, and while 
many of the more strictly toxic nephritides are due to poisons whose 
origin in the body is obscure and whose chemical composition is still 
unrecognized, there are certain known toxic substances that are capable, 
when introduced into the body in large enough amounts, of producing 
an acute nephritis; and others capable of inducing a chronic change in 
the kidney, provided the action be extended over a long period of time. 
(a) Exogenous Toxic Substances.-Of the exogenous toxic substances 
a long list might be given, including certain organic and inorganic 
chemicals used as drugs, and others whose entrance into the body is 
always a matter of accident or due to an intent to harm. Such substances 
are cantharides, turpentine, carbolic acid, chlorate of potassium, sali- 
cylic acid and its compounds, oxalic acid, the mineral acids, bichromate 
of potassium, alcohol, chloroform, phosphorus, mercury, lead. Long- 
continued action of many of these substances in smaller amounts, e. g., 
lead or mercury, may induce chronic nephritis. Morphinism may be a 
cause. Even chloride of sodium, which has at times been employed for 
the production of inflammatory and degenerative lesions of experimental 
nephritis (Stokvis, Levi, Castaigne and Rathery), has been regarded 
as an occasional cause of acute nephritis1 when used in large doses. The 
innocuousness as regards the kidneys of the curative sera, of tuberculin, 
of vaccine virus, etc., is one of the fortunate facts concerning these 
valuable diagnostic and therapeutic agents, but whether in exceptional 
instances a toxic nephritis may not be lighted up is not definitely settled. 
1 Cf. Tarino, La Presse Medicale, 1904, xx,.., 222. 853 
NEPHRITIS 
'fhe effect on the kidney of the injection of the vaccines in the treatment 
along the lines of the so-called "opsonic therapy" of Wright must also 
be carefully watched. In ptomaine poisoning damage may be done to 
the kidneys by ingested poisons. The whole question of the effects of 
adulterated food on the kidneys is one requiring careful consideration, 
and the use of such adulterants calls for proper legal restrictions. The 
question may also be raised whether at times a nephritis may not be 
induced by the excessive quantity of food, e. g., meat, that is eaten, 
overwhelming the kidneys by the quantity rather than the quality 
of the digestive and metabolic products. The too free use of highly 
seasoned foods has also been held responsible for some cases of nephritis. 
The exogenous toxic substances do not always enter by way of the 
alimentary tract. Chloroform and ether may be a possible excitant 
of nephritis, even when inhaled. The external application of drugs has 
in numerous instances been held responsible for inflammation of the 
kidney. Care should always be exercised in the use on the skin, and 
particularly when the surface of the skin is broken, of such remedies 
as carbolic acid, turpentine, bichloride of mercury, iodoform, pyrogallic 
acid, naphtol, and the preparations of tar. Acute nephritis has been 
reported in which the cause seemed to be the extensive application of 
balsam of Peru.1 Gassmann2 gives references to some six or seven cases 
in which balsam of Peru externally applied produced acute nephritis. 
In some lesions of the skin, such as eczema, the nephritis that is occa- 
sionally seen as an accompaniment is perhaps due to the formation of 
some toxic product in the diseased skin. Extensive burns,3 as is well 
known, are peculiarly prone to be followed by acute, often severe, changes 
in the kidney due to toxic substances resulting from the destruction 
wrought in the skin. Some, however, regard the hemolytic changes 
in the blood through the agency of the burn as the cause of the toxic 
symptoms and of the anatomical alterations. The intestine and kidneys 
are the chief avenues of elimination of this poison, and often show the 
most marked pathological lesions. The poison is in some respects 
comparable to the snake venoms. 
The long-continued use of the Rontgen rays may not be without harm 
to the kidney. This probably arises more from the destruction of leuko- 
cytes and of lymphoid or neoplastic tissue, with the development of 
toxic substances that are injurious to the kidney, than from the direct 
harmful effect of the ray upon the kidney itself. Warthin4 describes 
inflammatory and fibrotic changes with remarkable lime-salt deposits 
in the kidneys of patients with myeloid leukemia and Hodgkin's disease 
who had been treated for a long time with the Rontgen rays. The 
necessity of careful watching of the urine in such patients is clear. 
(b) Endogenous Toxins.-Most of the endogenous toxins are as yet 
unidentified, but it is possible that not a few of the cases of acute nephritis 
may be due to toxic substances rapidly formed within the body. 
1 L. H. Hoffman, Jour. Amer. Med. Assoc., 1907, p. 2086. 
2 Munch, med Woch., 1904, No. 30. 
3 Literature on burns in Pfeiffer, Virchows Archiv, 1905, clxxx, 367. 
4 Am. Jour. Med. Sc., 1907, cxxxiii. 854 
DISEASES OF THE URINARY SYSTEM 
(i) Acute gastro-intestinal disorders at times seem to be the starting- 
point of acute nephritis. Here, in many instances at least, micro- 
organisms or irritant chemicals have been introduced from without, 
but the disturbed conditions in the alimentary tract give rise to the 
formation of new toxic products which when absorbed act harmfully 
upon the kidney. Acute nephritis of this type, e. g., occurring in con- 
nection with the acute gastro-enteritis of children, is a good illustration 
of the frequent combination of causes of various kinds, microbic and 
chemical, exogenous and endogenous. It does not seem a rash assumption 
regarding many cases of chronic nephritis of otherwise obscure origin 
to look upon digestive disturbances as the etiological factor. Errors in 
diet and digestive functions faultily performed may easily be regarded, 
if continuing for a long period, as leading to chronic toxemias, with result- 
ing renal changes. In some instances bacterial growth in the bowel 
may be excessive and toxins increased in quantity, or the change may 
be qualitative rather than quantitative, the bacteria being different 
in kind. Or we may conceive of some protective chemical process in the 
bowel or liver as being deficient under pathological conditions, and a 
toxin that in health is rendered harmless, being absorbed, reaching the 
kidney and inducing inflammation. Suggestive experimental work along 
this line of the combined action of chemical and microbic causes has been 
done. O'Hare,1 by combining the action of uranium nitrate and the colon 
bacillus, was able to produce in rabbits a lesion similar to that of chronic 
nephritis in man. 
In children malnutrition with its gastro-intestinal disturbances may 
cause nephritis. This is seen in infants in hospitals and asylums.2 
(ii) When we broaden the conception so as to take in disorders of 
metabolism we may find a probable explanation for many chronic neph- 
ritides. But little definite knowledge is as yet possessed upon this subject. 
Still, one may imagine that faults on the part of such organs as the liver, 
pancreas, adrenals, thyroid gland, or even the muscles, might by mal- 
performance of function, perhaps internal secretory function, lead to 
chronic renal disease. And the influence of excessive worry, anxiety, 
business hurry, and nervous strain in the production of chronic nephritis, 
a fact regarded by many as explaining the apparent frequency with which 
Bright's disease is seen in modern life, may be due to faulty performance 
of function on the part of some of the viscera through perversion of 
nervous influence, or even to the presence in undue amount of some 
obscure toxic material, the result of excessive overuse of nerve cells. 
With jaundice, albumin and casts are often found in the urine. This 
result of the presence of biliary matter and perhaps other toxic material 
in the blood usually vanishes with the disappearance of the jaundice, 
although rarely a genuine degenerative or inflammatory lesion of the 
kidney persists. 
Long continuance of gout usually leads to more or less marked cardio- 
vascular and renal sclerosis, presumably from the influence upon the 
1 Arch. Inter. Med., 1913, xii, 49. 
2 Cf. Fry and Martin, Archives of Pediatrics, 1904, xxi, 19. NEPHRITIS 
855 
heart, vessels, and kidneys of the chemical substances present as the 
result of faulty metabolism. In diabetes, also, chronic nephritis is occa- 
sionally seen. Here the nephritis is apparently toxic, although the 
influence of excessive quantities of food, with unusual demands on the 
kidney in the way of elimination, may play a part. Obesity at times leads 
to sclerosis of the vessels, and contracted kidney may be found in the 
fleshy, especially, it would seem, in fleshy women. 
It is in place here to refer to the observations of some who have found 
that when injured renal tissue has been left in the body, as when the 
kidney is left in situ after ligation of the ureter or the renal vessels, the 
cells of the remaining kidney may undergo degenerative changes, believed 
to be due to the nephrotoxins (isonephrotoxins) developed from the 
absorption of the damaged renal tissue.1 This has been thought to 
explain in part the progressive character of some cases of nephritis. 
Others, e. g., Pearce,2 while able to induce nephritis by using heteronephro- 
lysins, have been unable to get positive results with isonephrotoxins. 
Martin Fischer3 has advanced the hypothesis, supporting it by experi- 
mental and clinical studies, that the fundamental pathological change 
in nephritis is an acid condition of the parenchymal cells of the kidney. 
These cells, he says, represent a colloid membrane interposed between 
the blood on the one hand and the urine on the other. If the contents 
of these cells become acid-as through the operation of any of the causes 
already enumerated-the colloidal albumin becomes "soluble" and 
appears in the urine. This same acidity explains the casts and the other 
urinary changes of nephritis, as well as the histological findings in the 
diseased kidney. In spite of sweeping generalizations often unwarranted 
by the experimental or clinical data, and though his attractive simplifica- 
tion of the conception of nephritis hardly takes due cognizance of the 
complexity of the facts of nephritis, especially of the chronic forms, 
Fischer's work should be followed up. The physicochemical and colloid 
explanations of many of the phenomena of nephritis are in many respects 
far more satisfying and rational than some of the others. Some of 
Fischer's experiments are as striking in their simplicity as they are 
startling in their results. They should be repeated and broadened, for 
they are concerned with the basic principles underlying such conditions 
as albuminuria, casts, the occurrence of oedema, etc. 
3. Cold.-Cold is, perhaps, as Bartels4 called it, an etiological scapegoat 
as regards nephritis. Clinical evidence is strong that at times exposure 
to cold precipitates an attack of acute nephritis or aggravates an already 
existing chronic nephritis. Just as in tonsillitis or pneumonia cold may 
favor the activity of pathogenic bacteria, so in the case of the kidney 
we may look upon cold as favoring the action of infectious or toxic agents 
that thus produce nephritis. How the cold works in these cases is not 
always clear. Changeable climate seems to favor the development of 
nephritis. Eichhorst saw relatively more cases on the East Prussian 
1 Cf. Isobe, Mitt a. d. Grenzgeb. d. Med', u. Chir., 1913, xxvi, 1. 
2 University of Pennsylvania Medical Bulletin, 1903, xvi, 217. 
3 Nephritis, John Wiley & Son, 1912. 
4 Ziemssen's Encyclopedia, American edition, xv, 254. 856 
DISEASES OF THE URINARY SYSTEM 
Coast than in the more equable climate of Jena and Berlin. Similar 
observations are recorded by Saundby and by Frerichs. 
4. Pregnancy.-Pregnancy has been recognized as a cause of nephritis 
since Bayer first called attention to the fact. There are certainly two 
conditions that have to be here considered. In the first place, some of 
the cases of nephritis complicating pregnancy are cases in which a 
previously existing, but unrecognized, nephritis has been aroused to 
fresh activity through pregnancy, which may be looked upon, therefore, 
as merely aggravating the condition. But in the second group are the 
cases in which kidneys previously healthy are injured during pregnancy, 
as shown by anatomical study as well as by urinary findings and the 
clinical symptoms of eclampsia. The cause of this disease of the kidney 
is still not clear. Bayer and others emphasized the importance of 
increased intra-abdominal pressure due to the pregnant uterus, and 
particularly direct pressure upon the vessels of the kidney or upon the 
ureter. 
Toxemia, however, undoubtedly plays an important part, as Virchow 
insisted. Pregnant women are often, through false notions of modesty, 
through fear, or because of indisposition, confined to the house, taking 
insufficient exercise and neglecting even the customary care of the skin. 
They are often obstinately constipated. Elimination is, therefore, 
deficient and toxemia favored. Besides, extra demands are made upon 
the mother in the way of supplying nourishment and elimination for 
the developing fetus. Metabolic processes, while active, may be per- 
verted, and toxemia result. Perversion of protein metabolism may have 
much to so with this toxemia. 
5. Predisposing and Contributing Causes.-Heredity.-There can be 
no question that a tendency to nephritis is at times transmitted. This 
is often an hereditary arteriosclerotic tendency, the kidney sharing in 
the general vascular change. The chronic forms may appear even in 
childhood. In one family observed by the writer there is a history of 
renal trouble in the parents and several of the uncles and aunts; one 
woman of fifty has chronic interstitial nephritis, and her three daughters 
and one son have had albuminuria from the age of twenty, at least, and 
cardiovascular changes are already in evidence. 
Age.-The young are more liable to have the parenchymatous forms, 
because of their greater liability to infectious diseases. The so-called 
interstitial forms are oftener seen later in life. 
Sex.-From greater exposure, severer physical work, and greater 
carelessness in the matter of food and drink, the male sex will show a 
larger percentage of cases of Bright's disease, although the influence 
of pregnancy and pelvic infections goes a long way toward increasing 
the percentage of cases in women. 
Occupation may predispose to nephritis. Workers in lead or mercury, 
those helping about breweries or saloons, where alcohol is often taken 
freely, are especially prone to disease of the kidney. Engineers, workers 
in the cooling-rooms of packing-houses, and others engaged in occupa- 
tions that expose them to extremes of heat and cold are peculiarly liable 
to the development of parenchymatous nephritis. The modern strenuous ACUTE NEPHRITIS 
857 
business life with its nerve strain and hustle seems to favor early renal 
and cardiovascular sclerosis. 
Other Diseases.-Diseases producing congestion of the kidney, e. g., 
uncompensated disease of the heart, favor the development of nephritis. 
Acute nephritis may lead to the chronic form. And, as has been already 
mentioned, the infections often lead directly to Bright's disease, but 
probably at times indirectly, the debilitated condition of the patient 
favoring the action of any accidentally operating cause that might 
produce nephritis, but which, acting in an individual who was healthy, 
would be without harmful result. 
ACUTE NEPHRITIS 
Etiology.-The ordinary causes-acute infections, intoxications, cold, 
pregnancy, etc.-have just been considered and need not be repeated. 
Pathology.-In acute nephritis both kidneys are involved, and usually 
equally involved. Exceptional cases of unilateral nephritis are recorded.1 
The kidney may be of normal size and show few or even no changes 
that can be detected by the naked eye. Ordinarily, however, it is some- 
what larger than normal, and the weight may be twice that of an average 
kidney. The tense kidney may bulge through an incision in the capsule 
like a hernia (Dieulafoy). The capsule strips readily. The color varies, 
depending largely on the amount of blood in the vessels, the hemor- 
rhages and the fatty changes that have taken place; it is usually grayish 
red or quite dark red, the stellate veins often showing plainly. The 
kidney usually feels rather soft. On section, the cortex is seen to be 
swollen, its grayish-yellow or lighter red color showing in sharp contrast 
to the deeply brownish-red pyramids. The cortex may show yellowish 
areas or streaks marking the degenerated tubular epithelium, with 
reddish lines representing the engorged vessels, or reddish dots due to 
the prominent glomeruli or to smaller or larger hemorrhages. 
Attempts to distinguish definitely between the purely degenerative 
and the more strictly inflammatory changes in these kidneys are only 
rarely successful. There are certain anatomical peculiarities of the 
kidney of nephritis, characteristic of different operating causes. For 
instance, the lesions of scarlatinal nephritis are largely glomerular; in 
diphtheria the tubular epithelium first shows degenerative changes, 
especially in Henle's loop; in cholera the epithelium of the convoluted 
tubes is particularly involved. Similarly in experimental nephritis2 
a selective action of the toxin employed is often seen. Thus, of chemical 
substances chromium salts and uranium nitrate induce a tubular neph- 
ritis, cantharidin affects chiefly the glomeruli, while vinylamin leads 
to necrosis of the medullary portions with inflammation of the renal 
1 Riesman and Miller, Arch. Int. Med., 1913, xi. 
2 H. A. Christian reviewed the literature on experimental nephritis in the Boston 
Med. and Surg. Jour., 1908, clviii, 416, 462. He and his co-workers have since then 
published several valuable studies on this subject; the latest is Study XIX in Jour. 
Exper. Med. References to the other studies are here found. 858 
DISEASES OF THE URINARY SYSTEM 
pelvis, sparing the cortex. With uranium nitrate, as shown by Richter,1 
human nephritis is imitated as to dropsy. The description of the anatomy 
of the kidney of acute nephritis here given will be that of what may be 
called the typical acute nephritis, or, if one please, the "average" kidney 
of acute nephritis, as seen at autopsy. 
The Malpighian Bodies.-Very often some seem absolutely normal, 
while others, even those in their immediate vicinity, may show extensive 
lesions. This irregular distribution of the pathological process in the 
kidney is found, as will be seen later, in the other renal structures, and 
in other forms of Bright's disease, and is the more remarkable when we 
think that the operating cause is so often a toxin or soluble chemical 
substance in the blood that must come in contact with all parts of the 
kidney. In acute nephritis Bowman's capsular space contains red and 
white corpuscles, desquamated epithelial cells in various stages of dis- 
integration, even to the extent of being represented by an amorphous, 
granular debris, and a fluid variously described as serous, albuminous, 
an inflammatory product, etc., often coagulated, and at times demon- 
strably containing fibrin threads. The amount of these substances may 
be very slight or so great as to compress the capillary tuft into a small 
space. And the proportion of the different ingredients may vary, in 
the one case the'sp^ace being filled with an albuminous fluid or with 
granular material, in another with red-blood corpuscles, this latter con- 
dition constituting one of the striking findings in some cases of hemor- 
rhagic nephritis. In fact, in most instances, renal hematuria is of 
glomerular origin. The cells of the capsule may be normal, although 
many of them commonly show degeneration, as evidenced by their 
swollen condition, their granular or hyaline appearance, the presence 
of fat droplets, and the indistinct or vanished nucleus. Large numbers 
of cells may have dropped off and be seen in the capsular space. This 
leaves bare areas in the capsular wall, although the denuded spots may 
be rapidly covered by newly proliferated cells, efforts at regeneration 
often being shown by mitotic figures. The crescentic masses, so com- 
monly described in the Malpighian bodies of acute nephritis, are made 
up, according to some, of masses of these proliferated cells lying between 
the basement membrane of the capsule and the capillary tuft, while 
others (Ribbert) regard the masses as made up of desquamated glo- 
merular epithelium. 
The capillaries of the glomerulus2 are often tensely filled with blood 
that may be in thrombus form. Cells of uncertain nature, perhaps 
leukocytes, are sometimes seen in great numbers within the lumen. A 
hyaline appearance of the entire tuft is often noted. The cells covering 
the glomerular vessels have undergone the changes just referred to in 
connection with the capsule. At times proliferation has been active, and 
little more can be made out than a compact mass of epithelial cells, 
with deeply stained nuclei. The hyaline appearance is seen in the 
kidneys in many acute infections, and involves the capillary wall. 
1 Beitrage zur klin. Med., Senator Festschrift, 1904. 
2 Cf. Christian and O'Hara (loc. cit., Study XIX) for excellent figures of these glo- 
merular changes in acute experimental nephritis. ACUTE NEPHRITIS 
859 
It can readily be understood from a consideration of the glomerular 
changes just described that the plugging of the capillaries with thrombi, 
the filling of the capsular space with exudate and debris, with resulting 
pressure upon the vessels of the tuft and upon the tubules, must result 
in marked disturbance of glomerular function. In the glomerular lesion 
is found the main, although not the sole, explanation of the albuminuria, 
a partial explanation of the oliguria, and perhaps, through the obstruction 
that is offered to circulation, one of the causes of increase in blood- 
pressure. Moreover, the circulatory disturbance in the capillaries of 
the glomerulus must contribute to the nutritional and functional dis- 
turbance of the tubular epithelium. 
The Tubules.-The same irregularly distributed or patchy arrangement 
of the diseased areas that was noted in the case of the Malpighian bodies 
is seen in the tubules. The cells are swollen, hazy or granular in appear- 
ance, the nuclei indistinct or invisible. In other cells the nuclei may 
still remain, but the brush-like appearance of the cell has disappeared, 
and it looks hazy or hyaline. Fat droplets are frequently seen. The 
lumen of the tubule may be perceptibly narrowed by the swelling of its 
cells, although, at times, the lumen is increased because the cells are 
flattened or more or less disintegrated and their places taken by frag- 
mentary relics, or they have entirely disappeared or are seen not in 
their proper places but in the tubules. Regenerative appearances are 
occasionally described. Red- and white-blood corpuscles are also seen 
in greater or less abundance, and casts of different kinds. In some 
instances the lesions in the kidney are confined to the tubules, constituting 
the so-called tubular nephritis. 
The Interstitial Tissue.-Usually, even in some of the more recent cases, 
an inflammatory oedema is shown by the widening of the intertubular 
spaces. Round-cell infiltration may occur, especially in the neighborhood 
of the glomeruli. Hemorrhagic areas are not unusual. The vessels 
show varying degrees of engorgement. In cases of longer standing, such 
as perhaps might be termed subacute, proliferative changes in the 
connective tissue may be detected. This is sometimes well seen in a 
slight thickening of Bowman's capsule. The term parenchymatous 
as commonly applied is in reality a misnomer, for in nearly every 
case of acute nephritis definite interstitial lesions can be made 
out. 
In some instances, especially of acute infections, the striking change 
is seen in the interstitial tissue, which may be the seat of an inflammatory 
oedema, but whose chief feature is the presence, sometimes focally, or 
again more diffusely, of larger or smaller numbers of cells that have 
been variously described by different writers, but which have been shown 
by Councilman1 to consist in large measure of cells identical with Unna's 
plasma cells. Degenerative changes in the epithelium of the tubules 
and glomerular changes may be slight or marked in this form of " acute 
interstitial nephritis," so that albuminuria and other ordinary urinary 
evidences of Bright's disease may be quite variable as to degree. The 
1 Transactions of the Association of American Physicians, 1898, xiii, 300. 860 
DISEASES OF THE URINARY SYSTEM 
so-called " lymphomatous nephritis" is of a somewhat similar nature, 
and is seen, for example, in the kidneys of typhoid fever. 
The changes in organs other than the kidney are often those of the 
primary disease, e. g., an acute infection. Dropsical conditions may be 
found, or there may be lesions of some complicating affection such 
as pericarditis or pleuritis. In cases of acute nephritis lasting over a 
few weeks hypertrophy of the left ventricle can sometimes be made 
out. Henschen1 and his pupils have shown this to be true in a number 
of instances. 
Symptoms.-From the clinical point of view there are two types of 
acute nephritis. The one is characterized by an abrupt, frank onset, 
with oedema, pallor, headache, and gastric disturbance, and by such 
scantiness of urine and change in color from admixture of blood as 
commonly to attract the attention even of the patient or the nurse to 
the fact that there is something wrong. The second type is less frank 
in its manifestations. Although the onset may be sudden there is no 
marked oedema or pallor of the skin, there is no complaint of headache, 
no nausea or vomiting, and the urinary change is only revealed by a 
close watching of the amount of urine and by its chemical and microscopic 
study. Scarlatinal nephritis may serve as typical of the first class; the 
acute nephritis occurring during the course of typhoid fever or pneumonia 
is fairly typical of the second class. 
The frank form, as has been said, is the one met with in scarlet fever. 
In many of the acute infectious diseases, especially when accompanied 
by high fever, a trace of albumin with a few casts can frequently be 
found in the urine. This is true of scarlet fever. As the fever subsides 
the casts and albumin disappear and the urine is practically normal. 
This is the so-called febrile albuminuria. The true scarlatinal nephritis 
is more apt to occur during convalescence. In some cases there has been 
no relaxation of the vigilant care on the part of nurse or physician; the 
patient is still in bed, still on restricted diet, and an apparently favor- 
able convalescence is rudely interrupted by the renal disease. Although 
it is, perhaps, more apt to appear following the severer attacks of scarlet 
fever, it is not infrequently seen after mild, even ambulatory, cases. 
While there are many deviations from the type, as here described, 
it may be said that the three striking features, at least the three features 
that are most prominent early in the disease, are oedema, uremic mani- 
festations-especially headache, drowsiness, and disturbance of the 
stomach-and the marked change in the urine. 
The oedema may come on with remarkable rapidity. The child's face 
in the morning may be seen to be puffy, the eyelids swollen, these appear- 
ances, with the obliteration of the wrinkles, the pallid, pasty color, and 
the watery eye, causing a peculiar apathetic, expressionless look that is 
quite characteristic. The same oedematous condition may be found on 
the back of the hands, over the lumbar vertebra? and sacrum, constituting 
the "lumbar pad," and in the loose scrotal tissue. The oedema at first 
may be rather firm and does not pit readily. This oedema may never 
1 Das Herz bei Nephritis, Jena, 1898. 861 
ACUTE NEPHRITIS 
become extreme, although in some instances it progresses and dropsical 
accumulations are found not only in all the subcutaneous tissues but 
in the peritoneal, pericardial, and pleural cavities as well. 
While dropsy in acute scarlatinal nephritis is usually quite general, 
it is sometimes capriciously fugitive, shifting for no assignable reason 
from one part of the body to another. It will often show a tendency to 
shift with the position of the patient, and be most marked in the depend- 
ent portions of the body. In patients in bed it can often be detected 
over the lower back, when not noticeable in the extremities. In certain 
rare instances the fluid collects in the serous cavities to a much more 
marked degree than in the subcutaneous cellular tissue. Cases of oedema 
without albuminuria, following scarlet fever, are occasionally seen. 
They were early described by Hamilton, Phillipp, Goodak, Henoch, 
Bartels, and later by several others, but the correctness of the observa- 
tions of Phillipp1 of a remarkable series of sixty such cases may be justly 
questioned. One such case has come under personal observation. Most 
of these cases resemble nephritis in all respects, although without the 
ordinary urinary accompaniments. Albumin and casts, in some instances, 
have appeared later. Autopsies in some have shown an underlying 
condition of nephritis.2 (Edema may exceptionally appear before 
albumin; casts (Rosenstein) and blood (Mahomed) may precede the 
albumin, while in other cases albumin may be present many days before 
oedema is noticeable. 
This fluid interferes more or less with the functions of various organs, 
e. g., of the stomach and intestine, whose walls may be cedematous, or 
of the lungs, as when the abdominal and pleural cavities contain much 
of the transudate and the free play of the lungs is interfered with by 
the pressure of the surrounding fluid. (Edema of the glottis, fortunately 
comparatively rare, may be serious or even fatal. (Edema of the uvula 
may be annoying and extremely alarming to the patient. Some of the 
cerebral symptoms, such as headache and apathy, may be in part 
explained by cerebral oedema. 
The urine is scanty. A few ounces only may be passed in twenty-four 
hours, and complete suppression may occur. There may, however, be 
a frequent desire to urinate and a somewhat painful vesical tenesmus 
may be present, only a few drops being squeezed out with each effort. 
Suppression may continue for many hours, and yet recovery be possible. 
The writer has known anuria to last sixty hours, in the case of a child 
who ultimately recovered. Rosenstein saw anuria of three days, Riegel 
of ten. The urine that is passed is turbid, smoky, reddish, brownish, or 
flesh-colored, usually acid, and deposits a heavy sediment. If the urine 
be alkaline, a relatively small amount of blood gives it a bright red color 
(Tyson). The specific gravity of the concentrated urine is at first high, 
often over 1.020 or even 1.030. There are, however, many exceptions to 
this rule. Albumin is present in large amount, even to 1 per cent., or, 
in rare instances, more. The daily loss seldom exceeds 20 grams, although 
Dickinson sets 35 grams as the limit. The percentage of solids, urea, 
1 Cited by Frerichs. 
2 Cf. Henoch, Berl. klin. Woch., 1873, No. 50. 862 
DISEASES OF THE URINARY SYSTEM 
chlorides, phosphates, is increased, although the total output for twenty- 
four hours, owing to the scantiness of the urine, is less than normal. 
Bartels noted, what has lately attracted much attention in connection 
with the dechloridation treatment of nephritis, that the chlorides were 
diminished, especially in cases attended by dropsy. Accurate clinical 
observation is needed along the lines laid down by Schlayer and Takayasu1 
who found striking differences in the elimination of different solids to 
depend upon the portion of the kidney affected in experimentally induced 
nephritis. Thus extensive tubular damage interfered with the elimination 
of sodium chloride and potassium iodide; lactose elimination, however, 
was affected by vascular damage. 
The microscope shows that the sediment is made up largely of red 
blood corpuscles, epithelium, casts, uric acid crystals, and amorphous 
urates. The red cells may be well preserved or broken down into a 
reddish-brown, granular detritus. Shadow corpuscles are numerous. 
White corpuscles and, as Senator has shown, many of the mononuclear 
type are seen. Epithelial cells are abundant and casts of various kinds 
are found. At first blood casts and epithelial casts are especially numer- 
ous, but soon hyaline and granular forms are seen, and fatty casts, 
as well as waxy casts, may be met. No one form can be regarded as 
characteristic of an acute inflammation. While casts in the albuminous 
urine of acute nephritis may perhaps be lacking in rare instances, care 
should be exercised in making such a statement, for often the absence 
of casts is to be explained by the early decomposition of the urine, 
especially if collected in an unclean receptacle in hot weather. The 
destructive digestive action upon casts of alkaline urine, and particularly 
of alkaline urine full of bacteria, should be remembered before one declares 
that the urine of a patient is free from casts. Cases without casts are, 
however, occasionally recorded, as by Dickinson. 
The molecular concentration of the urine is increased, as is its electric 
conductivity. The freezing-point is, therefore, lower than normal. The 
freezing-point of the urine, however, is subject to wide variations. There 
is retention of solids, e. g., urea, phosphates, and chlorides, and this 
retention, especially of salts like the chlorides, should bring the freezing- 
point nearer 0° C., as it sometimes does. But there may be such con- 
centration of the urine, owing to deficiency of water, that the freezing- 
point may be lower than normal, i. e., it may be below -2.3° C. A 
frequent phenomenon in disease of the kidney is the inability to pass 
a concentrated urine. The passage of an abnormally dilute urine occurs, 
constituting the hyposthenuria of Friedrich Muller.2 Hyposthenuria 
is seen not alone in chronic interstitial nephritis but also in acuter forms, 
especially when there is glomerular involvement, as in the form under 
consideration. Unless hyposthenuria be counteracted by polyuria, 
renal insufficiency must result. This condition is often seen early in 
acute nephritis, and although the urine is diminished in amount, yet it 
may contain but a small amount of solids, be of low specific gravity, 
1 Deut. Arch. f. klin. Med., 1910, xcviii, 17. 
2 Loc. cit., p. 71. Cf. also, for a discussion of hyposthenuria and polyuria in acute 
experimental nephritis, the article cited by Schlayer and Takayasu. ACUTE NEPHRITIS 
863 
and have a freezing-point nearly that of the blood. Slow and deficient 
elimination will be shown by the phenolsulphonephthalein test. 
After what may be called the initial shock of the disease, the nrine 
becomes somewhat more abundant, less dark and smoky in color, its 
percentage of albumin less, and the casts more varied in their character. 
One of the earliest signs of recovery is an increased output of urine. 
Especially if oedema has been extreme and there is a rapid subsidence 
of it, the amount of urine as convalescence is established may be excessive 
and the specific gravity as low as 1.010 or 1.005. Dickinson reports 
having seen 240 ounces in twenty-four hours. The albumin and casts 
gradually disappear, although spasmodic outbursts of albuminuria 
and cylindruria may be noted, often for weeks. Ernberg,1 discussing 
this postnephritic albuminuria as seen in children, is inclined to regard 
it as generally benignant and not necessarily an indication of a beginning 
chronic nephritis. Red-blood corpuscles may be found at times long 
after the albumin has finally disappeared (Rosenstein). 
Many of the symptoms that are now to be described are clearly of 
toxic, i. e., uremic origin. Nausea and vomiting are fairly common 
symptoms. They are at times so nearly coincident with the retention 
of urine and the albuminuria as to make one think of the existence of a 
toxin producing at the same time the lesion in the kidney and the dis- 
turbance of the stomach, perhaps through its nervous mechanism rather 
than a retention toxemia through faulty elimination attending urinary 
suppression. In other cases-in most cases-there is a rather close 
relation between the amount of urine secreted and the severity of the 
gastric disturbance. Within the first few days, when perhaps less than 
five or six ounces are passed, there is complete anorexia, nausea, and 
prompt rejection of food, drink, or medicine that may be put into the 
stomach. The tongue becomes coated and dry; stomatitis and gingivitis 
resembling that of scurvy have been described. There is a fetid odor 
to the breath, at times suggestive of urine. This urinous odor may be 
detected in the vomitus. The bowels may be constipated or loose, 
diarrhoea being oftener a late than an early manifestation. Vicarious 
elimination through the stomach and bowel is regarded by many as an 
explanation of the vomiting and the diarrhoea. 
There is rarely much fever. Occasionally an initial chill or chilliness 
will be followed by quite a sharp rise to 102°, or even more. Oftener 
the temperature even at the onset will be less than 100°, or even normal. 
It is not correct, however, to regard acute nephritis as an afebrile disease, 
for, in many cases, careful observations will show a slight rise. The 
fever rarely lasts more than a few days, unless inflammatory complica- 
tions or uremic convulsions with coma occur. Leube2 saw no case of 
nephritis with fever during an entire decade, and then saw several in 
succession that were febrile. 
The pulse increases in rapidity and often even quite early has a hard, 
high-tension quality,, showing a rise in blood-pressure. In other cases 
a slow pulse may be present. In fact, some regard bradycardia 
1 Nord. Med. Arkiv, 1911, Abt. ii. 
2 Diagnostik der inneren Krankheiten, 1895, i, 322 864 
DISEASES OF THE URINARY SYSTEM 
as quite characteristic of acute nephritis. Often even by the end 
of a month a definite enlargement of the left ventricle can be made 
out, and with the loudness of the first apical tone and the sharpness of 
the aortic second, make it clear that the vascular tension is high, a fact 
readily confirmed by the sphygmomanometer. Dilatation may occur 
at any time. These cardiovascular changes, however, are not to be 
detected in all cases, although a sharp aortic closure is common. As 
convalescence ensues, the pulse may become quite slow and intermittent 
or even irregular. Permanent cardiac derangement after acute nephritis 
is rare, unless infectious cardiac complications have occurred. Occa- 
sionally one sees a moderately hypertrophied heart in adult life, when 
from the history one would suspect an acute nephritic origin. 
The skin is dry and if oedema is excessive may be glossy and look 
unnaturally thin and transparent. Pruritus may lead to scratching and 
infection. Papular and erythematous eruptions sometimes occur, pre- 
sumably to be classed under the head of the toxic dermatoses. A few 
times with uremia a white frost-like deposit of urea has appeared on 
the skin. 
The blood is that of secondary anemia, the reduction in hemoglobin 
being more marked than that of the red corpuscles. The pallid, pasty 
appearance of acute nephritis is due in part to a genuine loss in eryth- 
rocytes and hemoglobin, and also to a thinning of the blood in the 
vessels due to hydremia, and to the spreading out of the capillary 
vessels over an increased area, caused by the oedematous swelling. 
The molecular concentration tends to be increased, but there are great 
modifications of this rule. An increase of oedema or of anemia gener- 
ally lessens the molecular concentration of the blood, and the freezing- 
point under these circumstances may be normal, -0.54° C. or even less 
than this, e. g., -0.56° C. 
Hemorrhages are relatively rare in acute nephritis, although nosebleed 
is sometimes seen and occasionally hemorrhages in the retina are noted. 
In the cases with purpuric manifestations, the renal condition appears 
to be secondary, the purpuric lesions or the erythematous nodes distinctly 
antedating the albuminuria. 
Respiratory symptoms are usually due to a bronchitis or to oedema of 
the lungs and bronchi. (Edema of the lungs in nephritis is, however,- 
quite often cardiac in its origin, although primarily to be ascribed to 
the kidney. The combination of bronchitis and pulmonary oedema may 
result in what has been termed "serous pneumonia." True lobar pneu- 
monia is rare as a complication, bronchopneumonia somewhat more 
frequent. Dyspnoea may be uremic or cardiac in origin, due to the exten- 
sive bronchitis and oedema, or may be caused by the pressure of accumu- 
lations of fluid in the pericardial, pleural or peritoneal sacs. True inter- 
current pleurisy is not so very rare. Cheyne-Stokes breathing is often 
a manifestation of uremia. Attacks of dyspnoea are apparently at times 
uremic or at times cardiac in character. . 
Headache is frequently an early evidence of nephritis. As uremic 
intoxication becomes more pronounced, it may be a most distressing, 
almost unbearable, condition. Dizziness and tinnitus mav. be other ACUTE NEPHRITIS 
865 
manifestations. Not a few patients grow apathetic, drowsy, even 
stuporous or comatose, without convulsions. The mind may be clouded 
and delirium of a low and muttering type or of a wilder character may 
manifest itself. Amaurosis, palsies and uremic deafness and retinitis 
are rare as compared to their frequency in chronic interstitial 
nephritis. 
Convulsions rarely occur until the nephritis has lasted for several days 
or weeks. They are of the epileptiform character, and are usually 
preceded and in a sense heralded by severe headache, vomiting, 
epigastric pain, with increase in pulse tension, and perhaps muscular 
twitchings. Coma may follow the attack, and is particularly apt to 
supervene on several attacks that follow one another in rapid succession. 
In some cases the torpor and drowsiness may pass into a coma, perhaps 
fatal, without there being any convulsion. These cases are more often 
those in which an early nearly complete suppression of urine has occurred. 
They resemble in some respects the toxemia of anuria as seen in cases 
of several weeks' standing1 rather than that of true uremia. 
General malaise, with more or less aching in the limbs, is apt to be 
present, particularly when there is much fever at the beginning. There 
is often pain in the back, of a dull aching character. At times it may 
be severe enough to justify Basham's description of an "urgent aching 
pain across the loins." Rayer's observation that he had never in acute 
nephritis seen a retraction of the testicle or the radiation of pain along 
the ureters has been generally confirmed. Even the passage of blood in 
the shape of clots is so rare that pain from this cause partaking of the 
character of ureteral colicky pain is almost never noticed. There may 
be some tenderness on pressure in the loins over the region of the 
kidney. Vesical tenesmus with some slight urethral burning during 
micturition may be annoying, but is seldom very painful. Concentration 
of the urine may explain in part the frequent and burning micturition. 
There is sometimes complaint of pain in the epigastrium, aside from the 
discomfort attending the nausea and vomiting. 
Nephritis from Cold; Nephritis a Frigore.-NAoAe one can hardly agree 
with Rayer or Stewart when they say that the most common cause of 
inflammation of the kidney is exposure to cold and wet, one must admit 
that at times a very definite influence of cold is seen in producing acute 
Bright's disease. Lassar's experiments on lower animals seem to show 
the positive influence of cold in this direction. It is apparently not so 
much cold alone as prolonged or repeated exposure to cold and wet, 
coupled with exhaustion, starvation, and the excessive use of alcohol. 
Clinically, nephritis of this type resembles very closely the type seen 
in scarlet fever. The onset is usually abrupt, the oedema frankly gen- 
eralized and the urine rich in albumin, casts, and blood. Chilliness, 
with some rise of temperature, may be present, and there is a dull pain 
in the loins. Uremic headache, apathy, nausea, convulsions, or coma 
may or may not be pronounced. Some of the cases are more insidious 
in onset, and in their long-drawn-out course might be classed as subacute 
1 For a good discussion of the differences between uremic and anuric intoxication 
phenomena, see Ascoli, Die Uraemic, 1903, p. 144, et seq. 866 
DISEASES OF THE URINARY SYSTEM 
or even be said to merge imperceptibly into the chronic parenchymatous 
form. Recovery from acute nephritis due to cold is the rule, although it 
is often a matter of many weeks or even months. Bartels saw a recovery 
after a duration of one year. 
Alocholic excess is a factor in the production of both acute and chronic 
nephritis. Strumpell describes cases as occurring in the heavy beer 
drinkers of Bavaria, particularly in the obese and after exposure to cold. 
The oedema in these cases was pronounced, and made its appearance 
rapidly; the urine was scanty and heavily albuminous, while casts were 
plentiful; blood was absent, and the urine was not smoky or even turbid. 
In the instances in which alcohol appears to be the exciting cause there 
is commonly a history of a definite, usually prolonged period of excessive 
drinking rather than of habitual indulgence; or some debilitating con- 
dition, such as tuberculosis, heart disease, or anemia, has already been 
present. The onset is often rather insidious than outspokenly active, 
and the course of the disease borders on the subacute or chronic paren- 
chymatous, the cardiovascular changes not being a striking feature. 
Many of the cases of excessive albuminuria and cylindruria accompany- 
ing acute alcoholism seen by the writer have been, as shown by the 
subsequent history, acute exacerbations of a chronic nephritis rather 
than a true primary acute inflammation. 
In many of the infectious diseases, as has been said, there is a form 
of nephritis differing in its clinical behavior from that met with in scarlet 
fever. The difference is seen in the more insidious onset, the lack of 
oedema or its comparatively slow and only slight development, in the 
absence of pronounced headache, nausea, and vomiting, and in the 
rarity of marked hematuria and scantiness of urine. In many of these 
cases, too, the symptoms of nephritis are lost in those of the primary 
disease that is still at its height, and they do not stand out prominently 
against the background of symptomless convalescence as in scarlet 
fever. It is possible that in the future clinical features characteristic 
of acute nephritis due to different infectious agents will be recognizable. 
As yet only the composite picture is known. The diagnosis depends 
almost entirely on the examination of the urine, which should always 
be made at the beginning of every infectious disease as well as at frequent 
intervals later. Febrile albuminuria and exacerbations of a chronic 
nephritis are to be excluded. Absence of oedema by no means rides 
out nephritis. The possibility that the nephritis is really due to drugs, 
cold or other infectious organisms than the one involved in the primary 
illness should also be kept in mind. 
In nearly every known infectious disease acute nephritis has been 
observed as a complication. Among these may be mentioned diphtheria, 
lobar pneumonia, influenza, typhus fever, smallpox, varicella, measles, 
erysipelas, rheumatic fever, septicemia. The purpuras not infrequently 
show nephritis, often with oedema. Ulcerative endocarditis, which is 
really a sepsis, often shows a sharp, virulent, acute nephritis which is 
sometimes clearly embolic in origin. With pulmonary tuberculosis 
nephritis of an acute or subacute type, with or without oedema, is not 
unusual. In the nephritis accompanying tuberculosis the heart is ACUTE NEPHRITIS 
867 
normal in nearly all cases.1 The relation of syphilis to nephritis has 
already been discussed. In malarial nephritis oedema is common and 
it may be present in the influenzal form. 
By this form of acute nephritis is meant something different from the 
so-called febrile albuminuria that is so commonly seen in most acute 
infections. This trace of albumin with an occasional cast or red-blood 
corpuscle is without accompanying clinical symptoms that can rightly 
be ascribed to renal change. While some anatomists regard the acute 
degeneration causing this as inflammatory, a sharp line must be drawn 
between this condition, coincident with the fever, and the nephritic 
form that may occur either at a time when the fever is present or has 
passed. This latter form is accompanied by symptoms due to defec- 
tive renal function, and by characteristic urinary findings; its existence 
usually long outlasts the duration of the primary specific infectious 
disease. 
In typhoid fever, acute nephritis may be an early occurrence, constituting 
the so-called renal typhoid. More commonly it occurs during the height 
of the fever or just as convalescence seems in sight. There is rarely any 
appreciable increase in temperature, complaint of pain on the part of 
the patient, or oedema. It is only by the frequent routine examination 
of the urine that the existence of the complication is recognized. Albumin 
and casts are abundant; blood is present in varying quantities. These 
urinary findings may last for from several days to many months. In 
such cases the outlook for recovery is generally fairly good, although 
there is not only the original disease but the added danger of uremia 
and such complications as pneumonia or serositis. 
In Asiatic cholera there is oliguria. In severer cases there is anuria 
w'hich may last for hours or days. What urine is passed is concentrated 
and contains an abundance of renal epithelial cells in various stages of 
degeneration, and often some albumin and a few casts. In some cases 
of cholera the urine is heavily albuminous and contains large numbers 
of casts, red-blood corpuscles, epithelial cells and debris. Indican and 
diacetic acid may be present. This form of nephritis is believed to be 
a strong contributory factor in the causation of the headache, convulsions, 
coma, and death that often follow at the end of a few days. Dropsy is 
rare. Recovery after anuria of seven days is exceptional. 
Bamberger, Litten, Aufrecht, and others have described a primary 
acute nephritis. Strumpell also refers to it. It is frank in onset, with 
chilliness, some fever, pain in the back or in the extremities, headache, 
nausea, and oedema. The spleen is said fit times to be enlarged. The 
urine is scanty and contains albumin, casts, and blood. After days or 
weeks recovery usually ensues, although occasionally death or a chronic 
form of nephritis results. For this so-called primary or idiopathic 
nephritis no cause is discoverable. Presumably some unrecognized 
infection or intoxication will explain the majority of the cases. 
The Kidney of Pregnancy.-During pregnancy renal changes are often 
met with that are accompanied, as a rule, by abnormal urinary findings, 
1 Walsh, in Third Annual Report of the Henry Phipps Institute, 1905-06, p. 357. 
Senator and Muller find the same lack of cardiac hypertrophy. 868 
DISEASES OF THE URINARY SYSTEM 
and at times by recognizable clinical symptoms. These lesions of the 
kidney, because of certain anatomical peculiarities, of the uncertainty 
as to their inflammatory nature, and because of the atypical accompany- 
ing clinical manifestations, are not generally classed as nephritic. The 
tendency to-day is to speak of this kidney as the "kidney of pregnancy." 
It is to be remembered that an already existing, although previously 
unsuspected, nephritis is liable to become aggravated under the influence 
of pregnancy. These instances of true nephritis with or without uremia 
are not to be classed with the so-called kidney of pregnancy. 
The explanations offered for the origin of the kidney of pregnancy are 
varied and in a measure largely speculative. They may be conveniently 
classed as (a) bacterial; (6) mechanical, i. e., pressure; (c) toxic; (d) a 
combination of these three causes. 
No proof that bacteria play the primary role has been advanced. 
Pressure upon the ureter, renal vessels or even the kidney1 itself during 
pregnancy or even, as Webster2 suggests, by the plugging of the pelvic 
opening for two or three days postpartum by the still large uterus, 
may explain certain renal changes. But the toxic theory first brought 
prominently forward by Virchow,3 in 1848, is worthy of the greater con- 
sideration. The present view is, however, that the toxemia is general, 
not essentially renal. Thrombotic, hemorrhagic and necrotic lesions in 
the liver may be as characteristic as the degenerative changes in the 
kidney. Puerperal eclampsia has been seen without renal disease. The 
toxin is unknown. It results in faulty protein metabolism. 
The clinical manifestations vary from a trace of albumin with a few 
casts in the urine, but no subjective symptoms of toxemia-a condition 
that is regarded by many as rather physiological than pathological, 
especially in the last weeks of pregnancy-to a heavily albuminous 
urine, containing casts and blood, and subjective symptoms suggestive 
of most profound toxemia, and culminating oftentimes in an eclamptic 
explosion. The urine, when this condition is at all advanced, is usually 
somewhat scanty, turbid, the specific gravity averaging higher than 
normal. Albumin is present and may be excessive in amount. Casts 
generally of the hyaline or granular varieties are present, as well as some 
red-blood corpuscles, a few leukocytes, and renal epithelium in various 
stages of degeneration. Ammonia is often high, the urea low, a point 
of some value in differentiating from a true nephritis. 
(Edema is common not only in the dependent portions of the body, 
as the legs, where pressure on the return circulation might in a measure 
account for it, but in the face", the hands, the back. Sometimes a pallor 
gives the patient the pasty look seen in typical cases of parenchymatous 
nephritis. Symptoms of toxemia are more or less pronounced and 
resemble those commonly described as uremic. Among these may be 
mentioned headache, dizziness, sleeplessness, apathy, dimness of vision 
amounting at times to amaurosis, nausea and vomiting, epigastric 
uneasiness or even severe pain, unusual dyspnoea, perhaps diarrhoea 
1 Halbertsma, Centralbl. f. d. med. Wissenschaft, 1871, No. 27. 
2 Text-book of Obstetrics, p. 314. 
3 Gesamte Abhandlungen, 1856, p. 778. ACUTE NEPHRITIS 
869 
or obstinate constipation. These may be the forerunners of an epilepti- 
form seizure, occurring in the later months of pregnancy, during labor, 
or in the first few days thereafter. If the attack passes away, recovery 
may ensue promptly, the urine clearing rapidly. 
The diagnosis of the kidney of pregnancy is usually a simple matter 
if the physician has knowledge of the condition of the urine at the 
beginning of pregnancy. Otherwise, he must consider whether he is 
dealing with a renal congestion, a chronic nephritis with the added 
element of congestion, or an acute nephritis. A positive diagnosis is 
at times impossible. Simple congestion rarely gives the large amount 
of albumin found in the urine of the kidney of pregnancy, nor does it 
cause the generalized oedema or the marked toxic symptoms of that 
condition. Of great help in the diagnosis of an old nephritis is the 
finding of typical cardiovascular changes or albuminuric retinitis, as well 
as a history of polyuria before pregnancy. It may be impossible to 
differentiate acute nephritis from the kidney of pregnancy, although 
especially liable to have more blood and more casts and to be attributa- 
ble to some acute infectious process. The urine in either the acute 
or chronic nephritis will not, of course, clear up as promptly on empty- 
ing the uterus, as in the case of the kidney of pregnancy, nor do the 
toxic symptoms subside as rapidly. The prognosis, except when 
eclampsia occurs, is not serious. If eclampsia occurs, the mortality 
of the mother is about 25 per cent.; for the child still greater. 
The treatment of the kidney of pregnancy and the nature and treatment 
of puerperal eclampsia are matters for discussion in a text-book on 
obstetrics, yet a brief word may be here said on the subject of therapy. 
Too great caution cannot be observed in watching for the appearance 
of albumin and casts in the urine of the pregnant woman, and for the 
occurrence of oedema of the face and hands, headache, unusual dizziness, 
blindness, epigastric pain, etc. These things should be viewed with 
suspicion, as possibly indicating the existence of the kidney of pregnancy 
with impending eclampsia. Special care should be exercised in the 
case of the woman who may have had eclampsia in some previous preg- 
nancy. It is to be remembered, too, that eclamptic seizures have 
occurred in the non-albuminuric pregnant woman, so that the toxemic 
symptoms should be regarded as notes of warning. For the eclampsia, 
sedatives, such as bromides, chloral, and chloroform, should be employed; 
bleeding may be of benefit, and saline infusions may help to dilute and 
wash out the toxin. Fischer's1 treatment by hypertonic solution of 
sodium chloride and sodium carbonate may here be of benefit; 1000 cc. 
of water containing 15 grams of sodium chloride and 20 grams of crystal- 
lized sodium carbonate are injected intravenously; the solution may be 
given per rectum. The uterus should be promptly emptied. 
In general, the treatment of the kidney of pregnancy is that of acute 
nephritis; the same hygienic and dietetic precautions, the avoidance of 
overexertion, a goodly amount of rest, daily warm baths, and as free 
elimination as possible through the bowel, skin, and kidney. 
1 Fischer, loc. cit. 870 
DISEASES OF THE URINARY SYSTEM 
Complications.-Among these must be mentioned bronchitis, which 
may lead to a bronchopneumonia. True croupous pneumonia is not 
so very uncommon, and its course is apt to be rapid. It may be readily 
overlooked, unless careful physical examination be made, for bronchial 
cough, dyspnoea from uremia or from cardiac causes, or perhaps from 
hydrothorax, may obscure symptoms by offering a plausible explanation 
for respiratory manifestations otherwise quickly attracting attention 
as possibly indicative of pneumonia. (Edema of the chest wall, fluid in 
the pleural sacs or pericardium, and bronchial rales often make physical 
exploration for pneumonic consolidation quite difficult. The upper lobe 
is said to be very frequently the one involved in acute nephritis. By 
some a form regarded as a 'Tobar non-croupous pneumonia," a serous 
pneumonia (Fiirbringer), is to be distinguished from the ordinary compli- 
cating croupous pneumonia. While one is seldom in doubt as to which 
disease is the primary one, occasionally when the early history of the 
case is lacking, as often happens in hospital practice, the question as to 
whether a pneumonia has given rise to an acute nephritis or the nephritis 
has been complicated by a pneumonia, is not an easy one to decide. 
The great frequency with which the pleura, pericardium, and peri- 
toneum show inflammation during acute nephritis is well known. Daily 
examination is necessary in order to detect these complications, and 
even slight pain and tenderness should receive careful consideration. 
Other complications or intercurrent troubles may, of course, occur, such 
as meningitis or erysipelas. (Edema of the glottis is a serious mani- 
festation which might be classed as a complication. 
Diagnosis.-The diagnosis of acute nephritis presents little difficulty 
if the physician is familiar with the condition of the patient before the 
onset of the renal disease; the sudden appearance of the characteristic 
urinary findings leaves little doubt as to the nature of the trouble. When 
one has no knowledge of the previous condition of the kidney there may 
be a question as to diagnosis. Among the conditions most liable to 
cause confusion are cyclic albuminuria, febrile albuminuria, congestion, 
acute exacerbation of a chronic nephritis, chronic parenchymatous 
nephritis, amyloid kidney, infarct, and more rarely such conditions as 
tuberculosis, tumors, calculus, pyelitis, etc. The main points in the 
differentiation may be briefly stated as follows: 
Cyclic albuminuria, or the albuminuria of adolescence, is seen in the 
young, unaccompanied by oedema, cardiovascular changes, or uremia. 
The urine shows no blood, only occasionally casts; the albumin is not 
constant, is usually rather small in amount, and is especially apt to be 
noted after a heavy meal, after exertion, or after the patient has been 
on his feet for a time (orthostatic albuminuria). 
Febrile albuminuria is seen during the acute infections accompanied 
by fever. The albumin is but a trace; casts and blood are not abundant; 
there is no oedema or uremia. No increase in blood-pressure that can 
be attributed to renal disease is made out. There are cases, however, 
as has been said, in which it is difficult to draw a sharp line between a 
marked febrile albuminuria and a mild grade of acute nephritis. 
In congestion of the kidney a cause is seen as in a non-compensated ACUTE NEPHRITIS 
871 
cardiac disease or other condition lowering arterial pressure. Dyspnoea, 
congestion of the liver, and oedema of the lower extremities, with other 
evidences of cardiac incompetence, may show the existence of such a 
cause. The general anasarca of nephritis involving face, hands, etc., 
is not present. The urine is concentrated, but contains what for acute 
nephritis would be a small amount of albumin and a small number of 
casts. The therapeutic test is often of great value; rest in bed with 
treatment directed to the cause, e. g., the heart, if successful will result 
in a prompt return to normal conditions in the urine. 
Chronic parenchymatous nephritis and the acute form run imperceptibly 
into each other. Unless we know the definite history from the beginning, 
showing an abrupt onset, a causal relation to an acute infection or acute 
intoxication, the early urinary suppression, hematuria, etc., a definite 
differential diagnosis may be impossible until careful watching and time 
enable one to determine the chronic character of the disease. 
A condition that is very common and one that frequently causes 
confusion as to diagnosis is a chronic diffuse or interstitial nephritis, 
on which there is engrafted an acute inflammation. The existence of 
the chronic trouble may have been unknown to either patient or physi- 
cian. The acute onset, oedema, headache, nausea, etc., call attention 
to the kidney, and the urine, richly albuminous and containing numerous 
casts and blood-corpuscles, resembles that of an acute nephritis. Sus- 
picion as to the previous existence of a chronic disease should be aroused 
by a history of polyuria-especially nocturnal-headache, dyspnoea, 
gastric disturbances, etc. When on examination typical cardiovascular 
changes are found, more marked than could be accounted for by an acute 
nephritis of only a few days' duration, or when an old albuminuric 
retinitis is found, there is strong ground for believing that the acute 
process has been lighted up on the basis of an old affair. It often happens, 
too, in cases of this kind, that a study of the twenty-four hours' urine 
will show an amount somewhat above the normal, a specific gravity a 
little low-say 1.012-while the albumin, blood, and casts are abundant. 
Prognosis and Termination.-Acute nephritis is always a serious 
disease. Yet it has a natural tendency toward recovery, and in the 
great majority of cases-the exact percentage it is impossible to state-a 
recovery ensues that seems to indicate a complete restoration of function 
on the part of the kidney, although some are inclined to look upon such 
a kidney as thereafter peculiarly vulnerable and especially liable to be 
again involved in a recurring inflammation. Early relapses or, more 
strictly, exacerbations of the acute nephritis are not so unusual, and 
should make one guarded in his statements as to outcome until the 
urinary and other evidences of the disease are well out of the way. 
The length of time that must ensue before recovery occurs varies greatly. 
One month is a short time. Yet even after six months, a year, or excep- 
tionally even longer, recovery may take place. 
Aside from recovery, a pseudorecovery is occasionally seen, viz., the 
passage of the acute into the chronic form without oedema. Rayer1 
1 Traite des Maladies des Reins, 1839, vol. ii, p. 112. 872 
DISEASES OF THE URINARY SYSTEM 
gives a very graphic description of these cases of supposed recovery 
which lull the unsuspecting patient and the easy-going physician into 
a false feeling of security, and which in later years show evidence of 
the long-standing existence of the renal disease that has been overlooked. 
Death in acute nephritis may occur in a variety of ways. Uremia 
is a common cause, with convulsions or coma, or perhaps indirectly 
through the exhaustion it brings about by loss of sleep, anorexia, vom- 
iting, diarrhoea, anemia, etc. In some instances there is an abrupt, 
nearly complete or quite complete suppression of urine. This may last 
for a few days without serious consequences, but unless the urinary 
elimination be reestablished, death from anuria follows, and this 
happens in a certain proportion of cases. The complications already 
mentioned may be the cause of death. Dickinson says that, while 
in those over sixteen uremia is the common cause of death, in those 
under this age in 50 per cent, it is inflammation of the respiratory tract, 
uremia taking second place. (Edema may contribute largely to bring 
about the fatal result. Cerebral hemorrhage is rare as compared to its 
frequency in the chronic forms. Occasionally an acute anemia from 
severe nosebleed, or hemorrhage from the stomach or bowel, will have 
a decided influence. Cardiac weakness and dilatation, sometimes 
sudden, may also be fatal. And, as stated, death may be long deferred 
and occur as the result of the secondary chronic form of the disease. 
No definite data as to how to make a prognosis in a given case can be 
given. Some help may come, at least in predicting uremia, from a 
cryoscopic study of the urine and blood, as well as from watching for 
a rise in blood-pressure which often precedes uremia. Various criteria 
on which to base a prognosis are given by different authors, but in reality 
one must judge each case on its merits and still feel, even after a careful 
weighing of all facts, that it is a very difficult and uncertain matter to 
forecast the future in acute nephritis. Bartels, for example, says that 
every case with complete suppression is fatal, but exceptions to this 
occur, as the writer can testify from personal observation. Fiirbringer 
regards the prognosis as especially bad when the urinary sediment is 
rich in lymph corpuscles. Dickinson thinks the total absence of blood 
in the urine is not a good sign, as bleeding relieves the organ. He also 
says that the majority of fatal cases die inside of six months. Other 
prognostic aids might be cited, but they are quite unreliable. 
Treatment.-Prophylaxis.-Just how much may be accomplished in 
the way of preventing acute nephritis in a given patient it is difficult 
to say. Yet undoubtedly the disease is often warded off by care in 
lessening or removing the influence of causes that are liable to produce 
acute inflammation of the kidney. Roughly speaking, the proper treat- 
ment of any acute infection may be regarded as prophylactic against 
disease of the kidney. The early and efficient use of antitoxin in diph- 
theria, or of quinine in malaria, will lessen the danger of nephritis. Simple 
sore throats deserve treatment because of the possibility of their being 
the starting-point of visceral complications, including nephritis. Recur- 
rent tonsillitis may call for removal of the tonsils. A mastoiditis or a 
pyorrhoea may require treatment. The free use of water as a diluent ACUTE NEPHRITIS 
873 
and eliminant, and attention to catharsis, may be the means of sparing 
the kidney undue irritation, and in this way may avoid nephritis. But 
knowing the remarkable tendency for this complication to appear during 
convalescence from acute disease, especially scarlet fever, not only 
should most careful attention be given the patient during the height of 
the disease but precautions as to diet, clothing, exercise, use of drugs, 
catharsis, etc,, should extend well into the period of convalescence. 
The study of 2100 cases of scarlet fever by J. McCraeMed him to confirm 
the prevailing view that scarlet fever favors the development of nephritis, 
but at the same time impressed him with the belief that care as to 
diet and prolonged rest reduced the risk. Whether Mahomed is right 
in thinking that the onset of nephritis in scarlet fever is heralded by a 
rise in blood-pressure and the appearance of blood coloring matter in the 
urine, there should be most careful daily watching, and lessened total 
output, traces of albumin, or of blood, or a few casts, should be a hint for 
unusual care. 
How far the external use of water may influence the kidneys is still 
a matter not definitely settled. Warm or tepid baths, sponge baths, or 
packs, when combined with the free drinking of water, are surely not 
harmful. The cold sponge or the bath in the treatment of typhoid 
fever is feared by some as possibly inducing congestion of the 
kidney. But unless nephritis already exists, the great advantages of 
the bath treatment of typhoid fever outweigh any hypothetical harm to 
the kidneys. As a matter of fact, when liquids are allowed freely, as 
in typhoid fever, and when the baths are properly administered, the 
amount of urine is increased and the amount of solids and toxins elimi- 
nated is also increased. And while the kidney is called upon to do this 
increased amount of work, the lessening of toxemia is one of the prime 
objects aimed at in the treatment of the infectious disease, and has a 
favorable influence in warding off nephritis. The good effect of the 
bath on the circulatory and nervous systems has indirectly a favorable 
effect on the kidney. Senator is fully convinced that bathing-even 
cold bathing in fevers, including scarlet fever-is not productive of renal 
harm. 
Drugs are sometimes used so freely as remedial agents as to induce 
nephritis. Alcohol may be given in too large amounts. Hexamethyl- 
enamin in large doses is an irritant to the urinary tract. Special 
caution is necessary in the use of salicylic acid and its compounds, 
turpentine, copaiba, carbolic acid, corrosive sublimate, chlorate of 
potassium, and other remedies mentioned under the head of Etiology. 
Some of these may be harmful through absorption from the skin. 
Lfithje's2 observations on albuminuria and cylindruria following the use 
of salicylic acid compounds are very instructive. When large doses of 
any of these drugs that are known to be irritants of the kidney are being 
given, the urine should be carefully watched, and albumin, casts or 
blood not interpreted in too offhand a manner as due to the infectious 
disease, and therefore an indication for still larger doses of the medicine 
1 Trans. Assoc. Amer. Phys., 1913, xxviii, 194. 
2 Deutsch. Arch. f. klin. Med., Ixxiv, 163. 874 
DISEASES OF THE URINARY SYSTEM 
employed, but as possibly directly connected with the therapy. It goes 
without saying that prompt and proper handling of a case of poisoning 
by such drugs as carbolic acid, chlorate of potassium, bichloride of 
mercury, etc., may prevent a serious acute nephritis. 
Active Treatment.-There is no specific for acute nephritis, no matter 
what its cause. The cardinal principles underlying the active treatment 
are: (1) The removal, when possible, of the cause. (2) Rest for the 
kidney, secured by throwing less work upon it, and by calling upon other 
organs, e. g., the skin and the bowels, to do vicariously some of the work 
of the injured organ. (3) To treat symptoms and complications. 
If the cause is remediable, as in malaria or syphilis, or when there 
has been alcoholic excess or too free use of irritating drugs, improvement 
may follow but is still uncertain; the damage to the kidney may have 
been serious, and even the removal of the cause may not be followed 
by the prompt subsidence of the renal symptoms. Yet it is the proper 
thing to do in every case. 
The patient should be kept in bed. He should be warmly covered 
and may with advantage sleep between flannel blankets or wear flannel 
or Canton flannel nightclothes. Fresh air in the sickroom is essential, 
but draughts should be avoided and the temperature of the room should 
be about 70° F. Strict adherence to the rule of rest in bed should be 
enforced until the disease has disappeared. In some of the more pro- 
longed cases, however, bed-life becomes very irksome, and some liberty 
in the way of sitting up or even of moving about may be permitted. 
This affords relief from the monotony of the recumbent posture, and 
while it may increase somewhat the amount of albumin in the urine, 
this drawback is fully compensated for by an awakening of interest on 
the part of the patient, an improvement in the appetite, better sleep, 
and better elimination. 
An important question and a very live one in each individual case 
is that of diet. No hard and fast rule can be given applying to every 
case. The food should be such as will not, when its residual metabolic 
products are eliminated, throw too great a burden on the kidneys by 
reason of amount or quality. The food, too, should be such as can be 
easily tolerated by the irritable stomach and bowels, so often met with 
in nephritis, and such that its digestion is simple and not attended by 
the formation of faulty by-products, whose absorption may be a still 
further cause of damaging the diseased kidney. The food that most 
nearly meets the requirements is milk, and this may be given during 
the entire course of the disease, at first perhaps alone, later with other 
foods. It may be said that early in the disease it is often better to give 
the stomach absolute rest for a day or two, no food being allowed unless 
the patient craves water, of which a little may be taken. In many 
cases of the scarlatinal type, the onset, as already described, is more or 
less explosive, and among the symptoms are severe nausea and vomiting. 
Milk, often even water, given at such a time merely excites attacks of 
retching, and it is worse than useless to attempt to force the patient to 
take it. It is difficult to make some parents understand this point, as 
they feel that as the child is sick, he should at once be given medicine 875 
ACUTE NEPHRITIS 
to check the disease, and plenty of food to keep up the strength. But a 
little explanation will usually enable them to see that the starvation 
for a day or two is really a kindness. 
The question of the amount of water or other fluid to be allowed an 
acute nephritic has been quite actively discussed, especially since von 
Noorden has emphasized the fact that if the inflamed kidney is to have 
rest, and if one of its functions in the elimination of water, the amount 
ingested should be restricted. The flushing-out process advocated by 
those who prescribe huge amounts of wTater he regards as unsuccessful, 
for the damaged organ refuses to eliminate the increased amount of 
water and the flushing of the tubules is not accomplished, and as illogical, 
because it asks an injured, inflamed part to do an increased amount of 
work when what it needs is a temporary rest. There is much truth in 
this view. The water, if given too freely when the kidneys are refusing 
to secrete more than four or five ounces daily, goes largely to increase 
the oedema. At first, then, water and milk, or other liquid as well, may 
with propriety be restricted to a few ounces a day. The writer has found 
it a fairly good rule to be guided largely by the thirst of the patient. A 
thirsty patient, craving water, may be given one to two quarts of fluid a 
day, provided the stomach tolerates it. The bowels, skin, and respiratory 
tract may be relied upon to take care of its elimination. The attempt 
to force a patient at this early stage to drink a gallon of water a day in 
addition to much milk is unwise. Not only will the kidney be unable to 
handle this large amount, but there is some danger that the flooding 
of the vessels may unduly strain the heart. 
Milk as an exclusive diet cannot with advantage be continued for 
too long a period; it becomes monotonous, and the amount required to 
maintain strength is something like three or four quarts daily, an amount 
that few individuals will tolerate for any great length of time. To the 
quart or quart and a half of milk may be added, therefore, cream, which 
is rich in calories; and cereals may also be taken, breakfast foods, oat- 
meal, sago, rice, farina, etc. Fruits are not injurious, baked apples, apple 
sauce, orange, lemonade, grape-fruit being relished and acting perhaps 
as diuretics as well. A diet made up largely of fatty and carbohydrate 
foods leaves less residue in the shape of solids for elimination through 
the urine.1 These foodstuffs, with but little of the proteins-possibly 
even less milk than is ordinarily prescribed-would seem to be peculiarly 
suited to cases of nephritis in which one wishes to spare the kidney 
excessive work. Not more than 80 or 90 grams of protein a day should 
be allowed, and during the acute stage less than this, say 40 or 50 grams. 
The amount contained in a quart of milk may be sufficient. Meat and 
broths should at first be forbidden. If the disease is prolonged, the 
craving for meat may become great and may with safety be satisfied 
by allowing a little meat once daily, such as a bit of bacon, chicken, 
fish, or even dark meat, like beefsteak, roast beef, or mutton. The 
prejudice against the red meats as opposed to the white has surely been 
largely unwarranted, and while it is unwise to allow a patient with acute 
1 K. N. Hanseen, Nord. Med. Ark., 1906, Abt. ii, No. 10. 876 
DISEASES OF THE URINARY SYSTEM 
nephritis large amounts of meats of any kind, later the taking of a small 
amount, even of dark meat, is permissible. Broths of various kinds 
and beef tea are better omitted until convalescence, as they are rich 
in extractives and may be injurious. Green vegetables may be taken in 
small quantities after the acute stage has passed, when bread and butter, 
toast, crackers, zwieback are allowed. 
The diet, then, at first should be milk; water is allowed in moderate 
amounts, thirst being a fair guide as to the amount, yet a total of more 
than two quarts of fluid daily being rarely exceeded. Later, in addition 
to the milk, cereals, fruits, gruels, green vegetables, and even some 
meat may be added. Rich and highly seasoned or spiced foods, fried 
and greasy foods, the sweets, such as cakes, pastries, pies, puddings, 
candy, etc., are best let alone. Salt should be reduced to a minimum, 
especially when oedema is marked. No alcoholic drink should be allowed. 
Elimination should be favored in every way; the kidneys should be 
encouraged to act, and the skin and bowels should be made the vicarious 
agents for performing some of the work usually performed by the kidney. 
Nature apparently works in this way through these channels, and also 
through the respiratory tract. Practically, we can imitate nature to a 
slight degree only in helping elimination through the respiratory tract. 
We may see that the patient is not deprived of his right to fresh air, 
which quite often, because of the overzealous efforts of attendants to 
prevent his "taking cold,'' is too rigorously shut out, and we may also 
by attention to the action of the heart and by not permitting pleural 
transudates to become too large, see that there remains no preventable 
hindrance to free respiratory action. 
The bowels should be kept open. Saline laxatives are preferable when 
they are tolerated by the stomach. A dram to one-half ounce of Epsom 
or Rochelle salts or phosphate of soda, taken in half a glass to one 
glass of water the first thing in the morning, will usually secure free 
watery movements of the bowels, and may also lower blood-pressure. 
Many of the natural or prepared saline laxative waters will answer 
equally well, e. g., Hunyadi, Rubinat, Carlsbad, etc. In other instances 
the vegetable laxatives taken at bedtime seem to work better, e. g., 
cascara, senna, or the pill of aloin, strychnine and belladonna. An 
occasional calomel purge is often very beneficial, and, especially when 
nausea is extreme, the use of calomel in often-repeated small doses (gr. 
yy to gr. gm. 0.006 to 0.03) will move the bowels and at the same time 
act helpfully in allaying the nausea. Brisker and more promptly acting 
cathartics may be required, especially when acute uremia seems impend- 
ing, and under these circumstances elaterium or elaterin (gr. to gr. 
yy, gm. 0.003 to 0.006), compound jalap powder, or even a drop or two 
of croton oil may be used. Elaterium too long continued irritates the 
stomach, and may be depressing. Enemas may prove of material help 
in keeping the bowels open, but in general in acute nephritis a little 
more thorough cleaning out of the alimentary tract is desired than that 
brought about by enemata. 
All diuretics are liable to fail in acute nephritis, as the kidneys are 
in such condition that they will not respond to any influences. Milk ACUTE NEPHRITIS 
877 
and water are among the simplest and best diuretics. Lemonade is 
also excellent, and to this may be added cream of tartar, one teaspoonful 
to the pint of lemonade, the cream of tartar being first dissolved in hot 
water, as it is poorly soluble in the cold. The lemonade thus prepared 
is taken cold or hot, as the patient prefers. If taken freely, this is diuretic 
and laxative. With a weak heart and low blood-pressure, digitalis and 
caffeine are of service in increasing the flow of urine. The citrate or 
acetate of potassium or sodium may be given in doses of from 10 to 30 
grains (gm. 0.6 to 2) to an adult, and seem to be non-irritating. Excreted 
as carbonates, they tend to alkalinize the urine and also increase its 
flow. Sodium theobromine salicylate (diuretin), in doses of 60 to 90 
grains (gm. 4 to 6) a day, is sometimes efficient, although its effects 
are often limited in acute nephritis, where the renal epithelium has 
undergone so great damage. Diuretin, like caffeine, is of special value 
when the heart is weak. Theocin, gr. iij (0.2 gm.) in a capsule, is also 
valuable. Cantharides, copaiba, cubebs, turpentine, that are sometimes 
advocated as diuretics, are far too irritating to the kidneys to be employed. 
Even gin, the household diuretic, is best avoided. And it is well not to 
push to the limit some of the simpler diuretics, such as the citrates and 
acetates, because of a possible harmful influence. Experimental work 
along this line, while inconclusive, suggests caution in the use of diuretics 
in nephritis.1 The writer has seen good diuretic results, with lessening 
of toxic symptoms, follow the use of Fischer's solution in acute nephritis. 
Due attention should be paid to the skin. Not only, as has already 
been stated, should it be kept warm, draughts and exposure to cold 
being avoided, but efforts should be made to secure free diaphoresis 
as a means of elimination. The amount of toxic material got rid of in 
this way may not be great, but there is some that escapes with the sweat. 
Patients, as a rule, express themselves as feeling better, and they have 
that appearance, and blood-pressure may be lowered. Simple lukewarm 
or hot tub baths, or, if the patient is too weak, sponge baths, are of benefit. 
A sitz bath or a good soak in a tub of hot water, followed by a rubdown 
and immediate rest in a warm bed, is often the means of promoting free 
action of the skin and also of the kidneys. If quite hot water be employed, 
it is well to keep a cool cloth to the head during the bath. If thirsty, 
the patient may take a drink of water or of lemonade. The hot bath or 
the sweat bath in nephritis must be watched. Occasionally a patient 
does badly, becomes cyanotic, feels faint, and has a feeble pulse. Such 
patients must be given a shorter bath or a lukewarm one only, or this 
plan of treatment must be given up entirely. 
Sweats are especially indicated when oedema is marked. Any procedure 
may be, legitimately employed that will induce free action of the skin 
without inducing too great weakness and without exposing the patient 
to the subsequent influence of cold. The objection to pilocarpine (gr. 
yo to gr. 0.006 to 0.01 gm.) is that it is a cardiac depressant. It will 
induce profuse diaphoresis. But an effect not desired is a profuse bron- 
chial secretion; with the weakened heart too many of the phenomena of 
1 Mosenthal and Schlayer, Deutsch. Arch. f. klin. Med., 1913, Bd. iii, p. 217. 878 
DISEASES OF THE URINARY SYSTEM 
oedema of the lungs become manifest, either for the good of the patient 
or the mental comfort of the physician. Occasionally in patients who 
sweat poorly by the external application of heat a small dose of pilo- 
carpine (gr. Ty) may be given hypodermically as an adjuvant. Large 
doses are certainly dangerous. It is to be remembered that pilocarpine 
once given differs from the ordinary means of inducing sweating, for 
its effects cannot be checked at will. With sweating by external means 
the further continuance of the diaphoretic measure can be promptly 
stopped if untoward effects are noticed. 
Various means for applying heat externally have been devised. A 
simple measure is to have the patient sit on a cane-seated chair, with a 
blanket pinned about his neck, thus making a tent covering the body 
below that point, and then to place a lighted alcohol or kerosene lamp 
beneath the chair. After a short time the body drips with sweat. Care 
must be exercised not to blister the patient and not to set fire to the 
blanket or clothing. Electric-light baths are an efficient means of 
securing the result. When patients are too weak to sit up, some means 
for sweating them in bed must be employed. 
A method easy of application is to make a tent of blankets, canvas, 
or rubber sheeting over the patient, the blankets being held up by sup- 
ports, such as half barrel-hoops. Into this tent a stovepipe of narrow 
caliber, such as any tinsmith can furnish, is conducted. This pipe, by 
an elbow, reaches nearly to the floor, and under its lower opening an 
alcohol or other light is placed. By this means the heated air is con- 
ducted into the tent in which the patient is lying, and a sweat is easily 
given. The method in vogue in the Presbyterian Hospital in Chicago 
serves admirably. The patient lies between blankets, and outside each 
blanket, the one under as well as the one above the patient, is a heavy 
rubber sheet. Hot bricks, in bags for convenience of handling, are placed 
about the patient, the blanket being so rolled that the body is protected 
from the brick by the cloth of the bag and by the thickness of the blanket. 
Alcohol is poured over the bricks and the blankets tucked in around 
the patient. A cold cloth is kept on the forehead during the sweat. A 
drink of lemonade is given before the sweat and during it, if the patient 
desires. In from twenty minutes to an hour, the length of time depending 
on the amount of sweat, the condition of the pulse, and the comfort of 
the patient, the procedure is stopped, the bricks are removed, the patient 
rubbed dry, and the damp blankets being taken away he is left on the 
warm dry sheet that has been previously arranged beneath the lower 
rubber blanket. Sweats of one kind or another may be given once or 
twice daily, or less often, depending on the degree of oedema and the 
effect on the patient. If the patient is comatose unusual care must be 
exercised not to blister or burn. 
Complications and annoying symptoms must be treated as they arise. 
Some of these, including uremia, will be discussed more fully in treating 
of chronic nephritis. The oedema may demand not only the sweats 
but puncture of the legs, paracentesis of the abdomen or of the pleura. 
(Edema of the larynx occasionally necessitates scarification or even 
tracheotomv. ACUTE NEPHRITIS 
879 
Drugs supposed to act as specifics in acute nephritis are of no benefit 
whatever, and it is useless or even harmful to give large doses of tannin, 
ergot, or methylene blue in the hope of effecting a cure. Surgery (acu- 
puncture, splitting the kidney, decapsulation, etc.) has a very limited 
field in the treatment. This will be taken up later. 
Pain over the kidney is often relieved by the hot-water bag, the 
electric pad (heat), or by mustard paste. Blistering is unnecessary. 
At times vigorous counterirritation seems to relieve not only the lumbar 
pain but an increased flow of urine is excited; the congestion of the 
kidney seems to be somewhat lessened. Severe headache occasionally 
requires bromide or even morphine. The latter drug should in general 
be used sparingly in acute nephritis, but in some instances'the effect is 
to increase the output of urine rather than to diminish it. 
After the acute stage much good may come from the use of some of 
the bitter tonics. Appetite and digestion may be much improved by 
nux vomica and hydrochloric acid. When anemia is marked, and 
especially when convalescence is delayed, iron is of great value. Some 
of the scale preparations of iron may be employed, or Bland's mass, 
or even the tincture of the chloride of iron, although this preparation 
is not always well tolerated by the stomach. It is here that Basham's 
mixture (mistura ferri et ammonii acetatis) may serve a useful purpose. 
It is not unpleasant to take, is non-irritating, and in doses of 5j to 5iv 
(4 to 15 cc.) often acts not only as a hematinic but as a diuretic. 
Cardiac stimulation may be necessary. Strychnine is here of service, 
and digitalis especially when blood-pressure begins to fail. This remedy 
as well as strophanthus and caffeine have also the effect of increasing 
the flow of urine. 
Practically nothing has been accomplished in the way of treating 
acute nephritis by specific bacterial products. Yet if microbic etiological 
factors can be definitely identified as the cause of a given case of nephritis 
there may be promise in the use of specific sera or of the so-called vaccines. 
Some measure of success will, it is to be hoped, attend the attempt in 
such cases to remove the operating microbic cause. Microbic pyelitis 
may be treated with specific serum or vaccine-and work of this kind 
has been done in this condition-and consecutive nephritis be prevented 
or ameliorated. The possible damaging effects of specific sera and 
vaccines on the kidnev are matters for careful consideration. CHAPTER XVI 
CHRONIC NEPHRITIS AND AMYLOID DISEASE OF KIDNEY 
JAMES B. HERRICK, M.D. 
CHRONIC PARENCHYMATOUS NEPHRITIS 
The term parenchymatous is in a sense a misnomer, as the patho- 
logical process is always diffuse, and the type, as already stated, shades 
imperceptibly on the one hand into the acute form, and on the other 
into chronic nephritis with induration and contraction. The description 
of this form may be made rather brief, as in many respects that already 
given of acute nephritis will apply to the chronic parenchymatous form. 
Etiology.-In most cases no definite cause can be assigned. Some 
factors, however, that when operating suddenly or with great intensity 
produce acute nephritis, may, if operating for a longer period or less 
severely, produce the chronic form of the disease. Long-continued 
exposure to cold explains its not infrequent occurrence in those who live 
or work in damp cellars, also its occurrence in bakers, butchers, and 
icemen. Alcoholism may also produce it. The acute infectious diseases, 
such as scarlet fever and malaria, which oftener produce the acute form, 
are said by many to produce the chronic form at times, or the acute 
form passes over into the chronic type. Malaria has been regarded by 
many-Rosenstein, Bartels, Thayer, and others-as a frequent cause of 
this type of nephritis. On the other hand, Wagner and some other 
writers dispute this fact. While direct proof that the gonococcus is the 
cause of acute or chronic parenchymatous nephritis is not easily available, 
the writer believes that it may occasionally produce such an inflamma- 
tion. Lurking in the prostate, the joints, or the Fallopian tubes, it may 
by systemic invasion and long after the acute manifestations have 
disappeared give rise to acute or chronic inflammatory inflammation 
in various organs or tissues, and among these may perhaps be, oftener 
than we think, the kidney. Chronic intoxications, where one must 
assume the condition of altered blood, may produce irritation and 
ultimately inflammation of the kidneys. It is seen occasionally in 
lead or mercurial poisoning; also in connection with syphilis, diabetes, 
or suppurating disease. 
Making allowance for the cases of acute nephritis and of amyloid disease 
that have been wrongly classed as chronic parenchymatous nephritis, 
the fact remains that pulmonary tuberculosis is one of the most frequent 
causes of chronic parenchymatous nephritis. Occasionally, in connec- 
tion with valvular heart disease, the condition of cyanotic induration or 
chronic passive congestion seems to give rise to this form of Bright's 
880 CHRONIC PARENCHYMATOUS NEPHRITIS 
881 
disease, although, as Rosenstein and Senator have suggested, there is a 
possibility that the heart disease and the kidney disease are due to one 
and the same cause, rather than that the lesion in the kidney is entirely 
secondary to the cardiac condition. 
Pathological Anatomy.-As already stated, the process is always 
diffuse and never limited solely to the parenchyma proper. It is largely 
owing to these varying degrees to which the interstitial fibroid process 
is present that several varieties of chronic parenchymatous nephritis 
have been described. What may, perhaps, be regarded as the type is 
the large white kidney of Wilks. This kidney is enlarged, weighing about 
250 to 300 grams (Fagge mentions a pair of kidneys weighing 29 ounces), 
light gray - even almost white -in color, the stellate veins showing 
distinctly. The kidney is soft, and on section the thin capsule is found 
to strip readily, leaving a non-granular surface. The cortex is swollen 
and pale yellow or grayish. The dark pyramids with their streaked 
markings show in striking contrast to the light and more homogenous- 
appearing cortex. The cortical markings are usually indistinct, and dull 
opaque spots or streaks are often to be made out in the midst of the 
more translucent areas. Minute reddish dots may be occasionally seen, 
due to hemorrhages (chronic hemorrhagic nephritis). 
Microscopically, there is a marked degenerative change in the epithe- 
lium lining the tubes, especially marked in the convoluted tubules. 
Individual cells are swollen, granular, fatty, with outlines often indistinct. 
The nuclei may be fragmented or invisible. The swollen cells may 
narrow the lumen of the tube, or by their desquamation the caliber 
may be increased. Casts of different kinds, epithelial cells in various 
stages of degeneration, granular debris, fat globules, and red and white 
blood corpuscles, may crowd the tubule. 
The Malpighian bodies show varying changes, much as in acute 
nephritis. They are usually enlarged. Epithelium with fatty degenera- 
tion is often seen in the glomerulus proper and in the capsule. Prolifera- 
tive change with nuclear multiplication is frequently one of the striking 
lesions. Swollen, desquamated and degenerate cells may fill the capsular 
space, and the capsule may be denuded or exhibit a lining of freshly 
proliferated cells. Red and white corpuscles may crowd the space 
(hemorrhagic form), or it may be distended with a clear inflammatory 
exudate, pushing the capillary tuft to one side. The w'all of the capsule 
may be thickened, and in some instances show slight fibrous growth. 
The capillaries may show hyaline changes in their walls and are often 
thrombosed. 
The intertubular connective tissue shows varying degrees of oedema. 
Round-cell infiltration may be here and there present. Small hemor- 
rhages may have occurred; in these cases pigment granules may be 
seen in the connective tissue (Ziegler). 
Many variations from this type of the large white kidney have been 
described, being dependent partly on the color, consistency and size, 
and partly on the degree of fibroid change present. The predominance 
of fatty changes produces the white or grayish color. If this kidney 
at the same time has somewhat advanced interstitial changes with 882 
DISEASES OF THE URINARY SYSTEM 
contraction, it is smaller, firmer, the capsule thickened and adherent 
in places, and the surface rough and granular. Bowman's capsule 
will show thickening and the glomerulus itself may be atrophied or its 
place taken by fibrous tissue. This is the small white kidney, a com- 
bination apparently of the fatty degenerative process with marked 
induration as well, the latter at times a sequel of the earlier parenchy- 
matous change-secondary contracted kidney-though in some instances 
these processes are perhaps coincident. Some of these kidneys are above 
the normal in size, and are, therefore, in the strict sense not contracted. 
In all these forms the kidneys are not uniformly affected, markedly 
involved areas often appearing in the midst of seemingly healthy tissue. 
Some describe as a separate variety of chronic parenchymatous nephritis 
a kidney of large size, mottled with reddish and light areas-represent- 
ing respectively small hemorrhages or highly vascular areas, and fattily 
degenerated and relatively anemic tissue-with slightly adherent capsule, 
the organ being firm from abundance of connective tissue. This is the 
large red kidney, or variegated kidney. 
Symptoms.-The striking features in the clinical manifestations of 
chronic parenchymatous nephritis are the slow, insidious onset, the 
characteristic urinary findings, and the marked degree of oedema. In 
most instances the physician is consulted either because of vague, 
indefinite symptoms, such as malaise, poor appetite, disturbance of the 
stomach or bowel, general weakness, or because some puffiness has been 
noted about the eyes or about the ankles. 
The Urine.-The amount is diminished. On an average, perhaps 500 
cc. would be the daily output. The specific gravity in general is normal 
or slightly above normal. The urine is acid, dark, often turbid. Occa- 
sionally there is a distinct opalescence from the presence of numerous 
fat globules. On standing there is an abundant sediment which consists 
largely of urates, casts, white- and red-blood corpuscles, epithelial cells, 
and amorphous debris. The reaction for albumin is prompt and shows 
a large amount. This is particularly true of the day urine. The quantity 
is ordinarily from 0.5 to 2 per cent. The total amount lost during the 
day will run anywhere from 5 to 30 grams. Exceptionally, larger amounts 
than this have been noted. The urea and solids are diminished absolutely. 
Relatively, however, they are usually in normal or even increased amount. 
In case improvement occurs, or there is the development of the secondary 
contracted kidney, the amount of urine will increase sometimes to as 
much as 5 or 6 liters. The specific gravity will be greatly lowered and 
the percentage of albumin will be decidedly lessened. The absolute 
amount of solids will be increased. The freezing-point of the urine in 
this form of nephritis is sometimes lower than normal, although it is 
influenced much by the degree of oedema and anemia, the blood-pressure, 
etc. Rarely it will be found as low as -2,6° C., oftener in the neighbor- 
hood of - 1° C. As an aid in the diagnosis of chronic parenchymatous 
nephritis cryoscopy is of little value. 
The microscopic study of the urine shows casts of nearly every variety, 
Hyaline and granular casts are abundant, and many of the latter are 
dark in color and contain coarse granules, Numerous broad casts are CHRONIC PARENCHYMATOUS NEPHRITIS 
883 
also seen. Waxy casts and casts with oil globules upon them are very 
common. Renal epithelial cells, many of them showing marked degener- 
ative changes and covered with fat globules, are found in abundance. 
Occasionally cases are reported in which casts are said to be absent, 
even though the amount of albumin is abundant. This may exceptionally 
be true, but the explanation is perhaps to be found in faulty technique, 
or in the fact that the urine is old or has undergone decomposition in 
the bladder. That casts may be dissolved by the presence in the urine 
of some pepsin-like body has been shown by Sehrwald. 
(Edema.-The oedema in this form of Bright's disease usually begins 
rather slowly and is first noticed as puffiness of the eyelids in the morning 
or about the ankles at night. It gradually increases, however, until 
we find the patient in the marked cases presenting an extreme degree 
of anasarca, with the face swollen, and wrinkles that give expression to 
the countenance obliterated, the hands, the arms, the back, the legs, 
all showing marked oedema. One of the most annoying and one of the 
most striking complications is the oedema of the loose tissue of the penis 
and scrotum. This may be extreme and even cause some difficulty 
in urinating. The serous cavities often contain fluid. Rarely there is 
a localized oedema, and one sees the collection of fluid limited to one 
pleural cavity, to the scrotum, or to the legs. Together with the oedema 
there is more or less anemia. This is due to the fact that the red-blood 
corpuscles and hemoglobin are actually diminished, and also to the fact 
that the blood is thinned because of the condition of hydremia. The 
capiHaries also are spread out over a more extensive surface, so that the 
anemia is apparently greater than it really is. With the oedema the 
anemia gives to the patient a peculiar puffy, pasty-like appearance which 
is quite characteristic, and enables one sometimes to make a diagnosis 
almost at a glance. The oedema, when extreme, causes a marked increase 
in the weight of the patient. When it disappears, the patient is seen to 
be greatly emaciated, and the skin hangs in loose folds where before it 
had been tense with the accumulated fluid. 
The waterlogged condition of the wall of the stomach and of the bowel 
interferes seriously with the performance of function of these two organs. 
The pressure of the fluid in the pleura and pericardium, as well as the 
upward pressure of the fluid on the diaphragm, when ascites is marked, 
interferes very much with the action of the heart and of the lungs. The 
patients are frequently obliged to sit up at night in order to breathe. 
The swollen condition of the legs and thighs, together with the general 
weakness, make it impossible for some of them to move about with 
any degree of comfort, so that their life really consists of lying in bed 
or sitting up in a chair. The tense skin may rupture or become abraded, 
and then, if infection occurs, serious inflammation may result. 
Reference has been made to the gastro-intestinal disturbance that 
comes from oedema. While oedema does not explain all of the disturb- 
ance, there is no nephritis in which the digestion is more interfered with 
than in this form. The appetite is often poor, and patients have a 
loathing for ordinary simple food. There is nausea, not infrequently 
vomiting; a feeling of fulness and weight amounting to positive distress 884 
DISEASES OF THE URINARY SYSTEM 
or pain is sometimes complained of after eating. The bowels may be 
constipated, but are often loose; ulceration of the intestine is occasionally 
an explanation for this diarrhoea. The tongue is coated; there is a fetid 
odor to the breath. This poor digestion is one reason for the great loss 
of strength, for the anemia and for the emaciation. 
Changes in the heart and bloodvessels are commonly present, although 
they are by no means so marked as in the cases of chronic interstitial 
nephritis. They may be entirely absent. If secondary contraction 
occurs, then cardiovascular changes may become pronounced. The 
dyspnoea of which these patients complain is often cardiac in origin 
from dilatation or myocardial degeneration, although the anemia, 
oedema, and uremia as well may contribute to produce the shortness 
of breath. 
Uremia is generally present, and while not such a striking feature as 
in some cases of acute nephritis, or in the typical chronic interstitial 
nephritis, still offers the explanation of many of the symptoms complained 
of by these patients. The malaise, some of the gastro-intestinal disturb- 
ances, headache, sleeplessness, are in many instances undoubtedly 
uremic in character, and as the disease goes on some patients have 
definite uremic manifestations in the shape of almost unbearable head- 
ache, convulsions, or coma. Retinitis and optic neuritis may occasionally 
be seen. Rarely the amaurosis not infrequently met with in the con- 
tracted kidney is seen in this form of Bright's disease. 
In some cases, after the evidences of chronic parenchymatous nephritis 
have lasted for many months, a change occurs which is quite remarkable, 
the dropsy becoming less, and finally entirely disappearing, the urine 
increasing in amount, becoming lighter in color, lower in specific 
gravity, and containing a smaller number of casts and a smaller percent- 
age of albumin. The condition of secondary contracted kidney has now 
appeared, and while the patient may flatter himself that he is decidedly 
better, or even entirely well, the careful physician will find on examination 
that the urine is still albuminous and contains a few casts. Hypertrophy 
of the left ventricle with increase in blood-pressure will also be present 
though in some instances the cardiovascular changes may be lacking. 
The manifestations of uremia appear, and the case runs the course of an 
ordinary contracted kidney. Through this somewhat favorable termina- 
tion of chronic parenchymatous nephritis life may be prolonged for 
many months, sometimes for several years. 
Complications.-The complications referred to under the head of 
acute nephritis are practically those that are met with in chronic paren- 
chymatous nephritis. Pneumonia, bronchitis, or oedema of the lungs 
may become serious and even the cause of death. Inflammation of the 
serous membranes-pleuritis, pericarditis, peritonitis-is met with. 
Intercurrent infectious, like erysipelas, may occur. Death is brought 
about at times from dilatation of the heart or from myocardial weakness. 
Alimentary disturbances in the shape of acute gastritis or enterocolitis 
may be serious complications. 
Diagnosis.-There is no difficulty whatever in diagnosing the existence 
of nephritis in cases of the type under dicussion, provided the urine is CHRONIC PARENCHYMATOUS NEPHRITIS 
885 
examined. An abundance of albumin and casts leaves no question 
as to the existence of nephritis. The marked oedema also helps in 
making this diagnosis. The only question is as to the variety. 
From acute nephritis the differentiation is often impossible unless 
one knows the early history. An abundance of red-blood corpuscles 
in the urine speaks for acute nephritis. Yet it must be remembered 
that in the chronic form microscopic blood may be found and occasionally 
a hemorrhagic type is seen with frequent renal hemorrhages causing 
hematuria of such severity as to be noted by the naked eye. In many 
cases, however, an attempt to differentiate between the two is unavailing, 
and one must be satisfied with saying that one is dealing with paren- 
chymatous nephritis without trying to tell whether it is acute, subacute, 
or chronic. 
From chronic interstitial nephritis of the typical variety the differen- 
tiation is easy. The abundance of albumin and casts, the marked oedema, 
the slight degree of cardiovascular changes, are all in such striking con- 
trast to the marked cardiovascular changes, the absence of oedema, the 
large amount of urine of low specific gravity and small amount of albumin 
and casts that are met with in contracted kidney, that the differentiation 
is simple. When secondary contracted kidney exists, differentiation from 
the primary contracted kidney is made by the preceding history of 
oedema and marked albuminuria. Yet many of our efforts to fit these 
cases of nephritis into definite pigeon-holes and label them as chronic 
parenchymatous or chronic interstitial nephritis are really useless because, 
as has been said, the cases often from the beginning are of a more diffuse 
character and present the characteristics of both types of disease. The 
best diagnosis that can be made here is chronic nephritis or simply chronic 
diffuse nephritis. Many cases from the onset show some cardiovascular 
change and have uremic symptoms, perhaps retinitis, like the chronic 
interstitial variety; but they show the oedema of renal origin, a urine 
rich in albumin and casts, and often of a specific gravity that is about 
normal or perhaps just a little below normal. To a case of this kind 
the name chronic nephritis, without any qualifying adjective, had best be 
applied, or one may employ Muller's expression and speak merely of a 
chronic disease of the kidney with dropsy. 
From amyloid kidney the differentiation is not always easy, and is 
sometimes impossible because the two diseases may be combined. 
Amyloid may be suspected, however, when any cause for amyloid, such 
as syphilis, tuberculosis, or chronic suppuration, exists, and when, along 
with the urinary findings, an enlargement of the spleen and liver can 
be made out. In amyloid, too, cachexia is more pronounced and there 
is generally less universal dropsy. The urine may show variations in 
amount, and casts are apt to be fewer than in the chronic nephritis. 
Serum globulin is present in increased proportion. Uremia and retinitis 
are relatively rare. 
From congestion of the kidney the differentiation is usually easy, the 
oedema being in the lower part of the body, and there being a definite 
cause for the congestion, such as a weak heart. The amount of albumin 
is usually less than in the true nephritis; the casts are fewer, and the 886 
DISEASES OF THE URINARY SYSTEM 
therapeutic test-rest and cardiac stimulants, with resulting improve- 
ment in the urine-will usually clear up the diagnosis. 
Prognosis.-This form of disease was once looked upon as entirely 
hopeless. Even now the prognosis is justly regarded as extremely bad. 
The collective report of Cabot, made a few years ago, showed that 
many physicians of good repute had seen stray cases of recovery from 
chronic parenchymatous nephritis. The question always arises in these 
instances as to where to draw the line between acute nephritis, which 
admittedly often gets well, and the genuine chronic parenchymatous 
form of the disease. Dropsy has been looked upon as having an important 
bearing on prognosis, but there seems to be no rule as to this, and the 
case that is accompanied by severe dropsy may have as good a prognosis 
as the one in which it is not so very marked. Some of the supposed 
recoveries, if carefully looked into, will be found to be instances in which 
the secondary contracted kidney has developed. In chronic paren- 
chymatous nephritis spontaneous improvement and relapse are not 
uncommon events. Death occurs from exhaustion in the greatest number 
of cases, this being brought about by inability to take, digest, and assimi- 
late food, by the anemia, and by the consequences of oedema. Death 
may also be brought about directly through the weakness of the heart, 
through some uremic manifestations, such as convulsions or coma, or 
through some of the numerous complications already mentioned. Few 
patients live longer than two years. 
Treatment.--In the way of prophylaxis little can be done in any 
individual case, although the chronic alcoholic may be cautioned against 
the possible effects of his bad habits, and the worker in cold, damp 
places may be advised of the dangers of exposure to extremes of heat 
and cold; but in practice very little can be done in the way of prophylaxis. 
In general, the active treatment is the same as in the acute form of the 
disease. Rest is of great importance. Rest in bed is usually instituted at 
the beginning of treatment, and the result commonly is that the albumin 
diminishes and the patient is better for the time being. Rest here should 
not be too absolute, however, and not be continued for too long a time. 
It becomes extremely irksome and monotonous, and when the disease 
is going to last for many months, one cannot expect a patient to stay 
in bed during all this period. It is much better, at times, to let the 
patient sit up and even indulge in a little exercise about the house, or 
in pleasant weather go outdoors; there is often a distinct gain in the 
appetite and digestive power; the patient sleeps better and the anemia 
is improved. The patient should be warmly clad and avoid exposure 
to cold. Woollen garments should be worn next to the skin. 
The question of diet is an important one, and what has been said 
regarding acute nephritis will apply to chronic nephritis, yet the same 
restrictions cannot be enjoined for so long a period. We cannot, in 
other words, keep the patient for months upon an exclusively milk diet. 
If we do, we find that the appetite disappears; nausea and diarrhoea 
are apt to occur, and there is great loss of strength and deterioration of 
the blood. Milk can, however, be one of the main articles of diet, and 
a patient may take with profit say a quart of milk daily, but in addition CHRONIC PARENCHYMATOUS NEPHRITIS 
887 
there should be other foods. Meat may be allowed in small amounts, 
perhaps once a day. The daily total protein intake should not be less 
than 80 grams nor much in excess of 100 grams. In this way the needs 
of the body are met without drawing upon the body proteins and there 
is no tax upon the kidney because of excessive amount of protein ingested. 
One quart of milk contains about 60 grams of protein. It makes little 
difference whether the meat be light or dark. Cereals, such as oatmeal 
and the ordinary breakfast foods, rice, sago, farina, tapioca, may be 
allowed freely. Fruits are also in order. Lemonade is a good diuretic 
and is frequently enjoyed by these patients. Some of the simpler 
vegetables may be taken. Broths should not be rich nor contain too 
much meat juice. Gruels made up with water or with milk are not 
harmful. Fried and greasy foods; sweets, such as cakes, pastries, pies, 
candies, and desserts; all rich and highly seasoned foods, should be 
omitted or taken in very small amounts. There is seldom any danger 
of the patient's overeating because the appetite is usually so poor that 
the endeavor is rather to get the patient to eat enough than to prevent 
him from taking too much. 
Water should not be taken in excessive amounts; it is not eliminated 
freely through the kidney, and tends to increase the oedema. Whether 
or not water be regarded, in part at least, as a metabolic product, the 
fact is that the diseased kidney has lost its power of passing large amounts 
of water rapidly from the body, it has lost its "diluting power" (Koranyi), 
or elimination is, at least, delayed (bradyuria), so that an increase in 
the intake of water results not in polyuria but in an increase of oedema. 
When, however, oedema is disappearing and polyuria has set in, one 
may assume more nearly patent glomerular vessels and tubules and a 
restoration of renal function in the way of power of eliminating water, 
and the amount of water ingested may now be increased and will be 
followed by a corresponding increase in the amount of urine. The rule is a 
fairly good one to let the patient take such water, milk, and other fluids 
as his thirst indicates. One and one-half to two quarts of fluid a day 
will represent a fair allowance. Wine, beer, and the stronger alcoholic 
drinks should not be allowed unless it be in exceptional cases, where a 
little wine may be allowed with meals. Smoking is not necessarily 
to be prohibited. The morning cup of coffee is something that patients 
usually cling to, and, as a rule, there is no harm in allowing this. 
Sodium chloride is frequently eliminated poorly by the inflamed 
kidney. Whether sodium chloride retention is a potent cause of oedema, 
the chloride being held in the body tissues, or w'hether both are merely 
phenomena of nephritis, with no relation of cause and effect, is a subject 
needing further investigation. Yet so many suggestive facts have been 
noted, the rapid fall of sodium chloride in the urine when ascites suddenly 
develops, its increase in the urine when oedema is disappearing, the 
production at will of a rise and fall of the oedema by increasing or lessen- 
ing the amount fed-and retained-to patients who have been experi- 
mentally observed, that one feels that there are many things that go 
to show a disturbance of water balance and alterations in osmotic pres- 
sure from chloride retention, that might easily result in an increase of 888 
DISEASES OF THE URINARY SYSTEM 
fluid in the intercellular tissues. The amount of salt necessary in the 
body is usually supplied by that found in the bread and milk ordinarily 
ingested. While one cannot make any extravagant claims for the treat- 
ment of the oedema of nephritis by the withdrawal of salt-dechlori- 
dation-still the investigations of Widal, Javal, Strauss, and many others 
seem to indicate that in some cases, at least, an ordinary or excessive 
amount of salt in the food increases the oedema and albuminuria, while 
a reduction of the amount tends to lessen the same. It is wise, 
therefore, to limit the amount of salt ingested. 
A point that is often not insisted on enough is that a patient with 
nephritis should be allowed the benefits that come not only from good 
food, but from fresh air. The fear of taking cold very often leads the 
patient to shut himself indoors and to deny himself the privilege of 
fresh air. A change of climate will sometimes benefit these patients. 
Going to a warm, dry climate, the patient can be in the open air, and 
in that way he is greatly helped, as elimination through the skin by 
invisible sweating is much greater. 
The anemia of this form of nephritis is combated not only by the 
fresh air and the food but usually by the giving of iron. Some contend 
that very large doses of iron should be given-30 to 60 drops of the 
tincture of chloride of iron-after meals. Iron is of great benefit in these 
cases, but the writer believes that James Tyson is right when he says 
that "large doses of iron should not be given. They are useless; lock 
up the secretions, cause headache, and increase the danger of uremia." 
The writer gives Basham's mixture oftener than any other preparation 
of iron. This is easily tolerated by the stomach, is not at all unpleasant 
to take, and seems to have some diuretic action as well as to act favor- 
ably in improving the anemia. 
Elimination in this form of nephritis is secured, as in other conditions, 
largely by the use of laxatives. Almost any laxative may be given, but 
the salines seem to act the best. The saline cathartics may be given on 
an empty stomach early in the morning, and enough should be taken 
to induce two or three rather loose watery stools. At times good follows 
from giving the saline several times during the day, or from using some 
of the stronger cathartics, like elaterin. This vigorous purging is apt 
to be rather depressing, and it is not always wise to secure a reduction 
in the oedema at the expense of the strength of the patient. Some of 
the vegetable laxatives, like cascara or senna, are of value, or phenol- 
phthalein may be used at night (gr. ij to v, 0.12 to 0.3 gm.) or smaller 
doses three times a day. 
The reduction of the oedema by means of sweats has already been 
referred to under the head of Acute Nephritis. It is of interest to note 
that Bendix1 finds in cases with the molecular concentration of the 
blood increased and the freezing-point lowered that there is a tendency 
toward lessening of molecular concentration and an approach toward 
normal of the freezing-point by the use of sweats. When this is normal, 
however, no change is brought about by sweating. Fear has been 
Deutsch, med. Woch., 1904, No. 7. CHRONIC PARENCHYMATOUS NEPHRITIS 
889 
expressed by some lest by sweating a too great concentration of toxins 
in the blood might result. Leube, for one, advises that liberal amounts 
of water be taken at the time a sweat is given, so that this tendency may 
be counteracted. Sweats may be given in any way that is most feasible. 
Many patients will get into the tub and take a hot bath at a temperature 
of 103° to 105° F., and then roll up in warm blankets in bed and sweat 
profusely. This is a very simple method. The sweat may be induced 
by the hot pack. The bath by means of the hot bricks, as described 
under the head of Acute Nephritis, is a simple method and especially 
suitable for hospital use. The electric light bath, or even the Turkish 
bath, where there are proper establishments, and where care can be 
given to the patient afterward to insure a prolonged period of rest 
and to see that he does not go out into the open air too soon, are 
methods of inducing sweat that are very efficient. Some patients 
undoubtedly derive great benefit from the sweat given once or even 
twice a day. The physician must judge in each case as to how long the 
sweat should continue as well as how often it should be given. 
(Edema very often calls for aspiration of the pleural or abdominal 
cavity, or puncture of the skin. When there is double hydrothorax of 
any considerable extent, and when dyspnoea is pronounced, aspiration 
should not be long delayed. With double hydrothorax sudden death 
has been met with more than once. While the fluid may reappear, 
still the drawing off of one quart or one quart and a half from the pleural 
cavity relieves the pressure upon the lungs, vessels, and the heart, and 
absorption is sometimes quite rapid after the aspiration. So, too, tapping 
of the abdomen is oftentimes followed by great relief in every way. 
The question of draining the legs, when the oedema is extreme, is one 
that arises very often, and the physician hesitates to make a puncture 
through the skin of the leg, knowing that the wound will remain open 
for many days and that there is great danger of infection. When a 
patient can have the services of a trained nurse, and when asepsis can 
be rigidly carried out, these punctures may Ke made with much more 
freedom than under other circumstances. The good results are some- 
times very striking. Fluid oozes for many days, and the oedema of the 
lower extremities disappears as well as the oedema of the scrotum, and 
to a certain extent the ascites and oedema of the abdominal wall. The 
operation may be done in one of three ways. The writer prefers many 
small punctures through the skin, made with the ordinary scalpel. 
Some prefer to make one large cut two or three inches in length down 
to the bone over the skin, while others prefer the use of the Southey 
tubes. Anyone of these methods is successful, and the dangers from one 
are about as great as from the other. 
Attention should be paid to the condition of the heart, and the use of 
strychnine, digitalis, or strophanthus is sometimes clearly indicated. 
The good effects of digitalis are often seen in the increased elimina- 
tion of urine as well as in the improvement in dyspnoea. Sleep is 
frequently disturbed in nephritis and may necessitate the use of bromides, 
or some of the hypnotics, like veronal or sulphonal. Morphine, or some 
other derivative of opium, in small doses is occasionally the best hypnotic 890 
DISEASES OF THE VRINARY SYSTEM 
to give. One must be very careful in using this not to give too large 
doses, and should also be careful not to induce the morphine habit. 
But there are many patients for whom a hypodermic of morphine given 
at night is the very best hypnotic to employ. Pain is rarely so great 
as to demand opiates. Sometimes the headache is extremely severe, 
and here opium will be called for. The treatment of the uremic com- 
plications, such as coma and convulsions, is the usual treatment referred 
to elsewhere. 
CHRONIC INTERSTITIAL NEPHRITIS. 
Introduction.-As already stated, three divisions of this form may be 
made: (1) Primary chronic interstitial nephritis; (2) secondary chronic 
interstitial nephritis; (3) arteriosclerotic kidney. 
It is no easy thing to classify these cases as they come to the physician, 
or even as the kidneys are studied in the dead-house. Secondary con- 
tracted kidney may closely resemble the primary form, and only a 
knowledge of the previous clinical history may enable one to recognize 
the true character. The relation of the renal lesion to the arteriosclerosis 
found during life and postmortem may be difficult to unravel. Three 
explanations are possible: (1) General arteriosclerosis may be primary, 
the kidney being secondarily involved. (2) The arteriosclerosis may 
be a result of primary renal disease that leads to cardiac hypertrophy 
and high blood-pressure, i. e., there is primary nephritis with secondary 
arteriosclerosis. (3) Or the vascular and renal conditions may be due 
to one and the same cause, developing independently of each other yet 
simultaneously. It may be added that some-and with much reason- 
object to the use of the term nephritis, implying as it does an inflamma- 
tory process, for in many of these kidneys there is more of atrophy 
with secondary fibrosis than of true inflammation. Such terms as 
granular kidney, contracted kidney, sclerotic kidney, cirrhotic kidney, 
are employed to describe this form or some modification of the same. 
Etiology.-The causes oT chronic interstitial nephritis of the secondary 
type are those already enumerated for the chronic parenchymatous 
form. The arteriosclerotic kidney has its etiological factor in any of 
the conditions that lead to general arteriosclerosis-lead, gout, syphilis, 
alcohol, heredity, severe muscular strain, overwork, worry, etc. 
Several years ago Rosenstein wrote that for the overwhelming majority 
of cases of genuine contracted kidney we know no cause. This statement 
holds to-day. Yet some facts seem fairly well established. The origin 
is in many, probably most, cases hemic, through the presence in the 
blood of material that acts on the kidney as a toxic irritant. Some of 
the causes enumerated for acute nephritis might, if long continued in 
milder degree, produce the chronic inflammation. Some French writers 
(Brault) recognize this by speaking of chronic interstitial nephritis as 
nephrite par intoxications lentes. Exceptionally an acute nephritis is 
the starting-point; a scarlatinal nephritis, for example, passes gradually 
into the contracted kidney. Dickinson1 described such cases. 
1 Allbutt's System, 1897, v, 376. 891 
CHRONIC INTERSTITIAL NEPHRITIS 
Heredity.-A hereditary tendency to chronic nephritis is undoubtedly 
seen at times. Reference has been made to an example of this in a 
woman with contracted kidney whose three daughters and one son 
show albumin and beginning nephritis, and several of whose ancestors 
had chronic nephritis. Dickinson, Eichhorst,1 Kidd2 A. V. Meigs,3 Pel,4 
and Frolich5 report family and hereditary nephritis. Tendency to 
early arterial degeneration is often hereditarily transmitted. In some 
families this is seen in cerebral hemorrhages; in others as myocarditis 
or pectoral angina, or again as contracted kidney. Or one member 
of the family exhibits one manifestation of the disease, e. g., the myo- 
cardial, while another has cerebral hemorrhage, and another has chronic 
nephritis. Not infrequently in one and the same individual there may 
be manifested not alone the nephritis, but the myocardial or cerebral 
evidences of arteriosclerosis. 
Congenital contracted kidney has been reported by Weigert and by 
Hellendahl. In childhood chronic interstitial nephritis is relatively 
rare, yet it has been seen by many observers. Some of these cases-a 
very small proportion surely-may have developed because of an 
inherited or family tendency.6 Sutherland and Walker7 report interstitial 
nephritis in infants, and refer to the fact that such nephritis due to 
syphilis is not unusual. 
Carpenter8 reviews the subject of nephritis in infants, and comes to 
the conclusion that infantile interstitial nephritis may be produced 
by toxins other than those of syphilis; possibly toxins of intestinal origin 
may be the cause in some cases. Occasionally from unknown cause an 
early arteriosclerosis develops, as in the case described by Egon Rach,9 
of a girl, aged thirteen years, in whom a chronic nephritis with dropsy 
was followed by hypertrophy of the left ventricle, rigid arteries, and 
death from cerebral hemorrhage. 
Gout is a common cause of chronic nephritis. There is not such a 
unanimity in regarding lead as the exciting cause of chronic nephritis. 
Many are inclined to look upon the contracted kidney developing in 
the course of chronic lead poisoning as due rather to the gouty condition 
that is so often a sequel of lead poisoning ("lead gout"). Olliver, in 
1863, described albuminuria in workers in lead. Since then numerous 
statistical studies have borne out the truth of this observation. Senator, 
Wagner, and Dickinson found many cases of contracted kidney among 
workers in lead. It would seem that lead alone without gout may produce 
chronic interstitial nephritis. 
Of the influence of alcohol in the production of nephritis there is little 
doubt. But observers differ widely in their estimate as to the importance 
1 Specielie Pathologic, fourth edition, ii. 2 Practitioner, 1887, xxix, 104. 
3 Transactions of College of Physicians of Philadelphia, 1883. 
4 Ztschr. f. klin. Med., 38, 127, with literature. 
5 Norsk. Mag. f. Laegevid, 1904, No. 8. 
8 Heubner. Ueber chronische Nephritis und Albuminurie im Kindesalter, Berlin, 
1897. 
7 Archives of Pediatrics, 1903, xx, 288, also British Medical Journal, 1903, i, 959. 
8 British Journal of Children's Diseases, iv, 421. 
9 Abstract in Deutsch, med. Woch., 1907, No. 34, p. 1387. 892 
DISEASES OF THE URINARY SYSTEM 
of alcohol as a causative agent. Thus of two French observers, Rayer 
placed alcohol at the head of the list of causes, while Lancereaux denies 
that alcohol is a common cause. Experimentally, little definite has been 
brought forth to show a direct influence of alcohol in the production of 
chronic interstitial nephritis. Clinically, the question is by no means 
settled. It would seem that alcohol is unquestionably an important 
factor in the production of chronic nephritis, not always through the 
direct action of the alcohol on the kidneys, but oftener indirectly through 
perversion of gastric and hepatic function, through induced faulty 
metabolism, through secondary digestive disorders, through exposures 
and excesses of various kinds, all the result of alcoholic overindul- 
gence. 
Not infrequently chronic interstitial nephritis can be traced to a 
preceding acute infectious disease that was complicated by acute nephritis. 
Many cases reported as due to the acute infectious disease are undoubt- 
edly instances in which a previously existing but unsuspected nephritis 
has been noted only because of the urinary examination at the time of, 
or soon following, the infectious process. Slight attacks of tonsillitis 
may be a cause more often than we have generally supposed. Most 
of the cases of chronic interstitial nephritis seen in childhood are probably, 
as Heubner suggests, due to previous infections-scarlet fever, measles, 
angina, pneumonia, intestinal disturbances due to bacteria-which may 
have been slight in character and in which no symptoms drew attention 
to the urine or kidneys. In this connection one is led to think of the 
marked acute parenchymatous degeneration so frequently present in 
these acute infections, of the cellular destruction often seen in this 
condition and in acute nephritis, of the numerous patches of visceral 
round-celled infiltration and of focal necrosis, and to surmise that in 
place of the destroyed cell or in the area of focal necrosis fibrous tissue 
may be formed and serve as a nucleus for the spread of a local or more 
extensive fibrosis, in accordance with Weigert's law of primary destruc- 
tion of specific tissue elements and replacement by newly formed 
connective tissue. 
A cause whose influence it is impossible accurately to estimate and 
to which reference has been made in discussing the general etiology, 
is repeated or chronic gastro-intestinal disturbances with faulty digestion, 
and the still more obscure faulty metabolism on the part of such organs 
as the liver, pancreas, or adrenal. Unnatural chemical products may 
be present in the blood under these conditions, and be the irritating 
cause of the change in the kidney. In this way alcohol, by disturbing 
the function of stomach, bowel, and liver, may be an indirect cause of 
nephritis. So overeating, or the eating of rich or improper food, the 
excessive use of proteins, in short, any often-repeated dietetic errors, 
may be conceived of as the underlying causative factor in the production 
of chronic nephritis. How much influence disturbances in the function 
of the liver, pancreas, thyroid, or adrenal may have is not clear. Nephritis 
in connection with hepatic cirrhosis is not uncommon, both perhaps due 
to the same cause; yet the influence of perverted function of the liver 
on the kidney, forcing it to eliminate improperly elaborated substances, CHRONIC INTERSTITIAL NEPHRITIS 
893 
is not to be underestimated. Caro1 found nephritis in from five to eight 
days after experimental thyroidectomy in cats. Diabetics often have 
albuminuria and true chronic nephritis may develop, possibly from 
overwork of the kidney. The relation of renal sclerosis and of general 
arteriosclerosis to perverted adrenal function is still unknown. Many 
cases of chronic interstitial nephritis may then have their origin in 
undetected anatomical or physiological changes in other viscera. 
The relative infrequency of this form of nephritis in the warmer 
climates has been frequently noted. This may be in a measure accounted 
for by the fact that in the warmer climate there is less exposure to cold, 
inclement weather, and sudden changes of temperature; the inhabitants 
consume less protein food, drink less strong alcoholic drinks, and are 
subjected to less wear and tear through the strenuous life. 
The kidney of pregnancy may be the starting-point of the disease, 
although some cases regarded as originating during pregnancy have been 
cases of chronic nephritis, with an acute exacerbation. 
Cardiac disease and chronic interstitial nephritis often coexist. The 
relation between the two diseases is not always clearly definable. In 
many instances the same cause has produced the nephritis and the 
valvular or myocardial lesion. In other cases a primary renal lesion has 
caused the secondary changes in the heart. In a few cases chronic 
interstitial changes in the kidney result from an incompetent heart, with 
its resulting long-standing passive congestion of the kidney (cyanotic 
induration), together with its accompanying toxic condition of the blood 
from cyanosis, alimentary disturbances, and faulty metabolism. Local- 
ized areas of chronic fibrosis in the kidney often result from renal infarcts 
that may have their origin in a diseased heart. 
Since Gull and Sutton, over forty years ago, called attention to 
the fact that certain diseased conditions affected the entire vascular 
system as a unit, some cases of chronic disease of the kidney have been 
regarded as but part and parcel of general arteriosclerosis. The causes 
of the arteriosclerotic kidney wmuld be those of arteriosclerosis in general: 
old age, heredity, syphilis, lead, gout, alcohol, excessive work, and 
preceding infectious diseases. Chronic interstitial nephritis is found 
oftener in males and in those past the age of thirty; the arteriosclerotic 
kidney, in the stricter sense, is rarely seen until after forty-five. 
Chronic fibroid changes may take place in the kidney when there is 
chronic obstruction to the outflow of urine, or disease of the pelvis of the 
kidney. Thus, in stricture of the urethra or ureter, in cystitis and 
pyelitis this is at times noted. While not in a strict sense of the same 
type as chronic interstitial nephritis, this " consecutive nephritis" may 
be here referred to, as it is practically a fibrosis. 
A traumatic origin of some cases of nephritis has been alleged. Kiister, 
Edlefsen, Curschmann (the younger), Engel, Posner,2 and others have 
written concerning it. Orth, in the discussion on Ponfick's and Muller's 
papers at the Congress in 1905, referred to specimens in his possession 
1 Mitt. a. d. Grenz, d. Med. u. Chir., 1907, xvii, 447. 
2 Deutsch, med. Woch., 1906, xxxii, No. 12, 454. 894 
DISEASES OR THE URINARY SYSTEM 
showing typical contracted kidney from subcutaneous injury of the kid- 
ney. Under trauma might also be included Newman's cases of nephritis 
in floating kidneys,1 in which condition Newman finds Bright's disease 
not so very uncommon; and also some cases of obstruction to the ureter 
with resulting circulatory, nutritional, and fibrotic processes in the 
kidney. Tornellini2 and Senator3 have still further discussed the experi- 
mental and clinical features of traumatic chronic nephritis. 
Many attempts have been made to produce experimentally a chronic 
nephritis of the type of the contracted kidney. These efforts have met 
with but indifferent success. The conclusions, too, in some instances 
are rather hastily drawn, the number of observations too few, and not 
enough consideration given to the fact that albuminuria and renal 
disease might have existed in the animals used prior to the experiments. 
In dogs chronic nephritis seems to be not uncommon.4 The results 
that have been the most nearly constant in the way of a chronic nephritis, 
and not merely acute or chronic degenerative lesions or those of temporary 
character, have been brought about by the long-continued use of small 
doses of the salts of lead. Haven Emerson5 has done suggestive, although 
not yet conclusive, work in attempting to produce chronic nephritis in 
dogs by using means that presumably materially alter the circulation 
in the kidney, and he argues in favor of circulatory stagnation and 
defective blood-supply to the kidney as potent causes of chronic nephritis, 
and as capable of being brought about by chemical or mechanical agents. 
But no experimental work can exactly or even approximately duplicate 
the conditions that seem operative in the production of chronic interstitial 
nephritis in man. The influence of heredity, dietetic errors, faults of 
metabolism, syphilis, many of the infections, the wear and tear of the 
strenuous life and of excessive mental and nervous strain-all these 
continuing perhaps for years-cannot be reproduced in experiments 
on the lower animals. Bradford6 in his Croonian lectures on Bright's 
Disease and its Varieties, reviewed the experimental work on nephritis. 
While showing its great value, he says that there are still lacking many 
of the conditions found clinically, and that the results (e. g., with 
nephrotoxins) are often far from conclusive. 
After all is said concerning the etiology of chronic interstitial nephritis, 
we come back to Rosenstein's statement, already quoted, that for the 
majority of cases we cannot assign a definite cause. In many cases a 
combination of causes seems to operate. . A peculiar susceptibility may 
explain why one individual will develop the disease, while another, 
under what seem to be exactly similar conditions, or even under condi- 
tions that would seem more likely to favor the development of nephritis, 
will escape. 
1 Glasgow Medical Journal, 1904. 
2 Vierteljahrsscher. f. gerichtl. Med., Band xxxiv, Heft 1. 
3 Cf. Senator, Berlin, kiln. Woch., March 16, 1903; also Engel, ibid., 1903, No. 10. 
4 Cf. Pearce, Univ. Penn. Med. Bull., 1903-04, xvi, 217; also Ophuls, Jour. Med. 
Research, 1908, 49. 
5 Arch. Int. Med., 1908, i, No. 5 (references to experimental nephritis). Cf. also 
O'Hare, ibid., 1913, xii, 49. 
6 London Lancet, 1904, vol. ii. CHRONIC INTERSTITIAL NEPHRITIS 
895 
Pathological Anatomy.-Primary Chronic Interstitial Nephritis.-Almost 
always the process is bilateral. There are probably occasional excep- 
tions to this statement (Israel, Senator, Klemperer), and at the very 
beginning of an acute or even chronic nephritis it is not impossible 
that one kidney alone may for a short time be involved. But such 
labored arguments as those of Bousson,1 striving to prove that unilateral 
nephritis might occur, and therefore does occur not infrequently, are 
more than offset by statements such as those of Guiteras, who in 500 
autopsies on patients with Bright's disease never saw one kidney alone 
involved, or of Kummell, who says that in the rich autopsy material 
at Hamburg no instance of unilateral nephritis has been seen. 
The kidneys are small, sometimes unequally so. The single kidney 
may weigh only fifty or sixty grams, occasionally even less than this. 
The color is variable, but in general is red or grayish red. The fatty 
tissue about the kidney is unusually abundant and may be quite firmly 
adherent to the true fibrous capsule. This latter capsule is often quite 
vascular, and is thickened and raised in uneven manner by the granular 
elevations of the kidney surface beneath, that alternate irregularly 
with darker red depressed areas that denote underlying contracting 
fibrous tissue. When the capsule is stripped off, it is found to be adherent, 
especially over these depressed regions, and when it is forcibly removed 
more or less of kidney substance is pulled away with it, leaving a rough, 
granular, uneven, reddish surface that is quite characteristic. The 
kidney is hard and cuts with increased resistance. Small retention cysts 
may be numerous. The cysts usually contain a pale-yellow, serous, or 
urinous-looking fluid that is albuminous, perhaps slightly blood-stained, 
and contains more or less urea. The cut arteries may be plainly seen, 
and may gape and show thickened walls. The cortex is narrowed; it 
may measure only 1 mm. In some places the pyramids lie almost 
immediately under the capsule. The pyramids, although absolutely 
shrunken, seem by comparison with the contracted cortex to be large. 
The cut surface is reddish in color, with a liberal mottling of gray due 
to the abundant connective tissue. Beneath the depressed areas on 
the surface, with the naked eye or a low-power lens, may be seen masses 
of fibrous tissue often extending quite a distance into the kidney. The 
lighter areas that form the projections on the surface represent the 
more nearly normal tissue, some of which may be compensatorily hy- 
pertrophied. There is commonly an abundance of fat in the renal 
pelvis. 
The microscope reveals a general increase in the fibrous tissue, a 
thickening of the vessel walls, destruction of glomeruli, and more or 
less degeneration of the renal epithelium. The cortex, especially the 
labyrinth, shows the most marked change, although the lesions are not 
uniform in their distribution. Even in the areas between the labyrinths 
that are more nearly normal the epithelium often shows some fatty 
degeneration, and foci of round-cell infiltration may give evidence of 
an early stage of the indurative process. 
1 Zeitsch. f. Urologie, 1907, i, 853. 896 
DISEASES OF THE URINARY SYSTEM 
Malpighian Bodies.-Many glomeruli are destroyed, being represented 
by structureless hyaline masses. Others show the remains of the capillary 
tufts in the shape of homogeneous or granular balls in which a few nuclei 
may still be seen. Again, the capillary tuft, the capsular space, and even 
the epithelium lining Bowman's capsule may appear normal, but a 
richly nuclear fibrous ring, often quite broad, surrounds the entire Mal- 
pighian body, or the ring may be dense and poor in nuclei 
The capsular space may be obliterated, the capillaries and capsule 
being adherent; or the space may be widened, the result of obstruction 
to the outflow of urine from obliterated tubules, the dilatation being 
on the order of a retention cyst. Compression of the tuft may thus 
result. Nuclear proliferation is often seen in the tuft. Especially in 
the small projections on the surface of the kidney that give it its granular 
appearance, large compensatorily hypertrophied Malpighian bodies 
may be seen showing little or no pathological changes. In places the 
bodies, from atrophy and contraction of intervening tissue, are closer 
together than in the normal kidney. 
It is easy to understand how the glomerular function is seriously 
interfered with by these changes and how the structure and function 
.of the tubular epithelium must be, in consequence altered. The glom- 
erular lesion, however, is not necessarily primary. The more correct 
conception is to regard the process as from the first more or less diffuse, 
and to look upon a change in one part as necessarily leading to change 
in another, after the manner of the vicious circle. 
Tubules.-Atrophy is more or less marked. Many tubules are narrow, 
lined with small flat or cubical cells, and quite collapsed. Others, from 
blocking of their excretory ducts, have become dilated with hyaline- 
looking or granular and fatty cells lining them, or have even formed 
retention cysts of various shapes and sizes. These cysts sometimes 
coalesce so as to resemble compound cysts. In some tubules all the 
cells have disappeared, leaving bare the basement membrane. In the 
areas that show compensatory hypertrophy, the tubules and cells at 
times seem larger than normal or even increased in number, reminding 
one of the somewhat similar, almost adenomatous increase of the healthy 
liver cells in hepatic cirrhosis. 
The Vessels.-An endarteritis or even a mesarteritis can usually be 
made out, the intimal thickening often perceptibly narrowing the lumen. 
The smaller intertubular vessels are specially involved and are often 
entirely obliterated. This must, by causing interference with the blood- 
flow, increase the pressure in the glomerular capillaries. This has been 
given as one explanation of the polyuria of chronic interstitial nephritis. 
The degree to which different arteries are altered varies, some showing 
marked thickening in the outer and middle coats, but especially in the 
subendothelial layer, others but slight changes. The sclerosis is some- 
times patchy, even in the individual artery, one portion of the circum- 
ference showing an extensive lesion, while the remainder of the ring is 
nearly normal. The lumen of the thick-walled vessel may be nearly 
normal, the pipestem-like artery gaping with wideopen mouth as it 
is cut across, while in other vessels the caliber is gradually narrowed CHRONIC INTERSTITIAL NEPHRITIS 
897 
until it is quite obliterated. Dickinson1 found by actual measurements 
that the caliber of the primary arteries was not altered even though the 
walls were thick. The obstruction to circulation, as he proved, w'as in 
the minute arterioles and in the capillaries, many of which were entirely 
destroyed. The roughened intima with the sluggish current that must 
flow through some of these vessels favors thrombosis, and thrombi may 
be seen in some of the vessels, such as the smaller interlobular arteries. 
From destruction of vessels there results a compensatory collateral 
venous circulation. Part of the blood escapes by way of the vessels of 
the renal capsule and the perirenal fat. 
The Interstitial Tissue.-This is increased. The thick, fibrous bands 
surrounding the Malpighian bodies present perhaps the most striking 
picture, but the newly formed connective tissue rich in nuclei, or the 
old scar-like bands and masses, may be seen nearly everywhere, between 
the tubules, in the pyramids, and about the vessels, and especially 
running down into the labyrinth from the surface depressions and sending 
out bands of fibrous tissue that encircle and ensnare the healthy tissue 
on either side. Masses of round cells representing young contractile 
tissue may be seen, especially under the capsule and around the glomeruli 
and vessels, from which points the process extends downward and out 
into the intertubular tissue. The contraction follows so soon that even 
though this nuclear overgrowth, as it has been termed, be excessive, the 
kidney is always small. In places, little or no relic of renal structure is 
to be made out, the section showing merely dense fibrous tissue. Some- 
times calcification is found in this adventitious fibrous tissue. 
Secondary Contracted Kidney.-This is seen in its earliest stage in some 
of the kidneys of chronic parenchymatous nephritis, the large white 
kidney, in which a few depressions on the surface and a beginning hard- 
ening from fibrosis show that had death been deferred for several months 
the kidney of secondary contraction would, in all probability, have 
been present. This kidney in reality seems much like a cross between 
the kidney of chronic parenchymatous nephritis and the contracted 
kidney. It is pale in color, of normal or diminished size, its capsule 
thick, the surface granular. The kidney feels firm to the touch. The 
cortex is narrow and pale. Fibrous tissue is seen in greater or less abund- 
ance, the glomeruli are in general small, surrounded by bands of fibrous 
tissue and at times have undergone atrophy and completely disappeared. 
Hyaline degeneration of the epithelium of the tubules is pronounced or 
the cells may have entirely disappeared, leaving the tubule denuded 
and seemingly dilated. The vessels may show mural thickening. The 
picture in advanced cases is not unlike that of the chronic interstitial 
nephritis. Bradford believes the contracted white kidney is a distinct 
entity and not related, on the one hand, to the large white kidney or, on 
the other, to the truly granular kidney. 
Arteriosclerotic Kidney.-This form is a not uncommon postmortem 
finding in those past the middle years of life, and especially in those 
who have had operating upon them for many years the causes favoring 
1 Lancet, 1895, ii; also Medico-Chirurgical Transactions, vol. xliii. 898 
DISEASES OF THE URINARY SYSTEM 
the development of general arteriosclerosis. The arteriosclerotic kidney, 
as already stated, is generally but one manifestation of a widely dis- 
tributed vascular sclerosis, so that at autopsy cardiac hypertrophy, 
thickened cerebral vessels, with perhaps rupture and hemorrhage, are 
commonly met with. The conception of the disease is that of a simple 
n on-inflammatory atrophy. The kidney itself is usually reddish or 
grayish red in color, and but slightly smaller than normal. In long- 
standing cases, however, there may be extreme reduction in size. It 
is firm to the touch, and the capsule that is not much thickened may 
often be stripped off readily without bringing away much of the kidney 
substance. The surface of the kidney is smooth, although here and 
there the local cortical atrophy may be revealed by a depressed area, 
and the presence of cicatricial tissue in such an area will be shown not 
alone by the microscopic examination, but by the fact that the capsule 
is bound to the kidney at this point by fibrous adhesions. A few sub- 
capsular cysts are occasionally seen. 
The hard cut surface may show gaping' vessels; the cortex is narrow. 
Some of the changes seen on microscopic examination are in many 
respects similar to those described under primary chronic interstitial 
nephritis; and it is, in fact, difficult to differentiate between changes 
that are purely degenerative or atrophic and those that are inflammatory, 
or to tell which change is primary. Many of the smaller vessels show 
intimal thickening. The small-celled infiltration is, however, lacking or 
but slightly marked. There is less striated connective-tissue thickening 
about Bowman's capsule than in the inflammatory form. Many of the 
Malpighian bodies are destroyed. In others, the capillary tuft may 
be obscurely outlined as to its details, being represented by a homo- 
geneous, hyaline mass, with a few scattered nuclei still visible. The 
capsule proper may be thickened; on its inner side it may be denuded 
of its epithelium, and it may even have contracted down so as to be in 
immediate touch with the tuft, the capsular space thus being obliterated. 
In this form of renal disease, as in most others, there is seen that remark- 
able irregularity in the distribution of the lesion-the "patchy" distribu- 
tion. This may result in normal glomeruli being seen side by side with 
those quite markedly altered or even completely destroyed. 
Many tubules will appear normal. In others, however, the atrophy is 
manifest in the small size of the cells, the loss of their normal markings, 
their flattened shape, or their total destruction. Often the narrowed 
tubule has collapsed, leaving a cord-like mass to represent it, or possibly 
a small retention cyst. These cysts may contain a clear fluid with masses 
of colloid-like material. The same colloid-like masses, occasionally a 
hyaline or granular cast or granular and fatty epithelial cells, may be 
found in some of the tubules. 
Among findings in other organs that are met with quite regularly in 
chronic interstitial nephritis must be mentioned the hypertrophy of the 
heart and the sclerosis of the arteries. Left heart hypertrophy is the rule, 
and is always present before enlargement of the right ventricle. In 
advanced cases and especially in cases where dilatation of the left heart 
has occurred leading to mitral insufficiency, there may be right heart CHRONIC INTERSTITIAL NEPHRITIS 
899 
enlargement, and the whole heart is truly bovine. The aorta and smaller 
vessels show more or less advanced sclerotic changes. Even when the 
aorta may not be markedly involved, the smaller arteries, e. g., in the 
spleen, will usually exhibit some degree of thickening of their walls. 
Exceptionally, typical contracted kidney has been found unaccompanied 
by arteriosclerosis or cardiac hypertrophy. Roth1 reports six such 
cases. Death was generally from uremia. In most of the cases blood- 
pressure had been low. The causes of these cardiovascular changes are 
discussed elsewhere.2 
Such accidental or complicating conditions as cerebral hemorrhage or 
dropsical accumulations, where toward the last there has been cardiac 
insufficiency, are often seen. The alimentary tract is usually in a state 
of catarrhal inflammation, and uremic ulcers may be present. Devic 
and Charvet3 reviewed the entire subject of uremic ulcers and found them 
to be present oftenest in the chronic interstitial nephritis especially 
when uremic symptoms are prominent. Dickinson's4 lectures also 
contain a comprehensive discussion of these ulcers. 
It will be in place to mention here some recent experimental work 
on the pathological anatomy of nephritis of which, while far from 
conclusive, is surely suggestive, and should arouse interest in further 
experimental work of this kind. Laederich5 finds that not only in 
animals, which die as the result of a sudden suppression of renal function, 
as by operative removal of the kidneys, are hepatic lesions due to toxic 
degeneration regularly found, but in cases in which a gradual renal 
insufficiency is brought about, certain peculiar hepatic cellular changes 
are found (etat clair avec surcharge glycogenique). This condition 
of renal insufficiency, if continued for a long period, finally leads to a 
periportal sclerosis. One sees, therefore, the interdependence of these 
two eliminating organs. The kidneys and the liver are closely related. 
Hepatic insufficiency can determine renal changes; experiment shows 
that renal insufficiency may induce reactions and lesions in the liver. 
Beaujard,6 in a critical review, describes the suprarenal lesions in 
nephritis, as found by several observers. Cortical hyperplasia is common 
in interstitial nephritis. One of three explanations is possible: (1) The 
suprarenal hyperplasia may be the cause of the hypertension and inde- 
pendent of the nephritis; (2) the suprarenal hyperplasia is the cause of 
the hypertension, but it is produced by the nephritis; (3) the supra- 
renal hyperplasia is a reaction to the chronic auto-intoxication provoked 
by the nephritis, along with hypertension, but is not the cause of the 
hypertension. Darre7 shows experimentally that in chronic nephritis 
there is, apparently from resulting intoxication, hyperplasia of the 
cortical portion of the suprarenal gland, with an apparent increase 
in function. This function Darre regards as an antitoxic one. These 
observations do not settle the question as to a possible relation between 
1 Virchows Archiv, 1907, Band clxxxviii, 527. 
2 For a resume of the subject see Senator, Deutsch, med. Woch., 1903, xxix, p. 1. 
3 Revue de Med., 1903, xxiii. 4 Brit. Med. Jour., 1876, i. 
5 Des Modifications du Foie consecutives aux Alterations Renales, Paris, 1907. 
6 La Semaine Medicale, 1907, No. 20. 
7 De Vinfluence des alterations du rein sur les glandes surrenales, These de Paris, 1907. 900 
DISEASES OF THE URINARY SYSTEM 
the hypertension of nephritis and the suprarenal. The hypertensive 
element of the suprarenal is supposed to emanate from the medullary 
rather than from the cortical portion. 
Wiesel,1 however, has found medullary hyperplasia in the adrenal in 
a case of subacute nephritis. He does not, however, interpret this as 
necessarily the cause of hypertension, but rather as a possible result or 
concomitant of cardiac hypertrophy. 
Symptoms.-Chronic interstitial nephritis is often entirely unsuspected 
until some sudden uremic outbreak, or perhaps an apoplectic seizure, 
leads to an examination of the urine; or the disease may be accidentally 
detected in the course of a life insurance examination, the applicant 
regarding himself as in perfectly good health and being entirely free 
from symptoms. On the other hand, the disease may, for a long time, 
be rich in symptoms and the cause of years of ill-health and semi- 
invalidism. There is no one type of the malady. The picture presented 
is a bizarre one and subject to great variations. 
The onset is generally insidious, therefore the date of its inception is 
unknown. What may perhaps be called a typical case is seen in one of 
middle years, who begins to fail somewhat in strength, is annoyed by 
headache or dizziness, has anorexia and other dyspeptic symptoms. 
Possibly he has noted a little polyuria, and has remarked that he is 
obliged to rise frequently at night to empty the bladder. For these 
rather indefinite symptoms he consults a physician, who finds him slightly 
anemic, with a heart enlarged, with blood-pressure high, and with the 
urine increased in amount, of low specific gravity, and containing a trace 
of albumin with a few casts. Possibly at this time retinal changes may 
be noted. (Edema is conspicuously absent. The disease, however, in 
spite of care on the part of the physician and the patient, makes steady, 
although perhaps very slow, progress, with many ups and downs. Later, 
evidence of cardiac incompetence is manifested, with the usual dyspnoea, 
palpitation and oedema; this failure on the part of the heart, uremia, 
or possibly cerebral hemorrhage, may be the cause of death. But as 
has been said, there are many variations, and with the multiform mani- 
festations of uremia, the numerous sequelae of cardiovascular incom- 
petence, the frequent intrusion of complicating maladies, the possible 
combinations are almost numberless, so that any clear-cut clinical 
picture of the disease cannot be drawn. The conditions that stand out 
most prominently and that form the basis of the diagnosis are the cardio- 
vascular changes, the urinary findings, and the uremic manifestations. 
The Urine.-Just when the urinary changes begin to manifest them- 
selves is seldom definitely known, but by the time a diagnosis of the 
disease is possible the urine, as a rule, shows the following characteristics: 
It is increased in amount, from 2000 to 4000 cc. being commonly passed 
in twenty-four hours, although much larger amounts are not infrequently 
seen. The nocturnal urine is often greatly increased in amount. Even 
before polyuria is manifest, frequency of urination may be noted. To 
this frequent urination Dieulafoy has given the name pollakiuria, and 
1 Wiener med, Woch., March 30, 1907. 901 
CHRONIC INTERSTITIAL NEPHRITIS 
he believes that it often precedes a polyuria. He further says that 
this pollakiuria is sometimes, particularly in women, or where it is a 
late manifestation, attended with considerable pain. As a rule, when 
there is an increased amount of urine, together with an increase in the 
frequency of micturition, the amount passed with each emptying of the 
bladder is considerable, although in some instances the product of each 
micturition is no more than is usual, or it may be even rather small in 
amount. Such frequency of urination is often noted at night, and when 
it occurs in a man beyond middle years may be wrongly looked upon 
as due to irritation from an enlarged prostate gland. 
The urine is light in color, slightly acid in reaction, and the specific 
gravity less than normal. Specific gravities of 1005 to 1015 are very 
common. This low specific gravity, as Traube demonstrates, is not 
influenced so much by profuse sweating, diarrhoea, and vomiting as is 
the urine of health. Seldom even when congestion is added by reason 
of a weak heart has the urine a specific gravity over 1016, is it dark 
colored, or has it a rich sediment of salts (Stern). The total amount 
of solids for the twenty-four hours may be practically normal. The 
percentage of solids, in a single specimen, is naturally low. When the 
heart fails, and blood-pressure is lowered, the total amount of urine 
is usually diminished, and with this there is a decrease in the total amount 
of solids. The sediment, even when the urine has stood for a long time 
or has been centrifuged, is quite scanty. In this sediment a few crystals 
of calcium oxalate or of uric acid may be found. Examination also 
shows a few epithelial cells, a few hyaline or granular casts of varying 
size, and an occasional leukocyte, many being lymphocytes,1 with perhaps 
a few stray red-blood corpuscles. 
The amount of blood, however, may be much greater. Larger amounts 
of blood occur with an acute exacerbation. Sometimes a tendency to 
recurrence of hemorrhages is seen. The exact relation of some cases of 
so-called essential hemorrhage from the kidney, or renal hemophilia, 
to chronic nephritis is not clear. Israel2 and Askanazy3 think paroxysmal 
congestive attacks will often explain it. Kusomoto4 finds rupture of 
vessels in the renal pelvis as the cause. Many writers of late believe 
not a few of the supposedly essential hemorrhages-hemorrhages with- 
out anatomical lesion-would prove to be, if studied more carefully 
as to cardiovascular findings, retina, casts, and the subsequent history, 
instances of chronic nephritis. Many such hemorrhages are from one 
kidney, and cease under nephrotomy.5 Kapsammer6 also speaks em- 
phatically against an essential hematuria; there is always some lesion, 
he says, often a chronic nephritis. 
There is no question that occasionally patients with chronic interstitial 
1 Cf. Senator, Virchows Archiv, Band cxxi; also Schntitgen, Berliner klin. Woch., 
1907, No. 45. 
2 Mitt. a. d. Grenz, d. Med. u Chir., 1900, 471; also Deutsch, med. Woch., 1902, No. 9. 
3 Zeit.f. klin. Med., 1906, Iviii, 145. 
4 Deutsch. Arch. f. klin. Med., Ixxxix, 405. 
5 Cf. H. A. Fowler, New York Medical Journal, November 25 and December 2, 
1905, with extensive bibliography. 
6 Nierendiagnostik und Nierenchirurgie, Wien, 1907, ii, 338 902 
DISEASES OF THE URINARY SYSTEM 
nephritis pass urine which is free from albumin. Postmortem, the renal 
lesion may be sufficiently distinct, yet no albumin and no dropsy have 
been noted during life (Stewart). These cases are, however, quite rare, 
and many of the instances in which chronic interstitial nephritis has 
been diagnosed, but no albumin found in the urine, are cases of arterio- 
sclerotic kidney. Yet in some patients who have unmistakable primary 
chronic interstitial nephritis albumin may be absent after periods of 
prolonged rest, as, for instance, in the urine passed on first rising in the 
morning. Nearly always there is serum albumin, very often but a 
faint trace. The total amount for twenty-four hours is usually from 
one to five grams. Later in the history of the disease, and particularly 
when there is beginning failure on the part of the heart, the amount of 
albumin is decidedly greater, and in many instances the amount varies 
very much, being greater when there has been overeating, undue excite- 
ment, exposure to cold, etc.; and with exacerbations the amount of 
albumin will very materially increase. So, too, the albumin is often 
very considerable because the case is, as has already been stated, 
rather one of chronic diffuse nephritis than in the stricter sense one of 
the interstitial variety. Albumose is occasionally present in considerable 
amounts. The exact significance of this is not clear. It is said in some 
instances to precede the appearance of albumin in the urine in chronic 
nephritis. The molecular concentration of the urine is diminished; the 
freezing-point is, therefore, nearer 0° C. than normal. 
In the arteriosclerotic kidney the urine may be free from albumin or 
show albumin only occasionally. The urine is, however, usually increased 
in amount, with the specific gravity nearly normal or slightly less than 
normal. With the centrifuge a few casts can usually be found. Excess 
in food, exposure to cold, overindulgence in drink, may cause an increase 
in the casts and a small amount of albumin to appear in the urine. 
Cardiovascular Changes.-The exact time at which the changes in 
the heart and vessels begin is seldom known in a given case. Senator 
is firm in his belief that he has seen albumin in the urine with polyuria 
for a long time before cardiovascular changes have made their appearance. 
In practice, however, it is a rare thing to find a case of chronic interstitial 
nephritis permitting of diagnosis in which the cardiovascular changes 
are not more or less well pronounced. The importance of recognizing 
these changes cannot be overestimated. It has frequently been said, 
and with much truth, that the cardiovascular changes in chronic inter- 
stitial nephritis are of fully as much importance from the standpoint of 
diagnosis as the study of the urine. 
The heart is increased in size and may be truly "bovine." The 
enlargement is chiefly in the left ventricle, the apex being displaced 
downward and to the left. The right heart may be pushed to the right 
so as to simulate enlargement, or later there may be a real enlargement 
of the right ventricle, that is, a general cardiac hypertrophy. False 
conclusions may sometimes be reached as to the existence of cardiac 
hypertrophy because of emphysema, which may conceal the true size 
of the heart. The apex impulse is usually strong, rather diffuse, and 
heaving. The first sound at the apex may be loud and booming, although 903 
CHRONIC INTERSTITIAL NEPHRITIS 
it is sometimes muffled. The closure of the aortic valves is accompanied 
by an accentuated, ringing tone, and the shock of the closure may often 
be palpated. With the greatly enlarged heart the point of maximum 
intensity of the aortic closure sound is often a little lower down and 
closer to the midsternum or even to the left sternal border than is 
normal. In many cases the loud, ringing, aortic closure is quite plainly 
heard at the apex. All these signs undergo many modifications when 
dilatation has occurred. Then the impulse of the heart may be feeble 
and wavy; the murmur of mitral regurgitation develops at the apex; 
gallop rhythm, doubling of the first tone, embryocardia, extrasystole, 
may also appear, and naturally dyspnoea, cyanosis, and dropsy are also 
manifest. In fact, a difficult problem is presented to the physician, if 
he happens to see the patient for the first time late in the course of a 
chronic interstitial nephritis, to tell whether the disease is primarily car- 
diac or renal. At this time a presystolic murmur somewhat like that of 
mitral stenosis is said by Bradford to be present. 
The peripheral vessels generally show changes. The arteries are 
tortuous and the walls frequently thickened. The blood-pressure is 
increased and the tension is high. The pulse may have a hard, incom- 
pressible, cord-like feel. It is difficult to estimate accurately the blood- 
pressure by the finger alone, as is proved by the use of the sphyg- 
momanometer. Systolic blood-pressures in chronic interstitial nephritis 
are very frequently over 170 mm. Hg., and in the more serious cases 
and late in the history of the disease the pressure rises to 220 or even 
considerably over this. Sphygmographic tracings generally show a 
rather gradual ascent and a blunt or square apex. With a failure of 
the heart there is naturally a fall in blood-pressure. The pulse under 
these circumstances will be smaller and is frequently irregular. Some 
phenomena of nephritis depend in part, at least, on this high blood- 
pressure, on the hypertrophy of the heart and the degenerative changes 
that have taken place in the vessels. Among these might be mentioned 
headache, dizziness, and hemorrhages. 
Uremia.-For many of the phenomena of chronic interstitial nephritis 
an explanation is offered by uremia. These toxic symptoms may be 
mild and of long standing, the so-called chronic uremia; or they may be 
brusque in their onset and malignant in their severity, as in sudden 
severe headaches, convulsions, and fatal coma, the acute uremia; though 
there is no special gain from the attempt to draw a very sharp- 
an artificially sharp-line between the acute and chronic uremic 
phenomena. 
One hardly knows where to begin the description, for in practice 
patients come to the physician with a most promiscuous variety of 
complaints, one organ or system of organs showing perversion of function 
in one individual, another in other. One patient consults his physician 
because of dyspepsia, or it may be for pruritus, poor vision, headaches, 
dizziness, diarrhoea, cough, dyspnoea, or nosebleed. Many come because 
they are "run down." They have lost in vitality, lack energy, seem 
listless, cannot endure physical or mental strain as formerly, and have 
lost in weight. This condition, due to chronic intoxication, is revealed 904 
DISEASES OF THE URINARY SYSTEM 
not alone by these subjective complaints but by the examination of 
the patient. He appears worn, tired, often anxious. He shows some 
emaciation. His color is pale or sallow, at times cachectic enough to 
make one fear the existence of a malignant growth. 
The blood shows an anemia of the secondary type, and the hemoglobin 
is often around 60 to 70 per cent. Hydremia is rarely present during 
the earlier stages of this form of nephritis, as in other forms of Bright's 
disease, and the specific gravity of the blood will be nearly normal. 
Late in the disease, when the heart has failed, the blood condition is 
more of a mixture of anemia, hydremia, and cyanosis. The freezing- 
point of the blood is generally normal, -0.57° C., until late, when 
severer uremic symptoms appear; then it is lower, -0.59° or -0.61° C. 
The blood contains a pressor substance regarded by some-Schur and 
Wiesel,1 Ehrmann2-as adrenalin, though Schlayer3 says more proof 
must be offered that the substance in the blood with the hypertensive 
and mydriatic qualities is really adrenalin, and brings forward some 
experimental work that seems to go far toward disproving the identity 
of this substance and adrenalin. In the later stages of the disease, 
when the patient has suffered for a long time from gastro-intestinal 
disturbance, such as nausea and vomiting, from dyspnoea, pain and 
loss of sleep, and when the heart's action is poor, the evidence of mal- 
nutrition is often very pronounced, and the sallow, haggard, emaciated, 
bedridden patient, with his anxious look, dyspnoea, tortuous, visibly 
beating temporals, makes a picture showing the ravages of a disease 
as relentless in its progress and as destructive of health as carcinoma or 
tuberculosis. And yet it is remarkable how, early in the disease, many 
persons, and especially adults, may for years preserve an outward appear- 
ance of health, florid countenance, with firm musculature, springy step, 
and active mentality. Some are plethoric and corpulent. 
Digestive disturbances sooner or later make their appearance. A loss 
of appetite, distress after eating, flatulence, coated tongue, occasional 
feelings of nausea, are common complaints even early in the course of 
the disease. Later, all these symptoms become aggravated. At times 
vomiting may come on in a manner almost explosive, much as in cases 
of cerebral disease, and in some instances it may be a question how 
much of the nausea and vomiting is due to central irritation, "nervous 
vomiting," so-called, and how much is due to a local condition of chronic 
gastritis that so often accompanies a nephritis, or to local irritation 
from the attempt on the part of the body to eliminate urea or its decom- 
position products, and perhaps other urinary constituents through the 
avenue of the stomach, i. e., vicariously, for the kidney. Epigastric 
pain may be complained of; hiccough may be annoying. At times a 
severe stomatitis is seen, and salivation is sometimes disturbing. Thirst 
may be extreme, especially when there is marked polyuria. The fetid 
odor to the breath is at times so pronounced and so characteristically 
urinous (ammoniacal; trimethylamin, Senator) as to be of suggestive 
1 Wiener klin. Woch., 1907, No. 23. 
2 Archiv f. exper. Pathol., Band liii. 
3 Deutsch, med. Woch., November 14, 1907. 905 
CHRONIC INTERSTITIAL NEPHRITIS 
help in diagnosis. It is usually an indication of extreme toxemia and 
is of bad prognostic import. 
The bowels may be constipated or may continue regular. Yet looseness 
of the bowels is apt to occur as a sequel to the faulty gastric digestion 
just mentioned. Diarrhoea independently of a disordered stomach may 
be annoying and weakening. Diarrhoea in general is to be regarded as 
due to toxemia, to the chronic catarrhal inflammation of the mucosa 
so common in nephritis, as secondary to gastric disturbance, or as the 
result of local irritation due to efforts at vicarious elimination on the 
part of the intestine. At times the stools are more frequent at night 
than during the day. The presence in the intestine of the so-called uremic 
ulcer may explain an intractable nephritic diarrhoea. 
Respiratory symptoms are not infrequent. Catarrhal bronchitis is 
common, with exacerbations in cold weather and with failing heart. 
Dyspnoea in contracted kidney is common, although the pathogenesis 
is by no means simple. In some instances a more or less continuous 
dyspnoea is present, yet aggravated by exertion, seemingly a dyspnoea 
partly uremic, yet in a measure cardiac. Again, it seems wholly cardiac, 
and is noted only on exertion, the heart being incompetent when any 
unusual demand is made upon it. Most characteristic, however, is a 
dyspnoea that is paroxysmal and very often nocturnal. The sufferer 
is wakened with a feeling of oppression and weight in the chest, some- 
times a distress that is painful and almost anginal in nature. He sits 
up in bed and leans forward, in order to breathe the more easily. His 
labored breathing is as in asthma, the piping and whistling sounds being 
made out on thoracic auscultation, or even heard at a distance. The 
attack may be over in a few minutes, to be repeated later in the night. 
Sometimes relief comes with the raising of thick mucus or a thinner 
watery fluid from the bronchi. What part is played by the heart in 
these cases, what by spasm of the bronchioles excited by toxins, what by 
the central nervous system irritated by the uremic poison, is not clear. 
It is often spoken of as a " cardiac asthma," occurring in the course of 
chronic interstitial nephritis when the heart is on the verge of failing. 
But the uremic element cannot be eliminated in many cases. 
Somewhat resembling the asthma-like paroxysms and sometimes 
complicating them is a sudden acute oedema of the lungs. Dyspnoea is 
extreme, cyanosis is marked, and the pulse may grow feeble. The chest 
shows fine and coarse rales of every description, although chiefly of the 
moist variety. There is a persistent cough and an abundant, foamy, 
serous sputum, often bloody. In how far this condition is congestive 
and due to a weak heart, how far uremic-toxic or even inflammatory, 
is not clear. It is at times a serious condition and may be an immediate 
cause of death. An acute oedema of the glottis may also occur, even when 
oedema is not present in other parts of the body. This may be so threat- 
ening as to demand tracheotomy or other radical measures for prompt 
relief, failing which, death may be caused by suffocation. 
When other symptoms of uremia are marked, as when the patient is 
stupid or even comatose, Cheyne-Stokes respiration is often present. 
But it may also be noted at times when the severer uremic symptoms 906 
DISEASES OF THE URINARY SYSTEM 
seem remote. The patient may be feeling fairly well and engaged in his 
regular occupation. The heart muscle, too, may be doing what seems 
to be good and efficient work, yet breathing of this type may be present. 
At times it may precede a fatal result by many months; it may even be 
present for a time and disappear. It is often a cause of no inconvenience 
to the patient; in other cases the periodicity is strikingly apparent to 
the patient, and the deep respirations are quite annoying. 
Among causes of dyspnoea should, of course, be mentioned such 
conditions as complicating pneumonia or pleurisy. An insidious hydro- 
thorax, too, is readily overlooked. This, especially if bilateral, is often 
a cause of dyspnoea; if not the sole cause, at least an auxiliary one. It 
is astonishing how, in some instances, the dyspnoea that has been 
explained and treated on the supposition that it was purely uremic, 
cardiac, or central, disappears when the transudate is removed. Peri- 
carditis or hydropericardium is an occasional cause of dyspnoea. 
Hemorrhages from the larynx or bronchi may occur, and these may be 
but one manifestation of a tendency to bleeding that is more or less wide- 
spread in this disease. In some instances a genuine hemorrhagic diathesis 
seems to develop, with bleeding from the gums, into and under the skin 
(purpura), and from various mucous membranes. Oftener, however, 
the hemorrhage does not seem to depend so much on a general blood- 
change as upon the degenerative alterations of the walls of the smaller 
vessels. Rupture of cerebral vessels is common in contracted kidney, a 
goodly percentage of cases of cerebral hemorrhage being due primarily 
to an underlying nephritis. This may occur even in the young nephritic. 
Nosebleed is very common, and when not clearly explicable on other 
grounds should always lead to an investigation as to possible nephritis. 
It may be slight and oft-recurring. Yet it may be severe enough to 
demand plugging the posterior nares. Strumpell and Senator have each 
seen two fatalities from this form of hemorrhage. Hemorrhage from the 
stomach, the bowel, the uterus, the kidney, may occur. Hemorrhage 
into the tympanic cavity or into the membrana tympani may cause 
deafness; and retinal hemorrhage may cause disturbance of vision. 
These various hemorrhages, while commoner in advanced chronic inter- 
stitial nephritis, may be among the early symptoms. 
The skin shows no characteristic features. Frequently it is dry and 
may occasionally be the seat of various lesions, eczema of various types 
being the one most frequently encountered. Itching is sometimes com- 
plained of, and is to be regarded as of toxic origin, comparable to the 
pruritus of diabetes, jaundice, and Graves' disease. At times the itch- 
ing may be noted early, and it may be so severe as to reach the dignity 
of a serious complication, especially because of its interfering with sleep. 
Pigmentation in nephritis, other than the sallow, cachectic hue already 
described, is relatively rare. Deposits of urea on the skin have been 
from time to time reported. Bartels1 saw the hairs of the beard covered 
with crystals of urea. In another instance, two days before death, he 
saw the face and the skin of the trunk covered with the same crystals. 
1 Ziemssen's Encyclopedia, American translation, xv, 430. 907 
CHRONIC INTERSTITIAL NEPHRITIS 
A sensitiveness to cold (cryesthesia) is regarded by some as unusually 
common in nephritis. So also the paresthesias described as tingling 
and numbness, especially in the fingers and toes ("dead fingers," doigt 
mort), are often present in this disease. They are not, however, peculiar 
to it, being seen in other anemic, cachectic states. 
The rarity of oedema in chronic interstitial nephritis has been mentioned. 
The oedema of cardiac incompetence very often appears late in the 
disease. Not infrequently one sees a case that is clearly of the type of 
the chronic interstitial variety in all respects save perhaps a little oedema, 
yet there is this one indication that the pathological process in the kidney 
is, after all, a diffuse one. (Edema in contracted kidney may be due also 
to an acute or subacute exacerbation of the nephritis. 
The nervous symptoms in chronic interstitial nephritis are in number 
legion, in their variety protean. Nearly all of them may, however, be 
regarded as toxic or hemorrhagic. The chronic degenerative and sclerotic 
lesions of the central nervous system are seen with comparative rarity, 
and acute inflammatory processes are due to complications. 
The symptoms of toxemia may show themselves in mild manner and 
for months or years, their manifestations being so slight and the increase 
in severity so gradual that the patient is hardly aware of the fact that 
he is in ill health. Yet on analysis of the testimony of the patient and 
his observing friends it will often be found that for some time there 
have been noted an easy mental fatigue, a lack of power of concentra- 
tion and of the former quick grasp of business affairs; sleep may be poor, 
or the patient is drowsy during the day. He wakes in the morning with 
a headache, is annoyed at times by a full feeling in the head or by transient 
dizziness. He grows irritable or morose. He tries dieting, takes a short 
vacation, uses laxatives and tonics, but obtains only temporary relief. 
During the further course of the disease these symptoms may become 
more pronounced. Conditions of semi-stupor may be present for days, 
or there may be periods of excitement. While delirium and mania are 
oftener seen late in the disease, they occasionally break forth rather 
abruptly when the patient seems to be doing well, or possibly before 
the individual regards himself as a patient, before he has noted symptoms 
of gravity sufficient to induce him to consult a physician. Delusional 
insanity (folie Brightique) is occasionally met with, and the delusions, 
e. g., of persecution, may be so extreme as to make it necessary to place 
the patient under restraint in an asylum. True melancholia is not 
encountered so often. 
Many nephritics are great sufferers from pain. Pain in the back, 
popularly regarded as so frequently an indication of Bright's disease, 
is a very rare complaint. A rare occurrence is colicky pain in the renal 
region often radiating along the ureter, as in true calculous renal colic, 
and accompanied by hemorrhage, often profuse. Blood-clots passing 
down the ureter explain the pain in some cases. In others, the explana- 
tion is probably that of Israel and of Askanazy, that both the hemorrhage 
and the colicky pain are to be ascribed to paroxysmal congestion. 
Neuralgias in the peripheral nerves may be the cause of pain, and 
peripheral neuritis is sometimes clearly demonstrable in these cases. 908 
DISEASES OF THE URINARY SYSTEM 
But the most frequent form of nephritic pain is headache. It may come 
on insidiously, but the attacks of pain grow more severe and more 
frequent. It may be like migraine in its periodicity and its hemicranial 
limitation. It is variously described by patients both as to its location 
and its character. The resemblance to cerebral tumor in some instances 
is worth noting. The severe headache, accompanied as it often is with 
nausea, vomiting, dizziness, and perhaps some mental disturbance, may 
resemble the symptom-complex of tumor of the brain, especially when 
an inflamed and swollen optic disk is discovered. 
Headache is such an ordinary every-day occurrence that familiarity 
breeds contempt concerning it. No persistent headache should pass 
without a careful urinalysis, and one should be especially suspicious of 
those headaches that make their first appearance at about the age of 
forty years, and suspicious also of a sick headache that, instead of growing 
better at about the age of forty-five years, continues with its old severity 
or even grows worse. The headaches of nephritis go far to explain the 
loss of sleep and irritability in some of these sufferers. 
The paresthetic sensations sometimes described have been mentioned 
in discussing the cutaneous manifestations-the dead fingers, the itching, 
cryesthesia either on contact or without, a sense of an "electric shock" 
especially just as one is falling off to sleep. Cramps in the muscles, 
especially those of the calf of the leg, are often annoying. At times the 
frequent recurrence of these cramps and their painful character seriously 
interfere with sleep, for they are prone to appear at night. 
The so-called uremic palsies are pareses or paralyses that may resemble, 
in their sudden onset and involvement of one-half the body, a hemiplegia 
from hemorrhage. But the paralysis is more commonly short-lived, 
lasting perhaps but a few seconds, minutes, or hours, and it usually is 
much more limited than to one-half the body, involving only an arm, a 
leg, or one side of the face. Transient aphasia is noted occasionally, 
or a deafness, or diplopia due to paralysis of some of the ocular muscles. 
These are comparable to the sudden transient blindness, the uremic 
amaurosis, and like it are central in origin, due to local cerebral oedema, 
or local concentration of the action of toxins on some motor centre, with 
temporary loss of function of a limited area of the brain. Minute hemor- 
rhages or areas of acute softening may explain some of these cases. 
Why uremic convulsions sometimes occur in such a sudden manner, 
unheralded by warning symptoms, is not clear. Apparently there is a 
cumulative action of the toxin, as is seen in the case of certain drugs; 
similar cumulative action is seen in lead poisoning. Usually premonition 
of trouble is given by severe headache, vertigo, nausea, dimness of vision, 
epigastric pain, and perhaps a rise in blood-pressure. The patellar reflex 
is generally exaggerated under these circumstances.1 
When a convulsion occurs there is seldom any aura, as in epilepsy, 
nor is there the cry so often heard in that disease. The eyes roll upward 
and usually to one side, the pupils dilate, and for a moment the patient 
seems gazing with a fixed stare into distance. Then a jerking of the angles 
1 Lion, Zeit. f. klin. Med., 1, 257, and Stevens, British Medical Journal, 1904, ii CHRONIC INTERSTITIAL NEPHRITIS 
909 
of the mouth is seen, the head draws to one side, the muscles of the face 
and neck become clonically convulsed, the fingers and arms are flexed 
and likewise convulsed, and soon the entire musculature of the body is 
in irregular, jerky, violent motions. The face becomes livid or purple; 
foamy saliva issues from the mouth, and it may be streaked with blood 
that comes from a bitten tongue. The pulse grows rapid and weak, 
perhaps irregular, during the seizure. There may be involuntary evacua- 
tion of urine and feces. A few seconds or minutes are consumed by the 
attack, which ends with a quieting of the muscular spasm, a deep-drawn 
inspiration, and a rather prompt recovery of consciousness. If, however, 
the patient has been in a stupor or coma preceding the convulsion, or 
if the attacks are frequently repeated, sleep, stupor, or deep coma will 
follow. Usually the patient is somewhat dazed for a time, and knows 
little more of the attack than that "something has happened." When 
attacks are repeated at short intervals the temperature often rises and 
preagonal temperatures of 105° F. or over are not unusual. The pulse, 
after frequently repeated convulsions, becomes rapid and weak. 
Convulsive seizures, in which the cerebral irritation is localized and 
the spasms of the Jacksonian type, are sometimes seen. Often slight 
jerkings or twitching of the muscles may be noticed, and may be the 
cause of considerable annoyance to the patient, who tries to keep the 
muscles still. Nystagmus, local tremor, local clonic muscular contractions 
are sometimes apparently due to this same local cerebral irritation. 
Death may occur in coma without convulsive seizures. Oftener coma is 
preceded by convulsions or by the long train of symptoms that make 
up the dismal picture of chronic uremia, months or years of malaise, 
loss of strength, dyspepsia, headache, recurrent vomiting, fetor ex ore, 
insomnia, dyspnoea, epistaxis, polyuria, mental depression, the gradual 
cutting off of one business care after another, semi-invalidism, confine- 
ment to the house, then to the chair, and finally to the bed. Coma coming 
on under these circumstances is usually fatal. 
The special sense organs may show anatomical changes or disturbances 
of function, none of which, however, may be called really characteristic 
except those of the eye. Taste is at times perverted, but seldom more so 
than in other severe intoxications. A loathing for food, a coated tongue, 
a fetid breath, are often coupled with the statement on the part of the 
patient that "food does not taste good" or things taste wrong. Com- 
plaints are occasionally heard of inability to smell or of disagreeable 
odors when none are about. 
Hearing is usually good. But there is often a ringing in the ears that 
is out of all proportion to the degree of anemia present, and that is to be 
viewed as toxic. Deafness, partial and transitory, may occur, comparable 
to the amaurosis and uremic palsies, and apparently due to disturbance 
of the auditory centres. Hemorrhage into the middle or inner ear is 
occasionally the cause of deafness, and a vertigo resembling that of 
Meniere's disease has been described (vertigo Brig lit iquef 
The ocular manifestations of chronic interstitial nephritis are common. 
For this reason and because of certain features that are peculiar, they 
deserve to be considered from the point of view of diagnosis as of the 910 
DISEASES OF THE URINARY SYSTEM 
first rank. Often, indeed, the diagnosis of this form of renal disease is 
first made by the oculist, or the crucial test is the finding on examination 
of the eye. While the retinal changes are the most characteristic, other 
subjective and objective symptoms are worthy of note. 
The amaurosis comes on, as a rule, suddenly, may be complete or 
partial, is bilateral and commonly transitory, lasting but a few minutes, 
or at most a few hours. Retinal examination in these cases shows 
nothing to explain the blindness which is central in origin. 
Diplopia due to uremic palsy of some of the ocular muscles is occa- 
sionally seen. So, too, are conjunctival and palpebral hemorrhage. 
While oedema is not at all characteristic of this particular form of 
nephritis, the watery eye, "Bright's eye," so-called, may be observed. 
Exophthalmic prominence of the eyeball-unilateral or bilateral-is 
comparatively common. Insufficiency of the external muscles of the 
eye, emaciation of structures about the eye, undue fulness of the retro- 
bulbar vessels, or rarely a hemorrhage in the orbit help to explain it. 
Retinal changes may produce no disturbance of vision that attracts 
the attention of the patient, and are only discovered as the result of 
routine examination. On the other hand, the lesion of the retina may be 
manifest by marked and sometimes early symptoms. It is particularly 
in patients of this class that the diagnosis of nephritis is made by the 
oculist, who is consulted before the physician. In rare instances these 
ocular lesions have been found before the urinary evidences of a chronic 
nephritis can be made out. The symptoms will naturally vary much 
with the extent to which the retina is involved, and especially with the 
damage wrought in the macular region. Dimness of vision, blurring 
of the outlines of objects seen, an appearance of a mist or veil before 
the eyes are often described. Blind spots may cause the patient uncon- 
sciously to turn the head to one side or the other, so that the light from 
the object looked at may strike the healthy, undamaged part of the 
retina, or he may be conscious of his ability to see much more clearly 
objects located in one position than in another, realizing that he has 
some defect in eyesight. These retinal changes are much rarer in the 
acute or chronic parenchymatous form, and in amyloid kidney unasso- 
ciated with chronic indurative processes they are probably not found. 
With the kidney of pregnancy, especially when it is of rather long stand- 
ing, they are not uncommon. Retinal hemorrhages, too, are found in 
the eyes of those with general arteriosclerosis, where the lesion is to 
be viewed as but one of the consequences of the general vascular dis- 
ease. 
For the rarer changes and for minuter details concerning the retina 
in nephritis, works on ophthalmology should be consulted. Aid must 
frequently be asked of the ophthalmologist in the interpretation of 
ocular symptoms and findings in chronic nephritis. 
The commoner changes in the retina of Bright's disease are whitish 
or yellowish patches, hemorrhages, diffuse retinal opacity from oedema, 
optic papillitis, diffused retinitis, atrophic changes consecutive to inflam- 
mation. Of these six changes enumerated by Gowers, the first three 
are common. Tirard would add to the last three the more uncommon, CHRONIC INTERSTITIAL NEPHRITIS 
911 
the occasional occurrence of extensive retinal detachment, which, of 
course, seriously impairs vision. 
No appearance is more strikingly peculiar than the yellowish or white 
spots that are seen about the disk and macula or scattered more widely 
throughout the retina. The spots may be but minute, glistening dots, 
or they may be larger and represent the fusion of several smaller ones. 
Spots as large as the disk may be seen; these larger ones are more apt 
to be located near the disk, and are thought by some to represent a more 
advanced stage of the degenerative process. Most characteristic is the 
grouping of small spots about the macula as a centre from which they 
radiate, fan-like, in every direction, each ray being made up of a succession 
of these whitish areas arranged as a broken line. The macula may appear 
dark red. At times the whitish areas are scattered so freely throughout 
the retina as to present an appearance as though one had with a fine 
brush spattered white enamel paint over its surface. 
Hemorrhagic extravasations are often present, sometimes with and 
sometimes without the whitish areas. These may be minute dots, larger 
irregular patches, or lines and streaks of blood running beside the vessel. 
They are sometimes "flame-shaped." These hemorrhages are more apt 
to occur in renal disease associated with marked arteriosclerosis, yet 
they are often found in cases of primary chronic interstitial nephritis 
where the sclerosis may be insignificant. The retinal changes of chronic 
nephritis are commonly bilateral. 
In some of these cases the veins are distended, especially distally to 
the point where an artery crosses a vein. These tortuous and distended 
veins are seen also in the cases where there is a neuritis or a neuroretinitis. 
Here the disk is usually slightly reddened and a trifle swollen, or it is 
greatly swollen and its outlines and all its details obscured. The arteries 
are small. Grayish and whitish streaks run out from the disk, the 
contour of the vessels often being lost at this point. Hemorrhages near 
the vessels, close to or at a distance from the disk, may be seen. The 
retina may appear slightly cloudy. 
The essential nature of each of these retinal lesions is not entirely 
clear, although they seem dependent on the degenerative changes in 
the vessels, the high blood-pressure, and perhaps upon the toxemic 
condition, or even in a measure upon the general malnutrition of the 
advanced nephritic. They are generally regarded as degenerative rather 
than inflammatory. These changes in the retina, often collectively 
referred to as albuminuric retinitis, are seen far oftener in advanced cases 
when vascular degenerative, perhaps markedly sclerotic, changes are 
pronounced, blood-pressure high, and toxemia clearly manifest. They 
are rightly looked upon as of bad prognostic import. The observation 
that patients seldom live more than two years from the time albuminuric 
retinitis is discovered has been abundantly confirmed, although there 
are exceptions to this rule. 
It must not be forgotten that retinal appearances much like those 
seen in Bright's disease may be seen under other circumstances. The 
swollen disk of brain tumor, meningitis, and other intracranial lesions, 
as well as of severe anemias, lead poisoning, etc., must be kept in mind, 912 
DISEASES OF THE URINARY SYSTEM 
Nor must it be overlooked that hemorrhages may often be seen with 
the ophthalmoscope in pernicious anemia, leukemia, ulcerative endo- 
carditis, sepsis, the so-called hemorrhagic or purpuric diseases, etc. 
Care must therefore be exercised in the interpretation of the retinal 
condition, and while some of the retinal appearances are almost pathog- 
nomonic, the safer way is to reach a conclusion as to the existence of 
nephritis only after a comparison with the other subjective and objective 
findings, i. e., to make albuminuric retinitis, like albuminuria and cardiac 
hypertrophy, take its place as a confirmatory sign in the symptom- 
complex rather than as an essentially pathognomonic sign. 
Complications.-In the strictest sense, cardiac incompetence and 
dilatation may be regarded as the natural sequences of chronic interstitial 
nephritis. But the failing heart so often dominates the picture and so 
modifies the course of the disease as to justify its being looked upon as 
a complication. True valvular disease from preceding endocarditis or 
sclerotic process is, of course, a complication in the narrower sense of 
the term. In its effects upon the nephritis it is practically identical 
with the secondary dilatation. The basis of the cardiac weakness is the 
exhaustion of the myocardium, which in many instances shows fibrosis, 
largely the result of nutritional disturbances due to sclerosed coronary 
vessels. 
Whether or not such gross or microscopic change in the heart muscle 
can be made out, the heart, although enlarged, finally from overwork 
shows signs of weakness. Dyspnoea is marked upon even slight exertion; 
it may be of the nocturnal asthmatic type already described. There 
is an annoying cough, and cyanosis becomes manifest. The ankles and 
legs show oedema, the liver is passively congested and can be felt below 
the costal arch, tender upon pressure, or causing, even when no pressure 
is made, epigastric and hypochondriac sense of weight or even pain. 
Gastro-intestinal disturbances are more marked and ascites may develop. 
The kidneys show the result of lowered blood-pressure and general 
passive congestion, the urine becoming scantier, of higher specific gravity, 
and containing more albumin and casts. In a word, the picture is cardiac 
rather than renal. The heart's action may be irregular and the pulse small. 
Gallop rhythm is frequently to be noted. Such a complication as cardiac 
incompetence, it is needless to say, is serious, with its possibilities of 
general passive congestion, hydrothorax, extreme ascites, thrombosis, 
or complete failure of the heart. And the danger from severe uremic 
manifestations is increased, as the already diseased kidneys are now 
seriously congested and renal insufficiency is more marked. 
Another complication, besides congestion, that may be engrafted on 
a chronic nephritis is an acute exacerbation of the inflammatory process. 
Sometimes a cause for such exacerbation can be discovered in an exposure 
to cold or damp, overexertion, an acute infection like pneumonia, acute 
bronchitis, or an angina, but often no explanatory cause can be assigned. 
The urine becomes scantier and of higher specific gravity, the albumin 
is increased in amount, and casts are abundant; blood may be present. 
CEdema of the eyelids, face, scrotum, or sacral region may appear. And, 
as in an acute nephritis, there may be anorexia, nausea, headache, CHRONIC INTERSTITIAL NEPHRITIS 
913 
dizziness, etc. Such exacerbations are not uncommon, and easily pass 
for acute nephritis unless the previous existence of the underlying chronic 
trouble is known. Such acute exacerbations may recur from time to 
time and death is not infrequently due to this cause. 
Under certain circumstances hemorrhage is of such a character as 
perceptibly to modify the course of the nephritis or even seriously to 
threaten life. Hemorrhage from the kidney may be of this nature. 
Epistaxis, as already stated, has occasionally proved fatal. The most 
common serious hemorrhage, however, is cerebral. This is usually in 
or near the internal capsule, is like the ordinary "stroke of apoplexy," 
and needs no further word of description. It is well, in giving a probable 
outlook in a case of this form of kidney disease, especially when blood- 
pressure is high and peripheral vessels sclerotic, to remember the possi- 
bility of the occurrence of this vascular accident. 
Catarrhal inflammation of mucous membranes is a very frequent, in 
fact almost constant, occurrence. At times these inflammations are 
severe, and the bronchitis, gastritis, or enteritis may be regarded as 
complicating conditions. These inflammations may be looked upon as 
in part congestive, as in the bronchi, stomach, or bowel, with a failing 
heart; in part they are uremic; in part, perhaps, toxic, in the sense that 
the mucous membrane is trying vicariously to eliminate poisons that 
should be eliminated through the kidney and is irritated by such poisons; 
in part microbic, infectious organisms more readily attacking the mucous 
membranes. 
The serous membranes seem peculiarly vulnerable during the course 
of nephritis. Peritonitis, in the writer's experience, has been extremely 
rare, although mentioned by nearly all authorities as relatively frequent. 
Pleuritis and pericarditis are much more common, though some of 
the cases described as pleurisy and pericarditis are probably instances 
of hydrothorax or hydropericardium. These infections are frequently 
mild, perhaps due to not very virulent organisms, and the resulting 
fever and pain may be slight. In fact, both these complications, par- 
ticularly the pericarditis, are apt to be insidious and to remain latent, 
and they are readily overlooked. The signs of pericarditis are notorious 
for their rapid change in character from day to day. Tirard thinks renal 
pericarditis shows this peculiarity to an unusual degree. 
The lowered vitality of the nephritic makes him particularly liable 
to infectious diseases. Pneumonia is not infrequent (Stewart, 7 per 
cent, of cases). The mortality, however, is not so much higher as one 
might expect, except when the pneumonia-often here a broncho- 
pneumonia-occurs as a complication in the later stages, when cardiac 
and renal incompetency have become marked and when death seems 
not far distant even without the complication. Other infections, such 
as erysipelas, angina, septicemia, may also occur. 
Diagnosis.-Not infrequently there is a disparity between clinical 
diagnosis and pathological findings. Cabot1 and Emerson2 have forcibly 
emphasized this point, making one feel really skeptical regarding our 
1 Jour.-Am. Med. Assn., March 18, 1905 
2 Ibid., January 6, 1906. 914 
DISEASES OF THE URINARY SYSTEM 
ability to make a correct intra vitam diagnosis of nephritis. Some of 
these errors are due to attempts to make a diagnosis with insufficient 
anamnesis; some are merely instances of an unwise enthusiasm that 
induces one to attempt to make a too refined anatomical diagnosis, 
perhaps an impossibility in the particular case. 
Some of these discrepancies are, of course, simply errors or blunders, 
the result of hasty or incomplete examinations by clinician or pathologist. 
The fact that the arteriosclerotic kidney is frequently present, although 
a non-albuminous urine is passed, is often overlooked; or the pathologist 
classes as chronic nephritis what really should be regarded as an arterio- 
sclerotic, atrophic kidney. Again, a small area in the kidney, perhaps 
a small infarcted patch, may be causing a slight albuminuria and cylin- 
druria and lead to the clinical diagnosis of nephritis, overlooked post- 
mortem, and the kidney passed as normal. Albuminuria from a con- 
gested kidney, from an altered blood-state, or from febrile conditions, 
may lead to a mistaken diagnosis of nephritis. Carelessness may also 
lead to misinterpretation of albuminuria due to pus or blood in the 
urine from some cause other than nephritis. Chronic prostatitis must 
be kept in mind in connection with this. 
Painstaking care in examination of patients particularly with reference 
to cardiovascular conditions and careful study not of single but of many 
samples of urine will reduce materially the number of overlooked cases. 
Furthermore, it is often of far greater importance to decide whether the 
kidney is functionally normal than to be able to make a diagnosis that 
is anatomically correct. When after thorough study of a case it is found 
postmortem that there is an unsuspected nephritis, one has simply to 
admit the shortcomings of our means of diagnosis. Non-albuminuric 
nephritis may be more common than has been taught. 
With failing heart, the differentiation from primary valvular, myo- 
cardial, or pericardial disease (adhesive mediastinopericarditis) is not 
always easy, and at times is possible only when one obtains knowledge 
of the previous history. The coexistence of aortic or of stenotic mitral 
lesions with a mitral leak is evidence in favor of organic valvular disease, 
as are signs of adherent pericardium. No test is, perhaps, of as much 
value as the therapeutic one of putting the patient at rest, restricting 
the diet, and administering suitable remedies, such as digitalis, cathartics, 
etc. If under these circumstances the heart diminishes in size, the apical 
murmur becomes louder, and the sound of the pulmonic closure grows 
sharper and more accentuated; and if with these evidences of improve- 
ment in cardiac tone the oedema disappears, the urine increases in 
quantity, the albumin and casts vanish, one may be reasonably certain 
that primary nephritis is not the cause of the cardiac incompetency. 
If, on the contrary, with improvement in the cardiac condition and dis- 
appearance of dropsy the mitral murmur disappears or grows fainter, if 
the aortic closure takes on a sharp, ringing, accentuated character, and 
if the urine increases to more than the normal with a low specific gravity, 
and if casts and albumin are constant, one may conclude that there is 
primary nephritis with secondary cardiac trouble. 
The urine of pure congestion of the kidney is apt to be more reduced CHRONIC INTERSTITIAL NEPHRITIS 
915 
in amount, of higher specific gravity, and to contain a smaller amount 
of albumin and fewer casts than when the congestion is superimposed 
upon a previously existing chronic interstitial nephritis by the failure 
of the myocardium. Even when congestion is added to the chronic 
interstitial nephritis, the amount of urine may remain normal and the 
specific gravity will often be below 1020 or 1018. With the pure con- 
gestion from primary heart disease, the amount of urine is often as low 
as 400 to 800 cc., and the specific gravity is usually 1020 to 1030. The 
absence of albuminuric retinitis and of typical uremic manifestations 
may have some weight in influencing one toward the diagnosis of primary 
cardiac disease. 
The difficulty of diagnosis is also great in many instances of general 
arteriosclerosis with enlarged heart and perhaps a systolic murmur at the 
apex and base from roughened mitral and aortic valves, and with albumin 
and casts in the urine. Differentiation between the primary nephritis 
with secondary arteriosclerotic vascular and cardiac changes may not 
be possible, and in a sense is not always of great practical importance. 
If the facts of the earlier history are obtainable, it may be shown that 
the thickened vessels and enlarged heart were present at a time when 
polyuria and albuminuria were slight and inconstant, and that they were 
marked long before any uremic symptoms were manifest. Albuminuric 
retinitis will be rare, although unilateral retinal hemorrhages may occur. 
Angina pectoris, irregular action of the heart, and evidences of myocardial 
degeneration, are more apt to be prominent symptoms than urinary 
changes or uremic manifestations. 
There is seldom cause for confusion of typical cases of either acute or 
chronic parenchymatous nephritis with the chronic interstitial variety. 
The frequent occurrence of general oedema, the scantiness of the urine, 
its higher specific gravity, the abundance of albumin, the numerous 
casts and the blood, stand in striking contrast to the insidious onset, 
absence of oedema, large amount of pale urine of low specific gravity, 
with but few casts and but a small amount of albumin. In both the 
parenchymatous forms cardiovascular changes are less marked and 
albuminuric retinitis is less likely to be present. 
It is not, however, an easy matter to determine in a given case whether 
there may not be a combination of chronic interstitial nephritis and the 
acute form, i. e., an acute process engrafted on the chronic, a so-called 
acute exacerbation of the chronic. This condition is by no means infre- 
quent. The urine in many respects will resemble that of acute nephritis; 
albumin and casts will be plentiful; blood may be present and the amount 
of urine may be less than normal. (Edema may develop. The existence 
of a long-standing nephritis may perhaps be suspected from the history 
of polyuria, thirst, and palpitation; marked enlargement of the left 
ventricle, sharply accentuated aortic tone, and albuminuric retinitis 
also point in the same direction. Often, too, a low specific gravity, say 
1013, although the other urinary findings are those of acute nephritis, 
will raise the question of the existence of a long-standing chronic nephritis. 
Rest and time may clear up the diagnosis as the acuter process disappears, 
leaving the case a plain one of chronic interstitial nephritis. 916 
DISEASES OF THE URINARY SYSTEM 
It has been stated on a preceding page that in many cases the only 
diagnosis that is justified by clinical and anatomical facts is the diagnosis 
of chronic nephritis or chronic diffuse nephritis. Such a diagnosis seems 
to be warranted when in a chronic nephritic we have the oedema, 
the abundant albumin and casts of chronic parenchymatous nephritis, 
with the cardiovascular changes, the retinitis, the uremia, and some 
of the urinary findings of the chronic interstitial variety. 
Secondary contracted kidney may be recognized if one has had the 
opportunity of watching the patient go through the stage of oedema and 
abundant albumin, and has seen the enlarged heart and polyuria appear, 
with a coincident disappearance of oedema and a lessening in the amount 
of albumin and the number of casts. Without such a preceding history 
the best one can do is to consider the case as one of chronic nephritis, 
differing from the typical contracted kidney only in its tendency to have 
a larger percentage of albumin than normal, the amount of urine being 
not as great as in chronic interstitial nephritis and the casts more 
abundant and darker (Bartels). Some oedema may still be present. 
Pure amyloid kidney may be recognized by the existence of some 
operating cause, such as tuberculosis-particularly chronic excavating 
pulmonary tuberculosis when associated with tuberculosis of the intestine 
-chronic suppurative processes, or syphilis in its later stages. The 
anemia and cachexia of amyloid, the dropsy, the enlarged hard liver 
and spleen, and the frequent diarrhoea from amyloid of the intestine, 
lend color to this diagnosis. The urine is apt to vary from day to day, 
both in amount and in its content of albumin and casts. In general 
it is increased in amount, its specific gravity low, and the amount of 
albumin considerable. Serum-globulin is present in larger proportion 
than in ordinary nephritis (Senator). Cardiac hypertrophy, albuminuric 
retinitis, and uremia are not associated with pure amyloid kidney. In 
some instances postmortem examination has shown amyloid degenera- 
tion in the kidney where a chronic nephritis is also present and where 
during life there has been no thought of amyloid unless the existence of 
tuberculosis, syphilis, or suppuration, or an enlarged spleen or liver has 
aroused suspicion of possible visceral amyloid change. 
The stage of convalescence from an acute nephritis may prove quite 
confusing. Here the urine is often increased in amount, of low specific 
gravity, and the previously large amount of albumin is represented by 
a small amount or a mere trace that may persist for many weeks, as 
may also a mild cylindruria. The preceding history is, when obtainable, 
of great assistance in the diagnosis. The absence of high blood-pressure 
and of enlarged left ventricle, and the tendency for all the urinary abnor- 
malities to disappear speaks for the absence of the chronic process. 
The so-called physiological albuminuria may be mistaken for chronic 
interstitial nephritis, largely because of the absence of oedema and the 
fact that the amount of albumin is usually slight and inconstant. The 
absence of cardiovascular changes, the rarity of casts, the fact that 
polyuria is not noted, should arouse suspicion when this condition is 
found in the young, that the albuminuria may not be due to an incipient 
chronic process. Plenty of time must be taken . . a thorough study of CHRONIC INTERSTITIAL NEPHRITIS 
917 
such a case to determine as to the periodicity of the albuminuria and 
the influence upon it of diet, position, and exercise. The writer agrees 
with Krehl when he states his belief in the existence of a physiological 
albuminuria-using the poorly applied term physiological to mean that 
there is no known anatomical, at least inflammatory, change in the 
kidney-and that complete restitutio ad integrum occurs. The amount 
of albumin in these cases may be considerable. Senator's caution is 
wise and safe when he advises one to view every supposed case of physi- 
ological albuminuria as a possible beginning chronic nephritis, and to 
regard an albuminuria as physiological only when it is transitory, when 
the amount of albumin is small, present in one who has not reached 
adult life, and when it appears only after what may be regarded as a 
physiologically exciting cause, such as a heavy meal, overexertion, etc. 
Albumin due to the presence of blood or pus in the urine ought not 
ordinarily to mislead one to a diagnosis of nephritis. The chemical and 
microscopic proof of the presence of these pathological substances, the 
direct variation in the amount of albumin with the variation in the 
amount of blood or pus, the fact that filtering them out removes all 
or the greater part of the albumin, the absence of casts and of cardio- 
vascular changes and uremia, together with the presence of some cause 
for the hematuria or pyuria, as stone or tuberculosis in the kidney or 
bladder, pyelitis, cystitis, prostatitis, etc., would induce one to recognize 
the albuminuria as the so-called spurious rather than true and nephritic. 
But combinations of the two conditions may be met with, as when a 
nephritic is a sufferer from calculous or tuberculous pyelitis; or the 
case may be one of ascending pyelonephritis, the so-called consecutive 
nephritis. Under these circumstances filtration and removal of the pus 
does not by any means remove the albumin; casts are found, and the 
blood pressure, the retinal findings, and uremic manifestations may give 
evidence of the existence of a true nephritis. 
The thirst, polyuria, and emaciation of contracted kidney may lead 
one to suspect diabetes mellitus. The examination for sugar, with negative 
result, and the finding of albumin and casts make the diagnosis plain. 
A low specific gravity, however, should not lead one too promptly to 
exclude diabetes, for when a diabetic has been drinking large amounts of 
water the specific gravity of the urine, although sugar-containing, may 
be below normal.1 Again, chronic interstitial nephritis may develop 
during the course of diabetes. When this takes place, not only are there 
cardiovascular evidences of this occurrence, albuminuria and cylindruria, 
but the specific gravity of the urine is lowered, perhaps even below the 
normal, and, strange to say, the glycosuria may disappear. This possible 
combination of diabetes and nephritis ought not to be forgotten, nor 
should the fact be overlooked that in some cases of diabetes there may 
be spells of freedom from glycosuria. A similar caution ought to 
be given concerning the misinterpretation of urinary findings during 
diabetic coma. Sugar is occasionally absent during such coma and is 
scanty. A small amount of albumin is common, and hyaline casts may 
1 Cf. Herrick, Amer. Jour. Med. Sd., 1900, cxx 918 
DISEASES OF THE URINARY SYSTEM 
be present in enormous numbers (Kulz's phenomenon). Under these 
circumstances, were one to rely upon the presence of albumin and casts 
alone, the coma might easily be regarded as uremic and the diabetic 
features entirely overlooked. 
A study of the urine for a short time, with the continued absence of 
albumin and casts, the unusually low specific gravity, e. g., 1004, and 
the absence of cardiac, vascular, retinal, and uremic changes, enable one 
to recognize diabetes insipidus. Rarely the two are combined. 
The frequent urination of the man past middle years, particularly 
the frequent nocturnal urination, may be looked upon as due to an 
enlarged prostate, unless the examination of the prostate gland and of 
the urine be made. Enlarged prostate may, of course, coexist with 
the nephritis. A trace of albumin or of nucleo-albumin from an accom- 
panying cystitis may add some confusion to the differentiation. 
Cystic kidneys may cause albumin and high blood-pressure. A careful 
physical examination will enable one nearly always to feel the enlarged, 
perhaps roughened, kidneys. Rarely the enlarged cystic kidney is 
unilateral. Developmental faults, as hypospadias or harelip, are some- 
times found at the same time. 
There| are, of course, numerous errors that are possible when due 
thoroughness is not exercised in the matter of subjective and objective 
examination, the mistakes being made chiefly because striking uremic 
symptoms are looked upon as manifestations of independent diseases, 
or as due to some other cause than the underlying nephritis, which is 
overlooked. Such mistakes are fortunately easily avoidable, the study 
of the urine and of the heart being usually all that is necessary to lead 
to the discovery of the renal mischief. Without going into details, it 
may be well briefly to mention a few of these possible sources of error. 
Among the commoner ones is to mistake as simple gastritis or dyspepsia 
the anorexia, distress from gas, nausea, fulness after eating, epigastric 
pain, vomiting, or perhaps diarrhoea that are evidences of uremic intoxi- 
cation. 
Neuralgias of various types, muscular cramps, or pruritus may have 
their real nephritic significance overlooked unless care is exercised. 
And a mistake that seems to be altogether too common is to misinterpret 
entirely the dyspnoeic, bronchitic, and "asthmatic" phenomena; the noc- 
turnal seizures of dyspnoea are very characteristic, and should always lead 
to a urinalysis. It has been noted that chronic nephritis may resemble 
tumor of the brain, because of the severe headache, vomiting, papillitis, 
and such cerebral symptoms as dizziness, tinnitus, disturbances of vision, 
and possibly even delirium or monoplegia. The urinary and cardio- 
vascular phenomena will put one on the right track. The simulation of 
malignant disease is not very close, yet the anemia, emaciation, local 
gastric disturbances, or perhaps hematuria or melena, may lend still 
further color to this thought. And without the careful examination so 
often referred to, it is an easy matter to regard the often vague symptoms 
of easy tire, nervousness, anxiety, sleeplessness, poor appetite, headache, 
dizziness, etc., as but evidences of physical or mental overwork, or of 
"nervousness," or neurasthenia. The temporary improvement under 919 
CHRONIC INTERSTITIAL NEPHRITIS 919 
tonics, a vacation, or a short trip away from home may be looked upon 
as a proof of the correctness of this view. The routine examination of 
the urine would avoid many a blunder. 
The differential diagnosis between uremic coma, on the one hand, and 
the coma of alcohol, opium, diabetes, and such cerebral condition as 
hemorrhage, embolism, or thrombosis, fracture of the base, meningitis, 
abscess, etc., on the other, might be discussed at length, but seems 
unnecessary, as each case has to be studied on its own merits, and no 
rules or tabular scheme of differential diagnosis will be found to be avail- 
able as an easy or ready-reference scheme of diagnosis. The facts of 
the previous history, when obtainable, are often of extreme value. The 
urine, obtained by catheter if necessary, the high blood-pressure, enlarged 
left ventricle, the tortuous vessels, the slight oedema, the urinous odor 
to the breath, and the albuminuric retinitis are all of immense help. 
The fact that transitory albuminuria may be present after cerebral 
hemorrhage, epileptic seizures, etc., should not be forgotten. And when 
fever and delirium occur with uremia the resemblance to the delirium 
or to the stupor and coma of typhoid or of sepsis may be striking. These 
cases are not so very infrequent. The writer once saw one of the best 
clinicians of Europe trip up on the differentiation between purulent 
meningitis and uremia. Often the diagnosis of uremic coma is to be 
made by exclusion. It is a pretty good rule to diagnose uremia as the 
cause of coma only after one has been able to exclude other causes. 
Possible combinations, such as alcoholism or cerebral hemorrhage with 
uremia, must not be forgotten. 
The toxic condition due to simple anuria, when there is suppression 
of urine, as from obstruction due to a calculus, or following anesthesia, 
presents some differences from that toxemia due to true uremia, i. e., 
nephritis. The fact of such difference has been emphasized especially 
by Ascoli,1 and seems to be at times clearly made out. There is commonly 
less headache, less pain, less intractable vomiting, but rather a gradually 
increasing restlessness, anxiety, sleeplessness, and general weakness. 
The pulse grows weaker. There is early tendency to stupor, and little 
delirium, except toward the last, when the slight mental wandering 
finally merges into a condition of unconsciousness. 
Prognosis.-Chronic interstitial nephritis is to be regarded as an 
incurable disease. Recovery is certainly a rare occurrence. Hospital 
statistics show a frightful mortality from chronic Bright's disease, and 
the cases there seen by physicians or in the clinics by students, are in 
serious condition, and many of them clearly but a short remove from 
death. To get a right view of this matter of prognosis the physician 
must go back to his statistics of the office consultation room, and his 
experience in private practice, and not let the college clinic or the ward 
of the charity hospital appear too prominently in the foreground. When 
this is done he will be surprised to find how chronic interstitial nephritis 
is not necessarily inconsistent with years of comfort, happiness, and 
usefulness, or even with ripe old age. And he learns that while it is 
1 Die Uraemie. 920 
DISEASES OF THE URINARY SYSTEM 
wrong to promise a cure to the individual in whom we find early the 
urinary and cardiac signs of that disease, it is just as wrong to hold out 
to him the gloomy prospect of a complete invalidism and an early 
demise. 
The patient is entitled to know that the progress may in the natural 
course of events be slow, that he is fortunate in having had detected in 
the urine this evidence of weakness on the part of the kidney, that it 
may be his salvation in leading him to regulate more carefully his habits 
of eating, drinking, and working, and result in a decided prolongation 
of life. We must make him realize that a kidney, although hopelessly 
anatomically diseased, may be functionally healthy and for a long time 
able to perform its duty. 
There is no set of rules that can be formulated by which one may 
decide as to the prognosis in a given case. One's experience and judgment 
here play important roles. The case must be considered as a whole, 
and attention not fixed too particularly on the amount of albumin, the 
number of casts, the size of the heart, the condition of the retina, etc. 
One must, in other words, individualize in the matter of prognosis. 
Upon cardiac integrity depends to a great extent the length of time 
the patient can hope to live. Excessive cardiac enlargement with high 
blood-pressure and symptoms, such as palpitation, dyspnoea, etc., lead 
one to fear that cardiac incompetence is imminent. Although rest and 
treatment may for a time restore cardiac tone and bring about great 
improvement in the general condition, the rule is that such a breakdown 
is a sign that the patient is constantly near the danger line, and that 
degenerative changes in the heart muscle are advanced. Intercurrent 
affections and acute exacerbations add to the gravity. 
The so-called uremic phenomena, when they are pronounced and 
persistent and when not evidently due to some acutely or temporarily 
acting cause, are of grave import. Such things as persistent headache, 
nausea and vomiting, loss of weight and strength, and the development 
of the cachectic appearance and signs of malnutrition are of this character. 
A typically " urinous" odor to the breath always seems to be associated 
with the severer and advanced forms of the disease. Personal experience 
with albuminuric retinitis tallies with the traditional fact that such a 
finding is indicative of an advanced kidney disease, and that death is 
seldom delayed more than two years. The urinary findings are rather 
uncertain so far as prognosis is concerned. Relative anuria is often of 
bad import, although it usually depends upon the condition of the heart. 
Toward the end albumin is apt to increase in amount. Cryoscopy of 
the urine unless combined with cryoscopy of the blood gives little help 
in the way of prognosis. Death in the near future is the usual result 
when convulsions or coma occur. 
The outlook in cases of the arteriosclerotic kidney is often grave, 
because of the attendant coronary sclerosis and myocardial degeneration. 
Yet many patients of fifty or sixty lead lives of considerable activity, 
although their vessels and heart show evidence of moderate sclerosis 
and although the trace of albumin and the few casts show that a similar 
condition obtains in the vessels of the kidney. CHRONIC INTERSTITIAL NEPHRITIS 
921 
High blood-pressure, even to 200 mm., is not necessarily indicative of 
immediately impending danger. Patients may carry such a pressure 
for years and enjoy a fair degree of health.1 Of greater significance in 
many cases is change in blood-pressure. A pressure that is seen to be 
going steadily up from month to month, in spite of care on the part of 
the patient and the exercise of his best skill on the part of the physician, 
is naturally a cause for alarm, while one that is stationary or that under 
treatment is lowered to near the normal may make one feel more hopeful 
as to the immediate outlook. Much may be learned also by watching 
the blood-pressure during a period of cardiac incompetence. 
The outlook in a given case often depends much on the intelligence 
of the patient and his willingness and ability, both mental and financial, 
to cooperate with the physician in carrying out treatment. 
The way in which death will come in a given case can seldom be 
predicted. Sudden coma will occasionally overwhelm one who seems to 
be doing nicely. Or one whose subjective symptoms are slight, whose 
blood-pressure does not seem dangerously high, succumbs to cerebral 
hemorrhage. Intercurrent disease, as pneumonia, carries off a consider- 
able proportion. A cardiac death with its dyspnoea and dropsy is reserved 
for a large number, while many die with uremic intoxication. Oftenest, 
perhaps, the final scene is a mixture of the uremic and cardiac, a most 
distressing picture, the only consolation for which is that death when 
it comes seems a relief from almost intolerable suffering. 
Treatment.-Not much is actually accomplished, at least consciously, 
in the way of warding off chronic intestinal nephritis, because little 
opportunity is offered for explicitly advising as to prophylactic measures 
to be carried out for the purpose of guarding against this disease, for 
one is uncertain as to who is "threatened" with it. Yet a timely word 
as to proper modes of living may be of help in this respect in the case 
of individuals in whose families there is a tendency to chronic Bright's 
disease and early arteriosclerosis. Warning may be given the worker 
in lead, the gouty individual, the alcoholic, and the one who is keeping 
pace with his more vigorous comrades in the strenuous life. Changes in 
habits of living in instances of this sort will undoubtedly do good in 
warding off this disease. 
Proper treatment of an acute infection, such as scarlet fever, with 
special watchfulness during convalescence, may prevent the development 
of acute nephritis that might possibly be the forerunner of the chronic 
form. Attacks of acute nephritis from whatever cause, and instances of 
sharp febrile albuminuria, should lead to watchfulness in the future, 
as they possibly indicate a special vulnerability on the part of the kidney. 
One should not neglect conditions that may cause chronic intoxications, 
such as repeated attacks of infectious troubles, malarial fever, oft- 
recurring tonsillitis, nasopharyngitis, chronic suppurative otitis, chronic 
bronchitis, syphilis; and one should also, for the same reason, strive to 
relieve chronic gastro-intestinal disorders. Cystitis and pyelitis should, 
of course, be relieved when possible. 
1 Cf. Theodore Janeway, Trans. Assoc. Am. Phys., 1913, xxviii, 333. 922 
DISEASES OF THE URINARY SYSTEM 
Prophylactic treatment, however, consists largely not in warding off 
the disease but in guarding against its more rapid progress. Great 
good comes from proper advice, properly followed, in the case of the one 
in whom, perhaps accidentally, the evidences of incipient nephritis are 
found in shape of a slightly increased blood-pressure, a beginning thicken- 
ing of the vessel wall, a trace of albumin, or a few casts in the urine. As 
Osler has somewhat paradoxically but happily said, the man of middle 
years whose trace of albumin is discovered is to be congratulated, for 
from this time on, if he be wise, he will be more careful and heed the 
warning, modifying his excesses in eating, drinking, and working. 
The active treatment necessarily implies the removal of the operating 
cause whenever possible. While this cannot always be discovered, and 
may not always be removable, something may at times be accomplished 
in the way of checking the progress of the disease by correcting disorders 
such as those just mentioned. Workers in lead may be instructed as to 
how to live, still keeping at their work, or, as is usually necessary, advised 
to give up this, for them, dangerous occupation. The gouty man is 
given instructions as to diet, the alcoholic warned of the harmful results 
of pursuing his habits of drinking. The man of extreme business activity 
is cautioned against a continuance of his excesses in this line. 
All these directions are, it will be noted, along the line of preventing 
a continuance of the previously operating baneful influences, and to this 
end of sparing the kidney unnecessary work our efforts should from now 
on be directed. In other wTords, the damaged organ must be given rest. 
Diet.-A dietary has to be planned that, while not harmful to the 
kidneys, is palatable and nourishing and will be tolerated for months 
or years. Milk diet alone is here an impossibility. To give enough milk 
to maintain the strength of an adult who is up and about means the 
taking daily of several quarts, and this is not always wise, because it 
adds to the volume of the blood and thus throws extra work on the 
heart; and besides, it increases the demand made on the kidney in the 
way of eliminating water, i. e., it violates one of the rules of rest. The 
protein content of this large amount of milk is also more than is desirable. 
The taking of such large amounts of milk to the practical exclusion of 
other foods soon leads to loss of appetite and to various disturbances of 
the stomach and bowels, with consequent anemia and emaciation. One 
feels like emphasizing strongly the harm done by limiting the food to 
milk alone. 
The protest here is against the diet being restricted to milk alone. 
Against milk as an article of food suitable for chronic nephritis nothing 
can be said. It is nourishing, as harmless in the way of irritating the 
kidney as any other food, and it supplies a needed amount of liquid. 
It may with distinct advantage be given to such a patient, and may even 
be the main article of food for long periods of time. 
Closely connected with the question as to the amount of milk to be 
given is the question as to what amount of liquid should be allowed the 
nephritic. In contracted kidney the necessity for washing out the 
tubules and freeing them from large amounts of debris does not exist, 
nor is there, as" a rule, a demonstrably great failure of elimination of CHRONIC INTERSTITIAL NEPHRITIS 
923 
solids. The total solids for twenty-four hours often reach the normal. 
The necessity, therefore, for the huge amounts of fluids sometimes given 
these patients is not so clear as one might suppose, and a certain 
contra-indication seems to exist, from the fact that these large amounts 
demand extra work on the part of kidney, heart, and vessels, organs that 
one wishes to spare so far as possible. 
The limitation of liquids to one and one-half liters per day, as is 
advocated by some, is perhaps wise, although too arbitrary. This is 
certainly not enough for many individuals. It seems better to allow 
some latitude in this respect, to say that one and a half to two liters 
per day is a fairly average amount, but that a patient's own thirst may be 
a reasonably safe guide unless it lead to extremes, e. g., one to two gallons 
per day. Some patients need explicit directions as to the amount of 
water to be taken; but no hard and fast rule can be given that is applicable 
to all. It is a good plan for all patients who are taking only a fair amount 
of liquid, or an amount that is for them a restricted amount, to take 
occasionally larger amounts, say two to four quarts per day. This plan 
is pursued by many who make trips several times a year to watering 
places. The same plan can be carried out at home by having one day 
a week for a "flushing-out day," a plan advocated by von Noorden. 
This limitation of the amount of fluids has been repeatedly advised 
by von Noorden and his pupils, and is supported by Pel, Koranyi, and 
many others. Some, however, like H. Strauss,1 take issue with von 
Noorden and advise against the too great reduction of fluids, believing 
that the elimination of toxins and the dilution of the blood outweigh 
any supposed danger. 
Alcohol is to be avoided as an irritant of the kidney. Occasionally 
a small amount of wine with meals may be allowed as a stimulant to the 
appetite and an aid to digestion, but the physician who permits this 
should know his patient well and be assured that there will be no excessive 
indulgence. Tea and coffee need not be interdicted. An excessive 
amount, however, may not only injure the kidney directly, but may 
have a harmful influence on the heart, vessels, and blood-pressure. These 
beverages must, therefore, be taken in moderation. The same statements 
may be made concerning tobacco, the excessive use of which is to be 
avoided. 
Rules as to diet2 in this disease must be general and quite flexible. 
Temperance and moderation as to food are to be enjoined. An excessive 
amount of food throws extra eliminative work on the kidney, tends to 
plethora and obesity, thus making unusual demands on the heart, and 
1 Berl. klin. Woch., May 25, 1908. 
2 Fuller details regarding diet in nephritis, and especially the question of meat as 
an article of food in this disease, may be found in the excellent discussion of the topic 
by Leube, in vol. vii of Penzoldt and Stintzing's Handbuch der Therapie; in the dis- 
cussions by Senator, Ziemssen, and others in the Verhandl. des IX Kongresses f. inner e 
Medizin in Wien, 1890, and in papers and discussions by Lepine, Grainger Stewart, 
and others before the International Medical Congress, Berlin, 1900. Diet was dis- 
cussed in the London Lancet, in 1893, by several English writers, among others by 
Hale White, Ralfe, and Donkin. Much interesting clinical experience is found in a 
symposium on the treatment of Chronic Bright's Disease published in the British 
Medical Journal, October 8, 1900. 924 
DISEASES OF THE URINARY SYSTEM 
adds to the danger of disturbing digestion. Simple, easily digested 
foods should be the rule, and these should be taken with regularity, in 
reasonable amount, and without hurry. Rich and highly seasoned foods 
should be avoided. There should be but little used in the way of stimula- 
ting condiments, hot relishes, sauces, pepper, and other spices, mustard, 
radishes, cress, rich or strong cheese. Cakes, puddings, pies, pastry, 
and candies should be eaten sparingly, as disorder of the stomach and 
bowel is liable to follow their too free use. 
The chronic nephritic cannot, without harm, be too long deprived 
of protein. The amount estimated as necessary, about 80 to 90 grams, 
would require the drinking daily of over two liters of milk, or the taking 
of fifteen eggs, or 400 grams of meat. It seems far better to let this 
amount be taken not in the shape of milk alone, nor of meat or eggs, 
but, as a mixed diet, some milk, perhaps a liter, and a moderate amount 
of meat and eggs. Most patients, at least in this country, must be 
restricted very materially in the amount of meat taken, for, as a rule, 
they are heavy meat eaters, many taking it freely three times a day. 
Meat once a day, with an occasional egg, will be found not only not 
harmful, but really of benefit, helping appetite, increasing the strength, 
and improving the condition of the blood. This, with the liter of milk 
and the small amount of protein contained in the other food taken, 
will furnish the amount of albuminous food necessary to meet the 
demands of the body, and to make up for the inconsiderable loss of 
albumin through the urine. Dark meats taken in these moderate amounts 
are not to be regarded as injurious. Whether meat is advised or not 
will naturally depend on whether it is well handled by the stomach and 
bowel. Harm may come from forcing the meat diet when it produces 
gastro-intestinal disturbances. Houghton1 believes that when in the 
course of a nephritis characterized by high blood-pressure there is indican 
in the urine, treatment designed to lessen the amount of protein putre- 
faction in the bowel will have a tendency to lower the blood-pressure 
by preventing the absorption of substances which accumulate by reason 
of the reduced kidney capacity. Temporary removal of meat and eggs 
from the dietary will here be indicated. 
Soups that are rich in meat extractives, such as contain an abundance 
of "stock," should be taken in moderate amounts only. Gruels and 
simpler soups may be taken more freely. Raw eggs are probably more 
harmful than cooked eggs, although Leube2 justly observes that there 
are few people who prefer raw eggs, and believes that the danger from 
taking a few uncooked eggs daily is not so very great. 
To make up the caloric value necessary for an adult, considerable 
carbohydrate and fat must be taken in addition to the protein. Of the 
latter enough is commonly ingested in the form of butter, cream, oil, 
and as a constitutent of some of the other foods. The carbohydrate 
(300 to 400 grams) is supplied by cereals of various kinds, bread, vege- 
tables, especially the young and green vegetables, and fruit. No special 
1 American Medicine, October 7, 1905. 
2 Senator, Berl. klin. Woch., 1882, No. 49; CsAtary, Deutsch. Archivf. klin. Med., 
1891, xlvii, 179; Ott, ibid., 1894, liii, 608. CHRONIC INTERSTITIAL NEPHRITIS 
925 
limitations need be placed as to kind or amount of these foods. Asparagus 
is regarded by some as harmful, although it may probably be taken 
without injury, if not used to excess. 
The dietetic treatment may be summed up in a few words by saying 
that the diet must be a mixed diet from which all highly seasoned, spiced 
foods and alcohol are excluded; meat and other proteins are to be 
taken in moderate or small amounts; cereals, vegetables, and fruits 
freely; the sweets sparingly. Milk is allowed freely, but neither it nor 
water is to be taken in excess. The total amount of food taken should 
not be excessive; the nephritic should not be a "heavy eater." 
physical overexertion is contra-indicated; not only does this act injuri- 
ously on the heart, that must be spared all unnecessary strain, but it 
makes a call upon the kidney to carry off an added amount of debris, 
the result of this excessive muscular exertion. Similarly, mental and 
nervous overwork may have to be curtailed. The keynote to the treat- 
ment in these respects, as in the matter of diet, is moderation. The 
patient with nephritis must have impressed upon him the fact that 
although he may be temperate as regards the use of alcohol, he may 
by intemperance in other respects, food, work, worry, etc., be doing 
himself as much harm as though he were indulging in alcohol to excess. 
Absolute rest in bed is seldom necessary for the patient with chronic 
interstitial nephritis, except during periods of acute exacerbation, 
cardiac failure, or in the later stages of the disease, unless it be, perhaps, 
when the patient first comes under the care of the physician, who may 
then deem it wise, in order to "get a line" on his patient, to put him to 
bed for a few days of careful observation. Physicians at times prescribe 
too much abstention from muscular exercise. The nephritic needs sucb 
exercise. Carefully regulated walking or gymnastics, or in selected cases 
massage, may be of benefit. Even mild and systematic mountain climb- 
ing may not be contra-indicated. It is surprising how, at times, a 
patient who has been confined to the bed or to the house will, on being 
allowed moderate exercise in the open air, show improvement in muscular 
strength, heart tone, blood condition, appetite, and show no harmful 
effects in the work of the kidney as evidenced by the urine. 
But relative rest, as above described, is of great importance. Business 
men must be encouraged to throw off some of their burdens upon younger 
shoulders, and instead of putting new irons into the fire, to take out a 
few. The yearly vacation should be lengthened, and, when possible, 
frequent trips away from business cares should be taken, in which the 
main occupation should be idling, with mild exercise in the way of 
walking, golf, fishing, etc., rather than severer sport. 
This naturally leads one to consider the value of special climates and 
of watering places. The main value of the life at such watering places 
lies in the change from the former routine work of the patient, the rest 
and relaxation in which he indulges, and his greater care as to diet. The 
use of the waters, too, inducing free catharsis and diuresis, is, unless 
long continued or too freely employed, of advantage, giving the patient 
the benefit of the "flushing-out" period, to which reference has been 
made. There is for this disease but little special virtue in any particular 926 
DISEASES OF THE URINARY SYSTEM 
water. In general, the alkaline waters, or, with anemia, the chalybeate 
waters, are to be preferred. Much of the advantage that comes from 
the water cure is dependent on the local conditions that prevail and upon 
the climate. Unless the patient is to have a reasonable degree of comfort, 
at least approaching that of his own home, he might better let well enough 
alone and not leave his pleasant bed and board. Occasionally a plain, 
unvarnished talk with the patient regarding the water cure is advisable, 
for he may have the notion that is quite prevalent that if he can only 
go to this or that spring he will be at once greatly benefited or cured, 
and he is willing to make sacrifice of time, money, and comfort. It is 
due him to know, and a kindness is done by informing him, that a cure 
is not to be looked for, and that more is to be thought of in his going 
to the springs than the water alone; one must look into the matter of 
climate, surrounding country, food, sleeping accommodations, com- 
panions to be met at the resort, possible amusement, etc. 
It is often better to disregard entirely the supposed water-cure feature 
and to have the patient go to some pleasant place or resort for an outing 
and a period of rest. In winter a dry, warm climate is desirable, such as 
that of southern Texas, New Mexico, Arizona, California, Mexico, 
Egypt, southern Tyrol, or the Riviera. In summer a cooler locality should 
be selected, and Canada, Northern Michigan or Wisconsin, the mountain 
regions of New England, New York, Virginia, or Colorado, may be sought, 
where there is the attraction of beautiful scenery and the advantage of 
pure air without too much heat. In the mountain regions mountain 
climbing must be interdicted. He must be advised to guard against 
sudden changes in temperature and unnecessary exposure to cold. 
Woollen underclothing or handy outer garments are great helps in 
this direction. Cold baths are to be avoided and the home physician 
must caution his patient, before he goes away, against the too free use 
of baths often advised because of some supposed curative effect. The 
chronic nephritic, with his heart perhaps on the verge of breaking down, 
is one who must exercise considerable care in the way of taking baths 
which are too prolonged or too hot. 
To the physician having in charge a patient with chronic interstitial 
nephritis there is no problem presented that is more important, yet at 
the same time more perplexing and difficult of solution in the individual 
case than that of how rightly to treat the heart. Cardiac hypertrophy 
and vascular hypertension are salutary conditions, compensating in a 
measure for the renal lesion; blood-pressure must not, therefore, be 
allowed to become too low. On the other hand, extreme hypertrophy 
and excessively high blood-pressure carry with them not only some 
unpleasant subjective symptoms, such as headache and dizziness, but 
constantly threaten such serious accidents as cerebral hemorrhage or 
cardiac incompetence and dilatation. How to steer the safe middle course 
between these two threatening conditions is indeed a perplexing question. 
When the heart has given out and dyspnoea, cyanosis, oedema, and 
the other well-known symptoms and physical signs of incompetency are 
present, the general object of treatment is clearly to relieve the work 
of the overburdened heart as much as possible, and to use means to CHRONIC INTERSTITIAL NEPHRITIS 
927 
increase its efficiency. These patients should be put to bed for several 
days or weeks. The diet should be greatly reduced in bulk, a nourishing, 
concentrated food being taken, such as eggs, cream, or cereals. The 
bowels should be freely opened by cathartics. Digitalis in doses sufficient 
to produce a perceptible impression on the heart should be given. 
No drug is of such value under these conditions as digitalis, and yet 
no drug requires more judicial skill and trained experience for its proper 
use and for a correct interpretation of its effects. The tincture in doses 
of 5 to 15 drops, the infusion freshly prepared from the leaves, 1 to 4 
drams (4 to 14 cc.), or the powdered extract, | gr. to | gr. (gm. 0.013 to 
0.02), are what the writer most often uses. Digalen or digitalin may 
also be employed, particularly when subcutaneous therapy is advisable. 
The results from the former are sometimes excellent. 
As substitutes for digitalis, strophanthus may be employed, and as 
adjuvants, caffeine or strychnine, or when prompt stimulating effects 
are needed, camphor may be employed hypodermically, from 1 to 3 
grains (gm. 0.06 to 0.2) dissolved in 10 to 20 drops of olive oil, being 
injected perhaps several times a day. Venesection is at times of wonder- 
ful benefit under these circumstances; 300 to 500 cc. should ordinarily 
be removed, and occasionally this should be repeated in a few hours or 
more; even 500 to 700 cc. may be taken at the first bleeding. Baccelli1 
has advised a somewhat novel method of bleeding, using the dorsal 
vessel of the foot rather than the veins of the arm, as is common. Ice 
to the precordia may help check excessive palpitation, and morphine 
is often of great help, especially with pain, restlessness and sleeplessness. 
The results from the treatment of cardiac incompetence can seldom be 
predicted. Often the breakdown of the heart is the beginning of the 
end. But it is remarkable how many of the patients whose condition 
seems truly desperate may be pulled together again, and enjoy months 
or perhaps years of comparatively fair health. 
How best to treat the high blood-pressure is a more difficult question. 
When present, the general rules as to diet, exercise and care of the 
bowels must be scrupulously lived up to. It is remarkable what may 
sometimes be accomplished in some of these cases by what may be called 
a temporary starvation plan of treatment, cutting down greatly the 
bulk of food taken, both solid and liquid, and employing concentrated 
but not bulky food, and not too much of that. Blood-pressure will some- 
times under these circumstances be promptly lowered, and a general 
improvement in the condition of the patient will follow. Relative rest 
or perhaps even rest in bed for a time may be important. The bowels 
should be kept open, although not loose enough to make the patient 
feel weak. When the pressure is very high and accompanied by severe 
headache, dizziness, and sleeplessness, bloodletting will often give 
prompt relief for the time being. One may sometimes see marked 
improvement in subjective symptoms and quite a drop in blood-pressure 
follow a spontaneous hemorrhage, such as a nosebleed; and the bleeding 
under these circumstances may be encouraged rather than checked. 
1 II Policlinico, 1907, xiv, p. 18. 928 
DISEASES OF THE URINARY SYSTEM 
Drugs for the lowering of blood-pressure are rather uncertain in their 
results, at least so far as lasting results are concerned. Nitroglycerin, 
gr. to gr. (gm. 0.0006 to 0.0015), will, if given often enough, some- 
times work wonderfully well. It must be given, however, not in any 
fixed dose, but in doses large enough to produce results, at times even 
gr. iV (gm. 0.0025) in one who has become habituated to its use. It is 
too often disappointing, results being nil, or a beating and throbbing 
headache follow the use of even small doses. The nitrites, e. g., nitrite 
of sodium, gr. j to v (gm. 0.065 to 0.32), may be given in solution, the 
physician feeling his way with this remedy as he does with nitroglycerin, 
and always beginning with a small dose; erythrol tetranitrate is a favorite 
with some. Potassium iodide in small doses, gr. v (gm. 0.32), may some- 
times be given with advantage. In fact it seems at times, when given 
for prolonged periods-months or years-to exert a very perceptible 
influence in softening the pulse and lowering blood-pressure, and while 
one must realize that there is danger of serious effects in the way of 
iodism from the giving of too large doses in cases of chronic nephritis- 
the writer has seen a fatal case from such overdosing-one is justified 
in giving the remedy in these small doses and for a long time. It is, of 
course, wise to stop occasionally for a few days during this prolonged 
period, and not to give it without any interruption. The favorable 
effects that are occasionally seen in some cases-not necessarily the 
syphilitic ones-seem unquestioned. It has sometimes seemed that 
good has followed the use of Donovan's solution (liquor arsenii et 
hydrargyri iodidi) in small doses, one drop three times a day. 
There is perhaps a tendency to use the vasodilators too early; although 
blood-pressure may be high, this is not always an indication for the 
immediate adoption of measures for its relief; such high pressure may 
be a compensatory necessity. 
The demands upon the kidney should be as light as possible, not only 
by regulating the kind and amount of food, the amount of physical and 
mental work, as already specified, but by striving to have the skin, 
lungs, and bowels do a part of the work of elimination. This has already 
been discussed in speaking of the treatment of parenchymatous nephritis, 
and need not be repeated here in any detail. Little can be done in the 
way of assisting elimination through the lungs save to keep up the 
action of the heart and to see to it that the patient has plenty of fresh 
air, both day and night. Daily warm or tepid baths should be taken 
to keep the skin in good condition, and those who have always been 
accustomed to the cool morning sponge bath will not be harmed by 
continuing in this way, being careful to avoid too severe or too prolonged 
chilling of the body, and being sure to secure a reaction. Occasional hot 
baths may be taken just before retiring. Sweats are not indicated, as 
a rule, unless uremia is threatening or oedema is marked. When oedema 
is pronounced in this form of nephritis, it is, as a rule, due either to an 
exacerbation of the chronic process or to cardiac weakness. Under the 
latter circumstances sweats are to be used with great caution, for fear 
of aggravating the condition of the heart. The bowels should be kept 
open, although free catharsis is seldom necessary, save when severe CHRONIC INTERSTITIAL NEPHRITIS 
929 
uremic conditions are threatening. Ordinarily, by regulating the diet, 
using plenty of fruit, green vegetables, coarser cereals, etc,, the bowels 
may be made to move daily. When necessary, a morning saline purge 
may be given; or some of the vegetable laxatives, such as cascara, aloes, 
or senna, may be given at night. Elaterium, a brisk calomel purge, or 
large doses of the salines may be helpful when coma or convulsions seem 
threatening or drastic catharsis is for other reasons indicated. Enemas 
may be of service in regulating the bowels. 
Venesection in the case of uremia may be mentioned as an attempt 
to secure vicarious elimination when the kidney is failing in its function, 
as some toxic material is removed in this way. 
Elimination through the avenue of the kidney itself, presumably the 
healthy parts of the kidney, is aimed at throughout the whole course of 
treatment by regulations as to diet and drink, by keeping up the action 
of the heart, by the institution of "flushing-out" days, etc. Special 
efforts, however, are made in this direction by the use of diuretics, when, 
for any reason the amount of urine or its content in solids is deficient. 
Digitalis and caffeine, acting largely through the heart, are of great value. 
Other remedies are the citrate and acetate of potassium and the sodium- 
theobromin-salicylate (diuretin). This latter remedy ought to be given 
fresh, before it has been long exposed to the atmosphere, and unaccom- 
panied by any acid which renders it inert. In doses of 60 to 100 grains 
(gm. 4 to 6) daily it is sometimes an efficient diuretic. Its good effects 
are most often seen when the relative anuria is largely dependent on 
cardiac weakness, with resulting renal congestion. Theocin in doses of 
3 grains (0.2 gm.) will often produce diuresis. Lemonade containing 
cream of tartar may also be used as a diuretic drink. 
Uremia is discussed elsewhere, and only a bare outline of its treatment 
will be given here. As a matter of fact, much of the treatment already 
described is in a sense the treatment of uremia. Should uremic coma 
or convulsions seem to threaten, as shown by severe headache, vomiting, 
sleeplessness or delirium, dyspnoea, muscular twitching, high blood- 
pressure, with irritable heart and perhaps gallop rhythm, vigorous meas- 
ures must be instituted. The patient is kept in bed, the bowels1 are 
opened by a colonic flushing, and a brisk purge of salts, calomel, or perhaps 
elaterium is given. A minimum amount of food is allowed for two or three 
days. Venesection will often give temporary relief, lessening the toxemia, 
lowering blood-pressure, and relieving some of the strain on the heart. 
Venesection may be followed by the use of normal salt solution, given 
subcutaneously, 500 to 1000 cc. Lumbar puncture will sometimes relieve 
symptoms temporarily.1 Just how this is brought about is not entirely 
clear, although the escape of a large amount of cerebrospinal fluid under 
high pressure serves to show that Traube's notion concerning uremia 
has at least a color of truth. Digitalis and caffeine may be necessary, 
or, on the contrary, help may come from nitroglycerin. Morphine 
is often indispensable. It relieves pain, restlessness, insomnia and 
delirium, helps to quiet the action of the heart, and at times actually 
1 See Willson, Jour. Amer. Med. Assoc., July 1, 1905. 930 
DISEASES OF THE URINARY SYSTEM 
seems to promote diuresis. Chloralamide is a favorite sedative with 
many. Convulsions may demand bromide or chloral, although morphine 
is more reliable and no more harmful. Chloroform is indicated when 
convulsive seizures are recurring frequently. 
(Edema in chronic interstitial nephritis is not common. When it 
occurs, it is due either to the weakened condition of the heart, when it 
would be treated in the manner already outlined, or to an acute exacerba- 
tion of the chronic process. Its treatment under this latter circumstance 
is that described under acute and chronic parenchymatous nephritis. 
Complicating conditions, or symptoms that become specially aggra- 
vated, may need special attention. The anemia is often benefited by 
iron. Basham's mixture (mistura ferri et ammonise acetatis) in doses 
up to gss (14 cc.), is a non-irritating preparation that acts also as a 
diuretic. Tincture of the chloride of iron is less easily tolerated by the 
stomach, but when given in plenty of water after meals may be used 
in doses of five to thirty drops. Some regard iron, particularly in this 
form, as having a beneficial effect, not only on the anemia but on the 
nephritic process itself, a belief that is, however, not very widespread. 
The iodide of iron or any of the other preparations, such as Blaud's 
mass, or the scale preparations, may, if preferred, be employed. Anemia 
is also combated by an abundance of fresh air, moderate exercise, and- 
a point of great importance-by seeing that in our endeavors to regulate 
the diet so as to suit it to the nephritic we are not really giving our 
patient food that qualitatively is improper and quantitatively is poor 
in caloric value. Relief of gastro-intestinal disturbances also contributes 
to improve the condition of the blood. Much stress ought to be laid on 
attention to the blood condition, not alone because when anemia is 
marked such annoying symptoms as weakness, dizziness, and palpitation 
become aggravated, but because with impoverished blood the power 
of the body to resist the disease becomes materially lessened, and the 
heart will not compensate as it should for deficiencies of the kidney. 
Careful attention to diet as specified, with the use of cathartics when 
necessary, will keep the alimentary tract in fair condition. In the later 
stages, however, symptomatic treatment will be demanded. Bitter tonics, 
as aids to appetite and digestion, may be indicated. The old-fashioned 
combination of tincture of nux vomica with hydrochloric acid will often 
serve a useful purpose. At times an acid condition of the stomach will 
be relieved by a few doses of soda or magnesia, or the mixture of rhubarb 
and soda. In some instances resorcin will relieve the distress from 
pressure and gas that follows eating. In extreme cases an abstinence 
from food for a day or two, with rectal feeding and enemata of salt 
solution, or the limiting of the diet for several days to the simplest articles, 
such as milk or rice water, will be necessary. Occasionally lavage gives 
relief. Hot applications or mustard plasters to the epigastrium may be 
tried; when nausea, vomiting, and epigastric distress are extreme and 
unrelieved by dietetic measures, the use of stomachics, and aids to 
digestion. Bismuth, oxalate of cerium, drop doses of carbolic acid, 
and various other remedies may be tried to help quiet the rebellious 
stomach, but they are very unreliable. At times very minute doses of CHRONIC INTERSTITIAL NEPHRITIS 
931 
morphine by the stomach may be of service, or, what is better in the 
bad cases, a hypodermic of morphine, giving the patient a quiet sleep 
and freedom, for a few hours at least, from the persistent retching and 
vomiting, following which sleep he may be relieved for a time of the 
severe gastric distress. Diarrhoea is often benefited by giving a sharp 
purge of castor oil, salts, or calomel, followed by some of the vegetable 
astringents, such as tincture of kino. Tannigen in 5 grain (0.3 gm.) doses 
may be of service. Vomiting and diarrhoea may reach a stage where 
they are practically intractable. 
Headache is relieved for a time by not overloading the stomach, 
keeping the bowels open, together with moderate exercise in the open 
air. But these simpler means will not quiet the suffering in the later 
stages. Here bromides may be necessary or an occasional dose of one 
of the coal-tar preparations, e. g., acetanilid, gr. iij (gm. 0.2), with per- 
haps | or | grain (gm. 0.02 to 0.03) of codein. Care must be taken not 
to put these coal-tar preparations too freely into the hands of patients, 
as the habit of using them too often is easily acquired, and the effects 
are often harmful. At times headache is relieved by lowering blood- 
pressure by nitrites. The plethoric individual with high blood-pressure 
may be bled. Later, morphine will have to be resorted to for the relief 
of the excruciating pain and to give sleep. Morphine is naturally a 
remedy that one should very rarely use in the earlier stages of chronic 
nephritis, because of its tendency to lessen secretions, and because of the 
danger of inducing morphinism. It is in the later stages of the disease 
that the greatest relief is afforded by this drug, which may be employed 
in the same way and for the same reasons that it is used in the later 
stages of carcinoma or of pulmonary tuberculosis, viz., to contribute 
to the comfort of one with an incurable malady. The good that comes 
from the relief of pain, vomiting, dyspnoea, and sleeplessness more than 
makes up for any effect on the secretions or possible morphine habit of 
a few weeks' duration. Bromides, codein, or heroin and other measures 
may be tried before resorting to morphine. 
Other annoying symptoms must be treated according to the principles 
that govern their treatment under other circumstances. The same 
is true of complications such as cerebral hemorrhage, pneumonia, or 
pleurisy. A word of caution is perhaps not out of order regarding the 
use of drugs that may seem indicated for these complications. Such 
drugs as salicylates, carbolic acid, or alcohol, must be given with care 
because of the danger of irritating the already injured kidney. The same 
may be said of the use of anesthetics; anesthesia in the case of the 
nephritic should be as brief as possible, for an exacerbation of a chronic 
nephritis is sometimes due to the use of ether or chloroform. 
The treatment of nephritis by supposed specific remedies, drugs, sera, 
or such things as raw kidneys, seems to be wholly without good results. 
Surgery-the decapsulation of or incision into the kidney-has been 
advocated as a means of treating nephritis. Some of the most ardent 
advocates of this procedure believe they are warranted in advising this 
operation in every case of chronic nephritis as soon as the diagnosis is 
made, provided the patient is not practically in extremis, and provided 932 
DISEASES OF THE URINARY SYSTEM 
a skilled surgeon is at hand. There follows, Edebohls believes, an 
" arterial hyperemization of the kidney. The result of this improved 
circulation in and between the tubules and glomeruli is the regenerative 
production of new epithelium capable of carrying on the secretory 
function." As a routine treatment it has not the support of the profes- 
sion. And when we think of the nature of a chronic interstitial nephritis, 
for instance, with its local renal fibrosis, its widespread cardiovascular 
changes, the toxemic origin of the condition, the influence of heredity, 
etc., it is difficult to understand how the improvement of the mechanical 
conditions in the kidney or even of its nutritional activity can work a cure. 
Temporary improvement is all one would expect, and, remembering the 
natural variability in symptoms in chronic nephritis, in the amount of 
albumin and casts, and noting, too, it must be added, the loose way 
in which diagnosis has been made in some of the cases recorded as 
instances of cure of chronic nephritis, one is forced to ask whether the 
recovery in some instances may not have been from an acute nephritis 
or possibly from some non-nephritic albuminuric condition. 
t In cases of acute nephritis and of congestion in which the kidney is 
swollen and the capsule tense, Harrison and others have advised a 
splitting of the capsule or its puncture for the relief of tension. Marked 
improvement has been seen to follow this procedure, although the well- 
known spontaneous recovery of most cases of acute nephritis makes 
one doubtful in a given case as to what benefit has really been derived 
from this particular treatment. 
The conclusions of David Newman1 represent, perhaps, the views of 
a surgeon who, while prepared to do a radical operation, is yet conserva- 
tive. He says: "The conclusions I have come to regarding the efficiency 
of incision of the capsule or of cleavage of the cortex are: (1) That the 
operation gives marked relief to the renal pain of chronic Bright's disease. 
(2) That in cases of hemorrhage, in which the bleeding is practically 
limited to one side, the operation should be recommended, as it has been 
frequently followed by cessation of the hemorrhage in chronic Bright's 
disease. (3) In cases of movable kidney associated with albuminuria, 
hematuria, tube casts, or blood casts, when due to causes resulting from 
the displacement, after the operation of incision and fixation these 
symptoms disappear permanently, but when coincident with Bright's 
disease only temporary good is effected by operation. (4) Anuria, 
dropsy, and dyspnoea may be temporarily relieved in chronic Bright's 
disease, but a cure is not effected. (5) That in anuria, with uremic 
symptoms arising in the course of acute or subacute infective nephritis, 
free incision of the capsule and cortex, by relieving the tension and 
congestion, enables the organ to resume its function, as shown by active 
secretion of urine from both kidneys after the operation. 
In general, it may be said that the profession looks askance, and 
rightly, at the indiscriminate operation upon every patient who has 
albumin and casts in the urine, and while in individual cases operation 
may perhaps be justified, an operation upon every case of nephritis is 
to be condemned. 
1 Brit, Med, Jour., October 8, 1904, ii. AMYLOID DISEASE OF THE KIDNEY 
933 
AMYLOID DISEASE OF THE KIDNEY 
The name "amyloid" was applied by Virchow to this particular 
form of degeneration. The name is a misnomer, as the substance is 
not starchy; it seems to be closely related to if not identical with some 
of the albuminous bodies. What is the mother substance and in what 
way amyloid material is deposited in the tissues by the blood are ques- 
tions that, along with others dealing with the nature and pathogenesis 
of the amyloid substance, need not be fully discussed in an article dealing 
chiefly with the clinical aspects of amyloid degeneration as it affects 
the kidney.1 
Etiology.--Rokitansky's observation (1842) that amyloid degeneration 
in general was found in connection with a cachectic state induced by 
chronic suppuration, syphilis, or tuberculosis, has been abundantly 
confirmed, as also his statement that it was, as a rule, a general process 
not limited to one organ, but appeared simultaneously in several, such 
as the liver, spleen, and kidney. Foremost among these etiological 
factors stands chronic suppuration, such as is seen in unhealed empyema 
of the chest, chronic osteomyelitis, pyelitis, bronchiectasis, etc. Tuber- 
culosis-particularly chronic tuberculosis of the lung with extensive 
cavity formation, tuberculosis of the intestine, tuberculosis of bones 
and joints with fistulous communication with the surface-is another 
cause, perhaps, as some contend, the commonest one. But it is possible 
that tuberculosis per se has less special influence in the production of 
amyloid than has the accompanying secondary pyogenic infection, as 
is the case in phthisical cavities, and bone and joint tuberculosis with 
fistulse. Syphilis is a third cause, especially late syphilis, the so-called 
tertiary form. Malarial cachexia, gout, lead poisoning, leukemia, 
carcinoma, beriberi, hypertrophic cirrhosis of the liver, actinomycosis 
of bone, rickets (syphilis?), have been regarded as rare and occasional 
causal factors. For a few cases no cause has been discovered. The 
earlier recognition and intelligent treatment of tuberculosis, syphilis, 
and suppurative affections contribute toward the eradication of amyloid 
disease. Experimentally, amyloid has been produced by some of the 
pus germs. This artificial amyloid at times develops with wonderful 
rapidity.2 Chronic inflammatory and fibrotic changes in the kidney 
are not infrequently found associated with amyloid degeneration in 
this organ. Both conditions may be due to a common cause or the one 
condition may in some way be the result of the other. 
Age and sex seem to have little influence except as they predispose 
to the contributing causes. Males are oftener affected, and the period 
of young adult and middle life furnishes the greatest number. 
1 In addition to standard text-books on pathology, among many other references 
that might be given, the following may be consulted on this topic: Rokitansky, 
Handbuch der path. Anat., 1842, iii, 421; Virchow, Arch. f. path. Anatomic, etc., vi, 
viii, xi; S. Wilks, Guy's Hospital Reports, 1856, ii; Lubarsch, Virchows Archiv, 1897, 
cl; Petrone, Arch, de Med. Exper., 1898, x; Davidsohn, Virchows Archiv, cl; J. Nowak, 
Ibid., cliii; Neuberg, Verhandl. der Deutschen patholog. Gesellschaft, 1904. 
2 Cf. Krawkow, Centralbl. f. ally, path., etc., May 20, 1895, vi. 934 
DISEASES OF THE URINARY SYSTEM 
Pathology.-The amyloid kidney is large, firm, and heavy, exeept 
when the amyloid degeneration is associated with a chronic indurative 
fibrosis, under which circumstances the kidney may be small, granular, 
and to the naked eye resemble the kidney of chronic interstitial nephritis. 
The kidney is pale, smooth, and the stellate veins stand out distinctly. 
The capsule strips readily except in case of association with fibrous 
changes. The section shows a smooth, glistening surface, with clear 
differentiation between the deep red pyramids and the wide, lighter, 
waxy-looking cortex. The glomeruli show distinctly, many of them 
" projecting like glistening dewdrops." Washed with a solution of iodine 
in potassic iodide (Lugol's solution), some of them stain a dark mahogany 
brown, showing the presence of amyloid material. The same color may 
be made out in other regions, showing the walls of vessels involved. 
It is in the bloodvessels of the kidney-the muscular coat of the 
arteries especially-that the amyloid change is to be made out. The 
extent, however, to which the vessels are altered varies considerably. 
The glomerulus may be converted into a structureless, homogeneous, 
waxy-like ball. Not only is each affected glomerulus apt to show an 
irregular patchy distribution of the amyloid changes in the capillary 
walls but the different glomeruli are very unevenly affected. The 
microscopic contrast between amyloid and normal tissue is more clearly 
brought out by staining. The order of frequency with which the different 
vessels are affected is variously stated, all observers, however, agreeing 
that the glomerular vessels stand at the head of the list. The afferent 
arteries, the vasa recta, the efferent vessels, the intertubular capillaries 
and arteries of the medullary substance, the capillaries of the cortex 
are in irregular order and, to varying degrees, also attacked. Even 
Bowman's capsule and the membrana propria of the tubules may show 
the change, and at times the epithelial cells themselves, the interstitial 
tissue and the capsule of the kidney. 
The remainder of the kidney is seldom normal. Frequently, and 
especially when the kidney is macroscopically like the large white kidney, 
the changes are indistinguishable from those of chronic parenchymatous 
nephritis. In other kidneys the development of fibrous tissue predomi- 
nates, and the condition might be classed as chronic diffuse nephritis, 
or as granular atrophy. The contracted amyloid kidney is believed 
by some to be met with oftener when syphilis is the primary disease. 
Along with the renal changes are to be found the lesions of the primary 
disease, the suppuration, tuberculosis, or syphilis. There is also an 
anemia, sometimes pronounced, and oedema is often present. Cardiac 
hypertrophy and arteriosclerosis are probably never the result of the 
amyloid disease of the kidney, but they are sometimes found in the 
cases in which amyloid is combined with chronic nephritis with indura- 
tion. Lastly, amyloid degeneration of other organs is present. A ery 
rarely the amyloid kidney alone has been found-in from 7 to 10 per 
cent, of cases.1 Generally, however, similar changes are found in the 
1 Cf. Rosenstein, loc. cit., p. 393; also Bull. Nordisk. Medic., Band xii, Heft 1. AMYLOID DISEASE OF THE KIDNEY 
935 
spleen and liver and not infrequently in the suprarenal gland, the wall 
of the intestine, or even in the heart. 
Symptoms and Diagnosis.-Mild cases cannot be recognized. A 
suspicion that amyloid exists might arise if an efficient cause is present, 
and if the albuminuria and other urinary findings are not typical of simple 
nephritis. In more advanced cases the patient is anemic and even 
cachectic in look. (Edema may be marked, even to the extent of hydro- 
thorax and ascites. Disturbance of the stomach and bowels is often 
present, a diarrhoea being sometimes the result of the amyloid degen- 
eration of the intestinal wall. The spleen is enlarged, hard, and palpable, 
as is the liver. The pulse is usually somewhat rapid, and is not of high 
tension. The heart is not hypertrophied. 
The urine is usually increased in amount, pale, of low specific gravity, 
clear, and with but little sediment. The solids are but little altered. 
It is rich in albumin, and Senator showed that the percentage of globulin 
was unusually high. Casts, especially hyaline and granular, are present, 
although not in such large numbers as the amount of albumin would 
lead one to expect. Blood is rare. Both the amount of urine and of 
albumin seem to be quite variable, and the specific gravity is sometimes 
not reduced. Even in the same patient there may be remarkable varia- 
tions from day to day. Cases of amyloid of the kidney without albumin- 
uria have been described.1 Leube2 reports an interesting case of a boy 
with vertebral tuberculosis and abscess formation, in whose urine no 
albumin was found, although daily examinations were made for weeks, 
as renal amyloid was suspected. At the autopsy there was found not 
only amyloid of the liver and spleen but the microscope showed unmis- 
takable amyloid of the glomeruli and vasa afferentia of the kidney, 
a condition in which one would expect albuminuria. Rosenstein, Litten, 
Wagner, and others, report cases without albumin. 
There is as much variation in the general appearance of the patient 
and in the constancy of the other symptoms as in the urine. Instead 
of the typically weak, pale, cachectic, emaciated individual with the 
muddy complexion and with the swellings of dropsy, the patient 
may be fairly strong, of ruddy complexion, fat, and with no dropsy. 
While the color may, as just stated, exceptionally be fairly good, there 
is commonly a pallor, even although the musculature and fatty panniculus 
are well preserved. This is due to the secondary anemia that is present. 
Uremia, at least uremia to be recognized as such, is extremely rare. 
Death is usually from gradual wasting and exhaustion, or due to com- 
plicating conditions, such as pneumonia, pleurisy, or peritonitis. Coma, 
toward the end, is commoner than convulsions; and even when the 
amount of urine is greatly diminished or nearly suppressed, headaches, 
uremic dyspnoea, and convulsions are rare, the condition resembling 
more the toxemia of anuria than that of true uremia. Retinitis is rare. 
When, however, the amyloid has been implanted on a kidney, the seat 
of a chronic interstitial inflammation, the cardiovascular changes, the 
retinitis, and uremia may be prominent. 
1 Cf. Straus, Soc. Med. des Hopit., June 10, 1881. 
2 Diagnose der inneren Krankheiten. 936 
DISEASES OF THE URINARY SYSTEM 
It is thus seen that no clean-cut picture of amyloid disease of the kid- 
ney can be drawn. The diagnostic features may be summed up much as 
they are by Leube when he says that amyloid of the kidney is only to be 
diagnosed when the liver and spleen-or at least one of these two organs, 
especially the spleen-are enlarged and hard as they are with amyloid 
degeneration; when at the same time there is a long-standing tuberculosis, 
suppuration, or syphilis; when the urine, although increased in amount, 
of low specific gravity, clear, and with but a faint sediment, is yet rich 
in albumin; and when the cardiovascular changes of chronic interstitial 
nephritis are lacking. 
Prognosis.-Virchow1 declared in 1885 that amyloid was incurable, 
that healing in the strict sense could not take place. Yet the process 
seems at times to remain stationary, and it is believed that at least a 
functional recovery occasionally ensues. This possibility is given some 
support by the observations of Raehlmann,2 who saw amyloid of the 
conjunctiva disappear. Clinically, however, amyloid kidney when far 
enough advanced to be recognizable is almost invariably fatal. Death 
may, however, be delayed for many years, even five or ten. Much 
depends upon the underlying disease, its amenability to treatment, the 
gravity of the accompanying nephritis, and the condition of the stomach 
and bowels. Some think the course of amyloid of the kidney due to 
syphilis is more prolonged than when due to other causes, and that 
syphilitic amyloid offers a more favorable outlook. Tirard3 states that 
the lung symptoms of pulmonary tuberculosis frequently undergo 
improvement with the development of the renal affection. 
i Treatment.-This consists in the early treatment of the primary 
disease. The proper handling of this disease may prevent amyloid. 
Early treatment, even after amyloid has developed, may retard the 
progress of the renal disease and produce, for a time at least, a functional 
recovery. Treatment of such conditions as chronic empyema, pyelitis, 
osteomyelitis, tuberculosis of the lungs, intestines, bones and joints, 
syphilis of bones, should, therefore, be as prompt as possible, and the 
decision as to the time and character of operation or other therapy 
should always be reached, with due weight being given the possibility 
of the occurrence of amyloid, or the influence of such treatment upon 
amyloid already existing. Fresh air, sunshine, and plenty of nourishing 
food are indicated as well for the original disease as for the anemia and 
cachexia attending the amyloid. Tonics are often of value. Iron and 
arsenic are indicated, and may be given in any form desired. Blaud's 
mass with arsenic is an excellent combination. The syrup or the pill 
of the iodide of iron may also prove useful. Potassium iodide is, of 
course, helpful if the lesions of late syphilis are present. Vomiting and 
diarrhoea will demand care as to diet and probably the use of various 
remedies, such as bismuth, tannigen, or even opium. But each case 
must be judged on its own merits, after all that is possible has been 
done in the way of removing or improving the fundamental and origi- 
nal disease. 
1 Berlin, klin. Woch., 1885, p. 813. 
3 Albuminuria and Bright's Disease, p. 247 
2 Virchows Archiv, vol. Ixxviii. CHAPTER XVII 
PYOGENIC INFECTIONS OF THE KIDNEY, URETER, AND 
PERIRENAL TISSUES 
THOMAS R. BROWN, M.D. 
It seems well to consider in one chapter the various pyogenic infections 
of the kidney and its pelvis-pyelitis, pyelonephritis, suppurative neph- 
ritis, suppurative pyelonephritis, pyelonephrosis, pyonephrosis, abscess of 
the kidney, and empyema of the renal pelvis. In the first place, the 
etiological factors are very similar, the same bacteria may be the primary 
cause, and the same predisposing factors may prepare the soil; in the 
second place, it is very difficult to differentiate the various forms of 
inflammation, as they so often occur together, one often causing another 
and fusing imperceptibly into it, while in the third place, any of these 
may arise by bacteria reaching the kidney or its pelvis by any one of 
the usual three routes-ascending or urogenous infection, metastatic, 
descending or hematogenous infection, or infection by continuity from 
some adjacent focus of inflammation. 
Pyelitis signifies an inflammation of the renal pelvis and its calices; 
pyelonephritis, where with this there is associated an inflammation of 
the kidney substance itself; suppurative pyelonephritis, pyelonephrosis, or 
surgical kidney, a suppurative inflammation of the kidney and its pelvis, 
associated with miliary or with larger abscesses in the kidney substance, 
and usually due to an ascending infection from lower portions of the 
urinary tract; suppurative nephritis, an inflammation of the kidney 
substance, usually hematogenous, traumatic, or by contiguity with the 
formation of miliary abscesses; while if we have one or several abscesses 
of larger size, usually due to the confluence of miliary abscesses, the 
condition is known as abscess of the kidney. In all cases of suppuration 
of the kidney, especially in the ascending forms, in which there is con- 
striction of the ureter or other obstruction to the flow of urine, we get a 
pyonephrosis, if the condition lasts for any considerable period, in which 
there is stagnation of urine and pus in the renal pelvis and its calices, 
causing destructive changes in the renal parenchyma and its subsequent 
conversion in many cases into a pus-filled sac, pyonephrosis differing 
from pyelonephritis merely in the degree of distension met with. Kiister 
speaks of this form of pyonephrosis as empyema of the renal pelvis, while 
according to this author it is best to confine the term pyonephrosis to 
the infected hydronephrosis, under which heading this special form of 
infection will be considered. In almost all cases in which the renal 
pelvis is diseased we meet with involvement of the ureter and its sur- 
rounding tissues, ureteritis and peri-ureteritis, leading frequently to 
subsequent constriction of the ureter and secondary pyonephrosis, 
937 938 
DISEASES OF THE URINARY SYSTEM 
while in cases of inflammation of the kidney substance, especially those 
in which the cortex is most affected, we may have an inflammation of 
the tissues surrounding the kidney, perinephritis, epinephritis, and 
paranephritis. The pyelitis consecutive to inflammations of the kidney 
substance is of minor importance in the majority of cases, although, on 
the other hand, the renal inflammations which follow pyelitis are of 
very great significance, almost always being associated with far more 
serious symptoms and a much worse prognosis than the pyelitis itself. 
By careful examination many cases of pyelitis can be diagnosed and 
cured before the kidney substance is involved; many cases of infection 
of the kidney and its pelvis will be avoided by the prompt recognition 
and the appropriate treatment of the antecedent causes; surgical inter- 
ference, if necessary, will be inaugurated early, instead of as a last hope, 
and the mortality figures will be correspondingly lowered. 
The great advance in our knowledge of the infections of the urinary 
tract has come, in part, from the development of better surgical methods, 
in part from more careful clinical studies, but in the main from the 
advances made in the field of diagnosis of diseases of the urinary tract- 
an advance so marked that in many diseases our whole conception of the 
underlying pathological process has undergone a complete change. 
From the clinical side, the introduction of the cystoscope has done 
much, but even more valuable has been the information derived from 
the catheterization of the ureters, by which the study of the urine from 
each kidney has been rendered possible. The laboratory has done its 
share by determining the bacteriological flora of the infections of kidney, 
ureter, bladder, and urethra, and by determining with a considerable 
degree of precision the functional ability of each kidney, of paramount 
importance when operation is under discussion. 
Many diseases of the kidney are never diagnosed because a systematic 
urinary examination is neglected; if this is done in every case, many 
of the vague diseases, especially in childhood, would be recognized as 
referable to inflammations in the urinary tract; indeed, we feel that there 
are certain questions which should be asked in every case presented to 
us: Are we dealing with a healthy or a diseased kidney? If pathological, 
what is the nature of the disease, and what are the etiological factors? 
Are both sides affected or only one, and if unilateral which side is 
diseased? In cases of unilateral inflammation, if operation of any kind 
is under discussion, can the other kidney successfully perform the 
necessary functions? If both kidneys are involved, one more than the 
other, is life possible with the less diseased kidney if it is desirable to 
remove the more diseased organ? 
Methods of Examination.-Cystoscopy.-The use of the cystoscope 
has added largely to our knowledge of urinary infections. Cystoscopy 
is,an extremely simple procedure in the female. It may be done with the 
patient in the knee-chest position, or in the dorsal position with or 
without elevation of the pelvis; many cystoscopes are used, but no 
better instrument for the purpose has been devised than that of Howard 
Kelly. In the male the procedure is somewhat more difficult, but still 
comparatively easy. The strictest asepsis is essential in either case; INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
939 
while, as a rule, anesthesia is not necessary, it may be required in very 
neurotic patients, or in case of a very irritable bladder or urethra. Berk- 
hardt and Polano distend the bladder with pure oxygen, as they believe 
it has a distinctly anesthetic effect. 
Besides giving a perfect picture of the condition of the bladder, its 
irritability or lack of irritability, its condition of distension or contraction, 
the presence of residual urine, foreign bodies, tumors, calculi, or com- 
munications with abscess cavities or with neighboring viscera, it also 
furnishes knowledge of great value as to the condition of the kidneys. 
The ureteral orifices can be carefully examined and deviations from the 
normal noted. The orifice may be gaping, invisible, or oedematous, as 
frequently seen in cases of calculus in the lower portions of the ureter, 
or it may be surrounded by an area of ulceration, as frequently seen in 
renal tuberculosis, while the discharge of pus or blood from the ureter 
may be recognized, and by this means the nature and site of the disease 
suggested, if not absolutely determined. It is also important to note 
the flow from each ureter; while normally, after the discharge of the 
first few cubic centimeters, the urine flows intermittently, in certain cases 
of hydronephrosis and pyonephrosis there is a continuous flow until the 
renal pelvis is emptied, and then a slow, sluggish dropping. When renal 
hematuria or pyuria is slight, it is difficult to make a diagnosis by cysto- 
scopic examination alone, as the fluid from the ureter does not materially 
differ from that present in the bladder, while sometimes we are obliged to 
wait a few moments after cystoscopy to determine the character of the 
flow from the ureteral orifices, as the act of introducing the cystoscope 
occasionally produces a reflex inhibition of kidney secretion. 
Ureteral Catheterization.-The process is somewhat difficult in the 
female, more difficult in the male, but it is absolutely essential in all 
cases of renal infection in which operation is under discussion, and 
most important in all other cases of suspected renal infection, for by this 
means alone is it possible to acquire that knowledge of the pathological 
anatomy and secretory peculiarities of each kidney which is indispensable 
to the proper treatment of this group of cases. 
Some have suggested the use of catheters colored with vermilion or 
cinnabar lacquers, which are impermeable to the x-rays, and which are, 
therefore, useful in certain cases, especially in the localization of calculi; 
while in certain cases it is justifiable to catheterize the ureters through 
a bladder opened by suprapubic incision. In introducing the catheter, 
we can tell much regarding stricture of the ureter, and also, by the use 
of a wax coating, as to the presence of calculus. Kelly has shown that 
there may be a reflux of air into the ureter through the air-distended 
bladder in the knee-breast posture, while others have demonstrated 
that in the case of certain animals a reflux of fluids is also possible; 
nevertheless, it is safe to assume that the bladder is water-tight under 
physiological conditions, although, of course, this is not so when bladder 
or ureter is diseased. Rovsing puts his entire faith in the cystoscope 
and the ureteral catheter, and to these he ascribes his great success in 
nephrectomy and the reduction of his mortality in this operation from 
13 to 3 per cent, since the routine introduction of these methods. 940 
DISEASES OF THE URINARY SYSTEM 
Urine Segregators.-The great weight of opinion is against the use of 
urine segregators, which were introduced because of the difficulties of 
ureteral catherization. These segregators are of two kinds, each devised 
to obtain separate urines from the kidneys, in one type an attempt being 
made to form a water-tight septum between the two ureteral orifices 
(as in the instrument of Luys and Cathelin), in the other to elevate the 
posterior wall of the bladder so as to make it act as the septum (as in 
the instrument of Harris). Tuffier believes that this mode of examination 
has won a definite place for itself in the domain of renal diagnosis, while 
it is unquestionable that it is of value in cases in which it is impossible 
to find the ureteral orifices. 
The Method of Obtaining Specimens.-It is essential that uncon- 
taminated urine should be obtained from the bladder in the case of 
cystitis, and preferably directly from the kidneys in infections of that 
organ. Various methods have been devised for this purpose, all designed 
to obtain urine free from contamination. A satisfactory method is 
as follows in the case of the female: The vestibule of the vagina and the 
mouth of the urethra having been carefully cleansed with bichloride of 
mercury or other antiseptic solution, followed by a thorough washing 
off with sterile water, the lips of the urethra are pulled apart by traction 
on the labia, and a sterilized glass catheter with a sterilized rubber 
cuff about 10 cm. on its distal end is introduced, the operator only touching 
the rubber cuff at about its middle. After the urine has flowed for a 
short time, so that if a few microorganisms have been introduced from 
the urethra they would have been washed out, the rubber cuff is with- 
drawn by traction on its distal end and from 10 to 20 cc. of urine collected 
in a sterile tube; the same method, with slight modifications, is available 
in the male, a metal or rubber catheter, of course, being substituted 
for the glass catheter. The efficacy of this method has been shown by 
the fact that in fifty-two control experiments made by the writer upon 
normal cases, in all but one no culture was obtained, and in this one 
colony of a white staphylococcus grew in the plate. Some clinicians 
advise a thorough irrigation of the urethra beforehand with some anti- 
septic solution, followed with sterile water. 
In obtaining urine from the kidneys, the only satisfactory method is by 
ureteral catheterization. In this case a cystoscope is introduced into the 
bladder, and through this a sterile ureteral catheter with a rubber cuff on 
its distal end is introduced into the ureter and inserted as far as necessary 
toward the renal region; if simply a study of the urine is the object, 
the catheter should only be inserted a distance of one to two inches in the 
ureter, especially if the bladder shows signs of contamination; while if we 
also wish to determine the presence or absence of stricture, calculus, or 
pyo- or hydronephrosis, the catheter must be inserted a greater distance. 
If there is infection of the bladder, great care should be taken; the bladder 
should be thoroughly washed out with some antiseptic solution, followed 
by repeated irrigations with sterile water; the ureteral orifice should be 
carefully swabbed with a solution of silver nitrate, and the catheter 
should be inserted but a short distance into the ureter. The success 
of this method is shown by the fact that in thirty-two control experiments INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
941 
carried out by the writer either upon perfectly normal individuals or on 
those with one normal kidney, but with infection of the other, and in 
some cases also with cystitis, only one showed any contamination. 
In obtaining specimens from the kidney, it is wise to advise the patient 
to drink rather copiously of water before the examination. It must be 
remembered that the greatest care must be taken to avoid trauma, 
although, notwithstanding this, chill, rise of temperature, and other 
symptoms may be met with occasionally after ureteral catheterization. 
Examination of the Urine.-After having obtained the urine, it is 
essential that within a very short time the examination should be made. 
The reaction should be tested in every case, because it tells us in a broad 
way something regarding the character of the microorganisms causing 
the infection. Besides the mere reaction it is important in certain cases 
to determine the degree of the acidity, which may be done in a fairly 
satisfactory way by titration of the freshly obtained specimen with a 
decinormal solution of sodium hydroxide, phenolphthalein being used 
as the indicator. Of course, when the ureters are catheterized the 
acidity of each specimen is determined separately. It is important to 
determine the reaction, because, in the first place, we may meet con- 
ditions simulating a cystitis but without infection, in which the con- 
dition is due to a urinary hyperacidity, probably of neuropathic origin, 
and, in the second place, because certain bacteria definitely increase the 
acidity of the urine, others definitely decrease it. As to the normal 
degree of acidity, upward of 100 investigations in normal individuals 
showed that on the average it requires about 25 cc. of the decinormal 
solution to neutralize 100 cc. of urine. 
The specific gravity should be determined because of the frequency with 
which a low specific gravity is met with in pyelitis and pyelonephritis, 
while it is especially valuable to compare the specific grav-ity of the 
urine from each kidney in cases of supposed renal infection. 
The test for albumin should always be made, because in a broad way it 
differentiates vesical from renal infections. Generally speaking, there is 
but little albumin in the case of a pure cystitis if the fresh specimen be 
examined, while, in the writer's opinion, although there are many who 
oppose this view, there is relatively an increase of albumin in pyelitis and 
almost always a definite increase in pyelonephritis. Speaking broadly, a 
marked disproportion between the grade of pyuria and of albuminuria 
speaks for cystitis, while, if considerable albumin is present, pyelitis is 
often present alone, or asssociated with cystitis. Rosenfeld states that 
the limit of the albumin content in the severest cystitis is 0.1 per cent, 
in maximo, 0.15 percent.; in pyelitis it is often 0.3 per cent., while 
Goldberg, who counted the red-blood cells and determined the albumin 
quantitatively, concluded that if the ratio of the latter amount in per- 
centage to the number of red corpuscles per cmm. is more than 1 to 
30,000, there is true albuminuria, while if less than 1 to 30,000, the 
albumin is accounted for by the blood alone. 
The microscopic examination is of extreme importance and should 
be made with great care. The centrifugalized specimen should be ex- 
amined, and at the same time, by allowing a definite quantity of urine 942 
DISEASES OF THE URINARY SYSTEM 
to stand a certain time, we learn something regarding the degree of 
infection, and the effect of any treatment we are employing may be 
roughly judged by the depth of this sediment. Special attention should 
be paid to the presence or absence of microorganisms, casts, pus cells, 
red-blood cells, and epithelial cells. As to the microorganisms, their number, 
motility, and morphology should be noted; stained specimens should 
always be made, and in every case in which there is the least suspicion 
of such infection, tubercle bacilli should be stained for; in cases in which 
bacteria are seen microscopically but the cultures are sterile, it is ex- 
tremely important that anaerobic cultures be made. In case of blood 
in the urine, the only way to exactly determine its source is by cystoscopy 
and ureteral catheterization. As regards pus cells, ureteral catheteriza- 
tion is essential in determining their source. The claim some make, that 
certain epithelial cells are peculiar to the pelvis of the kidney and the 
ureter, is erroneous, because exactly similar cells may be met with in the 
lower epithelial layers of the bladder, and consequently are found in 
cases of pure cystitis. As a criterion of the effect of any treatment, the 
number of pus cells and red-blood cells can be counted from time to 
time with a hematocytometer. 
Functional Activity of the Kidneys.-Within the past few years methods 
to determine the functional activity of the kidneys have been most 
carefully studied. These functional tests have proved of great value 
in making the prognosis of various renal diseases, but have perhaps 
their widest application in deciding the question whether or not operation 
is justifiable in various surgical diseases of the kidney. In the former 
case the mixed urine from the two sides has been studied, as a rule, while 
in the latter the more valuable findings are the functional activities 
of the separate kidneys determined by ureteral catherization, and the 
comparison of the urine obtained from the separate sides. 
Many methods have been employed, such as the determination of the 
urea and of the total nitrogen in the twenty-four hour specimen, cryos- 
copy of the blood and urine, the study of the elimination of various 
colored substances by the urine, these usually being administered hypoder- 
mically, the tests of the electrical conductivity of the urine, the de- 
termination of its toxicity, of the amount and specific gravity of the 
specimens from the two sides, and the flexibility of its reaction to large 
quantities of water administered by mouth, the chloride elimination, 
and also the rate of elimination of lactose, potassium iodide, and other 
substances administered by mouth, as well as the quantitative estimation 
of the ferments found in the urine, notably diastase, and the quan- 
titative estimation of the incoagulable nitrogen in the blood. In all 
cases of renal disease, and especially when operation is under considera- 
tion, it is of paramount importance to determine as far as it is possible 
the functional activity of the kidneys, especially after catheterization 
of the ureter, and the comparison of the urine from the two sides. For 
general purposes the phenolsulphonephthalein test as a criterion of 
general functional activity, the lactose test for the study of glomerular, 
and the potassium iodide or sodium chloride estimation for the study 
of tubular changes are possibly of most value, although there is no INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
943 
substance which is excreted entirely by glomerular, or entirely by tubular 
epithelium. Information of great importance can also be furnished by 
the determination of the incoagulable nitrogen in the blood. While on 
test is infallible, nevertheless by these functional tests information of 
great value may be obtained, although it is needless to say it must 
always be correlated with the clinical findings. 
Bacteriology.-Certain things should never be forgotten in making 
bacteriological examinations of the urine: first, the necessity of examining 
for the tubercle bacillus by the ordinary methods, and by animal in- 
oculation in all doubtful cases, especially when the urine is acid and 
shows no growth on the ordinary culture media; second, the necessity 
of making anaerobic cultures, if bacteria are seen in the stained centrif- 
ugalized specimens and no growth occurs on the ordinary media. 
The Bacteria of the Normal Urethra.-It is essential to consider these, 
because one of the common causes of cystitis is the introduction of some 
of these bacteria into the bladder by a catheter or other instrument. 
We may safely say that all the mucous membranes in contact with the 
air contain bacteria, and of these some will be pathogenic. Melchior 
found the colon bacillus in the vulva of healthy women in half those 
examined; Bouchard and Charrin found this microorganism frequently 
in this location, and it is probable that in a large number of cases the 
colon bacillus as w'ell as other pathogenic bacteria are to be found in the 
vulva and the vestibule of the vagina in women and on the glans in 
the male. As to the bacterial flora of the normal urethra much work has 
been done, and the results in the main have harmonized. All investi- 
gators have found many varieties of bacteria in the healthy urethra 
in both the male and female, including staphylococci and streptococci. 
Melchior found that only after very careful irrigation with boracic 
acid solution and subsequent catheterization could he obtain a urine 
free from bacteria. Kraus and Chvostek found bacteria in the urethra 
at a depth of 6 to 8 cm. in 60 per cent, of healthy males examined by 
them, while Schenk and Austerlitz found the urethra free in more than 
half the cases of normal women. 
The following bacteria have been found in the urethra: The colon 
bacillus, Staphylococcus pyogenes aureus and albus, various forms of 
streptococci, Diplococcus candidus, various forms of sarcina, leptothrix, 
Streptococcus liquefaciens, pseudogonococcus, smegma bacillus, pseudo- 
diphtheria bacillus, Diplococcus pyogenes, and many others. Of the 
pathogenic forms, such as the colon bacillus or staphylococci-in other 
words bacteria which can cause cystitis-Melchior has shown that they 
are present in more than half of the normal urethras. These results 
show the importance of the urethra as a source of infection of the urinary 
tract, and accentuate the necessity of extreme care in introducing 
catheters and other instruments. 
Urethritis.-Although the gonococcus is the cause of infection in 
the vast majority of the cases, we may have a urethritis due to other 
forms of bacteria, as the experimental urethritis brought about by the 
introduction into the urethra of various bacteria, especially various 
forms of staphylococci and diplococci. Among other causative factors 944 
DISEASES OF THE URINARY SYSTEM 
in urethritis may be mentioned the Streptococcus pyogenes, Micrococcus 
cereus albus, Bacillus coli communis, Staphylococcus pyogenes aureus 
and albus, Staphylococcus non-liquefaciens, tubercle bacillus, etc. It 
is not at all uncommon as a sequel of gonorrhea to find a condition in 
which the urine shows numbers of organisms-bacilli, cocci, diplococci, 
etc.-which unquestionably tend to keep up inflammation. 
Cystitis.-The bacteriology of infections of the bladder has for obvious 
reasons been studied far more thoroughly than the infections of any 
other portion of the urinary tract. Before taking up the findings in 
cystitis it will be well to discuss certain questions of importance in 
this connection, such as the mode of entrance of the bacteria, the pre- 
disposing causes of infection, and other etiological factors. 
As regards the mode of entrance of infection in the bladder, this may be 
through the urethra either from the organisms usually present, or from 
bacteria present on an instrument used; we may have a descending 
infection from the kidney; we may have an infection by direct trans- 
mission from the intestinal tract; we may have an infection carried by 
the blood stream to the bladder, or a direct extension from some in- 
flammatory focus localized in the pelvis or the lower portion of the 
abdomen. Examples of all of these modes of infection occur, but in- 
fection from the urethra, from instrumentation, or from direct extension 
are those most commonly met with. Infection from the intestine is 
especially liable to occur if there is a slight lesion or congestion of the 
intestinal wall, as in diarrhea or after other intestinal disturbance. 
In looking over the bacteriological findings in cystitis one is at once 
struck by the fact that in a great number of cases microorganisms are 
found which, as a rule, possess but slight pathogenic properties, and it 
would, therefore, seem probable that other etiological factors play an 
important part in the causation of cystitis. The function of the bladder 
epithelium is purely protective, and it is still a moot question whether 
absorption is possible from the healthy bladder. However, it has been 
shown by many investigators that infection occurs if the bladder mucous 
membrane be harmed or the urethra ligated, although in the case of 
Bacillus proteus, which decomposes the urine and renders it alkaline or 
ammoniacal, no other factor seems necessary. Melchior also found in 
rabbits that although bacteria introduced into the healthy bladder did 
not produce cystitis, yet an inflammation could be set up by the applica- 
tion of cold to the pubic region, by the injection of hot or cold water, 
or by artificial trauma, results similar to those obtained by Bumm in 
the case of the gonococcus and by Rovsing with a large number of 
bacteria. 
Among the more important factors which predispose to cystitis may be 
mentioned an ammoniacal urine usually due to the Bacillus proteus 
or other urea decomposing bacteria, various conditions which interfere 
with the bladder function and tend to impair its vitality, such as injuries 
and diseases of the nerves of the bladder, as in paraplegia and myelitis, 
congestion of the mucous membrane, especially the trigonal area, pres- 
sure, or obstruction to the flow of urine, pregnancy, excessive cold or 
heat, anything that prevents a complete emptying of the bladder, INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
945 
injury or trauma to the bladder, due to instrumentation, catheterization, 
operation or calculus, adhesions between the bladder and other organs, 
neoplasms, and conditions which lower the resistance of the body. 
Pasteur, in 1859, suggested that bacteria were the cause of urinary 
decomposition, but it was not until 1887 that Clado isolated his bacterie 
septigue de la vessie as the cause of cystitis, and the same year Halle 
described a short non-liquefying bacillus as the cause, which Albarran 
and Halle found in 47 of 50 cases of urinary infection, calling it bacterie 
pyogene and producing cystitis in animals by its introduction if the 
urethra was ligated. This bacterium was found later to be identical 
with the colon bacillus. Clado's bacterie septique, Krogius' bacille non- 
liquefiant, Morelle and Deny's Bacillus lactis aerogenes probably, and 
Rovsing's Coccobacillus ureoe pyogenes are all probably varieties of the 
colon bacillus, while the Bacterium vulgare and the Urobacillus lique- 
faciens septicus are identical with the Bacillus proteus vulgaris of Hauser. 
Marked polymorphism as regards motility and cultural peculiarities 
may be produced in the colon bacillus by variations in the culture medium 
and environment, and also marked changes' in the staphylococcus as 
regards grouping and chromogenic properties appear under similar 
conditions; it is, therefore, not at all surprising that a large number of 
different bacteria and cocci have been described. 
Albarran, Halle, and Legrain, in 1898, collected 304 cases from the 
literature, and found in 131 the colon bacillus 89 times in pure culture; 
other microorganisms found were Bacillus proteus, Streptococcus pyogenes 
(18 times), gonococcus and tubercle bacillus, while among the less common 
findings were the typhoid bacillus, the diplococci of Frankel and of 
Friedlander, Bacillus longus ureoe, Bacillus crassus, streptobacillus, 
urobacillus, coccobacillus, Micrococcus subfiavus, and Sarcina alba, 
Bacillus lactis aerogenes, Streptobacillus anthracoidis, yeast, various 
diplococci, the pseudodiphtheria bacillus, the Bacillus pyocyaneus, 
influenza bacillus, Filaria sanguinis hominis, bilharzia, echino coccus, 
various forms of yeast, and Amoeba coli. In recent years many have 
called attention to the frequency with which cystitis due to the colon 
bacillus occurs in children. 
Melchior, in 72 cases, found the colon bacillus 37 times (29 in pure 
culture); Streptococcus pyogenes in 4 (3); proteus of Hauser, 10 (4); 
tubercle bacillus, 4 (3); Diplococcus ureoe liquefaciens, 14 (11); Staphylo- 
coccus ureoe liquefaciens, 3 (1); Streptococcus anthracoides, 3 (0); gono- 
coccus, 2 (2); typhoid bacillus, 1 (1); Staphylococcus pyogenes aureus, 
4 (3); and coccobacillus, 1 (1). He found, as the vast majority of other 
investigators, that in most cases the urine is acid; in fact, with the excep- 
tion of the proteus and a few species of micrococci, such as the Micro- 
coccus ureoe liquefaciens, the urine is invariably acid; the frequency with 
which Rovsing found alkaline or ammoniacal urine is probably due to 
the fact that a large proportion of his cases were in old men with enlarged 
prostate, while Schnitzler's high percentage of alkaline cases is due to 
the fact that most of them were in cases of malignant disease, in which 
the proteus bacillus seems to thrive peculiarly well. Moullin, in 30 cases 
of cystitis, found the urine acid-or neutral in 24, alkaline in 6; he found 946 
DISEASES OF THE URINARY SYSTEM 
the colon bacillus 25 times (14 in pure culture), proteus bacillus 5 times, 
and the Streptococcus pyogenes 1 times. 
Albarran and Cottet found one species of bacillus and two of cocci in 
anaerobic cultures, a very important finding and one that should suggest 
the advisability of making anaerobic cultures much more often. 
Personal researches into the bacteriology of cystitis, published in 1899, 
showed in 26 cases of acute cystitis the colon bacillus in 15, the Staphylo- 
coccus pyogenes albus in 5 and aureus in 2, Bacillus pyocyaneus, typhoid 
bacillus, proteus bacillus, and an organism resembling in many respects 
the colon bacillus, 1 each, while in chronic cases the bacteriological 
findings were tubercle bacillus in 6, colon bacillus in 16, Staphylococcus 
pyogenes aureus in 3 and albus in 2, a bacillus resembling the colon bacillus 
in 1, the white staphylococcus, which decomposes urea, in 4, Bacillus 
proteus in 1, while in 2 cases the cultures, both aerobic and anaerobic, 
were negative. The comparison of the bacteria found in the acute and 
chronic cases shows no greater prevalence of the colon bacillus in the 
chronic than in the acute cases, which is important in that certain 
investigators claim that the colon bacillus frequently enters after the 
development of cystitis and drives out the other bacteria. In these 
cases the microorganism was met with in pure culture in all but one 
of the cases, in which case the colon bacillus and the tubercle bacillus 
were associated. In the 60 cases of cystitis in which bacteria were 
found, the colon bacillus was found in 31, the Staphylococcus pyo- 
genes albus in 7, tubercle bacillus in 6, the Staphylococcus pyogenes aureus 
in 5, the white staphylococcus, which decomposes urea, in 4, proteus 
bacillus in 2, and the typhoid bacillus, pyocyaneus bacillus, and un- 
identified bacillus, resembling in many respects colon bacillus, in 1 each. 
The urine was acid in the case of all the bacilli except Bacillus proteus, 
was generally acid, occasionally neutral, and very rarely slightly alkaline 
in the case of the Staphylococcus pyogenes albus and aureus, and alkaline 
or ammoniacal in the case of the white urea-decomposing staphylococcus 
and the Bacillus proteus. This series of cases consisted exclusively of 
women, and a comparison of the results found by others shows that the 
colon bacillus is somewhat more prevalent in women than in men, while 
the less common forms are more likely to be found in men. 
Ureteritis-This is practically the same as cystitis on the one hand 
and pyelitis on the other, for in the vast majority of cases the ureter 
becomes infected either from an ascending infection from the bladder 
or from a descending infection from the renal pelvis. In exceptional 
instances the ureter may become infected from some contiguous focus 
of inflammation, and cases have been reported in which a ureteritis has 
directly followed an acute appendicitis or an appendicular abscess. 
The ureteral epithelium is, like that of the bladder, very resistant to 
infection, and unquestionably many bacteria may pass down the ureter, 
if in a healthy condition, without setting up inflammation. If, on the 
other hand, the ureter is not normal, but is congested, dilated, or con- 
stricted, due to pressure, as from the pregnant uterus, or is diseased 
because of contiguous disease, its chance of infection is markedly in- 
creased. INFECTIONS OF KIDNEY. URETER, PERIRENAL TISSUES 
947 
Pyelitis, Pyelonephritis, and Infections of the Kidney.-Most of the 
tables of the bacteria found in pyelitis are of very little value, because 
the urine has been obtained from the bladder and not directly from 
the kidney by ureteral catheterization. Within recent years this latter 
method has been used and, although the number of cases is compara- 
tively small, nevertheless we know the microorganisms most likely 
to be found in infections of the renal pelvis or of the kidney itself. As 
to the source of infection, we may have an ascending infection from the 
bladder up the ureter, the kidney may become infected from the in- 
testinal tract, the bacteria being carried by the blood or by the lymph 
current; infection of the kidney may be but a part of a general infection, 
or bacteria may be carried from some nearby focus of infection, such as an 
abscess cavity, by the blood or lymph current, or by direct extension. 
The bacteria found in our series of 20 cases of pyelitis and pyelonephritis 
in which the urine was obtained by ureteral catherization, were as follows: 
Of 3 acute cases, in 2 with acid urine, bacillus coli was found once and the 
tubercle bacillus once, and in the 1 case with alkaline urine bacillus 
proteus; of 17 chronic cases, in 12 with acid urine the colon bacillus was 
found in 6, the tubercle bacillus in 5, and in 1 case no bacteria were found, 
while in 5 cases of alkaline urine the proteus bacillus was found in 3, and 
the white urea-decomposing staphylococcus in 2 cases. In all the chronic 
cases with alkaline urine a stone was found in the renal pelvis, and in 
several cases in which cultures were made from the centre of the stone 
the microorganism was found which was the cause of the pyelitis, suggest- 
ing that the cause of stone formation is primarily a mass of agglutinated 
bacteria about which the salts precipitated in the alkaline urine are 
deposited. In each case, both acute and chronic, the microorganisms 
were present in pure culture. 
The presence of accessory factors is far more difficult to determine in the 
kidney than in the bladder, but the fact that the condition is more likely 
to occur in people who are run down, anemic, or depleted by various 
diseases, or in whom there is a condition of stasis of urine due to pressure 
upon the ureter by a tumor or pregnant uterus, or by constriction of the 
ureter due to adhesions, or in whom the kidney is congested, suggests 
that here also accessory factors play an important part. Why one 
kidney should be affected and not the other is in most cases impossible 
to say, but it is suggestive that in two of this series the kidney affected 
was markedly displaced. As to the mode of infection, in 6 cases of this 
series the infection was undoubtedly ascending, and in 7 hematogenous 
as far as one could tell; in the tuberculous cases 2 were unquestionably 
hematogenous in origin, while in the other 4 it was impossible to tell, 
although clinically the bladder symptoms made their appearance first. 
The study of these cases suggested that if the kidney became infected 
first the bladder as a rule showed fewer lesions than if the bladder was 
affected first and the kidney secondarily. 
Albarran, Tuffier, Schmidt, Aschoff, and Savor have shown the impor- 
tance of the colon bacillus in infections of the upper urinary tract, while 
Melchior has shown that, if the colon bacillus is injected into the bladder 
and trauma produced or retention caused, in addition to the cystitis he 948 
DISEASES OF THE URINARY SYSTEM 
could produce pyelitis, pyelonephritis, abscess of the kidney, and suppura- 
tive nephritis, and that in certain cases the colon bacillus was even found 
in the circulating blood. Von Albeck has called attention to the frequency 
with which the colon bacillus is found in the urine of pregnant women. 
Bacteriuria.-This is the condition in which the urine becomes infected 
without any demonstrable lesion of the urinary tract. The epithelium 
of the urinary tract is extremely resistant to infection. In addition, the 
normal urine possesses very distinct bactericidal properties, as Lehmann, 
Richter, Rostoski, and others have shown, largely dependent upon the 
degree of acidity which the urine shows. Whether the normal urine 
does or does not contain bacteria has always been a matter of discussion, 
many investigators holding that it does not, while many others contend 
that it does. The weight of evidence certainly points to the belief that 
the urine of healthy individuals, if obtained under careful precautions, 
contains no bacteria, and in 88 observations on healthy human beings 
the writer did not find bacteria in the urine in any case. 
In infectious diseases, however, unquestionably bacteria can be found in 
the urine, as in typhoid fever, in which the bacilli are found in the urine 
in from 20 to 40 per cent, of the cases, tuberculosis, where either the 
tubercle bacillus or various cocci have been found, anthrax, plague, and 
various localized infections due to staphylococci or streptococci. The 
fact that most observers have found traces of blood and albumin in the 
urine in association with the bacteria in these cases, and also in experi- 
mental injections of bacteria into the blood, suggests that in all prob- 
ability the bloodvessels of the glomeruli undergo certain pathological 
changes before the bacteria can penetrate them. Nevertheless, according 
to Orth and Baumgarten the kidneys are permeable when lesions cannot 
be made out by microscopic examination, while Biedl and Kraus have 
shown that after the injection into the blood of various bacteria, within 
a few moments these same bacteria may be found in the urine without 
blood or albumin. 
In the vast majority of cases of bacteriuria the source of the bacteria is 
undoubtedly the gastro-intestinal tract, for it has been shown that even 
a slightly altered intestinal mucous membrane is pervious to bacteria; 
as a rule, ordinary constipation is not enough to allow this permeability, 
but if it is prolonged or associated with lesions of the mucous membranes, 
even though very slight, bacteria may reach the blood or lymph streams, 
and be carried to the kidney or the bladder, as the case may be, setting 
up a bacteriuria either of renal or of vesical origin. 
As to the bacteria found in bacteriuria, the colon bacillus is met with in 
the vast majority of cases, but other bacteria have been found, such as the 
typhoid bacillus, various streptococci and staphylococci, sarcina, Bacillus 
lactis aerogenes, and in rare cases even the Bacillus proteus. 
Conclusions.-There are certain other questions which should be touched 
upon. It is important to remember that the epithelium of this tract is 
extremely resistant to infection, and that in the vast majority of cases 
certain predisposing factors must be met with before inflammation is set 
up. It is probable that in men spontaneous infection of the bladder from 
the urethra does not take place, probably due t. the internal sphincter, INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
949 
while in women it unquestionably may occur, although in the great 
majority of cases instrumentation or some other condition which lowers 
the resisting power of the bladder precedes it. While entirely possible 
for a regurgitant blood-stream to carry bacteria from the urethra to the 
bladder, and even from the bladder to the kidney, these methods of 
infection must be rare. Under very slight pathological conditions of the 
intestinal tract, bacteria, especially the colon bacillus, may penetrate 
the intestine and enter the blood and lymph streams, to be carried thence 
to the kidney and bladder. 
As to the constitutional effects of pyelitis, cystitis, etc., these depend 
largely upon the amount of absorption, and this in turn is dependent on 
the extent of injury which the epithelial layers have undergone. Thus, 
in acute cystitis there is considerable absorption, because the superficial 
cells are rapidly destroyed and the absorption of the poisons formed is 
rendered easy; obviously, if anything prevents the free flow of urine 
from the renal pelvis or bladder, the chances of absorption are markedly 
increased. In chronic cystitis the constitutional symptoms are less, as a 
rule, because the covering of pus, mucus, etc., over the ulcerated surfaces 
usually renders absorption slight. As to the poisons which cause these 
constitutional effects, the only ones carefully studied have been those 
formed by the colon bacillus in its growth; indol and two ptomaines, 
putrescin and cadaverin, have been described. 
The use of the agglutination test in diagnosing these infections of the 
urinary tract has been used in a number of instances, although it must 
be remembered that when dealing with the same bacterium agglutination 
will only take place with a homologous strain. Of course, in all cases 
we may either use precipitation tests, the thread reaction, Pfeiffer's 
phenomenon, or the ordinary agglutination test. 
Etiology.-To get a proper conception of the various inflammations of 
the kidney and its pelvis it is absolutely essential to understand the 
causative factors involved, both the primary causes and the accessory 
factors. Practically all forms of inflammation of the kidney are due to 
bacteria, but in many cases, probably the majority, other factors must 
be present before infection occurs. In certain cases we may have a 
pyelitis or pyelonephritis due to various poisons and drugs, or to the 
toxins produced in various diseases. Under normal conditions the 
kidney and its pelvis shows marked resistance to infection; bacteria 
of various kinds have been injected into the circulating blood and into 
the bladder, but no infection has occurred in many cases unless some 
trauma or impediment to the flow of urine has been artificially produced. 
In many infectious diseases bacteria may pass through the kidneys 
without producing any permanent lesion. In some cases there is a 
true renal bacteriuria, in which the urine becomes infected without 
involvement of the kidney, and contains many bacteria, usually colon 
bacilli, but no pus cells; although, if stasis of urine occurs, or the 
resistance of the kidney is lowered, pyelitis or a renal infection may arise. 
The degree of infection in the individual case depends to a certain extent 
upon the number, virulence, and character of the bacteria and their 
mode of entrance, but far more in the majority of cases upon various 950 
DISEASES OF THE URINARY SYSTEM 
accessory factors which make the kidney a locus minoris resistentice, 
be those causes local or general. 
Bacteriology of Pyelitis, Pyelonephritis, and Suppurative Inflammations of 
the Kidney.-A great variety of bacteria has been found in these condi- 
tions, much the same flora, in fact, as that met with in cystitis, although 
the relative frequency of the different species is quite different. Among 
the organisms found may be mentioned Staphylococcus pyogenes aureus 
and albus, Streptococcus pyogenes, Diplococcus urece liquefaciens, a urea- 
decomposing white staphylococcus, pneumococcus, Bacillus proteus 
vulgaris, typhoid and colon bacilli, Sarcina flava and alba, diphtheria 
bacillus, gonococcus, influenza bacillus, and various rare bacteria, the 
microorganisms being usually found in pure culture, although occasionally 
a mixed infection is met with. In all cases in which the microscope 
reveals bacteria, but nothing grows on the ordinary media, one should 
make anaerobic cultures, or at least use special staining reactions, while 
in all cases in which there is any doubt as to the etiology, especially if 
associated with an acid urine, the tubercle bacillus should be carefully 
looked for. Lenhartz, in 80 cases of pyelitis and pyelonephritis, most of 
which developed during or after pregnancy, found the colon bacillus 66 
times in pure culture, paratyphoid bacillus 3 times, Bacillus lactis aerogenes 
twice, Bacillus proteus vulgaris twice, and Friedlander's pneumobacillus 
once. Von Albeck in 92 cases of pyelitis and pyelonephritis in pregnant 
women found the colon bacillus 76 times in pure culture, and 3 times 
with pyogenic cocci, staphylococci alone 4 times, and streptococci alone 
9 times. 
Rovsing found that the bacteria in men and in women differed in 
this ratio: in 18 cases in women the colon bacillus was found 16 times 
in pure culture, once with the Streptococcus urece, and the Streptococcus 
pyogenes aureus once in pure culture; in 14 cases in men the colon bacillus 
was found 5 times, Staphylococcus pyogenes aureus twice, Staphylococcus 
pyogenes albus twice, Bacillus liquefaciens once, Bacillus longus lique- 
faciens once, Sarcina flava once-all in pure culture-while in one case 
Staphylococcus pyogenes albus and Streptococcus pyogenes were found, in 
another Bacillus proteus vulgaris and staphylococcus. In a series of 
14 cases, 13 women and 1 man, observed by the writer, in all of which 
both kidneys were catheterized separately, the colon- bacillus was found 
8 times, Bacillus proteus vulgaris 3 times, a white staphylococcus, which 
decomposed urea but did not liquefy gelatin, twice; while in one, a case 
of thirty years' standing, no growth occurred, the bacteria evidently 
having died out. In all cases the bacteria were found in pure culture. 
According to Kiister, the colon bacillus is the cause of the infection in at 
least one-third of the cases of suppurative nephritis, while Guyon and 
many others have stated that in their experience the colon bacillus is the 
commonest cause of all the infections of the urinary tract. As to the 
bacteriology of bacteriuria, although the colon bacillus is present in the 
vast majority of cases, Bacillus lactis aerogenes, Staphylococcus pyogenes 
aureus and albus, Streptococcus pyogenes, Bacillus typhosus, sarcina, 
and even Bacillus proteus vulgaris, have also been described. That 
the organs and urine of absolutely normal individuals are free from INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
951 
bacteria has the weight of authority, and thus, at the present time at 
least, it is not fair to assume that we may have autogenous infections 
of the kidney. Whether the gonococcus of itself can cause infection of the 
kidney is still under discussion, although it is difficult to explain certain 
cases on other grounds. Certainly its virulence is slight, and when the 
predisposing causes are removed a rapid cure occurs in the majority 
of cases. 
Paths of Entry of the Bacteria.-In each case we must determine whether 
the infection is hematogenous, urogenous, by contiguity, or by the 
medium of a penetrating wound. Hematogenous or metastatic infection 
may occur in any condition in which bacteria may get into the circulating 
blood. In regard to the commonest cause of renal infection, the colon 
bacillus, it has been very definitely shown by Posner, Lewin, and others 
that a pathological intestinal wall is pervious to bacteria, and that 
although ordinary constipation (from one and a half to two days) is not 
sufficient, longer constipation or surprisingly slight lesions of the mucous 
membranes allow the bacteria to enter the circulating blood; it has also 
been shown that the virulence of this bacillus is markedly increased 
in diarrhoea and other intestinal diseases, and this probably explains 
why in some cases it does no harm in. its transit, while in others it may 
produce all grades of infection from a simple bacteriuria to a suppurative 
pyelonephritis. 
The urogenous or ascending infection is peculiarly interesting, especially 
because infection of the kidney so commonly follows that of the bladder, 
although there is still some question as to exactly how this occurs. The 
commonest cause of cystitis unquestionably is instrumentation, the 
catheter or other instrument often producing trauma, and introducing 
bacteria if the technique is faulty, while a study of the bacterial flora 
shows that it is quite possible for cystitis to arise from that source; in 
men it is improbable that spontaneous infection of the bladder from 
the urethra occtirs, but in women this source is undoubted. 
It is a moot question whether Petit's old view that under normal circum- 
stances no escape of the urine from the bladder into the ureters is possible 
because of the oblique course of the latter in the vesical musculature is 
supported by the facts. Lewin and Goldschmidt showed that this is not 
so in the case of rabbits, while Guyon and Courtade demonstrated that 
this reflux is far less likely to occur in dogs in which the bladder muscle 
is stronger. Sampson and Young found that considerable distension of 
the bladder in dogs, or in the cadaver, was possible without any fluid 
entering the ureter. Although Kelly showed a reflux of air from bladder 
to ureter, nevertheless it is highly probable that in the vast majority 
of cases in health no reflux of fluid occurs even with considerable dis- 
tension. In disease such a reflux undoubtedly does occur. Sampson 
showed that bacteria may be carried from the bladder to the kidney 
by the general circulation, the vesico-ovariorenal anastomosis, the blood- 
vessels of the ureter (all of these being examples of hematogenous 
infection), the lymphatics, or by the lumen of the ureter. 
We may unquestionably have direct transmission of bacteria by way of 
the lymphatics from the colon to the kidney, especially on the right side, 952 
DISEASES OF THE URINARY SYSTEM 
where the organs are in sueh close proximity, and this is peculiarly liable 
to occur in cases of nephroptosis. Whether urogenous or hematogenous 
infections are most common is undecided. It seems unquestionable that 
when the renal pelvis is affected first the infection is more likely to be 
urogenous, while, in inflammations beginning in the kidney substance 
itself, hematogenous infection is more common. 
Accessory Factors.-While bacteria are always the primary cause 
except in those rare cases in which inflammatory changes are produced by 
various drugs, poisons, and toxins, nevertheless in most cases other 
factors are involved without which the infection would not take place; 
although in the case of renal infections it is far more difficult to determine 
these predisposing causes than in the case of infections of the bladder. 
Certain bacteria, especially if very virulent, if present in very large 
numbers, or if they have the power to decompose urea, thus producing 
substances irritating to the renal pelvis, may cause infection with no 
adjuvant causes. Most of these accessory factors act either by lessening 
the general strength of the patient, by lowering the resistance of the 
kidney, by trauma, or by causing retention and stasis of the urine. The 
importance of this last factor has been determined, and stricture and 
encroachment upon the lumen of any portion of the urinary tract are 
among the most potent predisposing factors. 
Among the accessory factors may be mentioned: Various general 
and local infections; marked constipation and gastro-intestinal disease; 
calculus, although stone is more likely to be caused by pyelitis than the 
reverse; diseases of the kidney, such as the various forms of nephritis; 
cystitis, this in older people almost always associated with retention, 
and if long continued almost always leading to pyelitis or pyelonephritis; 
stricture of the ureter or of the urethra, narrow urinary meatus, and phi- 
mosis, these causing retention of urine, and the two former frequently 
causing not only pyelitis and pyelonephritis, but also pyonephrosis or 
empyema of the renal pelvis; wounds of the kidney or its pelvis; trauma, 
frequently associated with small hemorrhages or tears in the kidney 
substance, or in the perinephric tissues; chronic passive congestion; some 
near-by focus of inflammation, such as acute appendicitis, pelvic peri- 
tonitis, etc.; nephroptosis, or floating kidney, hypertrophy of the prostate, 
the pressure of tumors, inflammatory exudates, the pregnant uterus, and 
possibly the distended colon upon the ureter, and the constriction of the 
ureter, due to adhesions or consecutive to ureteritis and periureteritis; 
anemia, unhygienic mode of life, or malnutrition, intercurrent disease, or 
anything which may lower the general resistance; various parasites, 
such as actinomyces, Eustrongylus gigas, filaria, echinococcus, bilharzia. 
Tuberculosis of the kidney is sometimes followed by secondary infection 
with one of the pyogenic bacteria, as also paralysis of the bladder from 
injury or disease of the spinal cord, etc. Gonorrhoea probably sometimes 
causes infection of the kidney, but is more often followed by a secondary 
infection due to other bacteria. The use of instruments may not only 
produce trauma, but also introduce bacteria. Holding urine for a long 
period of time voluntarily may be a cause. Injuries to the rectum or the 
mucous membrane of any portion of the gastro-intestinal tract may INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
953 
allow bacteria to enter the blood-stream, and cold, possibly by lowering 
the resistance of the kidney, has been mentioned, although it is question- 
able whether this is really contributory. 
In metastatic forms of renal infection the disease is usually bilateral, 
while in the cases due to trauma or to contiguity, unilateral infection is 
the rule. In ascending or urogenous infections it is far more often 
unilateral. In our series of 14 cases of pyelitis and pyelonephritis, 7 of 
which were urogenous, 6 hematogenous, and 1 by contiguity, 13 were 
unilateral, 1 bilateral, and of the unilateral the right side was affected 
in 8, the left side in 5 cases. Other series give a far greater relative 
frequency of involvement of the right side than the left; the proximity 
of the right kidney to the colon and its tendency to ptosis may have 
something to do with this increased susceptibility. In all cases, if the 
infection has lasted for a long period, there is a tendency for the other 
kidney to become infected usually by way of the bladder, although in 
some cases it is remarkable how long one kidney may remain intact with 
advanced disease of the other, and even with cystitis. In the suppurative 
inflammations bilateral infection is more common than unilateral. 
As to age, pyelitis and pyelonephritis are met with in children, even in 
very young infants to a considerable extent, although this has only been 
recently recognized, and even now in the majority of cases the proper 
diagnosis is not made; girls are more frequently affected than boys. 
In the aged the condition is common, due to the prevalence of many of the 
accessory factors mentioned above. The common years are between 
twenty and fifty, that is, the time when urethral troubles are most 
common in men, genital troubles in women, while it is also common in 
later life in men due to the tendency to enlargement of the prostate, 
and associated cystitis with retention. 
Infections of the kidney and of its pelvis in pregnancy are of great 
importance. Von Albeck, in 7648 cases in Meyer's clinic, found pyuria 
in 392, and in 52 of these, that is, 14 per cent., there were signs which 
pointed to pyelitis or pyelonephritis. Lohlein and Olshausen have 
shown that the ureters are always dilated in women dying in labor, 
the dilatation being above the superior strait. Opitz has observed 84 
cases during pregnancy and the puerperium, while Swift, who collected 
41 cases, found that the right side was involved 37 times, the left side 
4 times, and that of the 29 women in which the information was obtained, 
15 were primiparous, 14 multiparous. 
Pathology.-Pyelitis.-The typical pyelitis is that met with in ascend- 
ing or urogenous infections, while that consecutive to renal inflammation 
is not likely to be so severe or to show such marked changes. In ascending 
pyelitis the pelvis of the kidney shows a most variable picture, according 
to the type of infection, its duration, its virulence, and with what acces- 
sory factors it is associated. The pelvis may not be dilated at all, may 
be slightly or moderately so, or if obstruction occurs below the pelvis, 
if persisting for some time, there may be an extreme distension. 
Acute catarrhal pyelitis gives the typical picture of an acute inflam- 
mation; the mucous membrane is congested, swollen, and hyperemic, 
while on its surface may be seen red-blood cells, pus cells, a few 954 
DISEASES OF THE URINARY SYSTEM 
desquamated epithelial cells, mucus and bacteria in greater or less 
amounts, phosphate and oxalate crystals if the urine has been rendered 
alkaline, and even bits of calculus, if that is the predisposing cause. 
The bacteria are often agglutinated masses, and these may be-the nucleus 
around which a stone may form, although this is almost exclusively 
confined .to the alkaline infections. Occasionally the blood is present 
in larger amount, due to trauma, the effect of certain toxins, to some 
peculiarity of the blood, or to an increased permeability of the blood- 
vessel wall. 
Chronic Pyelitis.-In this the picture is quite different. The mucous 
membrane is brownish or grayish red in color, discolored spots frequently 
mark the remains of old hemorrhages, the mucous membrane is frequently 
pigmented and practically always markedly thickened, while the veins are 
enlarged and tortuous. The covering of the mucous membrane is mark- 
edly dependent upon the nature of the infection, and especially upon 
whether the urine is acid or alkaline. In acid infections the mucous 
membrane is covered with a layer, often quite thin, and very thick only 
in a small proportion of the cases, consisting of mucus, epithelial cells, 
pus cells, usually a few red-blood cells, many bacteria often in clumps, 
and sometimes deposits of crystals of uric acid and urates; while in the 
alkaline infections the coating is much thicker, as a rule, usually muco- 
purulent, with a foul odor, with phosphate and oxalate crystals embedded 
in it. Ulceration is much more common than in acute pyelitis, and 
this is peculiarly so in those cases in which the urine shows ammoniacal 
decomposition. The ulcers are often very deep, and may in rare instances 
even perforate into the neighboring organs and tissues, especially the 
pararenal fat, leading to burrowing abscesses which may discharge 
externally or into a neighboring viscus, the fistulse usually being very 
persistent. Various forms have been described: gangrenous pyelitis, 
cystic pyelitis, granular pyelitis, pseudomembranous pyelitis, and fibrinous, 
croupous, or diphtheritic pyelitis. 
In cases of pyelitis consecutive to suppurative nephritis the pelvis is less 
likely to be seriously involved than in ascending infections, while in the 
latter cases all stages of the cysto-ureto-pyelonephritis may be of marked 
severity. The substances produced by the ammoniacal decomposition 
of the urine are peculiarly destructive to the mucous membrane, and in 
this class of cases the most severe forms of pyelitis are found. 
The corresponding ureter is usually involved in cases of ascending 
pyelitis, although in rare instances it may be entirely normal; especially 
important are the changes about the ureteral openings into the bladder; 
and a diseased condition of the mouth of the ureter is one of the most 
important diagnostic signs of renal infection. The mucous membrane 
of the ureter may be chiefly affected (internal ureteritis'), or the surrounding 
connective and fatty tissue may also be involved (external ureteritis or 
periureteritis'). The changes in the ureteral mucous membrane are of 
the same character as those in the mucous membrane of the renal pelvis. 
The changes in the ureter are much more common in ascending infections, 
although frequently met with in the descending type; often in the latter 
case only the upper portion of the ureter is involved. INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
955 
If there is obstruction in the ureter, or even in the urethra, we will get 
stasis of urine, and first distension of the pelvis, then of the calices. 
Finally, if the obstruction is not removed, the entire kidney may be 
destroyed and converted into a large pus sac-and thus we may get 
varying grades of pyonephrosis or empyema of the renal pelvis, or even 
hydronephrosis. Sloughing of the calices, or even of the entire pelvis, 
may occur, while frequently we have in one and the same picture the 
pathological changes characteristic of pyelitis, pyelonephritis, and 
pyonephrosis. The kidney may be converted into one large abscess or 
into a series of smaller abscesses separated by remains of the connective 
tissue, or may be converted into a fatty mass, often still containing a few 
pus cavities. The pus may become inspissated, calcified, or converted 
into a serous fluid by absorption. If the process extends through the 
kidney we may find inflammation of the capsule both fibrous and fatty 
sometimes associated with abscess formation. The gradual dilatation 
of the pelvis and the calices, with papillary flattening, and subsequent 
atrophy and destruction of the kidney substance, the medulla being 
affected first and the cortex afterward, is peculiar to ascending pyoneph- 
rosis, while in the descending form the ureters are less likely to be 
affected and the cortex shows earlier changes. In both cases the vessels 
in the pedicle are often of surprisingly small size. 
Besides the pressure changes, the kidney may be markedly involved 
by an extension of the infection, and we may get a chronic interstitial 
nephritis, suppurative pyelonephritis, pyonephrotic changes or abscess 
of the kidney, with possibly hypertrophy of the other organ. 
Ascending Pyelonephritis.-In certain cases it is surprising for how long 
a period of time the pyelitis may exist without involving the kidney 
substance itself; on the other hand, quite early in some cases, and in the 
majority of cases after a certain length of time, such involvement does 
occur. The bacteria usually invade the collecting and the uriniferous 
tubules, and the inflammation usually starts from these as a centre. 
Bacteria may penetrate into the lymph spaces and interstitial tissue; 
we may find scattered throughout the kidney, especially the medulla, 
although the cortex is also often involved, little areas of suppura- 
tion which subsequently coalesce into abscesses of greater size with 
associated destruction of the surrounding parenchyma. The kidney 
is usually larger than normal, and is often soft, while if the process is 
extensive we find abscesses of various size, usually with a fairly thick 
surrounding sac and in which septa are sometimes seen. Microscopically 
the affected tubular epithelium shows the usual inflammatory changes, 
becoming turbid and swollen, and finally disintegrating; fatty changes 
may occur, and sometimes proliferation takes place. In all cases of 
ascending pyelonephritis the medullary portion of the kidney is usually 
affected earlier than the cortical, and to a greater extent. 
Chronic interstitial nephritis is a quite frequent sequel of pyelitis, 
the connective-tissue proliferation being seen as much in the medulla 
as in the cortex, while it is very common to meet many of these patho- 
logical conditions in the same case. If suppuration has been present 
for a long time we may have amyloid degeneration of the kidneys 956 
DISEASES OF THE URINARY SYSTEM 
or of other organs, while in some cases the renal suppuration may 
be the starting-point of pyemia or septicemia, and in addition we may 
have extension of the suppuration, either by contiguity or metastasis. 
Hematogenous Infections.-In these the condition is far more likely to 
be bilateral than unilateral. We may find a pure pyelitis with practically 
the picture already described due to metastasis, but in the majority of 
cases the pyelitis met with in descending infections either arises simultane- 
ously with the infection of the kidney itself, or is a direct sequel to it; in 
some cases the cortex and pelvis may be involved at the same time, while 
in others the process is localized first, and often for a considerable time in 
the kidney substance alone. Areas of hyperemia are followed by suppura- 
tion and abscess formation, with masses of bacteria as the causative 
factor, but unlike the ascending infections the bacteria are more likely 
to be found in and about the bloodvessels, and the cortex is more likely 
to be primarily involved. The organ is usually swollen and of a rather 
mottled appearance, the little abscesses being easily seen through the 
capsule, which is peculiarly liable to become adherent. Due to the 
distribution of the bloodvessels we sometimes find that the areas affected 
become wedge-shaped, with the point directed toward the centre of 
tht' organ. When the process becomes chronic, the abscesses, more 
likely to be found in the cortex, become larger and give a rough appear- 
ance to the surface, while the changes in the medulla, although similar 
in nature, are neither so marked nor distributed with such regularity. 
It is not uncommon to find bacterial emboli in the bloodvessels. 
Traumatic Infections.-In these cases we meet, according to the nature 
of the wound and the character of the invading microorganism, either 
small, localized foci of inflammation surrounding the hemorrhages due 
to the injury, or larger abscesses filled with pus, necrotic tissue, bacteria, 
etc., with marked destruction of the renal tissue; in the most severe types 
the entire organ may be destroyed, and the suppurative process may 
involve the renal pelvis, the fibrous and fatty capsules, and the retro- 
renal fat. The abscesses may burrow along fistulous paths and reach 
the surface of some neighboring or even far-distant viscus, the frequently 
associated involvement of the paranephric fat rendering this compara- 
tively easy; the abscesses may rupture directly into the renal pelvis, 
causing a pyelitis; they may give rise to pyemia or septicemia, or they 
may set up metastatic inflammations. 
Infections by Contiguity.-In these the picture is much the same as the 
preceding one except that the extravasations of blood, the laceration of 
the kidney substance, and the signs peculiar to injury are lacking. 
In any form of renal inflammation, whenever the inflammatory process 
reaches the surface of the kidney, perinephritis with adhesions between 
the kidney and its capsule is likely to occur, and from this source the 
inflammation frequently spreads to the fatty capsule and retrorenal 
fat. 
Symptoms.-Many cases of pyogenic infection of the kidney and of its 
pelvis are devoid of characteristic symptoms, although careful examina- 
tion, especially of the urine, should throw light on a considerable pro- 
portion. The symptoms may be practically wanting or so vague and INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
957 
indefinite as to be regarded as due to some other cause. It is a good 
rule that in every case of doubtful etiology, especially if associated with 
slight pain or sensitiveness in the back or either flank, with vague febrile 
symptoms, or with constitutional disturbances without definite cause, 
a careful urine examination should be made with the use of the cysto- 
scope and the ureteral catheter if the urinary findings seem to warrant 
it. 1 rinary examinations are peculiarly valuable in infants and children 
when the symptoms are specially vague and confusing, and in whom 
the vast majority of cases go unrecognized. In many cases of renal 
infection the onset is very insidious, while in others the disease may be 
ushered in by most violent symptoms, severe pain, chills, and high 
temperature, severe constitutional disturbances, etc. Pyelitis may last 
for years with practically no symptoms, although, even in those of 
most chronic course, a careful history usually elicits some suggestive 
symptoms, such as slight soreness, occasional slight febrile attacks with 
no apparent cause, and slight urinary abnormalities. 
In acute pyelitis we may have the usual symptoms of an acute inflam- 
mation, fever, chills, constitutional disturbances, etc., while in the chronic 
form acute exacerbations are frequently met with, the symptoms usually 
resembling those of an acute attack, while between the attacks the 
symptoms may disappear or become very slight. It is not at all uncom- 
mon for the acute cases and the exacerbations of the chronic cases to 
be regarded as appendicitis, while mild types of the disease are frequently 
regarded as lumbago. 
It is often most difficult to determine when a pyelitis goes over into a 
pyelonephritis, for even the latter process may last for years without any 
striking symptoms. Usually, however, involvement of the kidney sub- 
stance is associated with a marked increase in the severity of the symp- 
toms, the local and especially the constitutional, while if both kidneys 
are involved very grave symptoms may supervene. In acute pyelitis 
and pyelonephritis death may occur quickly, or the patient may gradually 
wear out, the terminal symptoms being sometimes due to general toxemia, 
at other times to uremia or ammoniemia; the symptoms may suddenly 
or gradually disappear and a cure take place; the acute may pass into 
a chronic inflammation, or the condition may be chronic in character 
from its incipiency. 
In many cases of suppurative nephritis there is a complete absence of 
symptoms, the manifestations of the primary disease completely over- 
shadowing the renal manifestations, although in the traumatic renal 
suppurations and those in which the kidney is suddenly affected by 
metastasis from some local focus, the symptoms, as a rule, are more 
definite. In abscess sudden rupture may complicate the picture, the 
symptoms either becoming more or less severe, or even disappearing 
altogether, according to where the rupture occurs. In pyonephrosis 
the clinical symptoms are most variable according to the etiology. 
During pregnancy and the puerperium we should always keep in mind 
the possibility of bladder and renal infections. The presence of leuko- 
cytosis sometimes aids in the diagnosis. 
The main symptoms of the pyogenic infections of the kidney and its 958 
DISEASES OF THE URINARY SYSTEM 
pelvis are changes in the urine, pain, swelling, and constitutional dis- 
turbances, and these will be considered in order. 
Urine.-In many of the cases the patients themselves have noted 
urinary symptoms; and pain, increased frequency, and other symptoms 
may call the patient's attention to the urinary tract, although obviously 
these symptoms may be entirely referable to the bladder. If ureteral 
catheterization is done, it is important to watch the rate of flow; normally 
this is drop by drop, while in cases of pyonephrosis and hydronephrosis 
and pyoureter and hydroureter the flow is in a steady stream until 
the ureter or pelvis is emptied, after which the flow is usually very 
sluggish. When the bladder is infected it is especially important to 
obtain separate specimens from each kidney. 
In acute pyelitis the amount of urine is usually diminished, sometimes 
there is complete anuria due to the severity of the infection, the involve- 
ment of both kidneys, or to the stoppage of one ureter and the reflex 
inhibition of the other kidney. There is usually increased frequency of 
urination, sometimes with pain or burning, even when the bladder 
is not involved; the specific gravity is usually increased; the reaction is 
usually acid, but may be neutral or alkaline. In infections with colon and 
typhoid bacilli it is always acid; in fact, in certain cases its acidity is 
definitely increased; albumin is usually present, often in moderate 
amount, due partly to the pus and red-blood cells present, partly to 
the effect of the fever and toxins. According to most observers, the 
amount of albumin in uncomplicated pyelitis, whether acute or chronic, 
can be entirely accounted for by the pus and blood; personal observations, 
on the other hand, have seemed to show that even when there is no 
involvement of the kidney the albumin is present in greater amount 
than can be thus accounted for. Microscopically pus cells, red-blood 
cells, epithelial cells, mucus, sometimes fibrin, and in all cases numbers 
of bacteria, sometimes actively motile, are found. In case of hemorrhagic 
pyelitis, red-blood corpuscles are present in large amount; in a few cases 
a marked tendency of the pus cells to active pseudopodic movements is 
seen. If the bacteria cause alkaline decomposition of the urine, the 
reaction may be ammoniacal and the mucopus thick and ropy, with 
phosphate and oxalate crystals embedded in it. 
In chronic pyelitis and ascending pyelonephritis the amount of urine 
is usually increased, although oliguria, and occasionally anuria, are 
met with in the acute exacerbations; several liters are sometimes 
passed daily, while in personally observed cases the average amount was 
2200 cc. 
In chronic pyelonephritis the urine may be increased or normal in 
amount, as in pyelitis, although if both kidneys are involved oliguria is 
the rule. The specific gravity is usually low, varying with the amount 
passed, although high in the exacerbations. The color is usually light 
yellow, although it may be dark red in the exacerbations. The odor 
is usually slight except in alkaline infections. Albumin, consisting of 
a mixture of serum albumin and nucleo-albumin, is always present; 
in pyelonephritis the amount is dependent upon the degree of renal 
involvement, although in many cases it is absolutely impossible to INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
959 
determine from the albumin, or, in fact, from any other urinary findings, 
whether we are dealing with a case of pyelitis or pyelonephritis. 
It is important to determine the amount of sediment, as by its increase 
or decrease we can tell something about the course of the disease and the 
effect of treatment. Immediately after being passed, the urine is usually 
cloudy, due to bacteria and pus cells, and the sudden disappearance 
of this cloudiness is very suggestive of stoppage of the ureter. 
Pus cells are practically always seen and red-blood cells are usually 
present in small numbers. Bits of renal tissue, although very rare, are 
important in showing kidney involvement. The long-tailed or caudate 
transitional cells in a tile-like arrangement, which used to be considered 
diagnostic of pyelitis, are in reality not so, as they are met with in the 
lower layers of the epithelium of the bladder and ureter. Bacteria 
are always present, often in clumps, sometimes in casts, the latter espe- 
cially in pyelonephritis while hyaline, granular, and epithelial casts are 
found in certain cases of pyelonephritis. 
In suppurative nephritis and renal abscess there is usually neither in- 
creased frequency nor pain on micturition; the urine may be normal as 
to its amount and character. In all cases in which both kidneys are con- 
siderably involved, or the kidney which is not affected is not functioning 
properly, the quantity is diminished; the urine may contain blood and 
pus cells, renal epithelial cells, rarely bits of renal tissue, all forms of 
casts, including pus and bacterial casts, if there is much involvement 
of the kidney tissue near the tubules. The sudden appearance of a large 
amount of pus is very suggestive of an abscess rupturing into the renal 
pelvis, and is often accompanied by marked improvement in the symp- 
toms and a lessening in the swelling. In suppurative nephritis and 
descending pyelonephritis the bladder is not so likely to be markedly 
affected as in the ascending forms. In miliary metastatic abscesses of 
the kidney secondary to general infections the urine often shows neither 
pus cells nor red-blood cells, and if present they are usually found in 
very small numbers. 
Traumatic nephritis often begins with a transient hematuria followed 
by anuria. Practically the same urinary findings, barring the initial 
hematuria and anuria, are seen in infections by contiguity. Pyonephrosis, 
if closed, may have normal urine, while if open there is always pyuria, 
which may be intermittent. In bacteriuria the urinary symptoms are 
usually nil; in pure bacteriuria the urine contains no pus cells, but 
myriads of bacteria, usually colon bacilli. 
Pain.-Pain, sensitiveness to pressure, or a feeling of pressure or 
fulness, is often the first symptom that suggests any renal trouble, and 
if present it is a most valuable sign, although frequently absent, as, 
for instance, in some cases of pyelitis and pyelonephritis, in metastatic 
miliary abscesses, in long encapsulated abscesses, and in certain cases 
of suppurative nephritis and pyonephrosis. In pyelitis and pyeloneph- 
ritis there may be constant pain or sensitiveness to pressure, or these 
symptoms may only be present during acute exacerbations; in our 
series, pain, a feeling of pressure or weight, a girdle sensation, or sensitive- 
ness to pressure was present in more than 75 per cent, of the cases, 960 
DISEASES OF THE URINARY SYSTEM 
although in many instances slight and only elicited by careful questioning. 
Pain is usually more marked with stone, although in pyelitis alone the 
pain may be so severe, due to plugging of the ureter, that we may have a 
typical renal colic, which can only be differentiated from stone by the 
use of the x-rays, the wax-tipped catheter, or at operation. The pain 
often radiates downward to the thigh, perineum, or genitalia, or upward 
to the stomach or shoulder, and it is usually increased on exertion, while 
pronounced and persistent pain associated with chills and fever is fre- 
quently the sign of the formation of a renal abscess consecutive to pyelo- 
nephritis. Ureteral pain due to stone, stricture, etc., may be difficult 
to differentiate from renal pain. 
In pyonephrosis about half of the patients complain of more or less 
pain, a considerably larger proportion of pain on pressure, and many have 
a feeling of fulness or discomfort in the renal region. In hematogenous 
suppurative nephritis and pyelonephritis the pain is often rather diffuse 
at first, later being localized in the renal region, while in the miliary 
metastatic abscesses met with in the course of various general infections 
severe pain is rarely present. In infants and young children the presence 
of colicky pain of doubtful origin, with drawing up of the legs, and 
screaming if the upright position is assumed, should make us suspicious 
of cystitis, pyelitis, or pyelonephritis, and should require an immediate 
urinary examination. 
Swelling.-Swelling or tumor, if present, is of the utmost value, 
although its absence does not in the least rule out renal infection. If 
present at all, it is usually of slight extent, although rarely it may be 
marked, as in some cases of pyonephrosis, and in renal infections associ- 
ated with perinephritis and paranephritis; in these latter instances the 
overlying skin may be markedly edematous. In acute pyelitis the swelling 
is usually slight and often cannot be made out with certainty; in chronic 
pyelitis it is usually not demonstrable except during the acute exacerba- 
tions, when it may be quite marked; in pyelonephritis swelling may 
sometimes be made out, especially if there is obstruction to the How of 
urine. In pyonephrosis the kidney can often be felt, while in purulent 
nephritis with abscess formation the tumor, although rarely of large 
size, may usually be determined by careful palpation. In cases of infection 
by contiguity, although swelling is often made out, it is difficult to differ- 
entiate it from the primary process. 
Constitutional Symptoms.-These are usually present at some time 
during the course, although often regarded as due to some other cause. 
Pyelitis and even pyelonephritis may last for years without any apparent 
constitutional disturbances, especially when the organism is not decidedly 
virulent, the urinary stasis slight, and the patient naturally vigorous; 
nevertheless, careful questioning will usually elicit some, if very slight, 
symptoms, loss of strength, slight digestive disturbances, mild febrile 
attacks, etc. Encapsulated renal abscess may give no general symptoms, 
while in many cases of suppurative nephritis in the course of general 
infections, or due to contiguity from some neighboring focus of inflam- 
mation, the constitutional symptoms are in no way different from those 
of the primary disease. The constitutional effects depend to a great INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
961 
extent on the amount of absorption, and for that reason are always 
increased by any condition which obstructs the flow of urine. It has 
been shown that the poisons produced by certain bacteria have a marked 
effect upon the nervous system, and also can produce destructive changes 
in the gastro-intestinal mucous membrane. As these constitutional 
symptoms are seen in unilateral cases when the urine is normal as regards 
the amount of urea secreted, etc., they are probably due more to the 
toxins produced by the infection than to renal insufficiency. 
The general symptoms are the usual ones met with in fever and toxemia, 
although differing markedly in degree according to the virulence of the 
infection, the resisting power of the patient, the accessory factors present, 
the amount of urinary stasis, etc. The most common symptoms are 
chills, fever, and sweats, general physical depression, loss of weight and 
strength, and digestive disturbances. In acute pyelitis there is sometimes 
in additipn diarrhoea, while nausea and vomiting are quite common; 
the pulse is usually rapid and full. These symptoms last in their severity 
for only a few days, and then either disappear suddenly or gradually 
merge into those of the chronic form. 
In chronic pyelitis the patient may have increased thirst due to the 
polyuria, appetite is usually diminished, dyspeptic disturbances frequent, 
and slight fever and diarrhoea are also met with, these symptoms varying 
markedly in different cases, and possibly being absent altogether; there, 
may be a tendency to profuse sweating, sometimes although not always 
associated with exacerbations of the disease. Increased pulse tension 
and enlarged heart are not seen, as a rule, in pure pyelitis, while if the 
kidney is considerably involved the tension is usually high, and the 
heart occasionally hypertrophied; there are also sometimes uremic 
manifestation and changes in the eye-grounds. In the exacerbations 
the symptoms very closely resemble those of acute pyelitis. 
If the kidney is markedly involved in the inflammatory process, 
loss of weight, coated tongue, marked digestive disturbances, poor 
powers of resistance, and more or less fever are usually seen, the symptoms 
resembling to a considerable extent those of small contracted kidney. 
The more frequent these acute exacerbations of pyelitis and pyeloneph- 
ritis, the more marked the constitutional symptoms and the more rapid 
the course of the disease. 
Severe general symptoms are the rule in cases of renal suppuration 
secondary to trauma, by contiguity, or from some localized focus of 
inflammation by metastasis; in some cases a typhoid state with delirium 
and coma results. True uremia is rare, probably because this type of 
inflammation is usually unilateral, but in severe cases of alkaline infec- 
tions, especially if retention is marked, ammoniemia may occur. 
In the pyelitis and pyelonephritis of pregnancy the symptoms are most 
capricious, the highest fever and the most severe constitutional effects 
disappearing in some cases with great suddenness from no apparent 
cause, or simply due to rest in bed. In most cases, however, such an 
outcome does not occur, and we have the symptoms of a chronic pyelitis 
with very frequent exacerbations. In children restlessness, pallor, loss 
of appetite, and depression are often the only signs, and in these, as in 962 
DISEASES OF THE URINARY SYSTEM 
adults, the symptoms of the disease may simulate typhoid fever, tuber- 
culosis, influenza, or gastro-enteritis. The presence of chills and fever 
in infants is very suggestive of pyelitis. 
The/ewr in renal infections is quite variable; in the acute form and in 
the exacerbation of the chronic and in any conditions producing sudden 
stoppage of the flow of urine from the diseased organ, it is often very 
high, sometimes constant, but more often remittent or intermittent, and 
often associated with chills and profuse sw'eats. Remittent fever with 
chills is usually met with in purulent renal inflammations, whether 
metastatic, traumatic, or by contiguity, while repeated chills with septic 
temperature are suggestive of an improperly drained abscess. In ascend- 
ing pyelonephritis fever is rarely absent, while in open pyonephrosis fever 
and apyrexia are present with about equal frequency. 
In all forms of unilateral infection a sudden increase of the constitutional 
symptoms may be due to infection of the other kidney. Long-standing 
cases of renal inflammation or cases of great severity may give rise to 
pyemia or septicemia with their characteristic temperature charts, 
the patient dying of the pyemia or septicemia itself, from amyloid de- 
generation, from some intercurrent disease, the rupture of an abscess 
into the peritoneal cavity, or by hemorrhage from a necrosed vessel. 
Diagnosis.-In the diagnosis of renal infection many questions sug- 
gest themselves: Are we dealing with a disease of the kidney or its pelvis; 
if so, of what nature? Is one or are both sides affected? If operation 
is under discussion, is the remaining kidney able to properly perform 
the renal functions? 
Whenever we wish to determine whether the kidney is involved, and 
if so, to what extent, especially if operation is under consideration, we 
should make use of the so-called functional tests, which, though not 
certain, are at least helpful in many cases, the tests, of course, being made 
with the urines from the two kidneys obtained simultaneously. The 
functional integrity cannot be determined definitely, it is true, by these 
tests, as the time is too short, and other factors play a role, such as the 
reflex inhibition of a normal kidney by a diseased organ, but if positive 
they are of unquestionable value. The most important functional tests 
are the phenolsulphonephthalein tests, the lactose, potassium iodide, 
chloride, and possibly diastase determinations, although many other 
tests described for this purpose have a distinct value. 
A cystoscopic examination of the bladder should be made to determine 
whether cystitis is present, and to carefully inspect the ureteral orifices, 
for by their appearance we may determine with a high degree of prob- 
ability in many cases whether or not the renal pelvis or kidney is diseased, 
and we may also notice the character of the urine flowing from the two 
openings and determine whether there is any ureteral stoppage; in cases 
where they are difficult to find we may give indigo, carmine or methylene 
blue hypodermically, and the flow of colored urine will easily show us 
the ureteral mouths. In addition, by the use of the ureteral catheter 
we can determine the presence of stricture, and even measure very 
accurately its degree; we may measure the capacity of the renal pelvis 
and determine whether it is distended or not, while by using wax on the INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
963 
catheter tip we may determine the presence of stone. In infants it is 
often difficult to obtain the urine for examination, and for this purpose 
Rotch has suggested allowing the infant to lie on a pad of cotton with 
rubber underneath it, from which the urine may subsequently be squeezed. 
The examination of the kidney itself should be most thorough, as in 
many cases swelling or sensitiveness to pressure is our only valuable 
diagnostic sign. By inspection we may occasionally, although very 
rarely, make out a lumbar swelling, as in certain cases of pyonephrosis 
and suppurative nephritis, especially if associated with perinephritis 
and paranephritis, while some claim that the absence of the kidney may 
be told by change in the contour of the flank. Percussion is rarely of 
help except in cases in which the enlargement is so marked that it can 
be made out better by other means; occasionally by inflating the colon 
through a rectal tube and percusssion we may differentiate renal swellings 
from other tumors. Palpation is the most reliable method, and various 
procedures should be employed, the patient being made to exhale deeply, 
the legs somewhat flexed, and the patient sometimes lying on the back, 
sometimes on the side, occasionally standing; rectal and vaginal examina- 
tion should be made at the same time, the latter being especially impor- 
tant, since about one-half the ureter may be palpated by this method, 
and calculus, stricture, thickening, etc., determined. Sometimes, on 
account of pain, nervousness, very tight muscles, etc., the examination 
must be made under anesthesia. The x-rays may be employed, although 
they are not of great value except in ureteral and renal calculi, especially 
those composed of phosphates or oxalates; by the use of a catheter 
coated with some substance impervious to the x-rays the course of the 
ureter may be determined, while in abscess of the kidney and marked 
sclerotic changes we may get a deeper shadow than normal, sometimes 
even simulating stone. The .x-ray examination of the kidney after 
injection of coilargol through the ureteral catheter is of great value. 
Some employ exploratory incision, puncture, or injection, the former 
being preferable, as puncture may be followed by hemorrhage or per- 
sistent fistula; by puncture, pus mixed with urine will determine the 
nature of the swelling, while after injecting methylene blue into the 
tumor, if the urine is colored green within a few minutes it shows that 
the kidney is the source of trouble. 
The general symptoms in many cases first suggest the diagnosis. 
History of pain in the flank, often slight but usually elicited on careful 
questioning, has been present in most cases at some time during the 
course of the disease, often regarded by the patient as lumbago, or 
neuralgia; fever, malaise, sweats, chills, and digestive disturbances are 
important only in suggesting that some inflammation is present; if no 
other cause can be found, however, one should always think of pyelitis 
and renal suppuration, and the urine should be examined at once. In 
most of the inflammations of the kidney or its pelvis the leukocytes are 
increased; in mild cases of chronic pyelitis and pyelonephritis, open 
pyonephrosis, and encapsulated abscess leukocytosis may be absent. 
In pyelitis, whether acute or chronic, the diagnosis can almost always 
be made with certainty by the use of the cystoscope and the ureteral 964 
DISEASES OF THE URINARY SYSTEM 
catheter and by the examination of the urine, except in those rare cases 
of severe and rapid gangrenous or diphtheritic pyelitis consecutive to 
severe infection. It must not be forgotten, however, that pyuria may 
be due to causes outside the urinary tract, such as appendicular abscess, 
prostatic abscess, or pyosalpinx, rupturing into the bladder, ureter, or 
renal pelvis. 
In acute pyelitis the sudden appearance of localized pain associated with 
chill is an important sign, while in the chronic cases the previous history 
of the patient, especially constant pain in the flank or slight fever, is 
very helpful. The presence of casts and an increased amount of albumin 
points to pyelonephritis, although both of these, especially the former, 
may be wanting; as a rule, systemic disturbances become more marked 
with the involvement of the kidney. The result of treatment is of 
great service in determining whether pyelitis complicates cystitis. 
Whether the condition is unilateral or bilateral can always be de- 
termined by ureteral catheterization, and usually by a careful history of 
the case. In pyelitis the functional ability of the kidney is not affected, 
as a rule, while in pyelonephritis it is usually lessened. Beer has suggested 
as a differential test the abnormal retention and delayed excretion of 
methylene blue in the latter affection. In the rare cases of croupous 
and diphtheritic pyelitis the diagnosis can usually be made from the 
characteristic findings in the urine, and the same is true if parasites, 
fragments of stone, or bits of new growth are found in the urine. 
In both pyelitis and pyelonephritis lumbar pain and swelling are most 
important diagnostic points. The possible complications of pyelitis and 
pyelonephritis are many, such as pyonephrosis, abscess of the kidney, 
perinephritis, paranephritis, contracted kidney, fistula of the renal 
pelvis, calculus, ureteritis, and periureteritis. It is quite striking in 
how many cases, especially those in which acute exacerbations are 
marked, the diagnosis of appendicitis has been made, frequently followed 
by operation. Hunner reported four cases in which the two conditions 
were associated, the appendicitis being primary, the pyelitis or ureteritis 
secondary and transitory. In the miliary metastatic abscesses met with 
in the course of general infection a certain diagnosis is usually impossible. 
In all cases of renal suppuration the diagnostic difficulties are very great, 
yet in all the finding of the etiological factors, such as trauma, calculus, 
contiguous focus of inflammation, cystitis, urethral stricture, or prostatic 
hypertrophy, is helpful. The most important symptoms are the pain 
and swelling in the renal region and the pyuria. In renal abscess the 
sudden appearance of a large amount of pus in the urine, with a coincident 
decrease in the size of the tumor and usually in the constitutional symp- 
toms as well, will give us the diagnosis. In encapsulated abscess, closed 
pyonephrosis, or complete destruction of the kidney the urine may be 
quite normal. It is not uncommon for the healthy kidney to be regarded 
as the diseased organ because of its compensatory hypertrophy. 
In purulent nephritis and pyelonephritis the kidney, as a rule, is at first 
only slightly enlarged, although in the later stages it is usually sufficiently 
swollen to be made out by palpation; in empyema of the renal pelvis and 
kidney abscess, the tumor is frequently large and fluctuating, and INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
965 
practically impossible to differentiate by palpation from hydronephrosis. 
In cases where renal suppuration is suspected von Bergmann suggests 
squeezing the kidney with the palpating hands, to see if by this means a 
large amount of pus is not expressed into the pelvis of the kidney and 
thence into the urine. In pyonephrosis persistent pyuria is the rule, or 
sometimes pyuria with periods of clear urine between, these latter being 
associated with increase of the swelling and of the constitutional symp- 
toms. Cathelin reports a case of lumbar abscess from Pott's disease 
opening into the bladder exactly simulating pyonephrosis. 
Prognosis.-The course and prognosis vary markedly in different 
cases, depending upon the character and virulence of the infection, the 
accessory etiological factors present, the drainage of the kidney, the 
presence or absence of complications, and the general physical condition. 
The prognosis, other things being equal, is better in pyelitis than in 
infections of the kidney substance, in cases in which drainage is good 
than in those in which urinary stasis is marked, in acid than in alkaline 
infections. 
In acute pyelitis the course is usually rapid, the acute stage rarely 
lasting more than a few days; in very rare cases death may occur quickly, 
due to anuria with uremia, although, as a rule, either cure takes place or 
the condition becomes chronic. If proper treatment is inaugurated cure 
is usual where the cause is transient or easily removed, as in the case of 
irritating drugs, while in the case of the acute infectious diseases, cystitis 
and inflammations of the kidney substance, the prognosis of the secondary 
pyelitis depends largely on the character and duration of the primary 
disease and the possibility of carrying out satisfactory therapeutic 
measures. 
The course of chronic pyelitis is variable. It may be present for 
many years, especially if the causal factors remain; the symptoms may 
be very slight, with no appreciable impairment of the general health, 
this being most likely to occur in infections with the colon bacillus. 
On the other hand, the majority do not run so mild a course, while 
complete recovery is very unusual. This is especially so when the acces- 
sory etiological factors persist, as hypertrophy of the prostate, vesical 
paralysis, etc. The course is subject to very marked variations as regards 
the symptoms, and marked constitutional disturbances are not infrequent. 
In the writer's experience stone is always present in chronic infections 
due to bacteria which have the power to decompose urea; in 5 such 
cases, 3 due to Bacillus proteus vulgaris, 2 to a white staphylococcus, a 
phosphatic stone was found in each; in one case of infection with the 
colon bacillus a stone of uric acid and urates was found. 
Simple pyelitis may go on for years without renal involvement, but if 
such involvement occurs the usual sequels of destructive renal changes 
occur; if, however, the kidney is only slightly affected, the clinical picture 
in many cases is hardly appreciably changed. In all cases the prognosis 
is worse with alkaline infections, because of the greater destruction of 
the mucous membrane, the possibility of ammoniemia, and the proba- 
bility of stone. 
In the pyelitis of pregnancy spontaneous cure may occur, sometimes 966 
DISEASES OF THE URINARY SYSTEM 
simply due to rest in bed, at other times after delivery, but in many cases 
a chronic pyelitis, sometimes associated with salpingitis, or a bacteriuria 
remains. In children spontaneous recovery is quite common. 
In suppurative nephritis there are often no definite symptoms, while in 
other cases, if present, they are lost in those of the primary disease; 
death occurs in practically all these cases due to the almost universally 
fatal termination of the general septicemia, and to the fact that it is in 
the most severe types that the kidney is likely to be involved. In trau- 
matic suppurative nephritis the prognosis is fair if the pus can freely 
discharge into the renal pelvis, while if the discharge be external the 
symptoms may be mild, although here there is a great tendency to the 
formation of burrowing abscesses, retention of pus, etc., which finally 
end the patient's life. Practically the same course is followed in renal 
suppuration by extension, but the prognosis is much more serious. 
Renal abscess, whatever be the cause, may last for a long period of time 
with practically no symptoms; sooner or later, however, in the majority 
of cases, rupture takes place into the renal pelvis with the development 
of pyelonephritis, pyonephrosis, or empyema; perinephritis and para- 
nephric abscess are frequent accompaniments. 
Cases of pyonephrosis, if unilateral, may last for years, although 
oftener the constitutional disturbances are marked and the course more 
rapid; the prognosis is much graver if both sides are affected, or if the 
second kidney undergoes degenerative changes due to the toxemia. 
Cure may occur in pyonephrosis and in large renal abscess by the 
complete destruction of the kidney, but this is very exceptional. 
In the renal suppurations the course may be, on the one hand, very 
mild, sometimes even with no definite symptoms, and, on the other hand, 
may be associated with symptoms of the gravest kind; in all cases the 
prognosis depends largely upon the etiological factors; the much more 
satisfactory treatment of prostatic hypertrophy and chronic cystitis 
within recent years has unquestionably improved the prognosis. Pure 
bacteriuria may cause renal inflammation if the local or general resistance 
is lowered. Kiister mentions four favorable factors in the prognosis, 
the possibility of an early correction of the urinary stasis, youth, a 
strong constitution, and a unilateral lesion. 
Treatment.-Prophylaxis.-To properly carry out prophylactic meas- 
ures it is essential that we should recognize the usual etiological factors 
and remove them if possible. These may be roughly divided into two 
groups: first, those that lower the resistance of the kidney by producing 
retention of urine, trauma, congestion, etc., and second, those that fur- 
nish the infection either by direct extension, as in the case of contiguous 
foci of inflammation, or by metastasis, as in the case of distant areas of 
inflammation, or by an ascending urogenous infection. It is, therefore, 
important to avoid all irritating drugs; to adopt the greatest care and 
most rigid technique in the use of instruments; to avoid introducing 
infection or producing trauma; to treat with care and promptness all 
cases of cystitis and gonorrhoea; to remove if possible all causes of urinary 
stasis, as by operation in urethral stricture, phimosis, and hypertrophied 
prostate, and hydraulic dilatation in the case of contracted bladder; INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
967 
to remove such causes of irritation as stone, foreign bodies, etc.; to use 
some form of urinary antiseptic, such as hexamethylenamine after opera- 
tions, especially if on the kidney, or if the patient has to be frequently 
catheterized, after severe labors, during typhoid fever, in bacteriuria, 
etc.; to give large quantities of water under these conditions, either by 
mouth or by rectum, as by the latter method most of the fluid is eliminated 
by the kidney within two or three hours. It is advisable to give plenty 
of water in severe febrile diseases, in pregnancy, and in the latter case 
to insist upon a certain amount of rest in the prone or knee-breast 
position; and, in addition, in this as in all other cases, to build up the 
patient's health, avoiding above all things constipation; in children and 
infants, especially girls, to give plenty of water, and to insist on great 
cleanliness of the genitals, always washing from the front backward. If 
catheterization has to be done for any purpose one should be most 
careful in the technique and the patients should drink considerable 
water beforehand. In the traumatic cases prophylaxis is most important, 
asepsis and antisepsis in the treatment of the wound, rest, appropriate 
diet, plenty of fluid, and some of the urinary antiseptics. 
In the treatment of inflammations of the kidney and its pelvis it is 
essential that the causal factor should be recognized and removed if 
possible. In all cases the resisting power of the patient is to be 
increased by careful attention to the general health, correcting 
any disorders, especially digestive disturbances, constipation and 
anemia. 
In acute pyelitis and pyelonephritis the removal of the cause is some- 
times sufficient to produce a rapid cure. The patient should be kept 
in bed at an equable temperature, it being specially important to avoid 
chilling; the diet should be simple, a milk or buttermilk diet being often 
best; all irritating drugs, highly seasoned food, and beverages contain- 
ing alcohol should be avoided; an ice-bag may be applied, although 
a hot-water bag or hot, moist applications are generally more grateful 
to the patient; warm baths or sweats sometimes give much relief; if the 
fever is high, phenacetin, quinine, or some other such remedy is indicated, 
these being more effective than cold sponges. If the pain is very severe, 
dry or wet cups or very hot compresses may be tried, although usually 
recourse will have to be had to morphine or opium, either by mouth, 
hypodermically, or by suppository. The bowels should be kept freely 
open and the patient made to take much water, while if the stomach is 
upset, salt solution or sterile water may be given by enema or, in very 
severe cases, by infusion. 
The urinary antiseptics are practically always indicated-hexamethyl- 
enamine (urotropin), salol, etc,, in doses of from 5 to 10 grains three or 
four times daily, with the usual reduction in dose in the case of infants 
and children; these drugs are peculiarly valuable in acute infections, 
if one can judge from clinical observations. Sleeplessness and nervous- 
ness may be helped by the bromides, trional, or veronal. If the urine 
is acid, bicarbonate or citrate of soda or potash may be given; if alkaline, 
boric, benzoic, or camphoric acid, as it is probable that the growth of 
the bacteria is inhibited in a medium of different reaction from what it 968 
DISEASES OF THE URINARY SYSTEM 
is accustomed to. If the severe symptoms persist, nephrotomy may be 
necessary. 
In chronic pyelitis and pyelonephritis, if the cause has been determined, 
it must be treated promptly. The resisting powers of the patient are to 
be increased by the usual procedures. The medicinal treatment consists 
in the administration of urinary antiseptics, or of the astringents, lime- 
water, lead acetate, gallic or tannic acid, etc., or of such drugs as uva 
ursi, the balsams of copaiba and Peru, etc. Of these drugs, hexamethyl- 
enamine or its derivatives may be taken for a long period of time with- 
out doing apparent harm, although some claim that it should not be 
used in gouty or lithemic subjects, or when uratic calculus is present. 
In all cases of chronic pyelitis or pyelonephritis some of the urinary 
antiseptics should be tried, but the drugs of the other groups are but 
little used, as they do little if any good in the majority of cases, besides 
deranging digestion; in persistent, intractable cases, where the other 
means have been unsuccessful, they may be tried, however. Obviously 
in the case of the antiseptics the effect on the deeper tissues in much less 
than on the pelvic mucous membrane, and they are, therefore, of less 
value when the kidney itself becomes involved in the infectious process. 
It is wise to change the reaction of the urine by giving alkalis or acids 
by the mouth with water in large amounts; if the kidney itself is much 
involved, however, one should avoid giving too large amounts. In cases 
of ammoniacal decomposition chlorate of potash, boric, benzoic, or 
camphoric acids may be given. 
In the pyelitis and pyelonephritis of pregnancy artificial labor must be 
induced, or a nephrotomy or even nephrectomy performed if the symp- 
toms are very severe and very persistent and do not yield to the usual 
treatment. Dilatation of the bladder sometimes gives marked relief 
in this as in other forms of renal infection. Sometimes the patients 
are much benefited by treatment at one of the alkaline springs. The acute 
exacerbations are to be treated in the same way as acute pyelitis. 
Chronic pyelitis has been treated by Kelly, Casper, and others by 
instillation into or irrigation of the renal pelvis through the ureteral 
catheter, the results in most cases being most encouraging, especially in 
infections with the colon bacillus or the gonococcus. Solutions of boric 
acid or of nitrate of silver (1 to 2000 to 1 to 1000) or other antiseptics may 
be used every few days as an irrigation, or 5 cc. of a 1 to 2 per cent, 
solution of silver nitrate instilled; by these means a number of cures 
have been reported, Casper obtaining a cure in 12 stubborn cases, 9 
due to the gonococcus, 3 to the colon bacillus. If we have pyelonephritis 
or if the pyelitis is associated with tuberculosis or calculus, this treat- 
ment can only be palliative and should not be employed. The use of 
autogenous vaccines is indicated, although in the main the results of 
these have been discouraging. The author has employed this method 
in a number of cases of infection with the colon and proteus bacilli, 
but usually with very disappointing results. 
In certain cases operative treatment may be necessary, either neph- 
rotomy, nephrectomy, pyelotomy, or resection. In all cases, however, 
it is essential that the presence and the functional ability of the other INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
969 
kidney be determined before operation is performed. In double pyelo- 
nephritis, if the condition warrants it, operation may be performed first 
on one kidney, and at a later time on the other, the kidney being opened, 
washed out, and drained. If the pyelonephritis is associated with abscess 
formation, free opening and drainage or nephrectomy is indicated accord- 
ing to the extent of the process. Some brilliant cures in the case of 
unilateral pyelitis and pyelonephritis have been reported after neph- 
rotomy. 
In suppurative traumatic nephritis, and that by extension from 
neighboring infections or by metastasis from a distant focus of inflam- 
mation, the two main indications are to remove the cause if possible or 
to lessen its manifestations, and to make an early and free outlet for the 
pus. If an abscess arises after trauma, the wound should be widened, 
washed out, and drained, while in only very severe cases is resection, 
nephrectomy, or nephrotomy necessary. In cases of pyelonephritis, 
whether due to ascending or descending infection, we should first try 
the measures already described, diet, rest, the use of alkaline waters, 
urinary antiseptics, etc.; in many cases great relief is obtained by these 
methods, but if marked suppuration occurs operative treatment is 
necessary. In suppurative nephritis and pyelonephritis with the forma- 
tion of abscesses, operative treatment should be employed as early as 
possible, but not until the presence and the functional ability of the other 
kidney has been determined, even if an exploratory nephrotomy is 
necessary, although usually the results obtained by ureteral catheteriza- 
tion are sufficient. 
The possible operations are pyelotomy, pyelostomy, nephrotomy, 
nephrostomy, resection of the kidney, and nephrectomy. If the ureter 
is narrowed or closed, nephrostomy or pyelostomy should be done and an 
attempt made to dilate the constricted portions of the ureter from above; 
persistent fistula is a frequent sequel to these operations. On account 
of the well-known regenerative powers of the kidney, resection or neph- 
rotomy should be the operation of choice if only a comparatively small and 
localized portion of the kidney is markedly affected. When nephrectomy 
is done, as much as possible of the diseased ureter should be removed at 
the same time, although this is not so important as in the case of tuber- 
culous infections. It is always justifiable to perform these smaller 
operations first, and later a secondary nephrectomy if necessary. A 
primary nephrectomy should practically never be done if the second 
kidney is diseased for a nephrotomy with drainage of the more diseased 
organ will often given an opportunity for the patient's general health 
to be improved, so that the secondary nephrectomy, if found to be 
necessary, will offer a better prognosis. In pyonephrosis, nephrotomy 
or nephrectomy is usually necessary, although irrigation of the renal 
pelvis may be very beneficial in a small proportion of the cases. 
Ilovsing concludes that death from insufficiency of the other kidney 
should never occur if the modern methods of diagnosis are carefully and 
intelligently employed; if the urine is free from pus, albumin, and bacteria, 
the kidney may be regarded as normal, while the presence of pus and 
bacteria usually contra-indicates operation on the other kidney. Albumin 970 
DISEASES OF THE URINARY SYSTEM 
without pus and blood, according to Rovsing, is often simply a sign of 
toxemia, and is a strong indication for operation. 
As to the results of the operative treatment of suppurative nephritis and 
pyelonephritis, Kiister gives the following figures: In 100 nephrotomies, 
27 were cured, 56 were unhealed, and in 23 of these a secondary neph- 
rectomy was done, 17 died; 2 cases of resection each gave favorable 
results; in 143 lumbar nephrectomies there were 24 deaths, and in 7 
transperitoneal nephrectomies, 4 deaths. 
PERINEPHRITIS-PARANEPHRITIS-EPINEPHRITIS-PARA- 
NEPHRIC ABSCESS-PERINEPHRIC ABSCESS 
The words perinephritis, paranephritis, and epinephritis have been 
used loosely to signify indiscriminately inflammation of the perirenal 
tissues, while Rayer, who first differentiated inflammation of the perirenal 
tissue from that of the kidney, first made use of the term perinephric 
abscess. It is better to be more explicit, however, and to define peri- 
nephritis as inflammation of the fibrous capsule immediately surrounding 
the kidney; epinephritis, inflammation of the fatty capsule, and para- 
nephritis, of the retroperitoneal fat. Of the three forms of epinephritis 
described by Israel (exclusive of the tuberculous, the syphilitic and 
actinomycotic), which he calls fibrosclerotic, lipomatous, and phleg- 
monous, the first two are so extremely rare, and the last so frequently 
gives rise to paranephritis that it is wise to consider epinephritis and 
paranephritis together under the one term, paranephritis. 
Perinephritis, although very rarely an independent disease, and in the 
vast majority of instances secondary to various inflammations of the 
kidney or of the perirenal fat, is of great interest because, due to the 
dense adhesions formed and the inability of the capsule to be easily 
moved over the kidney surface, symptoms almost exactly like those of 
renal colic may be produced. 
Paranephritis, and we are now using the term to include inflammation 
both of the fatty capsule and of the retroperitoneal fat behind the kidneys, 
while much less common, is of far greater importance, as it gives rise 
to paranephric or perinephric abscess. Perinephritis and paranephritis 
often occur together, although the process almost always begins either 
in the fibrous capsule, the fatty capsule, or the retrorenal fat, extending 
then to the others. As to the frequency of the condition Kiister has 
collected 230 cases of paranephritis, finding that it is twice as frequent 
in men as in women, equally frequent on either side, and that most cases 
occur between the ages of twenty and forty years; only 4 or 5 cases 
have been reported in which both sides were affected. Nieven, in a 
series of 144 cases, found 97 in man, 47 in women, and in a series of 166 
cases, 26 in children up to thirteen years, the youngest being five weeks 
old; 5 cases were found between the ages of sixty and seventy years, 
while the greatest number were met with in the fourth decade; in 136 
cases the right side was affected 76 times and the left side 60 times. 
Etiology.-Paranephritis may be either primary or secondary, the 
former usually developing from penetrating wounds and injuries of the INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
971 
kidney and perirenal tissues, the latter usually arising from metastasis or 
extension of inflammation from neighboring organs or tissues. Among 
the causes of the so-called primary form may be mentioned penetrating 
wounds and various contusions, blows in the region of the kidney, lifting 
heavy weights, sudden strain, hard riding, in fact, any condition which 
may cause a slight tear with associated hemorrhage into the perirenal 
tissues, this acting as a nidus for infection if any bacteria are brought 
there by the blood-stream. Foreign bodies from the intestine have been 
the cause in a few cases, while in some cases exposure to cold is the only 
causal factor that can be made out. 
The so-called secondary form arises either by metastasis, the infection 
being carried by blood or lymph current or by direct extension from some 
neighboring focus of inflammation or suppuration, as in puerperal infec- 
tions. Kiister believes that the cases met with in contagious diseases are 
not due to the primary disease, but to a secondary infection with pyogenic 
bacteria. In all these cases it is not known whether the kidney or its 
capsule is affected first. 
The most common cause of paranephritis by direct extension is purulent 
inflammation of the kidney itself, while among other causes may be 
mentioned various suppurations in the pelvic cavity, such as parametritis 
and rectal abscess, appendicular abscess, psoas abscess, etc. Operations 
on the bladder and the genitals are followed occasionally by paranephritis. 
Of course, bacteria are always the immediate cause of the inflammation, 
and among those found in paranephric abscess may be mentioned staphyl- 
ococci, streptococci, the pneumococcus, and colon, typhoid, tubercle, 
and influenza bacilli. 
Pathology.-We are rarely able to study the early stages of paraneph- 
ritis, but probably there is no difference between this and inflammations 
elsewhere, except that in the traumatic cases the inflammation is probably 
preceded by small hemorrhages into the fat. When seen at operation or 
autopsy we usually find the fatty capsule and retroperitoneal fat con- 
verted either into one large abscess, or into several smaller abscesses 
separated from each other by more or less necrotic fat and connective 
tissue. The picture is similar to that met with in other abscesses, and 
a distinct pyogenic membrane is often seen if the condition has been 
present for a considerable length of time. The retroperitoneal fatty 
tissue is especially likely to be the seat of the pus; the upper and lower 
poles are frequently affected, while that portion anterior to the kidney 
is rarely involved, although if it should be we will find a circumscribed 
local peritonitis, occasionally a general peritonitis due to perforation. 
An abscess in the true fatty capsule tends to burrow along the ureter 
toward the pelvis, while one of the retrorenal fat points more toward 
the inferior or superior lumbar triangle. The pus is sometimes odorless, 
sometimes has a fecal odor, due probably to proximity to the large 
intestine, or it is putrid if gangrene has occurred. The kidney may 
undergo various inflammatory changes, although, as a rule, the fibrous 
capsule protects it for a long time. We may find amyloid degeneration 
or pleurisy with effusion on the affected side if the condition has lasted 
long. 972 
DISEASES OF THE URINARY SYSTEM 
Symptoms.-In the majority of cases, due to the fact that the lesion is 
so deep seated and that the symptoms are usually masked in the early 
stage at least by the primary disease, an early diagnosis is difficult to make. 
In certain cases of insidious infection of different parts of the body, 
however, the first symptoms may be referred to the paranephric region, 
and only later the fact made out that the primary focus of infection is 
elsewhere. If the condition follows injury, the symptoms are more 
likely to be referred definitely to the paranephric region, pain usually 
being the first symptom. In the secondary cases as the disease progresses 
the true nature of the lesion usually can be made out. The three im- 
portant symptoms are pain, lumbar swelling, and fever. The pain 
is usually the first symptom, often extremely severe, localized in the 
lumbar region, and increased by every movement, and by direct pressure. 
The fever may be remittent or intermittent, the usual condition, or it 
may be continuous, high or low, or absent altogether. The local swelling 
usually first appears in the back, and by palpation a smooth, elastic, 
usually fluctuating mass, generally fixed, and not affected by the respira- 
tory movements, can be made out. It is, as a rule, more diffuse, not so 
well defined, and not so distinctly limited as a renal tumor. The skin 
is often oedematous if it points outward, while it may also become 
reddened and swollen when the inflammation gets near the surface. 
The urine, as a rule, is normal except in those cases in which the 
primary disease is one of the kidney or its pelvis. The general symptoms 
are those usually found in abscesses. If rupture occurs the size of the 
tumor may diminish and the pain disappear. As to the localization of 
the seat of the abscess, Maas, Roberts, and others have mentioned 
special symptoms; difficult breathing with persistent vomiting and 
pleuritic pain would thus suggest suprarenal abscess; constipation and 
flexion of the hip, infrarenal; pain on pressure and early lumbar tumor, 
retrorenal, while there are no typical symptoms, except possibly those 
of a local peritonitis, to suggest an abscess in front of the kidney. 
Course.-The primary and secondary forms of the disease differ 
markedly as to course and duration, the former usually beginning sud- 
denly with a fairly rapid course, the latter being slow and insidious. 
In every case the course is dependent upon the position of the abscess, 
the direction of its burrowing, the character of the primary disease, and 
the associated complications. The pus may burrow along the psoas 
muscle to Poupart's ligament, along the ureter into the bladder, or may 
rupture into the intestine, especially the cecum or colon, ureter, peri- 
toneal and pleural cavities, and in many cases fistuke occur, which, 
although persisting a long time, usually spontaneously heal. In rare 
instances the kidney may undergo gangrene due to thrombosis of its 
vessels, or an atrophic nephritis may be caused by the contraction of 
the inflamed perinephric tissue. Rosenberger collected 26 cases of 
perforation: 6 into the intestine, with 2 deaths; 13 into the pleural 
cavity and lungs, with 8 deaths, and 3 into the peritoneal cavity, with 
3 deaths. Even in favorable cases the duration of the disease is several 
weeks, while in the unfavorable cases, especially those secondary to 
causes which persist, the condition may last for years, and death may INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
973 
finally supervene, either by pyemia or septicemia, by gradually wearing 
out the patient, or by the development of amyloid degeneration. 
Diagnosis.-Early diagnosis is always difficult because, in the first place, 
the most important symptom, tumor, cannot be made out early, and in 
the second place, the symptoms are usually masked by those of the 
primary disease; specially difficult are the rare cases without fever. 
Pain, the first symptom, is frequently regarded as due to lumbago, 
although in the latter disease this is usually bilateral, less likely to be 
associated with leukocytosis, and is usually not so definitely localized 
in the soft parts. The general symptoms often suggest one of the acute 
infectious diseases. It is always well to remember, as Israel insists, 
the fourfold character of the symptoms in paranephritis, the general 
toxemia, localized symptoms, such as pain, those due to the extension 
of the abscess, and those due to acute metastatic involvement of the 
kidney, such as vomiting and changes in the' urine. Even with pain, 
fever, and localized swelling the condition must be differentiated from 
all other causes of similar signs and symptoms in the kidney itself; but 
here the examination of the urine, and the fact that in paranephritis 
the swelling is less distinctly limited, is usually retrorenal, and is affected 
little by the respiratory movements, should be helpful. The urine is 
normal, unless the disease is consecutive to a pyelitis or pyelonephritis. 
In distinguishing other abscesses in this region, extensive appendicular, 
psoas, and parametritic abscesses and abscess of the subcutaneous 
tissue, great difficulties may be experienced, although usually a careful 
examination with a consideration of the etiology and course will make 
the diagnosis certain. In doubtful cases puncture is justifiable, and if 
there is much admixture of fat with the pus we are probably dealing 
with a paranephric abscess. In a few cases the .r-ray may be helpful. 
Prognosis.-This depends on the conditions surrounding the special 
case, being most favorable in those cases pointing outward, or where 
surgical interference is early, and thus, as a rule, good in the primary 
type of the disease, and least so when the pus is difficult to recognize 
or to reach, when the primary disease is intractable, or when complica- 
tions occur. The prognosis is peculiarly dependent upon the skill of 
the physician in making an early diagnosis. In Kiister's series of 230 
cases of paranephritis there was a complete cure in 145, a persistent 
fistula in 6, while death occurred in 79, that is, 34 per cent, of the cases. 
Treatment.-Before the diagnosis can be made with certainty some of 
the symptoms, notably pain and fever, require treatment. We may use 
the Paquelin cautery, hot and cold applications, cupping, various drugs, 
aspirin, phenacetin, the salicylates, etc.; with very intense pain morphine 
must be given hypodermically. It is highly improbable that any of these 
measures have the least effect on influencing the disease. As soon as the 
diagnosis can be made with certainty there is but one course to pursue; 
the abscess must be freely opened and drained, its cavity explored so 
that all pockets of pus can be broken down, while if there is any question 
of the kidney being also involved it must be investigated by palpation, 
or by incision, and nephrotomy or nephrectomy be done if necessary. 974 
DISEASES OF THE URINARY SYSTEM 
URETERITIS-PERIURETERITIS 
With few exceptions inflammation of the ureter occurs only in associa- 
tion with an ascending infection from the bladder or a descending infection 
from the kidney and its pelvis, and for that reason as independent affec- 
tions ureteritis and periureteritis are of small moment, their symptoms 
being practically included in those of the primary disease. Pyogenic 
inflammations of the kidney and its pelvis, except those of a transitory 
nature, practically alwrays involve the ureter to a certain extent, although 
often only the upper portion is affected, while ureteritis consecutive to 
bladder inflammations is less common. As to its etiology, the causative 
factors are the same bacteria which give rise to pyelitis on the one hand 
and cystitis on the other. Israel, White, Stein, and Viertel have each 
reported cases of primary ureteritis, the symptoms being those of a 
nephralgia with hematuria, while a chronic proliferating ureteritis of 
doubtful etiology has been described. Tuberculous ureteritis is especially 
important, for in most cases of renal tuberculosis the ureter becomes 
involved, often along its whole course, so that the nature of the disease 
may be revealed by a cystoscopic examination; whether tuberculosis of 
the bladder can infect the ureter and subsequently the renal pelvis by 
direct extension is still a matter of discussion, although certain findings 
are difficult to explain otherwise. Among other etiological factors 
of importance may be mentioned various new-growths and areas of 
inflammation in the neighboring tissues, pyosalpinx, appendicular 
abscess, etc., and especially ureteral calculus, for whether primary or 
secondary, the ureteral wall may be so injured that inflammatory changes 
will be easily set up if pyogenic bacteria are present. Those cases of 
ureteritis and periureteritis due to extension of inflammation from some 
nearby focus are interesting, as when such infection occurs from the 
inflamed appendix, and such cases are especially important because of the 
possibility of overlooking the primary disease. 
The ureter is usually markedly thickened, especially in tuberculous 
ureteritis, and if the lower portion is affected the vesical orifice is swollen, 
oedematous, or ulcerated. Frequently the periureteral tissues are 
involved, and we have a periureteritis, or rarely a periureteral abscess, 
which may be edematous, infiltrated, or ulcerated, while it is very common 
to meet constriction of the lumen, sometimes complete closure, kinking 
of the ureter in its course, or dilatation, the last being specially likely 
to occur above a stricture or an impacted stone, and sometimes leading 
to hydronephrosis, pyonephrosis, or pyoureter. 
Symptoms.-The symptoms of ureteritis and periureteritis ordinarily 
met with in association with kidney or bladder infections are of no 
special significance, but it must not be forgotten that stricture of the 
ureter may produce symptoms simulating very closely those of nephro- 
lithiasis or nephralgia. The course of ureteritis is practically the same as 
that of the primary disease, and yet it undoubtedly plays an important 
role in the development of complications. In diseased conditions a 
reflux of fluid from the bladder can undoubtedly occur, and thus the INFECTIONS OF KIDNEY, URETER, PERIRENAL TISSUES 
975 
ureter has a very important intermediary role in the development of 
pyelitis and pyelonephritis consecutive to cystitis. 
Diagnosis.-This may be safely made if the physical signs, especially 
the urinary findings, show the presence of pyelitis or pyelonephritis, 
while in cases of cystitis which do not yield satisfactorily to treatment, a 
ureteritis and probably also a pyelitis may be suspected. In such cases a 
cystoscopic examination of the ureteral orifices with the use of the ureteral 
catheter is of paramount importance, while in the case of women the 
thickened ureter met with in ureteritis, especially in the tuberculous 
form, may be palpated through the vagina. Ureteral strictures and 
kinks may be made out easily by ureteral catheterization, Kelly even 
measuring the tightness of the stricture by a careful estimation of the 
pull on the catheter or the resistance to its withdrawal, while if the a-rays 
are used in conjunction with a catheter impervious to these rays the 
course of the ureter may be accurately determined. In cases in which 
stone is suspected as a causative factor, by means of the wax-tipped 
catheter or the a-rays its position may be determined, especially if the 
stone is composed of phosphates, oxalates, or carbonates. In the case 
of the x-rays we must be careful not to mistake a phlebolith for such 
a stone. It is possible if there is infection only of the lower portion of the 
ureter to find pus in the urine if the ureteral catheter is inserted but a 
short distance, while if it is pushed beyond the infected area the urine 
is clear. 
Treatment.-This is closely connected with that of the primary 
disease. It is well to remember the frequency with which the ureter is 
involved in infections of the kidney and its pelvis, for many failures 
have resulted from a lack of appreciation of this fact, especially in cases 
of tuberculous infection. It is therefore essential, if nephrectomy is 
done, that if possible the diseased portion of the ureter be removed at the 
same time, even if this requires a complete ureterectomy with removal 
of a portion of the bladder wall; this is peculiarly so in cases of tuber- 
culous nephritis and pyelitis. Periureteral abscess must be treated 
by incision and drainage, either externally or, in the case of women, by 
the vagina. If stone is associated with ureteritis, ureterotomy, uretero- 
nephrotomy, or ureteronephrectomy must be done according to the 
size and position of the stone and the condition of the kidney. In such 
cases, as well as in stricture of the ureter due to other causes, resection 
and anastomosis have been done, although in most cases a fistula remains. 
Occasionally operative treatment can be better carried out through the 
bladder, the perineum, or the vagina. C H A P T E R X V1 11 
TUBERCULOSIS OF THE KIDNEY 
THOMAS R. BROWN, M.D. 
Tuberculosis of the kidney is met with in two distinct clinical forms: 
First, as part of a general miliary tuberculosis, both kidneys usually 
being involved, and the renal disease being usually of comparatively 
slight significance, because it is but a part of the general infection; and 
second, the so-called primary renal tuberculosis, in which the disease is 
confined mainly to the urinary apparatus. Obviously the term primary 
is used in a clinical rather than in an etiological sense, as it is questionable 
if there are any cases of primary renal tuberculosis in the true sense of 
the word, and Krbnlein, therefore, suggests the terms combined and 
solitary. This clinical differentiation, however, is of the utmost impor- 
tance, as our attitude toward the two is absolutely different. In one 
there is practically nothing to-be done, and the diagnosis, made with 
great difficulty, if at all, helps little, if any, in our subsequent treatment; 
while in the other form the health and life of the patient depend upon a 
proper appreciation of the condition and an early diagnosis, for in this 
form prompt and proper treatment is followed by brilliant results in a 
large proportion of cases. It is, therefore, this second form of the disease, 
primary, primitive, or solitary tuberculosis of the kidney, or chronic 
localized tuberculosis, to which most attention should be directed. 
For many years the character of the disease was entirely misunderstood, 
and the reasons for this were manifold; in the first place, the disease as 
seen by the pathologists was usually advanced, bilateral and incurable, 
and generally associated with considerable involvement of other organs; 
in the second place, for a long time tuberculosis was supposed to be 
peculiarly liable to affect the genito-urinary tract in its entirety, and 
hence the misleading phrase urogenital tuberculosis; while in the third 
place it was thought that in the great majority of cases the kidney was 
infected from the bladder by an ascending or urogenous route-all 
these views obviously suggesting the inadvisability of local treatment. 
These views were entirely incorrect, for the so-called primary form of 
the disease is in its incipiency almost always unilateral. It is only infre- 
quently associated with genital tuberculosis, and even then there is 
rarely any direct connection between the two; it is usually due to a 
hematogenous or descending infection, the kidney being affected first. 
In its early stages at least the primary source of infection, a tuberculous 
gland, etc., is often of slight moment, and the prime requisite for success- 
ful treatment is its early recognition. 
Treatment must be mainly surgical, and yet the success of the surgeon 
is absolutely dependent upon the acuteness and skill of the physician 
976 TUBERCULOSIS OF THE KIDNEY 
977 
in making an early diagnosis. Exactly why the tuberculous process 
should engraft itself upon one system, and remain confined to that system 
for a considerable period of time, we do not know; but the urinary system 
is no exception to this rule, and it is surprising for how long a time tuber- 
culosis of the kidney alone, or of the kidney, ureter, and bladder, may 
persist without any active manifestations of the disease elsewhere. 
Etiology.-The only question under discussion is that relating to the 
origin of the primary form, for in the case of acute miliary tuberculosis 
and the involvement of the kidney in the terminal stages of tuberculosis 
elsewhere the infection is hematogenous, the renal disease being but 
part of a general tuberculosis. The etiology in that form in which the 
involvement of the urinary system dominates the picture is of the utmost 
importance. There are three possible ways in which the kidney may 
become infected by tubercle bacilli: (1) The hematogenous or descending 
route; (2) the ascending or urogenous; and (3) infection by continuity 
from some adjoining focus. The last of these, though interesting, is ex- 
tremely rare and of slight clinical importance. Cases have been described 
of extension from spinal caries, tuberculous empyema, tuberculosis of 
the adrenals, of the intestines, and of the peritoneum. In this connection 
the suggestion that renal involvement following vesical tuberculosis 
may be by continuity through the course of the ureter is of interest. 
The relative importance of the ascending and descending modes of 
infection has been the subject of much discussion. Guyon and many 
of the older clinicians taught that hematogenous infection was extremely 
rare. The work of Baumgarten, Albarran, Israel, and others has shown 
how erroneous these older views were, and has given us the proper 
conception of the pathogenesis of primary renal tuberculosis. Baum- 
garten by animal experiments showed that the infection in tuberculosis 
travels with the current, not against it, in other words, from the kidney 
to the bladder; that in the genital tract the epididymis is the favorite 
seat of primary infection, but that the involvement of the two systems 
is quite independent of each other, although the bladder may be infected 
in either case, very rarely, however, from the genital system. Walker 
inoculated the bladders of several hundred rabbits with bovine tubercle 
bacilli, and his experiments show that the kidney is practically never 
affected by an ascending pyelitis or pyelonephritis; he found in his 
entire series only one case which could be ascribed to this mode of infec- 
tion, and showed that the ureter is often affected, although generally 
showing but simple dilatation, and that the urinary organs were affected 
very rarely from the genitalia. Israel reported four cases of tuberculosis 
of the epididymis and the kidney on the same side without involvement 
of the bladder, showing that tuberculosis of the kidney and genital 
apparatus may occur together without extension from one to the other, 
both in all probability being infections of hematogenous origin. To quote 
from the same author: "A large number of cases of tuberculosis of the 
urinary apparatus show that the kidney is either the only or the first 
affected portion," and he bases these conclusions on the following facts: 
postmortem tuberculosis of the kidney with no other disease of the 
genito-urinary apparatus; lasting health of the patient after removal 978 
DISEASES OF THE URINARY SYSTEM 
of the tuberculous kidney; the localization of the tuberculous changes 
in the bladder about the ureteral orifices; and the presence of fresh early 
tuberculosis limited to these same localities. 
As a rule, in experimental hematogenous infections the bacteria gather 
mostly in the glomerular capillaries, going thence into the surrounding 
tissues, the smaller bloodvessels, or through Bowman's capsule into 
the uriniferous tubules, as Walker, Bubay, and others have shown. The 
extreme rarity of primary tuberculosis of the bladder in another argument 
in favor of the hematogenous origin of renal tuberculosis, Kelly having 
seen but one such case. It must also not be forgotten that if the bladder 
were the seat of the disease the kidney might be infected from this either 
by direct extension of the process up the ureter-a less likely mode of 
infection-or by the blood-stream as from any other tuberculous focus; 
in this latter case this may be either by the general circulation, the 
vesico-utero-ovariorenal anastomosis or by the bloodvessels of the ureter, 
and in the later stages of the disease the infection of the second kidney 
is probably either by this route, or from some other tuberculous focus. 
Many authors absolutely deny the possibility of a urogenous infection 
of the kidney, but Albarran, Walker, Kiister, Wildbolz, Rovsing, and 
Casper have proved its possibility in a very small percentage of cases. 
The primary source of the infection often cannot be determined, 
probably being some infected mediastinal, bronchial, or mesenteric 
gland, or some slight bone lesion, while in other cases an apical tuber- 
culosis, a cheesy gland, or a tuberculous sinus may be found. Garceau's 
figures seem to show that the lungs or the intestinal tract are the most 
common source of infection in renal tuberculosis. Kelynack found the 
lungs affected in 70 per cent, of his cases of renal tuberculosis, while 
Flick and Walsh from studies made at the Phipps Institute consider it 
probable that more than half of the patients suffering from pulmonary 
tuberculosis eventually have tuberculosis of the kidney, and that tubercle 
bacilli are excreted in the urine in all cases of active tuberculosis. 
Accessory Etiological Factors.-In most cases it is impossible to find 
out any special predisposing factors, although it is highly probable 
that at the time of its infection the kidney suffered some lowering of 
its resistance, possibly due to some transitory cause. Among the pre- 
disposing causes wThich may be mentioned are an inherited tendency 
to tuberculosis, chronic pyelitis, cystitis and urethritis, gonorrhoea, con- 
genital deformities, especially lobulated kidney, pregnancy, which may 
produce urinary stasis and renal congestion, floating kidney, cold- 
frequently mentioned, but extremely doubtful-calculus, hypernephroma, 
hydronephrosis, trauma, and any conditions which may produce urinary 
stasis, such as hypertrophy of the prostate, phimosis, and stricture. 
In floating kidney the lowered resistance is probably due to congestion. 
Kiister found this as the apparent cause in 18 of his 403 cases, and this 
may be the reason why women are affected more than men, and the 
right kidney more than the left. 
Age.-As regards primary tuberculosis of the kidney practically all 
authors agree that the commonest age is between twenty and forty 
years. In Roberts' series 4 cases were met with in the first decade, 5 TUBERCULOSIS OF THE KIDNEY 
979 
in the second, 6 in the third, 9 in the fourth, 9 in the fifth, and 2 in the 
sixth; in Kronlein's 51 cases, 7 were between seventeen and twenty, 
23 in the third decade, 14 in the fourth, 6 in the fifth, and 1 in the sixth. 
In Morris' 12 cases, 7 were older than thirty years, 5 between eleven 
and thirty years. Cases of primary tuberculosis have been met with in 
infants a few months old, and in adults over seventy years of age. 
Sex.-In regard to primary tuberculosis there is a great divergence 
of opinion as to which sex is more frequently involved, most of the 
English writers stating that more cases are found in men, most of the 
Continental writers more in women. All the more modern statistics 
show that the disease is unquestionably more prevalent in women, 
Casper stating that it is twice as frequent. Of Kronlein's 51 cases, 38 
were women. In acute miliary tuberculosis Morris found, in a series 
of 29 cases, 18 males and 11 females. Of 46 children under fourteen 
years of age in Hamill's series, 32 were boys and 12 girls. 
Pathology.-In acute miliary tuberculosis, both kidneys show a dis- 
seminated tuberculous infection, the tubercles appearing as minute gray 
nodules usually surrounded by a hyperemic zone, solitary or grouped 
together in cortex or medulla, the former being the favorite seat. The 
nodules are frequently arranged in rows following the course of the 
interlobular vessels, and often closely resemble small infarctions. Even 
in this form we may find the infection definitely limited to the areas 
supplied by one branch of the renal artery. It is not impossible for 
the bacteria to escape through the glomerular bloodvessels, especially 
if the walls should be injured, setting up changes in the uriniferous 
tubules and renal pelvis-Cohnheim's excretion tuberculosis. The 
changes are most likely to be noted in the interstitial connective tissue, 
where the characteristic cell proliferation, formation of giant cells, etc., 
can be seen, with associated degenerative changes in the adjoining 
parenchyma. Necrosis and caseation are not common because of the 
early death of the patient in the majority of cases. 
In primary renal tuberculosis it is common to make a division along 
pathological-anatomical lines, according to which portion of the organ 
is most markedly affected. Kbnig describes two forms, the solitary, 
in which there is no connection with the renal pelvis, and the pyelitic. 
Israel makes three divisions: phthisis caseosa, frequently associated 
with perinephritis and paranephritis, and often leading to pyonephrosis; 
tuberculous ulceration of the points of the papillae, much less common, 
but if present associated with a tendency toward severe hemorrhage; 
and the chronic disseminated tuberculous form, resembling the kidney 
of acute miliary tuberculosis, except that the disease is unilateral, the 
tubercles are larger, and the later processes of necrosis and caseation 
are more likely to be seen. Oppel differentiates cortical and medullary 
tuberculosis, while Tuffier divides the tuberculous infiltrations into three 
groups-tuberculous pyelonephritis, with or without cold abscess, massive 
degeneration, and tuberculous hydronephrosis. 
The pathological picture depends largely upon the duration, the 
rapidity with which the changes take place, and the accessory factors. 
In most cases at a later period the process affects mostly the papillae 980 
DISEASES OF THE URINARY SYSTEM 
and the pyramids, and the pelvis is usually involved, although in some 
cases the disease is confined entirely to the parenchyma, in rare instances 
localized in one pole, which, according to Zondek, is due to the fact that 
it is supplied by a single large branch of the renal artery. Animal experi- 
ments and the more recent studies seem to show that in the early stages 
the medullary or cortical interstitial connective tissue is most likely 
to be first affected, the bacilli gathering in the cortical layer, in the 
Malpighian bodies, or in the capillaries outside the glomeruli, and extend- 
ing thence as already described. Tubercles may develop in the glomeruli 
themselves, in the uriniferous tubules, or the renal pelvis, as well as in 
the interstitial connective tissue; whatever be their situation, infection 
may be carried secondarily to the papillae, the pyramids, or the renal 
pelvis. In the secondary focus the disease may progress more rapidly, 
while it is possible for the primary focus to show signs of healing; this 
is one of the reasons why so many renal infections were erroneously 
regarded as urogenous, and shows how impossible it is to determine the 
relative age of the process in different portions of the kidney. 
The kidney may undergo complete destruction-Tuffier's massive 
degeneration-due to early ureteral closure by downward extension of 
the process, and in this form the kidney is represented by a fibrous sac 
filled with a cheesy, greasy, or calcified mass. When the renal pelvis 
is involved its mucous membrane is thickened and shows ulceration, 
the whole surface sometimes being involved; peripyelitis is not uncom- 
mon, rarely with perforation into the adjacent tissues. In the various 
tuberculous foci fresh crops of tubercles may develop by direct extension 
or by metastasis. If the ureter is more or less impermeable, a pyonephrosis 
may develop, this being especially likely if there is a secondary infection. 
A considerable portion of the kidney substance may remain intact, or 
the organ may be converted into a sacculated mass, the abscesses or 
cavities being separated by bands or bars of renal tissue; the whole 
medulla and a large portion of the cortex may be converted into a large 
cavity, or the kidney may be changed into a shrivelled-up, putty-like 
mass, due to complete and permanent ureteral closure. Cheesy abscesses, 
whether large or small, may become inspissated, undergo calcareous 
change, or be discharged into the renal pelvis, causing a marked and 
characteristic change in the urine; as a rule, tubercle bacilli are found in 
these discharges, often in nests or clumps, and sometimes shreds of renal 
tissue. The kidney usually is enlarged to a greater or less extent, 
sometimes considerably so if there is marked obstruction to the flow 
of urine and we may have a hydronephrotic or pyonephrotic sac; a 
polycystic tuberculous kidney has also been described. 
Perinephric and paranephric inflammations are quite common in renal 
tuberculosis, the infection being either by direct extension or by metas- 
tasis, the former being more usual. 
Changes in the ureter are very frequent, especially in those forms in 
which the renal pelvis is involved, and are almost always present in the 
later stages. If ulceration of the mucous membrane of the renal pelvis 
is present it is likely to extend down the ureter, which may be dilated in its 
upper part, while farther down it may be moiv or less impermeable, TUBERCULOSIS OF THE KIDNEY 
981 
due to the inflammatory process. The mucous membrane of the 
ureter may show fresh tubercles, oedema, swelling, and areas of 
ulceration, while it is not at all uncommon for the periureteral tissues 
to participate in the inflammatory process. In some cases the major 
portion of the ureter may be unaffected and the diseased process mainly 
confined to the lower portion, especially the ureteral mouths, which 
may be of abnormal shape, the surrouding mucous membrane being 
either reddened or oedematous, or showing definite tuberculous changes. 
Halle and Motz, from a study of the pathological preparations at the 
Necker Hospital in Paris, found that the disease was in some instances 
entirely confined to the ureteral mucous membrane; sometimes ureteritis 
obliterans was met with and frequently changes in the ureteral mouths 
and periureteritis. In Roberts' 32 cases of renal tuberculosis the ureters 
were diseased in 30. 
The bladder is involved in a large number of cases of renal tuberculosis, 
although it is surprising for how long a time it may remain unaffected; 
in the later stages it is practically always diseased. The changes may 
be limited to the area surrounding the ureteral openings, or may be more 
extensive, in some cases the entire mucous membrane being involved. 
In Roberts' series the bladder was involved in 21 and the urethra in 
7 of 32 cases. 
The other kidney may remain absolutely normal or may be infected 
from the one primarily diseased. The infection of the second kidney 
may be metastatic or in rare instances, according to many observers, 
the infection may arise from the bladder by direct extension through 
the ureter or by the urogenous route, this latter mode of involvement 
being denied by many careful observers, and unquestionably of extreme 
rarity. The second kidney may show signs of compensatory hyper- 
trophy, chronic interstitial changes, or amyloid degeneration; Albarran 
describes the following pathological conditions which may be referable 
to the other kidney: transitory albuminuria, persistent albuminuria, 
nephritis, hemorrhagic nephritis, and simple cylindruria. 
Unilateral or Bilateral Involvement.-There is, as might be expected, 
marked discrepancy as to whether the condition is more likely to be 
bilateral or unilateral, according as the figures are obtained from autopsy 
records or from clinical observations. In a series of 12,732 autopsies, 
bilateral involvement was present in 62.3 per cent., unilateral in 37.6 
per cent., while in some of the older series, in which obviously the disease 
was not studied until very late, bilateral involvement was frequent; 
in Roberts' series of 32 cases, 19 were bilateral, 13 unilateral. 
In the more modern clinical statistics, however, there is a marked 
preponderance of unilateral involvement. Douglas found this to be 
80 per cent.; Bevan, 90 per cent.; Albarran, 91 per cent.; Mirabeau, 
at least 50 per cent.; Kronlein, 92 per cent.; Israel, 92 per cent.; Kummell, 
88 per cent.; and Facklam, 91 per cent. As regards the frequency of 
involvement of the two sides, Kuster's series of 368 cases showed the 
right side alone involved 189 times, the left side alone 163 times, 
both sides 16 times; most figures show this preponderance of the right 
side. 982 
DISEASES OF THE URINARY SYSTEM 
In 6000 autopsies at the Pathological Institute of Prague, 1317 were 
tuberculous, and of these 5.6 per cent, showed renal involvement; in 
3424 autopsies at the Massachusetts General and Boston City Hospitals 
there were 24 cases of caseous renal tuberculosis; Billet and Barthez 
found involvement of the kidneys in 49 of 315 tuberculous children; 
Dickinson, in 300 autopsies on subjects over twelve years of age, found 
renal tuberculosis 11 times; in 300 under twelve years of age, 49 times; 
in 2410 autopsies at the Middlesex Hospital there were 29 cases of miliary 
and 15 of primary renal tuberculosis. According to Wagner, surgical 
or primary renal tuberculosis is present in about 10 per cent, of all cases 
of tuberculosis. The proportion of cases which show renal involvement 
should in all probability be larger than those given in the figures above, 
in which the main dependence was upon the macroscopic appearance. 
Symptoms.-In acute miliary renal tuberculosis characteristic symptoms 
referable to the kidney are rarely present; oliguria and albuminuria 
may be due to renal involvement or be but a sign of general infection; 
hematuria is frequently met with; tubercle bacilli, although usually 
found if carefully looked for, may not be indicative of any marked 
involvement of the kidneys, as they are found in the urine in most cases 
of general miliary tuberculosis and advanced phthisis; lumbar pain may 
be complained of, but is not uncommon in general infections. As, how- 
ever, the renal disease is but a part of a general miliary infection, or 
appears as a terminal infection in severe lesions elsewhere, our inability 
to determine whether the kidney is involved is of little moment. 
In chronic or primary renal tuberculosis the conditions are very different, 
the whole future of the case depending upon a prompt and clear recogni- 
tion of the symptoms. Unfortunately symptoms referable to the kidney 
may be absolutely wanting at first, the patient only making complaint 
when the bladder becomes involved or the constitutional disturbances 
are very evident. The clinical course may be divided into four stages: 
(1) The latent stage; (2) from the involvement of the pyramids to the 
infection of the bladder; (3) the stage of bladder involvement; and 
(4) that of the infection of the other kidney. In the later stages diag- 
nosis, as a rule, should not be difficult, but a successful issue depends 
on our being able to make an early diagnosis, and it is, therefore, the 
early symptoms that are especially important. In the majority of cases 
careful questioning and a thorough investigation will reveal some symp- 
toms suggestive of renal disease. It is possible, however, for the 
disease to run an absolutely silent course, even until the kidney is com- 
pletely destroyed, while the length of the latent period depends upon 
whether the involvement of the renal pelvis is early or late. Even in 
marked disease of the cortex there may be no symptoms whatsoever. 
As seen clinically the first symptoms, both objective and subjective, 
are usually referable to the bladder, and many cases for a long time 
have been regarded as simple cystitis or irritable bladder. 
The most important symptoms are: (1) Changes in the urine, both 
as regards its flow and its physical, chemical, and microscopic constitu- 
tion; (2) local swelling and pain; (3) constitutional disturbances. The 
first of these in the majority of cases is by far the most important. TUBERCULOSIS OF THE KIDNEY 
983 
1. Urine.-The first symptoms are usually disturbances of urination. 
There is an increased frequency, with burning, sometimes cramp-like 
pains, usually beginning about the middle of the flow, increasing to the 
end, and ceasing with the complete emptying of the bladder. This 
increased frequency is especially likely to be present at night, and may 
be due to a reflex stimulation of the bladder, an associated cystitis, or 
perhaps excessive acidity of the urine. As a rule, although not always, 
these disturbances are not severe except when the bladder is involved, 
when they may assume the most painful proportions, strangury, dysuria, 
and frequency of urination sometimes reaching an almost incredible 
degree. Incontinence is seen in a few cases, and Bazy regards this if 
present as a very important early symptom. The increased frequency 
may be constant or intermittent, and with the pain may unquestionably 
precede the involvement of the bladder for a considerable time. For 
this reason it is probably the most important symptom, as it calls atten- 
tion to the urine and suggests the advisability of making a careful exami- 
nation. Roberts reports a patient voiding on an average 160 times 
daily, in whom the bladder, however, was but slightly diseased; in 
another micturition was incessant until nephrotomy with drainage was 
performed. In some cases, even before the increased frequency and 
pain, the patient notices cloudiness of the urine. 
The amount of urine varies markedly; according to some it may be 
diminished at first, while according to Guyon, Tilden Brown, and others, 
polyuria is a cardinal early symptom, especially nocturnal polyuria; 
in many cases the amount is practically normal. In the later stages the 
amount may be normal, diminished, or even increased according to the 
extent of destruction of the kidney tissue and the degree of hypertrophy 
of the sound kidney. When both sides are extensively involved, or when 
the flow from the diseased side ceases, due to stoppage in the ureter, we 
may have oliguria or even anuria. If both kidneys are catheterized, 
it is interesting to note the larger amount from the normal kidney, and 
its much quicker and more marked response to the taking of fluids by 
mouth. The various functional tests furnish information of great 
value. 
The reaction is always acid unless the disease is complicated by an 
alkaline cystitis or pyelitis, or unless the patient is taking large quantities 
of alkalis. In some cases the acidity is increased. If there is an associated 
infection with one of the urea-decomposing bacteria the odor may be 
very foul, this being more likely to occur in the later stages. 
The albumin present varies considerably in amount. It is usually 
small in the early stages, corresponding to the amount of blood and pus 
present, while later it is likely to be increased because of the frequent 
presence of an associated interstitial or parenchymatous nephritis in 
other portions of the diseased kidney. If the specimen is obtained directly 
from the diseased kidney, even in fairly early cases, a moderate or con- 
siderable amount of albumin is the rule. 
The urine may be absolutely clear, as, for example, when the ureter 
is temporarily blocked or permanently closed, or when the disease is 
entirely confined to the cortex; the examination of the sediment, however, 984 
DISEASES OF THE URINARY SYSTEM 
is of the utmost importance, and, as a rule, it is the finding of pus cells, 
often red-blood cells, and tubercle bacilli that gives the diagnosis. 
Pus cells are almost always present, although in varying amount; it 
is sometimes the cloudiness of the urine which first calls the patient's 
attention to his trouble. Pyuria is usually more marked if the renal 
pelvis is involved, and especially if there is an associated tuberculous 
cystitis, or a mixed infection, while it is not at all uncommon for the 
urine to become suddenly thick with pus after the rupture of an abscess 
into the renal pelvis. 
The presence of tubercle bacilli is of the utmost importance, and, 
excepting in cases of general miliary tuberculosis or an active tuberculous 
process elsewhere, it is the most important diagnostic sign of primary 
renal tuberculosis. They may be found in the great majority of cases 
if the sediment obtained from a considerable amount of urine is centrif- 
ugalized and repeated examinations are made, preferably at intervals 
of several days. They are rarely present in large numbers, and often 
require very careful searching of many specimens; if the bladder is 
involved they are usually found with greater ease, although even here 
time and patience are required. Nests or clumps of the bacilli are often 
found embedded in the masses of pus, crumbling caseous material, necrotic 
tissue, and detritus which are present in the urine when an abscess 
ruptures into the renal pelvis. In 195 cases collected by Kiister in which 
tubercle bacilli were searched for, they were found in 94, not found in 
101, although unquestionably with greater care and persistence they 
could be found in a far larger proportion. 
Blood in the urine is a very important symptom, microscopic blood 
being found in the great majority of cases and macroscopic blood not 
uncommonly. Red-blood cells are peculiarly likely to be present in the 
early stages, and a macroscopic hematuria may be the first sign noted. 
Macroscopic hematuria is usually intermittent, rarely profuse, as a 
rule not affected by rest or exercise, and associated with pyuria usually 
of moderate grade. According to Casper, hemorrhage is more likely to 
occur in the early stage, as the progression of the disease is associated 
with increasing obliteration of the bloodvessels. Tuffier, Albarran, 
Pousson, and others have reported cases of severe bleeding, requiring 
immediate operation, in renal tuberculosis, while Askanazy has reported 
five cases of his own and a number from the literature in which more or 
less marked macroscopic hematuria recurring at intervals was the earliest 
symptom, usually coming on suddenly and in some cases being the 
only sign of disease for many years; in one case sixteen, in another 
thirteen years elapsed before other symptoms appeared. The blood may 
sometimes entirely stop up the ureter, producing colicky pains, which 
often disappear with the appearance of worm-like blood-clots in the 
urine-blood-casts of the ureter. Klebs believes that these early hem- 
orrhages may be due to an angiotoxin produced in the growth of the 
bacteria in the body. 
Epithelial cells from the renal pelvis, ureter, or bladder are usually 
present and may show signs of fatty degeneration. Casts were found 
by Hunner in 10 per cent, of his cases, although, according to others, TUBERCULOSIS OF THE KIDNEY 
985 
both hyaline and granular casts are found much more frequently than 
this; they may come exceptionally from the other kidney, which may 
be affected by the circulating toxins. Granular amorphous masses, 
crumbling cheesy material, bits of kidney tissue, masses of friable detritus, 
often with tubercle bacilli embedded therein, fibrous tissue, and elastic 
fibres are occasionally found, and are of great diagnostic value. 
2. Local Swelling and Pain.-Local swelling is an important but incon- 
stant symptom, although in the later stages it may often be made out, 
or at least a feeling of increased resistance or of distension to the palpating 
hand, the organ frequently being less movable than in health. The 
presence of perinephritis or paranephritis increases the chance of finding 
a palpable tumor. The local swelling is usually not very marked except 
with pyonephrosis, hydronephrosis, or paranephric-abscess. 
Local pain, frequently absent or slight in the early stages of the disease, 
may occur spontaneously, may be constant or paroxysmal, sometimes a 
true renal colic, or may only be elicited by pressure, the former being, 
as a rule, more a dull ache, a sensation of fulness, dragging or pressure, 
or a sense of soreness than a severe pain. This is usually due to stretching 
of the capsule, and may radiate to the bladder or thigh. Tuffier's forme 
douloureuse with neuralgic pains in the renal region is extremely rare. 
Bazy finds three points where pain may be produced by pressure, para- 
umbilical, subcostal, and lumbar, while pain and tenderness in the 
costovertebral triangle is common if there is much perinephric or para- 
nephric involvement. In some cases the pain, as well as the swelling, 
is referred to the healthy kidney which has undergone compensatory 
hypertrophy. 
3. Constitutional Disturbances.-These are usually present, although, 
as a rule, not marked until fairly late. It is not uncommon to find a 
gradual impairment of the general health, diminishing strength, fatigue 
on slight exertion, and unaccountable dyspnoea. In other cases, but 
these are rare, the constitutional symptoms may develop rapidly and 
the picture resemble typhoid fever; such a resemblance is not uncommon 
in the later stages. As a rule, the constitutional disturbances develop 
gradually, while in some cases the condition may persist for a long time, 
with no apparent impairment of the general health. In the later stages 
the constitutional symptoms are marked-emaciation, anemia, cachexia, 
anorexia, and other digestive disturbances, fever, chills, and profuse 
sweats. These symptoms are usually more severe and develop more 
rapidly if the bladder becomes involved, or if there are signs of active 
tuberculosis elsewhere, and it is always important to determine whether 
some of the symptoms at least are not referable to an active lesion outside 
the urinary tract. In rare instances primary renal tuberculosis may 
develop with the typical symptoms of acute nephritis, oedema, nausea, 
vomiting, oliguria, etc.; oedema may also be present in the later stages, 
especially if both kidneys are involved. 
Fever is present in a fair proportion of the cases, although often absent 
during the latent stage. According to Israel, fever is present in only 22 
per cent, of the cases of uncomplicated renal tuberculosis, and in 80 
per cent, if the bladder is also involved; but these figures, especially 986 
DISEASES OF THE URINARY SYSTEM 
the former, are too low. In the early stages fever, if present, is likely 
to consist simply of a regular or intermittent evening rise of one or several 
degrees, generally after exercise, while in the late stages, especially if 
associated with marked bladder involvement, it is usually irregularly 
intermittent, remittent, constant, or of the hectic type, in this latter 
instance profuse sweats being a common accompaniment, especially 
night sweats, while in some cases frequent chills occur. 
Digestive disturbances are frequent in the later stages, while diminution 
of appetite is a not uncommon early symptom. In advanced cases 
marked gastro-intestinal disturbances are common. 
The pulse is rapid if nephritis is present or in advanced cases, its rate 
otherwise being dependent upon the degree of fever. Reitter believes 
that hypotension of the pulse is of importance, as he found it in 6 of 10 
cases of renal tuberculosis even with marked evidences of nephritis. 
Anemia, oligemia, oligochromemia, or oligocythemia is present in all 
advanced cases, and may appear rather early; in uncomplicated cases 
the leukocytes, as a rule, are either normal or diminished, the neutrophiles 
being especially reduced, while if there is a secondary infection, leuko- 
cytosis is the rule. If both kidneys are markedly diseased, the freezing- 
point of the blood may be less than -0.6° C. 
Course.-The course of primary renal tuberculosis is chronic and 
may last months and even years; the disease, while progressive, often 
develops so slowly that no changes may be noted in long periods of time. 
The difficulty or inability of determining the exact beginning makes it 
impossible to tell the exact duration, but from the first appearance 
of symptoms to the end, five or more years may elapse, and in some cases 
symptoms have been present for more than ten years. In half of 
Kronlein's cases the symptoms had been present one year, in the other 
half two to four years or longer, while in Kelly's group of 62 cases the 
average duration was three and a half years, one patient having had 
definite symptoms for thirteen years, yet showing on operation some 
secreting tissue in the diseased kidney, and the other kidney normal. 
A number of complications may occur; the perinephric and paranephric 
tissues frequently show involvement, often associated with increased 
pain, swelling, and severe constitutional disturbances, while disease of the 
ureter and bladder is extremely common. The other kidney may show 
toxic changes, a simple pyelitis, or typical tuberculosis. The picture may 
be confused by the development of a ureterovaginal or vesicovaginal 
fistula, while by metastasis or direct extension other organs may be 
involved in the tuberculous process, or the cheesy abscesses may rupture 
externally or into the neighboring organs. 
The cause of death may be exhaustion or septicemia, the latter being 
especially likely to occur if the paranephric tissues are extensively 
diseased, or if there is a severe mixed infection; metastasis and general 
dissemination of the tubercle bacilli; metastatic tuberculosis of other 
organs, as most commonly the lungs, the intestines, the peritoneum 
etc.; amyloid disease; extension of the disease to the tissues surrounding 
the kidney, with abscess formation and subsequent rupture, and in very 
rare instances uremia, the latter occurring when both kidneys are diseased, TUBERCULOSIS OF THE KIDNEY 
987 
or in some cases when one is removed and the other is tuberculous, shows 
signs of nephritis, or is absent altogether. 
Diagnosis.-The realization that renal tuberculosis is usually unilateral, 
that its origin is almost exclusively hematogenous, and that it is a disease 
very susceptible to treatment if recognized early, makes the necessity 
of a prompt diagnosis of the utmost importance; in fact, if a cure is to 
be hoped for, early diagnosis is essential. It is important that w'e should 
make the diagnosis, if possible, before the appearance of marked con- 
stitutional symptoms and involvement of the bladder. This may be 
extremely difficult from the quiet afebrile course of the latent stage and 
its marked freedom from striking symptoms. It is necessary to consider 
carefully the family history, the past history, the general appearance of 
the patient, the presence of pain, dysuria, polyuria, hematuria, increased 
frequency of micturition, etc., to examine the urine thoroughly, to use 
the cystoscope and ureteral catheter, to make careful bacteriological 
studies, and in some cases to give tuberculin. 
It is a good practice to look for tubercle bacilli in every acid, sterile, 
purulent urine, and to suspect renal tuberculosis in cases of slight urinary 
disturbances or constitutional disturbances with no apparent cause. 
Physicians should pay more attention to complaints of lumbar pain 
localized in one side and persisting for some time. The possibility of a 
tuberculous origin should be remembered in every case of renal hematuria 
without definite cause. It must not be forgotten that chronic gonorrhoea, 
renal calculus, or neoplasm may be associated with tuberculosis, and 
the discovery of the former does not necessarily exclude the latter. To 
make a positive diagnosis tubercle bacilli must be found in the urine, 
and proved to come from the kidney, while if this is not possible a pre- 
sumptive diagnosis may be often made from the local pain and swelling, 
sterile renal pyuria, renal hematuria, and tuberculous lesions elsewhere. 
The study of the urine gives, as a rule, the most important signs, pyuria, 
hematuria, and the finding of tubercle bacilli giving the diagnosis in 
the majority of cases. The urine should be obtained by catheter to 
avoid contamination with the smegma bacillus, while, whenever possible, 
separate specimens should be obtained by the ureteral catheter. The 
urine should be studied with special care when increased frequency, 
especially nocturnal, and pain on urination has been noted, and also, 
according to many clinicians, in cases of polyuria with no apparent 
cause. Red-blood cells are usually present, although often only demon- 
strable microscopically, while macroscopic hematuria is often very abrupt 
both in its onset and its disappearance, and may occur intermittently. 
Pyuria is usually present and of great importance. 
The finding of tubercle bacilli in the urine gives the diagnosis if proved 
to be derived from the kidney, which is easy when ureteral catheteriza- 
tion is possible. We must not forget that they may be met with in the 
urine, however, in the case of active tuberculosis elsewhere. If the urine 
is obtained by ureteral or urethral catheterization the ordinary means 
of staining and studying the bacteria are all that is necessary, but if 
voided specimens are examined the tubercle bacillus must be differentiated 
from the smegma bacillus. This may be done either by animal inoculation 988 
DISEASES OF THE URINARY SYSTEM 
or by certain staining methods. Ekehorn found tubercle bacilli in 
every one of his 55 cases by careful search, although according to 
Casper they can be found in but 70 to 80 per cent, of all cases. Personal 
experience agrees with that of Ekehorn, although it is often necessary 
to make frequent examinations of the centrifugalized sediment. In 
suspicious cases where they are not found, guinea-pigs should be inoc- 
ulated with the sediment, and, if it contains tubercle bacilli, in from 
four to six weeks definite tuberculous lesions will develop. 
Functional tests of the urine from the separate kidneys should always 
be made when possible, although it is well to remember that a tuber- 
culous kidney may give almost normal readings; however, the figures 
from a kidney with advanced disease in the majority of cases are low. 
By cystoscopy we can determine whether the bladder is involved, and 
the character and extent of the disease, while by studying the condition 
of the ureteral openings and the contiguous mucous membrane the 
unilateral or bilateral character may be determined with a fair degree 
of accuracy, this being greatly helped by watching the urine flowing 
from each ureteral orifice; in some cases this urine may be studied. A 
dislocated, retracted ureteral mouth surrounded by reddened or swollen 
mucous membrane or by distinct ulcerations is very suggestive of tuber- 
culous disease of the corresponding kidney, especially if the bladder 
shows slight involvement elsewhere. A cloudy or bloody urine from one 
ureteral orifice will often give the diagnosis, while the functional ability 
of the two sides may be gauged to a certain extent by the relative amounts 
flowing from each; if the bladder is much diseased, chromocystoscopy 
is of great value in helping us to find the ureteral orifices. 
The ureteral catheter should be used if possible in every doubtful 
case. Albarran and Nitze shut off the diseased side with a large catheter, 
and thus obtain urine from the other side without catheterizing its 
ureter, but this is only of value when the bladder is not involved. There 
is frequently considerable difficulty in introducing the catheter into the 
diseased side, while if definite ureteral stricture is present considerable 
force may be necessary, the finding of such a stricture being a very 
important sign of renal disease. By the ureteral catheter the presence 
of the. two kidneys can be verified, and the urine from the two sides 
studied separately. 
An exploratory nephrotomy may be necessary if the cystoscope and 
ureteral catheter cannot be used. 
The x-rays are sometimes helpful in showing that the kidney is enlarged 
or thickened although of more value in the differentiation of renal tuber- 
culosis from calculus, x-ray pictures of the kidney after collargol 
injections through the ureter should also be employed. 
The finding of a thickened ureter by vaginal examination is much more 
frequently met with in tuberculosis than in any other renal lesion. 
Tuberculin may often be employed in doubtful cases, the subcutaneous 
method being more satisfactory than the ophthalmic or skin reaction 
or the methods by suppository or inunction. Froment has recently 
reported 100 cases in which the agglutination test of Arloing and Cour- 
mont was used successfully. As in all cases of renal tuberculosis there TUBERCULOSIS OF THE KIDNEY 
989 
is some focus, albeit a small one, of the disease elsewhere; it is necessary 
to obtain a local as well as a febrile reaction to confirm the diagnosis. 
Differential Diagnosis.-The conditions for which renal tuberculosis 
may be mistaken are pyelitis, pyelonephritis, empyema of the renal 
pelvis, calculus, renal cancer, hypernephroma, cystic kidney, and essential 
hematuria. Renal cancer and calculus are most likely to cause confusion, 
while it must not be forgotten that in some cases these diseases and 
tuberculosis may coexist. In calculus, pyuria, as a rule, develops 
slowly, colic is frequent and usually severe, the pain extending down 
the ureter and being associated with profuse sweats. A frequent, scanty, 
high-colored, scalding urine, with gritty particles, is passed sometimes 
after the attack. Usually there is no evening rise of temperature, and 
the general nutrition is well preserved, while the hematuria and pain 
are lessened by the recumbent position and are usually intermittent. 
The .r-rays and the wax-tipped catheter may definitely decide the diag- 
nosis. In malignant tumors of the kidney or its pelvis the bleeding is 
often profuse, with no apparent cause, and with a marked tendency to 
intermit; the urine is often normal, pyuria being far less common than 
in tuberculosis; pain is unusual, swelling is common, while in the later 
stages cachexia is present. Pyelitis or pyelonephritis due to the pyogenic 
bacteria may occasionally simulate renal tuberculosis, but the presence 
of the bacteria and, in the cases with marked suppuration, the higher 
fever and more severe constitutional symptoms should make the diagnosis 
easy in most cases. The possibility of hypernephroma must not be for- 
gotten if the a-ray and bacteriological examination are negative and 
tumor is present. 
Hematuria without pain may also be met with in chronic interstitial 
nephritis, renal angioma, floating kidney, hydronephrosis, certain tropical 
diseases, and, from no apparent cause, the so-called idiopathic or essential 
hematuria. In urethral hematuria the urine is usually bloody at first 
and later clear, in vesical hematuria clear or lightly tinged, and then 
progressively darker, while in renal hematuria the urine, as a rule, is 
uniformly colored; the source of the blood cannot be determined definitely 
by these means, however, but only by the use of the cystoscope and the 
ureteral catheter. Great vesical tenesmus with increase in the frequency 
of urination points to cystitis, but does not exclude renal disease. 
In uncomplicated tuberculosis leukopenia is the rule, while in all 
septic processes due to mixed infection leukocytosis is usually met with. 
Anemia is more common in renal cancer and tuberculosis than in calculus. 
The low blood-pressure described in renal tuberculosis may help in 
making a diagnosis. Secondary involvement of the adrenals may play 
some part in the production of leukopenia and low blood-pressure. 
Prognosis.-This depends on a large number of factors-upon whether 
operation is or is not performed; upon the stage of the disease, whether 
it is unilateral or bilateral, whether the ureter and bladder are involved, 
and whether there is any active tuberculosis elsewhere; the prime requisite 
for a favorable prognosis is an early diagnosis. The prognosis is unfavor- 
able if the disease is let alone, although there is some discussion regarding 
the advisability of immediate operation at an early stage. Pathological 990 
DISEASES OF THE URINARY SYSTEM 
anatomy shows that healing may occur spontaneously, although Kiister 
has been able to find but one case where a spontaneous cure could 
be proved clinically. In rare instances the kidney may be completely 
destroyed and remain encapsulated. Several writers have reported 
spontaneous recoveries, and Godlee and others insist that if climatic 
and hygienic treatment were tried in the early cases a number would 
be definitely cured. Albarran, however, denies that a spontaneous cure 
has ever taken place, and Kelly has never seen a medical cure, although 
in a number of early cases he tried rest, forced feeding, fresh air, etc., 
for a number of months. 
The exact status of tuberculin therapy or treatment with attenuated 
living bacteria has not been determined, but if it should prove successful, 
early renal tuberculosis should prove a useful field for this mode of 
treatment. At the present writing, however, it seems that as the prognosis 
is unfavorable if let alone, as cure is improbable under general hygienic 
treatment, and as the chances of recovery are so much lessened by delay, 
early operation is the treatment for primary renal tuberculosis, if we can 
determine definitely the presence, the functional ability, and the freedom 
from disease of the other kidney and the absence of extensive tuberculosis 
elsewhere. However, we must not forget that this form of renal disease 
is always secondary, and that even after its removal the patient for a 
considerable period of time should be carefully treated in the hope that 
the primary focus may become entirely healed. It is surprising in how 
many cases bladder tuberculosis is susceptible of successful treatment 
after the removal of the diseased kidney. 
Treatment.-The general prophylaxis is the same as in tuberculosis 
elsewhere-fresh air, sunshine, good food, keeping the nutrition of the 
body at its highest point, and lessening as far as may be the chance of 
exposure to the germs of tuberculosis. If tuberculosis should be present 
in the body it should be treated as early as possible along the approved 
lines. The special prophylaxis consists in removing at once any focus 
of tuberculosis that may be present in the body, in the epididymis, 
glands, joints, bones, etc., and to obviate all existing conditions 
which tend to lower the resistance of the kidney, especially diseases of 
the urethra, prostate, and bladder, gonorrhoea, etc. 
The present attitude is that in the vast majority of cases surgical 
treatment offers the only hope of real cure, and that the earlier this 
treatment is inaugurated the better the chance of recovery. It is beyond 
question that at the stage in which the disease is usually recognized the 
condition will advance under any other form of treatment, and it is 
only those cases in which an extremely early diagnosis is made in which 
general treatment would be at all justifiable. We realize that amyloid 
disease or toxic nephritis of the other kidney will render the prognosis 
much less favorable, and will usually preclude operative treatment. 
It is therefore important to remove the source of the toxins before 
such changes occur, while the longer the operation is postponed the 
greater the chance of a more general tuberculosis and the less the chance 
of recovery when operation is performed. The older view was that 
active tuberculosis elsewhere, especially in the lungs and the bladder, TUBERCULOSIS OF THE KIDNEY 
991 
was a distinct contra-indication to operation, but more recent work has 
shown that in the case of the latter even extensive disease is no bar to 
nephrectomy, while in the case of the former, although in general an 
advanced active lesion would preclude operation, yet in a number of 
less active and not so advanced cases distinct improvement may follow 
the removal of the kidney. If the symptoms referable to the kidney 
and bladder are very marked, and the pain, tenesmus, increased fre- 
quency of urination and constitutional disturbances are making life 
a burden to the patient, it is justifiable even in advanced cases to take 
some risk in the hope of ameliorating the condition. 
Surgical Treatment.-The operations which may be considered are 
nephrectomy, nephrotomy, nephrostomy, and partial resection of the 
kidney, although the first of these is always the operation of choice if 
the circumstances warrant it-that is, if the other kidney is healthy and 
the general condition of the patient is such as to warrant the operation. 
In nephrectomy it is of paramount importance that the presence and 
healthy condition of the other kidney be determined. According to 
Rovsing, the absence of albumin, pus, or bacteria from the second 
kidney may often be relied upon; if pus and bacteria are present, 
removal of the first kidney is usually contra-indicated, while if albumin 
but no pus or bacteria is found, it is not a contra-indication, the albumi- 
nuria being due to toxic changes and usually disappearing rapidly 
after the removal of the diseased organ. 
Kummel divides renal tuberculosis into three groups, surgically speak- 
ing: (1) The early stage, when operation can be done; (2) when one 
kidney is severely and the other slightly diseased, and here, according 
to Kummel, if the freezing-point of the blood is -0.56° to -0.57° C., 
the more seriously diseased organ may be removed, while if -0.6° C., 
nephrotomy must be done; (3) where the ureteral catheter cannot be 
used, and here an exploratory nephrotomy should be done, and from 
the findings and the cryoscopic index of the blood the proper treatment 
can be decided upon, but most surgeons do not rely on blood cryoscopy 
as Kummel does. 
The extraperitoneal operation should always be done, while if the 
perinephric and paranephric tissues are markedly involved some surgeons 
do an extracapsular rather than the more common intracapsular extirpa- 
tion. There is always some danger of the shock, depletion, and other 
constitutional disturbances incident to a severe operation, lighting up 
a tuberculous focus elsewhere, but experience shows that this is unusual. 
Pregnancy is not a contra-indication. If there are other secondary 
tuberculous lesions, such as in the epididymis, glands, etc., or if the primary 
foci can be determined they should be removed at the same time if pos- 
sible. If tuberculosis is advanced elsewhere, nephrotomy or nephrostomy 
is often a preferable operation, while if after this operation the fever, 
constitutional symptoms, etc., disappear or markedly abate, a secondary 
nephrectomy may be done if the ureteral catheter and the functional 
tests show the other kidney to be healthy. 
According to Kelly the ureter, if diseased, and the portion of 
bladder about the ureteral opening, if involved in the tuberculous 992 
DISEASES OF THE URINARY SYSTEM 
process, should be removed at the same time as the kidney, or at a 
later operation if the patient's condition does not warrant it being 
done primarily. Kummel inserts a platinum needle into the lumen of 
the ureter from above and heats it to a white heat, and Bevan cauterizes 
the ureteral mucous membrane with pure carbolic acid, although some 
surgeons believe that the ureter had best be let alone, as it usually heals 
after removal of the kidney. In some cases, however, a persistent sinus 
is left, while in other cases it is impossible to cure the bladder until a 
secondary ureterectomy is done. 
Involvement of the bladder, even if advanced, is no contra-indication 
to nephrectomy. Sometimes after nephrectomy the bladder heals 
spontaneously, while if tuberculous cystitis persists, besides the usual 
constitutional measures local treatment may be employed, Rovsing 
finding that instillation of solutions of carbolic acid, 5 to 6 per cent., 
is the most effective local treatment. In very severe cases draining the 
bladder and the use of the constant bath may be necessary. 
Nephrotomy or nephrostomy is only justified when the patient's con- 
dition is such that a nephrectomy is impossible, when both kidneys are 
involved, or when ureteral catheterization cannot be performed. After 
the nephrotomy, if the condition of the patient markedly improves, 
as is often the case, and if we have been able to determine the functional 
ability of the other kidney, a secondary nephrectomy is advisable in 
many cases. 
There is a great temptation to do a partial resection or partial nephrec- 
tomy if the tuberculous focus seems definitely localized, and this has been 
done with success; but in the great majority of cases some tuberculous 
foci are left behind in the parenchyma, and for that reason the weight 
of evidence is in favor of absolutely abandoning this operation in favor 
of total nephrectomy except in rare cases of bilateral disease where it 
seems to be more indicated than nephrotomy. 
In the case of perinephric abscess secondary to renal tuberculosis, 
opening and draining the abscess is all that is done at first, while later 
secondary nephrectomy may be necessary. After the former operation, 
as well as after nephrotomy, persistent fistula is not uncommon. 
The results of operative treatment both as regards immediate and ulti- 
mate result have been in the main favorable, although figures in the 
latter connection are more difficult to obtain and are often less definite. 
The operative mortality, which formerly was from 20 to 25 per cent., 
is now from 3 to 10 per cent. Casper found that in the practice of five 
surgeons before the use of the cystoscope, the ureteral catheter, and the 
functional tests, the mortality in 139 cases was 21.7 per cent., while 
after the use of these methods the mortality in 130 nephrectomies by 
the same surgeons was 10 per cent.; Rovsing, in 112 nephrectomies, has 
reduced his mortality from 13 to 3.3 per cent. As regards the ultimate 
results of nephrectomy, the figures are very encouraging. Kummel 
reported that 32 of 43 patients were living and well some time after the 
operation; Albarran was able to follow 39 for a considerable period of 
time, and only 5 died of tuberculosis; Kelly got a complete cure in 
all of 21 patients in whom the bladder was not involved, and in 18 of 36 TUBERCULOSIS OF THE KIDNEY 
993 
where it was extensively diseased, the cures being from two to twelve 
years; Israel in 29 cases got cures of from one to nine years in 11; 
Kiister, 11 complete cures of from one to seven years in 17 cases; Schede, 
16 cures of from one to ten years in 22 cases; and Czerny, 11 cures of 
from one to twenty-one years in 27 cases, in 16 of which secondary 
nephrectomy was done. 
As regards nephrotomy, in a series of 72 cases from different surgical 
clinics, 7 were cured completely, 18 had a persistent fistula, 28 required 
a secondary nephrectomy, and 21 died. As regards kidney resection, 
few figures are obtainable. Morris reports 7 cases with 4 cures of from 
two to four years 
Medicinal, Climatic, and Hygienic Treatment: Tuberculin.-Some believe 
that it is advisable, if an early diagnosis can be made, to first try general 
treatment, as a cure is theoretically possible and a small number of 
clinical cures have been reported. It would be most interesting to treat 
a series of very early cases by climatic, dietetic, and hygienic measures, 
and this would be comparatively safe if the weight, temperature, general 
and local condition, and the urinary findings were watched with extreme 
care, so that at the first sign that the disease was progressing operation 
could be done at once. Recently there has been a distinct feeling that 
specific treatment may prove successful. Birnbaum used tuberculin in 
the treatment of 23 cases of renal tuberculosis, and found it most helpful, 
although only in the very early cases in which fever was absent. 
Symptomatic Treatment.-When cure is impossible it is important to 
make the patient physically comfortable by careful attention to 
both the general and the local symptoms, and such care may be rewarded 
by considerable temporary improvement. The pain must be relieved, 
in some cases by simple analgesics, in others by opium or morphine; 
occasionally severe hemorrhage must be controlled; the fever may be 
reduced by sponging or by antipyretics. In all cases a generous, nutritious 
dietary, a proper climate and attention to the personal hygiene should 
always be insisted upon. When the bladder is diseased, irrigation, 
topical application, and hydraulic distension may be employed; while if 
the pain and tenesmus are intense, it may be necessary to open and 
drain the bladder. CHAPTER XIX 
TUMORS OF THE KIDNEY 
HUGH HAMPTON YOUNG, M.D. 
Hypernephroma.-In the discussion of this subject there is much 
confusion, owing to the various names that have been used by different 
authors for the same tumor, viz., perivascular sarcoma, venous endo- 
thelioma, lymphatic endothelioma, epithelioma with clear cells, adenoma 
with clear walls, etc. The descriptions and illustrations which have been 
given all bear such a striking likeness to the tumor now called hyper- 
nephroma that these names should be discarded until a precise nomen- 
clature can be agreed upon. 
Etiology.-In a series of 176 cases of hypernephroma collected from 
the literature by Garceau, the age at which the disease occurred varied 
from eighteen months to eighty years; by far the largest number (60 
per cent.) occurred between forty and sixty years of age. 
Pathology.-The first accurate description of the pathology of the tumor 
was published by Grawitz in 1883, and it was he who first considered 
that it arose from aberrant adrenal tissue, which is so frequently found 
in the kidney. Previous to this the tumor was supposed to be a variety 
of lipoma. In 1894 the name hypernephroma was suggested by Lubarsch. 
Grawitz made no attempt to classify the growth, saying that at times 
it resembled adenoma, at others sarcoma, and at others carcinoma; 
but he gave the following reasons for his belief in its adrenal origin: 
(1) The position of the growth under the capsule where adrenal "rests" 
are generally found; (2) the resemblance of its most characteristic cell 
to those of the adrenal; (3) the characteristic fatty infiltration of the 
tumor cells of the adrenal, which is a constant feature of the cortical 
cells of the adrenal, but is never seen in the normal renal cortex; (4) 
the presence of a capsule which separates it from the adjacent kidney 
substance; (5) the arrangement of cells in columns, as in the fascicular 
portion of the adrenal cortex; (6) the amyloid degeneration in the blood- 
vessels, which is rarely seen in other tumors, and the fact that the 
metastases from these renal tumors exactly resemble those of tumors 
which are definitely of adrenal origin. 
Since the publication of Grawitz there has been much discussion and 
confusion in the literature in regard to the histogenesis of these tumors 
which will be found in Garceau's work on Tumors of the Kidney. 
The occurrence of adrenal rests has been the subject of considerable 
study. Imbert found them in different organs in 92 out of 100 autopsies, 
in the kidney in 8 per cent, of the cases. Wilson and Willis1 consider 
1 Jour. Med. Research, vol. xxiv, p. 73. 
994 TUMORS OF THE KIDNEY 
995 
that most if not all so-called "adrenal rests" are probably of Wolffian 
origin. They state that there is almost no evidence, embryological or 
histological, in support of Grawitz's hypothesis that the so-called " hyper- 
nephromas" have their origin in adrenal rests, but contend that these 
tumors arise from islands of nephrogenic tissue (primitive renal blastema). 
They state that such tissue is sometimes present in the adult kidney 
and appears capable of forming tumors of the non-infiltrating mixed 
tubular, papilliform and sarcoma types, so characteristic of the so-called 
hypernephromas. 
The location of hypernephromas in the kidney is usually in the upper 
pole, just beneath the capsule. There may be one nodule or several, 
which may be small or large, the whole tumor varying in size from that 
of a pea to that of an adult human head. They are usually encapsulated 
and sharply contrasted with the surrounding or adjacent renal tissue, 
which often shows evidence of atrophy and interstitial nephritis. The 
consistence in the smaller tumors is often firm, but wffien the tumor is 
large it is usually soft, and blood-cysts are often seen. Areas of more 
or less extensive hemorrhage in the tumor tissue are found on section, 
and large areas of necrosis are common. 
Histology.-The similarity to adrenal tissue is most marked in the 
small hypernephromas. The stroma is largely composed of capillaries 
upon which the cells lie without intervening tissue, ranged in rows, 
sometimes two or three deep. These cells are,- as a rule, rather larger 
than the normal adrenal cell, polygonal in shape, and contain much 
fat. Giant cells and karyokinetic figures are sometimes seen. Chemical 
examination reveals glycogen and lecithin, which along with fat are 
also found in normal adrenal cells. In the large tumors there is a certain 
amount of fibrous tissue in the capillary stroma, and the polygonal cells 
are often arranged in distinct alveoli. This alveolar arrangement has 
given rise to the opinion that the disease is a carcinoma or an alveolar 
sarcoma. Papillary formations are also seen, and the arrangement in 
rows is composed of more cells than in the small tumors. In the larger 
tumors necrosis not infrequently occurs, generally in the centre of the 
mass and most remote from the peripheral blood-supply. 
Invasion.-The tumor may be only a small nodule in an otherwise 
healthy kidney. With time, however, the tumor invades the kidney 
more and more, causing first a pressure atrophy, finally in some cases 
completely replacing the kidney and forming a large lobulated irregular 
mass which is usually completely encapsulated. Neighboring structures 
may be invaded, but this is rare, as is also invasion by the lymphatics. 
As a rule, the systemic invasion is through the veins. It is not uncommon 
to find the renal veins invaded by the tumor, which may conform to the 
shape of the vessels and grow intravenously to great distances. In one 
of the writer's cases the vena cava was filled with a non-adherent growth, 
which extended upward through the diaphgram and down to the brim 
of the pelvis. The renal vein on the opposite side was invaded almost 
up to the kidney. Another case is reported in which the thrombus 
extended into the auricle of the heart. Loosened emboli are carried 
through the blood-current to remote portions of the body. Metastases 996 
DISEASES OF THE URINARY SYSTEM 
have been found in the brain, bronchi, diaphragm, heart, liver, intestines, 
omentum, pancreas, pleura, peritoneum, skin, uterus, urethra, and in 
various portions of the bony skeleton. These metastases reproduce 
exactly the histological characteristics of the parent tumor. In rare 
cases the tumor mass grows out into the renal pelvis, but no case has 
been found in which the ureter was invaded. 
Symptoms.-Hypernephroma is so variable in its growth that the 
symptomatology is by no means uniform. Many of the cases in which 
the tumor is small, benign in its character, and very slow of growth, 
may present no symptoms, and in such cases the tumor is often dis- 
covered postmortem. In others a small tumor may be accompanied 
by abundant symptoms, and if at the lower pole of the kidney may be 
detected by palpation. In those cases in which the tumor assumes a 
malignant character the growth may be rapid and the symptoms marked. 
The three cardinal symptoms are hematuria, pain, and tumor. 
Hematuria.-This is the most frequent sign of malignant tumors of 
the kidney in adults. In 83 cases reported by Desnos, hematuria appeared 
before every other symptom in 41 cases; Israel places it at 70 per cent.; 
Denoclara at 65 per cent.; Albarran at 54 per cent., and Kiister at 52 
per cent. Garceau found hematuria a prominent symptom in 50 per 
cent, of 106 cases, but in 35 cases it was absent. In some it is the sole 
symptom, and in one of Israel's cases was present for twelve years. 
Generally the bleeding comes on insidiously and continues several 
days, after which it may not reappear for several months. The attacks 
become more frequent, as a rule, with the progress of the growth, and 
often recur with regular periodicity. The urine is usually markedly 
colored with blood, and frequently large clots are passed. Rarely the 
advent of bleeding is presaged by a dull pain in the side, sometimes 
simulating renal colic. In such cases the ureter has usually become 
blocked by a clot, and for a time the urine voided may be free from 
blood. This is usually followed by cessation of the pain, accompanied 
by the sudden reappearance of blood and the passage of clots. 
Statistics show that the hemorrhage is not influenced by position or 
occupation, occurring as frequently at night as during the day. In spite 
of their frequent repetition, the hemorrhages rarely weaken the patient 
so greatly that operative intervention is necessary to stop the bleeding. 
The sudden change from very bloody to perfectly clear urine is of con- 
siderable diagnostic importance, showing that the ureter has become 
blocked. Worm-like blood-casts of the ureter are not uncommon. 
Pain.-This is often absent for a long period, and is rather variable 
in its character. Many hypernephromas reach considerable size with- 
out causing any pain. In some it is merely a dull ache in the lumbar 
region, but occasionally the pain runs downward along the sacral and 
pelvic nerves. It usually comes on spontaneously without relation to 
exercise or bodily position, and in some cases may be quite severe for a 
short while. Pressure on the kidney does not usually increase the pain, 
but the patient is sometimes unable to lie on the affected side. 
Tumor.-When the growth is of the voluminous type a perceptible 
or palpable tumor of the flank is one of the most important symptoms. TUMORS OF THE KIDNEY 
997 
According to Garceau, tumor is usually the first sign of hypernephroma, 
and in 143 cases it was present in all but 17 cases. In many of the cases, 
in which the disease begins at the upper pole of the kidney, palpation 
will not detect it until late, and in a few cases in which the tumor remains 
small it is never discovered during life. The growth generally preserver 
the usual shape of the kidney, and may be uniformly smooth. Very 
often it is irregular, lobulated, or nodular. When the tumor is large 
the flank is deformed and the shape of the tumor may be apparent on 
inspection. In cases of moderate size it may be perceptible only on 
bimanual examination. The usual site of the tumor is in the lumbar 
region, but extending forward in the abdominal cavity, and generally 
lying between the ribs and iliac crest, with no space between the tumor 
and the lumbar muscles. Small tumors are often movable, but the larger 
ones are generally fixed. The x-ray has not as yet proved reliable in 
demonstrating tumors of the kidney. In determining the character of 
the tumor its relation to the colon is of great help, and the following is 
quoted from Garceau: "The kidney is normally situated behind the 
colon, and when enlarged by a tumor it must develop in the layers of 
the descending colon; hence the colon will be found in front of the tumor 
or toward its inner side. Tumors of the liver crowd the colon down 
and may override it; tumors of the stomach also crowd the colon down, 
while tumors of the pancreas almost invariably appear above the trans- 
verse colon, and in a few instances behind it. A tumor growing in a 
movable kidney may enter the central zone, but unless fixed it can be 
slipped back into position. Tumors of the adrenal push the colon forward 
and inward. The central region, besides uterine and ovarian tumors, 
may contain growths of the small gut, the mesentery, omentum, and 
also enlarged retroperitoneal glands. The spleen must be on the outside 
of the descending colon, but if greatly enlarged may override it entirely; 
there is no line of resonance between the kidney dulness and the vertebral 
spines as there nearly always is in the case of splenic enlargement. 
Tumors ordinarily close to the abdominal wall may in consequence of 
adhesions be separated from it by intestines; in this case there will be 
tympany in front of them. Tumors of the spleen, liver, and uterus may 
present these characteristics, and especially tumors of the ovary." 
Changes in the Urine.-There are no changes in the bladder urine 
in any way characteristic. Hematuria may be the only abnormality. 
In the intervals the urine may be perfectly normal. 
Other Symptoms.-Renal neoplasm may produce symptoms due to 
compression of surrounding structures. One of the most common is 
varicocele, and it is considered quite significant when present on the 
right side. In 20 cases Kapsammer found marked circulatory dis- 
turbances of the inferior membranes and of the abdominal wall. In 
one of the writer's cases in which the vena cava was almost completely 
obstructed by a large intravenous growth, the peritoneal veins were 
greatly dilated, and with the portal veins, which were also dilated, 
took care of the return circulation from the inferior extremities and 
the abdomen. (Edema and ascites are sometimes present in such cases. 
Jaundice may occur, flue to obstruction of the common bile duct or 998 
DISEASES OF THE URINARY SYSTEM 
extension of the disease to the liver. Only rarely does the tumor growth 
cause painful symptoms from compression of the nerves, and marked 
pain in the spine often indicates metastases. Gastric symptoms, nausea, 
vomiting, and occasionally hematemesis have been reported, and may 
indicate either metastases or uremia. Dyspnoea may be present. 
Cystoscopy.-If hematuria is present, a jet of red urine can usually 
be seen to escape intermittently from the affected side. If the urine is 
only faintly colored, it may be impossible to detect any difference 
between the two sides; and if the hemorrhage is very great, it may 
be difficult to get a field clear enough for accurate observation. For 
the latter cases the "evacuation" cystoscope may be very helpful. 
In some cases the ureteral orifice may be abnormal-it may be 
dilated, as a result of the pressure of clots, or it may be surrounded 
by hyperemic, swollen, or oedematous mucous membrane. In some 
cases the simple cystoscope shows nothing definite (especially between 
attacks of hematuria), and ureter catheterization is advisable in order 
to determine the functional value of the two kidneys. A small amount 
of blood from either ureter is of no importance, as it may be traumatic. 
In determining the renal function, the phthalein test furnishes the 
most information. The concentration of phthalein and urea is usually 
equal to that of the healthy kidney, but the absolute amount excreted is 
decreased. Radiographs taken after injection of the renal pelvis with 
10 to 15 per cent, collargol may show marked and sometimes character- 
istic changes in the shape, size, and character of the pelvis and calices. 
Duration.-In a list of 27 operated cases collected by Garceau the 
tumor had been present for fifteen years in 1 case, twelve years in 1, 
ten years in 2, eight years in 2, seven years in 2, six years in 5, five years 
in 6, four years in 2, three years in 5 cases; but in another list of 89 
cases the duration of the symptoms when nephrectomy was performed 
was not over a few months in 53 cases. The duration of the disease is 
generally shortened by the early appearance of metastases, which may 
be of large size, very painful, and lead to exhausting symptoms which 
completely overshadow the renal affection. In a series of 21 cases 
collected by Garceau, in which metastases were present and no kidney 
operation performed, it is a notable fact that in only 4 cases had the 
duration been more than one year when death resulted. In nearly all 
of these cases the metastases, particularly of the bones and lungs, were 
of more moment than the renal tumor. 
Diagnosis.-In most cases the patient has not suffered from pain, 
and the presence of hematuria has alone attracted the attention. 
The diseases most commonly confounded with hypernephroma are 
tuberculosis, calculus, hydronephrosis, pyonephrosis, and tumors else- 
where in the abdomen. 
Tuberculosis of the kidney is first to be considered and excluded in 
all cases. In tuberculosis pus is generally present in the urine between 
the crisis of hematuria, and by careful search tubercle bacilli can generally 
be discovered. Great care must be taken to exclude the smegma bacillus. 
The smegma bacillus may be found in the anterior urethra, but never 
back of the external sphincter, and if the penis is thoroughly cleansed TUMORS OF THE KIDNEY 
999 
and the anterior urethra irrigated, none of these organisms will be found 
in the voided urine. As an additional precaution, it is well to have the 
patient void in three sterile glasses and to make the bacteriological 
examination from the third glass. If bacteria are found resembling the 
tubercle bacillus in form and not decolorizing with acid, one can be 
sure that it is the tubercle bacillus. When the results are negative, 
the tuberculin test may be advisable. 
The presence of foci of tuberculosis in other organs may be of great 
assistance; this is particularly true of the genito-urinary tract, as nodules 
in the prostate and seminal vesicles or in the epididymis are not infre- 
quently found. Non-tuberculous renal infections are, however, not 
infrequently associated with prostatitis characterized by more or less 
extensive induration, often closely resembling tuberculosis of the prostate. 
The cystoscopic picture of the ureteral orifice is generally of great diag- 
nostic worth. In tuberculosis it is apt to be dilated, often gaping, some- 
times ulcerated, and surrounded by an area of vesical tuberculosis; 
whereas in hypernephroma only a slight hyperemia or dilatation of the 
ureteral orifice is seen. Tuberculosis is rarely associated with the great 
enlargement of the kidney often seen in hypernephroma, but in early 
cases the diagnosis may be extremely difficult. 
Renal calculus may also simulate hypernephroma. It is usually 
more painful and the kidney less enlarged, but the writer has seen a case 
in which the kidney was immense and contained fourteen large stones 
(several larger than hen's eggs), in which there had never been pain, 
hemorrhage, or discomfort, and the patient sought relief because of 
occasional febrile attacks. The radiograph is here of great diagnostic 
value. Pyuria is not of great value, as it may be present in renal 
calculus and hypernephroma, although more common in the former. 
Hydronephrosis, pyonephrosis, and perinephritis may all be associated 
with an enlarged indurated mass closely simulating neoplasm, and the 
occasional presence of hematuria may make the resemblance close. On 
the other hand, intermittent distension of the renal pelvis accompanied 
by tumor formation and crises of pain which are so characteristic in 
certain forms of hydronephrosis, the writer has seen in a case of hyper- 
nephroma. In this case during the periods of bleeding the tumor mass 
would occasionally become greatly enlarged. This was always associated 
with sudden cessation of the hematuria (evidently due to blocking of 
the ureter with a clot) and severe pain. 
When hematuria is the only symptom it is often very difficult to make 
a diagnosis, and we must consider not only tuberculosis and calculus 
(both of which may present this symptom alone), but also the essential 
renal hematuria of Senator and Klemperer, the hemophilic hematuria 
of Senator, the hematuria of pregnancy (Guyon), and the hematuria 
which accompanies certain cases of chronic nephritis (Pousson). 
These hematurias present «a most perplexing and little understood 
class of renal disorders and have led to much confusion. It has been 
definitely shown that hemorrhage may occur from a kidney in which it 
is impossible to discover any macroscopic or microscopic lesion, and 
may reappear with such frequency and abundance as to be serious. 1000 
DISEASES OF THE URINARY SYSTEM 
Some have asserted that this is almost always assoeiated with a localized 
nephritis which is sometimes unilateral, but that such is not generally 
the case has been abundantly proved. The question of such nephritis 
is, however, of sufficient importance to warrant the catheterization of 
the ureters in all such cases, both during and between the attacks of 
hematuria. The writer has suggested the injection of about 15 cc. of 
a 1 to 3000 solution of adrenalin chloride into the renal pelvis through 
a ureter catheter. In three cases of essential renal hematuria this treat- 
ment was followed by a disappearance of the hematuria, which at this 
writing seems to be permanent. While it might be possible to com- 
pletely stop the hemorrhage from a hypernephroma, it seems very 
probable that it would soon recur and the presence of pain and tumor 
would of course lead to suspicion of neoplasm. 
Other tumors of the abdomen have to be considered in making the 
diagnosis, but we have not the space to do more than call attention to 
the usual absence of urinary symptoms in such cases and to the general 
principles of abdominal examination and diagnosis. 
The diagnosis of hypernephroma from other forms of renal tumor, 
carcinoma, sarcoma, and malignant adenoma is often impossible. 
The benign tumors fibromas, adenomas, lipomas, etc., are rarely 
associated with hematuria or pain. Polycystic disease of the kidney is 
more apt to be bilateral and free from hematuria. In later stages it is 
accompanied by symptoms of renal insufficiency, headache, nausea, 
etc., and marked decrease in total renal function, which do not often 
occur in hypernephroma. Radiographs of the injected pelvis in poly- 
cystic disease are very characteristic. 
Teratomas and rhabdomyomas occur so rarely as to make diagnosis 
almost impossible. In hydatid diseases of the kidney, booklets may be 
found in the urine. 
Treatment.-Medical treatment, except of a symptomatic or palliative 
character, is of little use. An early operation should be performed in 
all cases where the condition of the patient admits of it, and in recognition 
of this fact an early diagnosis should be aimed at. When the tumor 
is large, operation should usually be undertaken unless complications 
of considerable severity, sufficient to cause the patient to be denied a 
chance of cure or relief, are present; for it is true that in some cases the 
pain is so considerable that operative relief should be afforded, even 
though the chance of cure is remote. 
Operation.-Before this is attempted the patient should be in the 
best possible condition and the functional ability of the supposed sound 
kidney should be determined by ureter catheterization and the phthalein 
test. If the hemorrhage continues and immediate operation is not to 
be thought of, the injection of adrenalin through a ureter catheter may 
be employed. Operative technique is hardly within the scope of this 
article, but it may be well to state that complete nephrectomy should 
almost always be done, and that it may be performed either intra- or 
extraperitoneally. Nearly all authors are agreed that the lumbar extra- 
peritoneal route is preferable for all but the large hypernephromas. By 
extending the oblique lumbar incision downward and inward it is possible TUMORS OF THE KIDNEY 
1001 
to get a very large field of operation, to see the depths of the wound, 
and to ligate the vessels of the pedicle separately (after carefully examin- 
ing them to see that no intravascular neoplastic growths are present). 
It is agreed that the fatty capsule, the adrenal and adjacent glands 
should be removed with the kidney, if possible, but that it is unncessary 
in the case of hypernephromas to remove much of the ureter. 
The intraperitoneal route is in favor with most surgeons for large 
tumors, especially those in children, and with some for the smaller tumors. 
The advantages claimed for it are the large field obtained, the ability 
to palpate the other kidney, to ligate the bloodvessels of the pedicle 
before attempting to free the kidney from the surrounding adhesions 
which are apt to bleed profusely, to remove the fatty capsule, glands, 
and adrenal more thoroughly, and to detect thrombotic growths in the 
renal vein or vena cava before attempting fruitless procedures on the 
kidney. 
Operative Results.-The statistics are unfortunately meagre. Garceau 
states that in 176 cases of hypernephroma collected by him there were 
143 nephrectomies, with 33 operative deaths (occurring within two 
months after the operation), a mortality of 23 per cent. These statistics 
cover a period of fifteen years, and the mortality is probably much less 
now. Isreal has published 17 cases of nephrectomy for hypernephroma. 
Of these, 16 were operated upon by the lumbo-abdominal extraperitoneal 
route, with 3 immediate operative deaths from heart failure or shock. 
In 4 cases death from recurrence or metastases resulted in five months, 
eighteen months, and two years (2 cases) respectively. In all of these 
cases the patient was greatly benefited, although all were extensive. 
Eight patients were still alive and well when the publication was made. 
In 2 cases two years, in 2 cases six years, and in 1 case nine years had 
elapsed since the operation. When it is considered how long the tumor 
had generally been present, its size and the weakened condition of many 
of these patients, the results are very encouraging. With early diagnosis 
and prompt operation the mortality should be reduced greatly. 
Carcinoma of the Kidney.-As a result of a more careful pathological 
study of kidney tumors, carcinoma has become in recent years exceed- 
ingly rare. The great histological variations in hypernephroma, the 
transition in various parts of the tumor to the adenomatous, carcinom- 
atous, or sarcomatous type, often render the true nature of the tumor 
extremely difficult to determine. Undoubted carcinoma of the kidney 
is exceptionally rare, and its existence is doubted by some authors. 
Neuhauser1 in a study of 69 tumors from Israel's clinic found that 65 
were apparently typical hypernephroma; 2 of the tumors he classed 
as hypernephroid carcinoma and 2 as hypernephroid sarcoma. In the 
2 cases designated as hypernephroid carcinoma portions of the tumors 
were typically cancerous and formed cell nests not unlike those seen in 
mammary cancer. Other portions had the typical appearance of true 
hypernephroma. He is very positive in his statement that all carcinomas 
of the kidney arise from hypernephroma. On the other hand, Garceau 
1 Arch. f. klin. Chir., 1906, vol. Ixxix. 1002 
DISEASES OF THE URINARY SYSTEM 
has reported three carcinomas, about the nature of which there is appar- 
ently no doubt, while we have been able to find one true adenocarcinoma 
at the Johns Hopkins Hospital. This has been reported by Cullen.1 
Of the 4 cases which we have been able to verify, 2 were in women and 
2 in men, and the ages ranged from twenty-six to forty years. 
Pathology.-According to Waldeyer,2 carcinoma of the kidney arises 
from a proliferation of the renal tubules. The infiltrating form is agreed, 
almost by common consent, to be the most frequent form of carcinoma, 
and of the 4 cases referred to above, 3 were of the infiltrating type, 1 
only being a definite adenocarcinoma. In none of the infiltrating forms 
was the kidney markedly increased in size. The shape of the kidney is 
usually well preserved and the cancerous growth invades it quite regu- 
larly, producing a uniform enlargement. In the case of adenocarcinoma 
the tumor mass was somewhat kidney-shaped, irregular in outline, and 
about five times the size of the normal kidney. On palpation the tumor 
seemed to be cystic. On section no renal tissue was demonstrable, the 
greater part of the tumor being soft and consisting of a spongy homo- 
geneous tissue resembling carcinoma. On microscopic section the 
tumor was seen to be a glandular growth; the gland type was particularly 
well marked and the acini were very regular in size. 
Symptoms.-The first symptom noted in the infiltrating forms was 
acute agonizing pain in the region of the affected kidney, of a radiating 
character in one case. In the case of adenocarcinoma, a tumor mass 
was the first symptom. Hematuria was persistent and abundant in one 
case, slight and recurrent in two, and absent in one. A tumor mass was 
noted in three cases; in one case no enlargement of the kidney was 
demonstrable. The duration of symptoms varied from one to four 
months, and death occurred in the three infiltrating forms in from 
seven weeks to seven months after the onset of the first symptoms. 
In the case of adenocarcinoma the patient died six years after operation 
with extensive general metastases. 
Diagnosis.-It is impossible to clinically differentiate carcinoma from 
malignant hypernephroma or other malignant forms of kidney tumor. 
With the exception of the early, severe, radiating pain, there is 
no differential point which would make one suspect the possible 
cancerous character of the disease. 
Treatment.-(See section on Hypernephroma.) 
Malignant Papillary Cyst Adenoma.-A separate classification is 
usually reserved for this rather uncommon tumor. It bears a close 
resemblance, histologically, to benign adenoma, and most frequently 
a papillary type of tumor prevails. While, histologically, the picture 
resembles closely benign adenoma, at times a distinctly malignant picture 
is seen. These tumors are almost always malignant and should be 
treated as such. The kidney is seldom much enlarged, is nodular and 
hard, and, on section, shows numerous small cystic areas full of a gray 
or deep red material. At times the growth becomes infiltrating, and 
in such cases gives the histological appearance of the infiltrating type 
1 Jour. Amer. Med. Assoc., 1905. 
2 Virchows Archiv, 1867, vol. xli, p. 493. TUMORS OF THE KIDNEY 
1003 
of carcinoma. The symptoms and treatment are identical with those 
described under Hypernephroma. 
Adenomas.-These may be either benign or malignant, isolated or 
multiple. The small multiple adenomas of the kidney are not infre- 
quently found at autopsy, and vary in size from a millet-seed to that 
of a pea. They are usually found beneath the capsule, but occasionally 
are seen within the parenchyma of the kidney. The large variety is 
much more rare. On section, these tumors are grayish white in color, 
friable, frequently infiltrated with blood, and sometimes studded with 
cysts. Benign adenomas usually present no symptoms, even the 
large forms rarely producing any discomfort, hematuria or palpable 
tumor. The so-called malignant form of adenoma resembles carcin- 
oma of the kidney so closely that it seems unwise here to attempt to 
differentiate them. 
Sarcoma of the Kidney.-Many cases of sarcoma of the kidney have 
been described in children, but careful microscopic examinations have 
shown that they were almost always mixed tumors. Sarcoma is much 
rarer than hypernephroma in the adult. In Rosenstein's 30 cases 
there were only 8 in which the patient was over twenty years of age, 
6 being in the period from forty to sixty years of age. In the adult these 
tumors do not reach the enormous size seen in children, and Albarran 
says that they seldom are larger than two fists in size. He recognizes 
three forms: (1) Those which start in the capsule and which may for 
a time be encapsulated and more or less separated from the kidney; 
(2) those in which the tumor has its origin in the region of the hilus; 
and (3) those beginning in the parenchyma, which are the most frequent, 
and are present either in an infiltrating or a nodular form. 
We have had the opportunity of studying two cases of pure sarcoma 
of the kidney occurring in children: one was a small, round-cell sarcoma 
occurring in a girl eighteen months of age, and noticed eight weeks before 
death occurred; the other in a boy, four years of age, of a pure, spindle- 
cell variety, had been noticed three months before death occurred. In 
the case of the round-cell sarcoma, metastases were found in the lungs 
and in the spindle-cell sarcoma in the retroperitoneal lymph glands. 
According to Garceau, the capsule is most frequently the origin of 
the growth from which place the soft tissues are invaded. Sarcoma of 
the kidney is very similar to that of malignant hypernephroma of the 
kidney in its progress, symptomatology, and prognosis. The tumor, 
as a rule, remains encapsulated and metastasis occurs through the veins. 
In some cases the duration of the disease is only a few months, but in 
other cases (particularly the spindle-cell variety) it may be several years. 
Symptoms.-The three cardinal symptoms of renal tumors, hematuria, 
pain, and tumor, are found in cases of sarcoma, and it is almost impossible 
to make a differential diagnosis between hypernephroma and sarcoma. 
The treatment should consist in early nephrectomy in all cases; the 
prognosis even then is not good, owing to the frequency of metastases. 
Embryonic Tumors of the Kidney.-As in the case of other organs, 
the kidney is subject to tumors arising from inclusions or occlusions of 
apparently embryonic tissue; these, however, differ somewhat from the 1004 
DISEASES OF THE URINARY SYSTEM 
fetal tumors of other organs. The typical dermoid cyst of the kidney 
is very rare indeed, only two cases having been reported: one by Haeckel1 
and one by Paget.2 Pure rhabdomyoma of the kidney is also extremely 
rare. The typical mixed tumor of the kidney is, however, not a very 
rare occurrence in children. The histogenesis of the tumor is rather 
indefinite, Weigert claiming that they arise from the Wolffian body, 
and Wagner that they arise from the early kidney segment or "urniere." 
Muus3 describes six tumors to which he has had access, and discusses 
the origin of these growths. He believes that they occur as a result of 
some very early pathological process in the embryonic kidney, a certain 
portion of early developing kidney being thus retarded in growTth; the 
rest of the structure developing along normal lines. 
These tumors were early recognized, and seemed to have caused 
much confusion, being designated variously as "embryonic adenomyo- 
sarcoma," "embryonic adenoma," "sarcoma carcinomatosum," "adeno- 
sarcoma," etc. They occur for the most part in young children, one 
case having been reported, however, in a woman thirty-four years of 
age. The ages of the majority of the patients range from nine months 
to eight years. There is no difference in regard to sex. 
The tumors, for the most part, are very large, smooth, or rather 
irregular or nodular, and are rather soft in consistence, especially when 
degenerative changes have taken place. On section they show a rather 
dense capsule, and the character of the cut surface varies in appearance 
corresponding to its constituent elements. Areas of softening and 
cysts are quite frequent. Where myxomatous tissue occurs the tumor 
has a soft, jelly-like consistence. According to Garceau, the growth arises 
in the parenchyma and does not infiltrate the kidney tissues as an 
ordinary malignant growth does, and it seldom involves the pelvis, the 
ureter, or the bloodvessels. The capsule of the tumor seldom ruptures, 
and the tumor is rarely adherent to the surrounding tissues. Extension 
into the renal veins may occur, and even direct invasion of the vena cava, 
but is not so common as in other malignant tumors. The tumors grow 
very rapidly, and may reach an enormous size in a very short time, in 
some cases filling almost the entire abdominal cavity. Weigert has 
described the only case of multiple mixed tumors, which occurred in 
the kidney of a stillborn child, and gave the appearance of atypical 
tubules of epithelium, growing principally between the kidney pyramids 
and ending in atypical glomeruli. Metastases are rather uncommon. 
The tumors are composed of various tissue elements which usually 
are quite independent of each other. These elements grow with varying 
degrees of rapidity, the connective-tissue elements generally predomina- 
ting. These tumors are composed of two or more of the following struc- 
tures: epithelial cells lying either in tubular arrangement or in irregular 
masses or "pearls," which freely anastomose; connective-tissue cells, 
sarcoma-like in appearance, and of the round- or spindle-cell variety; 
myxomatous tissue; smooth and striated muscle; cartilage; bone; fat; 
1 Berl. klin. Wchnsch., 1902, vol. xxxix. 
2 Lectures on Surgical Pathology, London, 1853. 
3 Virchows Archiv, 1899, vol. civ. TUMORS OF THE KIDNEY 
1005 
and two authors have mentioned a neuro-epithelial tissue. Connective 
tissue is the predominant feature, forming the framework in which the 
other tissues lie, and may so predominate as to lead to the diagnosis of 
pure sarcoma unless careful search is made from various parts of the 
tumor mass. Hibert states that there are no true sarcomas of the kidney 
occurring in children, but that all such cases should be regarded as 
mixed tumors. Smooth muscle tissue sometimes forms a large amount 
of the tumor substance, and is at times interwoven very closely with the 
connective tissue. The striated muscle is of less frequent occurrence 
than smooth muscle, but has been found in 25 per cent, of the cases 
studied by Walker and in 42 per cent, of those studied by Garceau. 
The epithelial structures when present are of varying types. They 
may occur as tubular or glandular structures, the tubules being lined 
by epithelium of cuboidal type, and arranged in from one to three layers 
on a basement membrane. The tubules may form lobules separated 
by connective-tissue strands; at other times the epithelial cells lie in 
irregular groups or masses, which freely anastomose with one another. 
Symptoms.-The presence of a tumor mass is the earliest symptom 
in the majority of these cases. These tumors lie in the affected area, 
show a very rapid growth, and sometimes attain a tremendous size. 
Hematuria is rather uncommon and only occurs probably when the 
mass invades the pelvis of the kidney, which is rather late and rare. The 
tendency of the tumors to remain encapsulated renders hematuria a 
rather unusual symptom. Pain is uncommon and occurs late in the 
disease, the symptoms mainly being referable to the pressure of the 
enlarging mass. Late in the disease emaciation and rapid loss of weight 
occur. The duration is usually less than a year. 
Diagnosis.-A rapidly enlarging tumor mass in the kidney area with 
early emaciation and cachexia in a child is the symptom most charac- 
teristic in this disease. Hematuria occurs late and is infrequent. The 
methods of diagnosis are similar to those described under hypernephroma. 
Treatment.-Early diagnosis and prompt surgical intervention offer 
the only hope of cure. The percentage of operative recoveries has much 
improved in recent years, but the outlook is gloomy, as recurrences have 
occurred in all but three of the operative cases noted. 
Benign Tumors.-These include adenoma, angioma, lipoma, fibroma, 
and myxoma. The adenoma have been described. Angiomas are 
generally small and lie beneath the capsule. They may, however, vary 
in size from that of a pea to that of a walnut, and are occasionally seen 
in the medulla. Lipomas are also rare, and usually lie beneath the 
capsule. One case of lipoma the size of a child's head has been reported. 
Fibromas are usually minute and are found in the cortical portion, but 
are sometimes seen in the medullary portion. 
Symptoms.--There are none unless the growth is large. Hematuria 
is very rare. Pain may occasionally be present, but is usually very slight, 
although it may be very severe if the tumor is large. In such cases 
symptoms produced by pressure may also be present. The diagnosis 
is usually made when the tumor is large and operation is generally 
indicated. Unless one can be certain as to the non-malignant character 1006 
DISEASES OF THE URINARY SYSTEM 
of the disease, it is best to perform nephrectomy, although in certain 
cases partial nephrectomy may suffice to extirpate the tumor. 
Tumors of the Pelvis of the Kidney.-These growths are very rare, 
more frequent in men than in women, and occur between the ages of 
forty and sixty. They are usually of two forms, a papillomatous and a 
flat, non-papillary form. The papillomatous forms are the more frequent 
and are very similar in character to the papillomas occurring in the 
bladder. Albarran has been able to collect 18 cases from the literature. 
Tn one case the papilloma grew down the ureter and subsequently 
invaded the bladder. Of the non-papillary forms, only 13 cases could 
be collected by Albarran. These are described for the most part as 
alveolar epithelioma. A squamous-cell carcinoma of the pelvis is exceed- 
ingly rare, one case having been described by Albrecht.1 Although the 
histological character of some of these tumors of the pelvis is not malig- 
nant in appearance, they, however, are to be classed as malignant 
tumors. Stone in the pelvis of the kidney has been mentioned as an 
exciting cause of these growths. There is no definite symptomatology, 
hematuria, which is apt to be profuse, being about the only symptom 
present early in the disease. Attacks of pain from the passage of blood- 
clots are apt to occur, and in the papillary form pieces of tumor are 
occasionally, but rarely, found in the urine. The diagnosis is usually 
made as a result of surgical exploration. The prognosis is grave. In 
the nine cases reported by Garceau, recurrence followed in seven, either 
as distant metastases or in the scar of the wound. The treatment is 
excision-complete nephrectomy. 
1 Arch. f. klin Chir., 1905, vol. Ixxvii. CHAPTER XX 
URINARY LITHIASIS: RENAL AND URETERAL CALCULI 
HUGH HAMPTON YOUNG, M.D. 
Definition.-Primary renal calculi may be defined as masses of urinary 
salts deposited in an amorphous or crystalline form in and about an 
organic nucleus and held together by an organic matrix. For the most 
part they presuppose a diathesis in which certain inorganic salts are 
supplied in excess to the kidneys for excretion; precipitation of such salts 
in the pyramids of Malpighi, consequent trauma to the tubular paren- 
chyma in its attempt at elimination, and a urine in process of formation 
of a composition such as will find difficulty in dissolving out the precipi- 
tated salts and prove favorable to their further precipitation subsequently 
in the kidney itself, the renal pelvis or bladder. Certain inorganic calculi 
form by precipitation of salts into necrobiotic tissue. 
Classification.1-Primary calculi are renal in origin, but the secondary 
calculi may form in any part of the urinary tract. We may distinguish 
calculi, according to the number, as the "solitary" and the "multiple," 
and according to their position as renal, pelvic, ureteral, etc. 
According to their composition they may be classified as: (1) The 
organic, of uric acid and its salts, calcium oxalate, cystin, xanthin, and 
urostealith. (2) The inorganic, consisting of the phosphates of lime 
and magnesium, and the carbonate of lime. 
According to origin they may be classified hypothetically as: 
1. "Of crystalline origin," when they may be primarily resultant 
from irritation of the renal tubules by crystals. 
2. " Of necrobiogenic origin," when their first cause may be degenerated 
renal epithelium which invites calcification. 
3. "Of microbic origin," when their starting-point is infection of the 
urinary tract with urealytic microorganisms. 
Secondary calculi, which are common to all dilatations of the urinary 
tract, may form in the renal parenchyma itself or in the renal pelvis, 
and thus come under the designation "renal calculus." The conditions 
necessary for their formation are: (a) An infection of the living tissue, 
with a urealytic microorganism (proteus bacillus, certain staphylococci, 
etc.), with consequent inflammation, the freeing of ammonium carbonate 
and the appearance of pus in the urine, and (6) obstruction to the out- 
flow of urine causing a stagnant pool in which a slimy mucoid matrix, 
composed of pus cells gelatinized by ammonia, may rest long enough 
to allow of sufficient infiltration with ammonium magnesium phosphate 
1 Leon Sourdille, La lithiase renale primitive. Arch. g^n. de chir., September, 1907. 
Roy, La gravelie phosphatique primitive, • These, Paris, 1898. 
1007 1008 
DISEASES OF THE URINARY SYSTEM 
to produce solidification. In pyonephrosis one finds this slime infiltrated 
with phosphates in every degree of consistency in freshly voided urine. 
The essential salt of this secondary calculus is ammonium magesium 
phosphate, the formation of which in the urine is dependent on the 
addition of free ammonia to unite with the normal magnesium phosphate. 
Calcium phosphate and ammonium urate are also common constituents 
of this stone. The so-called "fusible calculus" is composed of ammonium 
magnesium phosphate and calcium phosphate. All phosphates tend to 
be friable in consistency and white to gray in color. 
Composition of Primary Calculi.1-By far the most common are the 
mixed stones of urates and calcium oxalate in varying proportions and 
usually in layers in which one or the other salt predominates sufficiently 
to reveal on section more or less complete concentric rings. Frequently 
calcium phosphate and sometimes calcium carbonate or even cystin add 
a layer or more. Either the urates or oxalate may be lacking in these 
mixed stones, but they are most commonly associated. The phosphates 
and carbonate of lime are usually found together in the inorganic stones. 
Very rarely, if ever, do any of these salts form the sole constituent of a 
calculus. Should an ammoniacal infection supervene on these primary 
calculi they become invested with triple phosphates, and henceforth 
further growth is due to phosphates and carbonates alone. 
If the outside primary layer of such a stone is composed of urates, a 
transitional ammonium urate layer intervenes between it and the 
phosphates, due to the ammonium of the urine combining with the uric 
acid of the primary calculus. Prout held that such a transitional layer 
of ammonium urates also occurred when a triple phosphate layer was 
enveloped by urates, but this must be a very uncommon occurrence. 
In a report by Kahn and Rosenbloom2 quantitative analyses of 25 
renal calculi and vesical calculi are given, which show that true renal 
calculi are almost entirely composed of calcium salts. Their work con- 
firms that of Rowlands and also that of Mackerell, Moore, and Thomas, 
who found that renal calculi were composed almost entirely of calcium 
oxalate; that uric acid is usually absent, and if present it is so only in 
very small traces; that phosphates are commonly present. 
In most of Kahn's analyses calcium oxalate formed from 70 to 90 per 
cent., uric acid from 1 to 10 per cent, and phosphorus pentoxide 2 to 7 
per cent. Some variations occurred, but not enough to disprove the 
fact that uric acid is of much less importance than calcium in renal 
calculi. 
Physical Characteristics.-The physical characteristics of calculi vary 
greatly and are somewhat indicative of their composition. On these, 
rather than on chemical analyses, have been based many statements 
as to the nature of renal calculi. The so-called uric acid gravel is 
formed of fine reddish hard granules like cayenne pepper and some- 
times of a size up to that of a pea. These are most commonly seen as 
precipitates in acid urine which has been standing for some time. 
1 The major portion of this section on the etiology and composition was written 
for me, after a laborious study of the literature, by Dr. George S. Gordon. 
2 Jour. Amer. Med. Assoc., Dec. 21, 1912, p. 2252. URINARY LI TH I ASIS 
1009 
The hemp-seed gravel is similar, but of a dark gray or black color. 
Its chief constituent is calcium oxalate. 
Phosphatic sand occurs in " alkalinuria" as white masses of amorphous 
calcium tribasic phosphates; or in cystitis as secondary white crystalline 
triple phosphate with an admixture of calcium phosphates and ammonium 
urate in a slimy mucoid matrix. 
The most infrequent nearly pure calcium dibasic phosphate calculus 
is generally of the size of a small pea, cuboidal, with rounded edges and 
angles, grayish in color, smooth of surface, hard, and with a crystalline 
fracture. Multiple oxalates are very like these calcium dibasic phos- 
phate calculi and are apt to be definite in composition. 
The "mulberry stone" of calcium oxalate is tuberculated, stained 
blackish by altered blood, very hard, and of varying size up to that of a 
walnut or over. 
The "pebble" of urates is of similar dimensions, oval, of sandy surface, 
medium hardness, and grayish to reddish from admixture with urinary 
coloring matters. 
"Staghorns," or "coral calculi," are of the same materials, i. e., urates 
(Osler), color, consistence, and surface appearance, but of size and 
shape like a mould of the renal pelvis. 
The "jackstone" calculus, of brownish to blackish color and hardest 
consistency, is another form of oxalate (Fowler1). 
The xanthin calculi are "of a pale yellow color and exhibit a waxy 
lustre when rubbed" (Adami2). They vary in size from a pea to a 
hen's egg. A cystin calculus is hard, oval, light amber, glistening of 
surface, rough and granular but non-crystalline, and resembling small 
masses of amber stuck together without definite arrangement (Fowler). 
Urostealiths are " in the moist state soft and elastic at the temperature 
of the body, but in the dry state they are brittle, with an amorphous 
fracture and waxy appearance" (Hammarsten3). 
Calcium carbonate calculi "have mostly chalky properties and are 
ordinarily white" (Hammarsten). "Naunyn differentiates two forms 
in man, the one brown and spicular, the other pale and smooth, but of 
relatively great hardness" (Adami). 
Nucleus.-This is usually a solidified agglomeration of the same salts 
of which the calculi are composed, and forms the core. It differs from 
sediment inasmuch as it has a colloid matrix, and on the other hand 
from stone in not being laminated. It originates in the renal tubule, 
which is the only part of the urinary tract of small enough calibre to 
retain so small a body. As it increases in size it erodes the renal tissue, 
and if this takes place toward the renal pelvis it frees itself ultimately 
into a calyx, where it may unite with other similar nuclear forming 
material and become gravel or stone, pass on to lodge in the renal pelvis 
or other portions of the urinary tract, or be voided in the urine. 
Esbach4 says that a primary phosphatic nucleus is always replaced 
1 Johns Hopkins Hospital Reports, 1906. vol. xiii. 
2 The Principles of Pathology, 1908, vol. i. 
3 Physiological Chemistry, 1908. 
4 Les Calcules Urinaires, Paris, 1885. 1010 
DISEASES OF THE URINARY SYSTEM 
by oxalates or urates if they afterward envelop it. Tuffier1 has demon- 
strated experimentally that foreign bodies, unless they can supply an 
organic material for urinary contents to lodge in, do not form nuclei. 
Bilharzia eggs were said by Fagge to form the nuclei of uratic calculi in 
Egypt. Blood-clots sometimes form the core of a stone. Fullerton, 
basing his opinion on the analysis of seven calculi, holds that bacterial 
agglomerations do not form nuclei. Inorganic calculi usually lack a 
nucleus, unless formed about a foreign body. 
Size.-The size varies from that of fine gravel to the limit imposed 
by their enveloping-tissue bed. As the result of abnormal back pressure 
due to interference with the outflow of urine or to erosion of tissue by 
the growing calculus, a stone may be even larger than any normal 
expansion of the urinary tract. 
Form.-The forms assumed are dependent on their composition, the 
shape of their nucleus or nuclei, pressure from contiguous stones (in 
which case they become faceted), the conformation of the tissue bed in 
which they form, and on the way the urinary stream impinges on their 
surfaces to add fresh lamime or erode, according to whether the urinary 
contents favor growth or disintegration. 
Color.-Calculi are composed of colorless crystals and matrix. Their 
varying tints come from the urinary pigment, uroerythrin (Adami), or 
from blood-pigment, and vary as these vary in affinity or amount in the 
urine. When urates form, urinary pigments are much more in evidence 
in the urine than when phosphates or cystin calculi form, and con- 
sequently are more apt to be colored. Oxalates, if of coarse surface, 
erode into the vascular layer of the urinary tract, and blood-pigment 
stains them. Smooth oxalates are whitish. Cystin calculi may change 
color on exposure to the air, probably because they contain urobilinogen. 
Number.-Probably no calculus forms from a single salt-impregnated 
renal cast, but about an agglomeration of such. Multiplicity depends 
on the coalescing of such infarcts either in situ by erosion into neighboring 
tubules or after expulsion into a calyx. The adhesiveness of the mucoid 
matrix would vary with the amount of salts it contains, and if it is 
saturated it tends to form the nucleus of a stone by itself; while if it is 
in a more glutinous condition and comes in contact with similar infarcts 
fusion would occur. In the first instance multiple stones would form, 
and in the second a single calculus. If this hypothesis be correct there 
would hardly be a limit to the number of calculi forming in a kidney, 
and such is the case. On the other hand, many of these nuclei would 
escape in the urine before attaining size enough to prevent their exit. 
Bilaterality.-Holt,2 after 1000 autopsies on infants, states that 
granular deposits are generally seen in both kidneys. Legueu3 holds 
that in half of the cases where calculi form in one kidney the other 
is similarly affected. Albarran4 considers the frequency of stone on both 
sides as an argument in favor of the systemic origin of calculus. 
1 Etude sur la chirurgie du Rein, 1889. 
2 Diseases of Infancy and Childhood. 
3 Les calcules du rein et de 1'uretere, Th^se, Paris, 1891. 
4 Lancet, 1892, vol. i, pp. 1345, 1339, URINARY LITHIASIS 
1011 
Disintegration of Calculi.-Adami, speaking of uric acid stones, says: 
"The evidence seems to be conclusive that through keeping the urine 
alkaline through long periods by giving sodium bicarbonate, alkaline 
soaps, etc., not merely is gravel arrested but the stones within the 
bladder after such treatment show clear evidence of erosion." 
Etiology.-Age.-Calculi are found in the kidney throughout life, 
but are very rare in old age. Fry and Martin,1 in a study of 100 hospital 
infants under the age of three months, found an abundance of uric acid 
in the voided urine of 26 of them, of whom 19 died, and in 7 of these 
autopsies were done which demonstrated uric acid infarcts in the apices 
of the pyramids. Holt says, basing his remarks on 1000 autopsies, 
that "small renal calculi are very common in infancy," but they are 
usually voided during the first two years of life. He found one large 
renal calculus. By far the greater number of clinicians hold that renal 
calculus is rare in early life, but in the light of these figures they are 
evidently at fault. Calculi in the kidneys are most in evidence about 
the fourth decade. To this period belong the urate infarcts of the gouty 
and the calcium oxalate stone. Osler refers to the calcium phosphate 
infarcts of old age. Old people are not so prone to stone in the kidneys, 
because a "crystalline diathesis" declares itself, if at all, before this 
period, and the patient has passed all his calculi (at least as far as the 
bladder), had them removed by operation, or has a ureter sufficiently 
dilated, by the previous passage of stone, to offer no obstruction to the 
passage of calculi to the bladder. 
Sex.-That renal calculi occur more frequently in men than in women 
is generally accepted, but there do not appear to be statistics showing 
the relative frequency. Small renal calculi which pass into the female 
bladder are easily voided, but the same anatomical structures tend to 
hold them in the kidney in the female as in the male. 
Heredity.-Hereditary predisposition, the "peche original" of D'Etiolles, 
is almost universally admitted, and many authorities hold that urate 
gravel ranks as an evidence of gout. Oxalates and xanthin are so closely 
related to urates that they may be fathered by the same etiological 
factors. Cystinuria and a tendency to form cystin calculi also "run in 
families." 
Occupation.-"Sedentary occupations seem to predispose to stone" 
(Osler). D'Etiolles held that exercise was the "bellows blowing" which 
gave a good intake of oxygen through the lungs and thus secured combus- 
tion of tissue waste, and statistics and observation bear out the theory 
that stone formation is generally dependent on occupation only so far 
as the occupation is an active or sedentary one. Those engaged in 
plumbing and who use alcohol in excess are predisposed to renal calculi 
as to gout. Hutchinson called attention to the freedom of sailors from 
stone and attributed it to their salt diet, but D'Etiolles states that 
naval officers, notwithstanding they ate an excess of salted food in his 
day, were as prone to calculi as others. Civiale's list2 of prominent 
men, "victims of the sharp and craggy stone that cruelly pricks and 
1 Trans. Amer. Pediat. Soc., 1903, p. 150. 
2 Traits de Vaffection calculeuse, Paris, 1838. 1012 
DISEASES OF THE URINARY SYSTEM 
tears," includes, among others, Cromwell, Bacon, Boerhaave, Louis 
XIV, George IV, Napoleon I, Peter the Great, Montaigne, Newton, 
Horace Walpole, Fothergill, Hartley, Harvey, Mascagni, and Scarpa. 
Diet.-How absolutely unestablished is the etiology of calculi could 
be no better demonstrated than by noting the discord of deductions 
drawn by eminent authorities in the attempt to incriminate diet as 
causative. Cadge and Dickinson held that hard drinking-water was the 
cause of stone in Norfolk. Denny thought absence of lime in drinking- 
water caused stone in Holland. A. E. Roberts holds that stone in India 
is uncommon among those natives whose food contains sodium chloride, 
and Hutchinson believed that sailors were exempt from stone because 
of their salt diet. Yet Morris says that "salted meats are inducive of 
renal concretions," and D'Etiolles held that naval officers, who in his 
day ate much salt food, were especially subject to stone. Many maintain 
that ingested oxalic acid is a cause of oxalate calculi, yet Chabrie lived 
on food rich in oxalates for a month and did not succeed in finding 
oxalates in his urine. 
If the theory so well put by Futcher, "that owing to some organ or 
organs failing to produce a ferment (which normally is necessary for 
the proper destruction or oxidation of uric acid) oxidation of uric acid 
does not occur, and consequently accumulates in the blood in excess," 
is correct, then the ingestion of food rich in nucleins would cause an 
excess of uric acid and possibly xanthin to be presented to the kidney 
tubules for excretion; and this is a prime step in calculus formation. 
Exclusion from the diet of nucleins would cut off this supply of 
material. 
There is now a consensus of opinion (Guyon, quoting Chabrie, 
excepted) that ingested oxalic acid appears, at least in part, unchanged 
in the urine. It does not seem improbable that, as demonstrated by 
Dickinson and Roy, the drinking of lime-water furnishes one of the 
bases for inorganic calculi. 
Distribution.-Stone is common in the cold as in the warm climates, 
in the moist as in the dry, in the highlands as in the lowlands, inland as 
well as in countries bordering on the sea. It is common in Iceland. 
There are "stone districts" in England (Norfolk, Bristol, etc.), the west 
of France, about Moscow in Russia, some parts of Germany, in lower 
Egypt, in the uplands of India, and in Holland. In America stone is 
fairly evenly distributed and favors no particular locality. Norway, 
Sweden, and Styria were said by Roberts in 1866 to be practically free 
of stone. It is very common in India and China. 
Previous Diseases.-Almost every form of disease is referred to by 
authorities as causative of renal calculi, and it would be strange indeed 
if each of them had not been at one time or another the precursor of 
stone. Their etiological relation is not at all proved except in the fol- 
lowing ailments, whose role has been more or less fully substantiated: 
1. Those diseases which interfere with the complete combustion of 
food or tissue waste into urea and permit of the circulation in the blood 
of an excess of uric acid, oxalic acid, xanthin, or cystin. These tend to 
form organic stones in the kidney. Such diseases are: (a) Intestinal URINARY LI TH I ASIS 
1013 
disorders which allow the toxic mid-products of mucosal enzyme diges- 
tion, such as albumoses, etc., to reach the liver and by affecting it produce 
"hepatic incontinence." (6) All liver diseases which interfere with its 
urea-forming function; especially to be noted is hepatic cirrhosis, (c) 
Lung disease which limits the intake of oxygen, (d) Cardiac and arterial 
diseases (whether or not produced by alcohol or lead), which do not 
allow of sufficiently free circulation to permit the blood to be well 
oxygenated, (e) Gout. (J) Diseases which may supply an excess of 
uric acid to the kidney without the necessity of its passing through the 
liver, such as leukemia. 
2. Ailments which produce a fatty degeneration of the renal tubular 
epithelium, such as (a) the above diseases, which are accompanied by 
crystalline deposits in the kidney causing fatty degeneration, (b) fevers 
and (c) obesity. 
3. Fagge attributed part of the frequency of stone in Egypt and 
Natal to Bilharzia eggs in the urinary tract, which provide a nucleus. 
4. Disease characterized by renal hemorrhage, such as hemophilia 
and tuberculosis. The blood-clot acts as a nucleus. 
5. Oxaluria has been found in certain forms of dyspepsia of a some- 
what neurotic type, in confirmed obesity and in diabetes (Adami). 
6. " Alkalinuria" is due "first to a diet which raises the alkalinity of 
the blood, as a vegetable one, in gastric diseases with considerable loss 
of hydrochloric acid to the body through hypersecretion with motor 
insufficiency and vomiting or lavage, perhaps diarrhoea also, and spe- 
cially as a symptom of neurasthenia (Peyer), without any of the above- 
mentioned causes. In such a case during a period of neurasthenia a 
diminution in the phosphoric acid to about half and an increased calcium 
output have been found. The nitrogen was also decreased. It seems 
to be excessive calcium, relative to phosphoric acid, which leads to 
precipitation. It occurs in persons also after sexual excesses and in the 
depression following psychical exaltation, in which case the cause is 
not known, but a nervous control suspected. It is often found among 
mental cases (Heinicke)" (Emerson). 
Fullerton states that microorganisms do not form the nucleus of 
stone, although they may be present in the layers surrounding it. Thus 
it would seem that the bacilluria which so often accompanies and follows 
typhoid fever for so long a period is not specially likely to favor 
calculus. Secondary calculi of ammonium magnesium phosphate and 
other secondary salts follow local infection, such as is specially liable 
to supervene on spinal paralysis. 
Is it necessary to go farther than the "urinary functions" to determine 
the cause of gravel? In other words, can the kidney act independently 
of other glands and tissues and elaborate material for stone without 
regard to what abnormal or normal metabolism provides for it? We 
think it cannot. Sufficiently pertinent facts are known to indicate 
that no gland or tissue acts independently of other tissues even in disease. 
Moreover, excretory glands to functionate properly depend on other 
tissue to put proper end products of metabolism into the blood-stream. 
1. Urinary Reaction.-In its relation to the formation of calculi: 1014 
DISEASES OF THE URINARY SYSTEM 
L. Lickwitz1 states that uric acid and its salts have a high concentration 
in the urine in spite of the sodium ions present. (Salts of sodium diminish 
and albumin increases the solubility.) This is explained by the colloidal 
structure which he attributes to the urine. The formation of a sediment 
depends more or less on its colloidal substances. Evidently acidity 
exerts an influence. These colloids are responsible for the high uric 
acid and urate content of the urine. The reaction of the urine does not 
affect calcium oxalate as shown by its insolubility in strong mineral acids. 
He illustrates the importance of these colloidal substances by two experi- 
ments. In the first, he extracted with ether a colloidal substance from 
urine. The phosphates precipitated rapidly after this removal. The 
second experiment was performed by dializing urine in the presence of 
water, the urinary salts being crystalloids dialyze and precipitate easily 
in the aqueous solution. The precipitate most often is composed of 
calcium oxalate. 
2. Crystallization.-As the forms of crystals may have to do with the 
production of matrix material, the more spiculated being more irritating 
would produce more tissue degeneration, and thus perhaps more irregu- 
larly shaped nuclei. Once embedded in their matrix their forms are 
modified, as shown by Orde, and probably no longer have to do with the 
general outlines of calculi, only inasmuch as they may or may not super- 
saturate a nucleus to such an extent that it will not adhere to other nuclei. 
3. Origin of Uric Acid.-All the uric acid which passes through the 
liver is normally converted into urea by a uricolytic enzyme, but about 
half of the endogenous uric acid escapes the liver, and this is excreted 
normally unchanged by the kidneys. It amounts to approximately 0.7 
gram per day. When in excess it deposits in the renal pyramids as 
amorphous or crystalline bodies like tophi in the ear or chalk stones. 
Excess of uric acid supplied to the kidney for excretion may be due to: 
(1) Failure of the liver to produce sufficient uricolytic enzyme to trans- 
form uric acid into urea, or (2) excessive formation of endogenous uric 
acid which can short-circuit the liver, as it were, in reaching the kidney. 
It does not seem likely that the liver is solely at fault in these diatheses 
although it is held that the kidney is "more sinned against than sinning" 
when stones form. The fault may be one mainly of the liver, still the 
liver in its turn may have its handicap thrust upon it by gastro-intestinal 
disturbance, diseases of the lungs, leukemia, anemia, cardiac disease, 
etc. Moreover, other tissues than the liver may be responsible for 
combustion of waste products and their default be the main cause of 
calculus formation, but this seems very unlikely. In leukemia the uric 
acid from the nucleins may reach the kidney in very considerable quan- 
tities unaffected by the liver metabolism. 
Origin of Xanthin.-Another of the mid-products of metabolism which 
furnishes the salts for renal calculi is xanthin. This is merely uric acid 
less one atom of oxygen, and that it is so very rarely found in the urine 
would indicate that it is almost always oxygenated, at least to uric 
acid, in the body. Still there may be a very small amount of it in normal 
1 Abstracted in Journals D'Urologie, November 15, 1913. URINARY LITHIASIS 
1015 
urine. Its excess would be due to the lack of an oxydase, probably of 
the liver, or to excessive endogenous formation. 
Origin of Oxalic Acid, C2H2O4.-Chemically, Simon says, "oxalic acid 
may be regarded as a complete oxidation product of uric acid." Oxalate 
calculi are so often mixed with urates as to indicate a close relation 
etiologically, and clinicians, in speaking of causation, have very often 
drawn no distinction between the two. Like uric acid, it may be 
exogenous or endogenous, and "is increased in various diseases in which 
the oxidation processes are manifestly at fault." On the other hand, 
pure oxalic calculi, if they exist, would demonstrate that the "oxalic 
diathesis," recognized by Adami, is independent of "uric acid diathesis." 
On the other hand, authorities recognize indigestion in neurasthenia as 
causative of oxaluria; oxalic calculi do not dissolve in alkaline urine; 
they often have a layer or more of calcium for their base, all of which 
would seem to indicate some relation to the "alkalinuria" diathesis. 
Origin of Cystin, C6H2N2S2O4.-This salt, so uncommon in urine and 
the calculi of which are so rare, has been the subject of much controversy 
and research. Fowler, after passing under review the various theories 
of its origin, concludes: "Cystinuria, or the presence of cystin in the 
urine, is, therefore, to be looked upon as an indication of defective 
proteid metabolism. . . . It is not known in what part of the body 
cystin is formed, but the suggestion was made long ago that the liver 
is responsible. We have seen that the recent work of Friedmann lends 
some support to this view. It remains, however, for further clinical 
and experimental work to solve the question." 
Origin of Calcium and Magnesium Phosphates and Calcium Carbonates.- 
These salts escape through the urinary tubules as sediment in what 
Emerson calls "alkalinuria" (the commonly but falsely so-called "phos- 
phaturia"), a condition in which "we are dealing with a diminished 
acidity, and it seems with a diminished excretion of phosphoric acid 
and an increased elimination of lime" (Hammarsten). "Recent study 
of these cases with symptoms of neurasthenia and a phosphatic sediment 
in the fresh urine would indicate an abnormality in the calcium metab- 
olism-an absolute increase of this with a decrease of phosphoric acid" 
(Osler). These, however, are the amorphous phosphates, and do not 
tend to form calculi except secondarily to an aseptic necrosis. In the 
"phosphatic diabetes" of Tessier, on the other hand, calcium salts never 
precipitate in the urine. These amorphous phosphates, the crystalline 
calcium phosphate, calcium, carbonate, magnesium phosphate (amor- 
phous), magnesium phosphate (crystalline), are normally present in 
the circulation in some form and may deposit in necrobiotic cellular 
tissue to form the non-nucleated, non-laminated, pure phosphate stone 
so-called, or layers on an oxalate or other organic calculus. No diathesis 
to increase the amount of lime in the organism is necessary to explain 
this. The process is very similar to the calcification of a tuberculous 
focus. On the other hand, if there be a phosphate and carbonate diathesis 
in which these salts in a crystalline form are furnished to the kidneys 
in excess resulting in degeneration of the renal epithelium, inorganic 
stone may have the same genesis attributed to organic calculi. 1016 
DISEASES OF THE URINARY SYSTEM 
4. Origin of the Matrix for Organic Calculi.-(Urates, oxalates, cystin, 
and xanthin.) Rainey is said to have been the first, in 1858, to call 
attention to the effects of colloids on crystallization. Orde's experiment 
of crystallizing calcium oxalates in gelatin demonstrated that salts take 
on bizarre shapes or become amorphous under such conditions. Tuffier 
found that an aseptic foreign body placed in the renal pelvis of a dog 
became in time merely frosted with urates and phosphates, and that 
there was no agglomeration of salts. The colloid cement to hold the 
crystals together was wanting. "Poisoning with oxalic acid (Robert, 
Kusner, and Newberger) leads to abundant deposits within the kidney 
of calcium oxalates" (Adami). Ebstein and Nicolaier fed dogs on amide 
of oxalic acid, and at autopsy they demonstrated not only oxalate of 
lime in the tubules, but also fatty degeneration of the epithelium. Sour- 
dille says, "The elimination of crystals in the interior of secreting 
tubules does not take place without wounding the tubules." This is 
"nephrite lithogene"-a nephritis set up by the crystals which pro- 
duce a colloid material for organic stone as distinguished from 
"nephrite lithiasique" or a nephritis the result of calculus in the kidney. 
Strickly speaking, both forms are due to stone, but in the former only 
crystals are present to cause nephritis. 
Origin of Matrix for Inorganic Primary Calculi.-(Calcium carbonate 
and calcium and magnesium phosphate.) Litten, in 1881, tied the renal 
artery, and necrobiosis of the epithelium of the renal tubules followed, 
which formed the matrix for deposition of calcium salts. Dupre found 
necrosis in the renal epithelium in infants who had been poisoned by 
Spanish-fly blisters, and calculus followed. The writer has seen a micro- 
scopic section of the kidney of a man poisoned with corrosive sublimate 
which shows the renal tubules stripped of their lining cells and filled 
with granular deposits, presumably of lime, embedded therein. "Klotz 
showed that if celloidin capsules filled with fat or a fatty acid be inserted 
into the peritoneal cavity of a rabbit, in the course of a few days these 
are found to contain an amount of calcium far in excess of that present 
in the body fluids of the animal" (Adami). One can hardly avoid the 
conclusion that intoxication by ingested poison or by disease which 
would be severe enough to cause necrosis of the renal tubular epithelium 
would furnish a matrix for calcium and magnesium salts to precipitate 
in. But some of these salts are also crystalline, and as such, owing to 
an alkaline diathesis if supplied in excess to the kidneys for excretion, 
may be capable of setting up a lithogenous nephritis similar to that 
induced by the organic crystals. 
Ohlmacher1 thinks that bacterial infection plays an important role 
in the formation of renal calculi. He quotes 4 cases of Wright in 
which staphylococci were found, and gives details of seven cases, in 4 
of which the staphylococcus, and in 3 the colon bacillus was found. 
The 4 staphylococcus cases all had typical attacks of renal colic, but 
the colon infections were less typical. In only 1 case was operation 
performed (vesical calculus). In the other cases the author claims a 
cure (or relief of all symptoms) by injections of autogenous vaccines. 
1 Jour. Amer. Med. Assoc., April 19, 1913, p. 1213. URINARY LITHIASIS 
1017 
5. Sediment, Gravel and Stone.-When these salts are washed out of 
the tubules of the kidney, why do they at one time form urinary sedi- 
ments, at another gravel, and at another stone? The salts which are 
excreted as sediment in the fresh urine are, for the most part, amorphous 
and consequently not so irritating to the renal epithelium as to induce 
inflammation, with a resultant colloid into which the particles of salt 
may precipitate. These may continue for years without the formation 
of true gravel or stone. 
6. Formation of Calculi.-Fluid flows through the tubules, dissolves 
the solids in the tubules, and is in part absorbed; what is left leaves the 
tubule as the finished product-urine-which thence flows through 
calices, renal pelvis, etc. Now, if it can dissolve out the salts in the 
tubular epithelium, but owing to absorption not hold them in solution, 
and they are amorphous urates or phosphates, it carries them as sedi- 
ment with probably little or no irritation to any part of the urinary 
tract. If the salts are crystalline and sufficiently infiltrate their matrix, 
they may occlude a tubule or more at first, but ultimately be washed 
out entire or in an agglutinated mass of similar plugs from other tubules 
forming gravel. Yet again these crystals, forming infarcts, may erode 
their containing tubule and cement themselves to similar infarcts in 
neighboring tubules in the kidney itself, may then erode into the calyx, 
and again form gravel. 
They may be retained in the renal tissue still longer and erode into 
tubules with patent lumina, through which fresh salts may be added 
to their composition. They may erode in one place into a calyx, yet 
not free themselves from their kidney bed, and increase in size on the 
renal pelvic side by deposition from the supersaturated urine, passing 
their outcropping into the calyx. They may free themselves into a calyx 
as a nucleus so large as to be voided only with colic or remain to become 
laminated because of the changing nature of the urine contents in which 
they are bathed. Once the nucleus is of size to be retained it will be 
bathed by the products of renal inflammation until the renal cells recover. 
Thus a matrix for whatever salts may be precipitable in the urine is 
furnished to supply fresh layers on the calculus. Stones may remain em- 
bedded in the kidney for their entire period of existence, but considering 
that they form in the renal pyramids and have the pressure of urine 
behind them and the power of necrosis by pressure in front, it is little 
wonder that they practically always slough out into the calyx, thence to 
be voided or remain for increasing growth in the calyx, pelvis of the 
kidney, ureter, bladder, or prostatic urethra. 
Pathology.-Lesions of the Kidney and Ureter.-When the calculus is 
aseptic the kidney may remain fairly healthy, and there may be no 
inflammatory complications. Albarran claims that every calculous 
kidney, although it may appear normal, presents lesions of nephritis. 
He thinks these alterations are of etiological relation, but, also, that 
when the calculus is formed the lesions become aggravated as a result 
of the elimination of salts. This form of nephritis is diffuse, beginning 
by epithelial lesions, w'hich are soon accompanied by interstitial sclerosis. 
In the more advanced periods the kidney is retracted and becomes 1018 
DISEASES OF THE URINARY SYSTEM 
nodular. The capsule becomes adherent, and numerous small cysts 
are seen. In certain cases, according to Albarran, the kidney is very 
large and studded with cysts of various sizes, resembling a polycystic 
kidney. If the calculus obstructs the ureter more or less completely, 
hydronephrosis develops. This may be associated with marked dilatation 
of the pelvis and calices, with great thinning of the renal cortex. It has 
been shown that intermittent and incomplete stoppage of the ureter 
with a calculus is much more apt to lead to hydronephrosis than a com- 
plete blocking. In one of the writer's cases, in which the ureter was 
completely blocked and five calculi were present, the kidney was mark- 
edly contracted and atrophic, forming in reality a fibrous capsule for 
the calculi. There was apparently no secreting substance left, and no 
fluid secreted. In some of these cases of contracted kidney the perirenal 
fat becomes greatly increased, forming a large, fat, tumor-like mass 
around the kidney. Renal calculi may remain for years without any 
accompanying bacterial infection, but it is more common to find bacteria 
present, and they may easily precede or follow a lithiasis. In some 
cases this infection is of a mild degree, and accompanied only by a slight 
chronic inflammation of the pelvis and a certain amount of nephritis. 
In other cases numerous small focal areas of infection are present in the 
renal substance, and pyelonephritis exists. 
When the inflammation becomes severe, with extensive abscess of 
the pelvis of the kidney, pyonephrosis usually results, often associated 
with great thickening or complete destruction of the cortex and the 
formation of a large, irregular fluctuating mass. At times the cystic 
distension involves only a portion of the kidney. This happens par- 
ticularly in cases in which the renal pelvis is of unusual type, viz., those 
cases of multiple pelvis or with two or more ureters. In one of the 
writer's cases there was a large pyonephritic abscess of the upper half 
of the left kidney, the lower half of the kidney being normal and emptied 
by a separate branch of the ureter, which joined the other branch about 
seven inches below the kidney. The cystic distension of the kidney may 
reach an enormous size. There is often considerable perinephritis, and 
in some cases the capsule becomes greatly thickened and very fibrous. 
Number.-The number of stones may vary greatly. In 48 cases 
operated on by Israel, there were 26 with more than one calculus, the 
largest number being 36 in one kidney. From one of the writer's patients 
thirty-four stones were removed from the right kidney and fourteen from 
the left six weeks later. According to Israel both kidneys are the site 
of stone in 27 per cent, of the cases, and according to Legueu in 50 per 
cent. According to the writer's experience these figures are too high. 
Location.-Calculi are most frequently in the pelvis or in one or more 
calices. At times they may be embedded in the substance of the kidney, 
and at others have passed beyond the pelvis into the ureter, in which 
there are three points at which calculi most commonly lodge. These 
places are points of natural constriction of the ureter, and lie (1) just 
below the beginning of the ureter, (2) just at the crossing of the iliac 
vessels, and (3) in the terminal portion of the ureter. A calculus which 
has escaped from one of the calices or pelvis into the ureter may stop URINARY LITHIASIS 
1019 
at any one of these points, or it may pass into the bladder and remain 
there as a vesical calculus. Not infrequently these are caught at the 
ureteral orifice, where they produce a fusiform-like swelling or project 
into the bladder. 
Symptoms.-The symptoms of renal calculus are very variable. In 
those cases which are associated simply with the passage of sand there 
may be no symptoms at all, but more often there is a feeling of discomfort 
in the back or region of the kidney, which is relieved by its passage. 
Not infrequently, however, this sand produces an irritation in the 
ureter, bladder, and urethra during the passage. When a definite calculus 
has been formed the symptomatology depends considerably on its loca- 
tion and its movements. Not infrequently there are no subjective 
symptoms produced, and in one case the disease was present for a period 
of many years, and the only symptom which attracted the patient's 
attention was a recent onset of fever followed by pyuria. Yet in this 
case fourteen large calculi, some considerably larger than a hen's egg, 
were present. In another case a calculus remained in the ureter for ten 
years without symptoms after the first attack of colic. 
In a study of twenty-one cases there was a history of pain in 17, and 
in 13 cases it was of a colicky character, radiating toward the groin and 
generally into the testicle. Only one was described as radiating to the 
end of the penis, and in this case several calculi were passed per urethra. 
The pain is most commonly described as that of a dull, aching character, 
located in the small of the back on the affected side and sometimes 
beneath the ribs in front. This pain is generally increased by active 
exercise, by riding on horseback or in a rough vehicle, and by stooping 
forward. Most often it is slight in character, although more or less 
continuous. In a few cases, however, it is severe, and occasionally is 
present also on the other side of the back. The presence of a reno-renal 
reflex (i. e., pain referred to a sound kidney from a diseased kidney in 
which there is no pain) has now been recognized in a sufficient number 
of cases to warrant the acceptance of this as a rare but definite occurrence. 
This remarkable symptom must be carefully borne in mind. An appar- 
ently clear history of calculus is not, therefore, sufficient to decide as to 
the kidney involved; the wrong kidney has been operated upon in quite 
a number of cases. The character of the calculus has much to do with 
the severity of the pain and the traumatism produced, according to 
Osgood, who says that a sharp, rough calculus the size of a pinhead may 
produce the most agonizing colic, while a smooth stone nearly as large 
as a cherry may remain in the pelvis or ureter throughout life without 
severe pain. Calculus in the kidney or in a calyx may produce a pain 
referred all along the ureter, and a calculus impacted in the lower end 
of the ureter may produce typical colic in the region of the kidney. 
lienal colic, which is the most characteristic and most distressing 
symptom of calculus, fortunately occurs at more or less prolonged inter- 
vals. It is frequently ushered in by vomiting, which is soon followed 
by pain of extreme violence in the lumbar region of the affected side, 
usually associated with muscle spasm, which causes the patient to 
double up and frequently to get on his hands and knees. Radiation 1020 
DISEASES OF THE URINARY SYSTEM 
of the pain from the lumbar region along the side downward and in- 
ward toward the groin and into the scrotum and testicle occurs, causing 
marked retraction of the latter. The course of this pain is usually sup- 
posed to follow the genitocrural nerve. In some cases it extends also 
down the ureter into the bladder, and is associated with vesical irritability 
and frequency of urination; but usually this is rare, except when the cal- 
culus has passed to the lower portion of the ureter or into the bladder. 
An attack of colic may be associated with great systemic depression, 
chills, fever, rapid pulse, pallor, and severe gastro-intestinal disturbance, 
and not infrequently persists in its intensity for several hours, until it 
has been relieved by the use of large doses of morphine. Not infrequently 
several injections of morphine are necessary to obtain relief, and it is a 
noteworthy fact that the patient is able to withstand much larger doses 
during these attacks than at other times. Fortunately, nephritic colic 
is apt to disappear after the first attack and not to recur for several 
months, although occasionally it may recur for several successive days 
and cause great prostration. During or after the attack the urine 
usually contains a certain number of red-blood cells, and occasionally 
leukocytes; but in some cases both of these may be absent. The cessa- 
tion of the colic is sometimes due to the successful passage of the calculus 
into the ureter, and occasionally into the bladder, but most often no 
calculus is passed, and the cessation of the attack must be attributed to 
a change in position of a calculus-a stone which has become engaged 
in the upper end of the ureter may in some way become misplaced. 
In this series of 21 cases, colic was present at one time or another in 
13, but in only 7 cases was there a history of the passage of a calculus 
into the bladder and out through the urethra. Owing to the fact that 
small calculi may not be observed, these figures may be erroneous. 
Renal colic is not, however, absolutely diagnostic of stone. It occurs 
with other diseases in which the ureter suddenly becomes blocked, either 
by a blood-clot, a fragment of tumor, a mass of muco-pus, or torsion of 
the renal pedicle. It is also simulated very closely in certain cases of 
chronic prostatitis and seminal vesiculitis. Hematuria is also a variable 
symptom. In some cases it is more or less continually present, and in 
others it is never present macroscopically. In the 21 cases it wras present 
at one time or another in only 8, according to the statement of the 
patient. When infection and inflammation occur secondarily to calculus, 
and the pus formation is considerable, hematuria is less apt to occur, 
in the writer's experience, and often the attacks of colicky pain disappear. 
The presence of a swelling noticeable to the patient is rare, and occurred 
in only 3 of these cases. Gastro-intestinal disturbances are fairly common 
according to some authors, but were present in only 5 of this series. 
Digestive disturbances are most apt to indicate uremia and should lead 
to a very careful study of the renal function. 
Anuria is one of the most alarming and serious symptoms which 
occasionally occur with nephrolithiasis. Watson, who has made a careful 
study of this subject, lays down the underlying causes as follows: (1) 
The simultaneous blocking of the ureters of both kidneys; (2) the blocking 
of the ureter of one kidney, the other kidney being functionally incapable; URINARY LITHIASIS 
1021 
(3) the blocking of the common stem of the two ureters when they are 
fused, or of the single ureter of a fused kidney; (4) the blocking of the 
ureter of one kidney and the lessening of the function of the other by 
reflex influence, the latter organ being normal or but moderately diseased. 
Calculous anuria is one of the most fatal complications of the disease, as 
shown by the fact that in 110 cases treated expectantly there were 80 
deaths, a mortality of 72 per cent., and in 95 cases treated by operation 
there were 44 deaths, a mortality of 46 per cent. 
Vesical irritability may, according to Watson, Desnos, and others, 
be the only sign of renal calculus. In the writer's case vesical symptoms 
were present in only 6 of the 21 cases, and in very few of these was this 
more than a slight irritation. Apparently the bladder is usually free 
from irritation, unless a calculus has passed through the ureter or has 
become lodged in its lower end, in the juxtavesical, intramural, and intra- 
vesical portions of the ureter. In the Transactions of the American 
Association of Genito-urinary Surgeons for 1907 the writer reported 7 
cases of calculus lodged in the lower portion of the ureter-2 intravesical, 
3 intramural, and 2 juxtavesical-and the following conclusions were 
drawn: When the stone is situated in the ureter just above the bladder 
the symptoms are pain in the pelvis, sometimes radiating to the penis, 
but not associated with increased frequency of urination, with pain in 
the rectum or on ejaculation. Intermittent renal colic occurs, and 
perhaps pain in the testicle. When the stone is situated in the intra- 
mural portion of the ureter and does not project into the cavity of the 
bladder, there may or may not be frequency of urination; but there is 
always a pain radiating into the penis at the end of urination, and there 
is generally pain on ejaculation, either during intercourse or with noc- 
turnal emissions. In one of the three cases there was also pain in the 
rectum. Intermittent attacks of renal colic also occurred in these cases. 
When the stone is caught in the ureteral orifice and projects into the 
bladder the symptoms are more severe than in other locations, and 
present a remarkable and typical symptom complex of pain, renal, 
vesical, rectal, seminal, and testicular in character. In one of the cases 
with this syndrome, the patient complained of a frequent desire to 
urinate, pain in the bladder, radiating to the glans penis at the end of 
urination, a constant severe pain in the rectum, which was worse on 
defecation, a severe pain during sexual intercourse, which came on at 
the moment of ejaculation, and intermittent attacks of pain in the left 
kidney and testicle. Examination showed a calculus about 1 cm. in 
diameter projecting partly into the bladder through the ureteral orifice. 
All of these symptoms disappeared after removal of the calculus. The 
explanation of this combination of symptoms is evident as soon as we 
remember the intimate association of the lower end of the ureter, the 
seminal vesicles, the rectum, and the bladder. 
Diagnosis.-The examination should include a thorough study of the 
patient, including careful physical examination, urinalysis, cystoscopy, 
ureter catheterization, radiography, functional diagnosis of the kidneys, 
etc. Abdominal examination is unfortunately often very unsatisfactory. 
In many cases nothing can be made out in the region of either kidney, 1022 
DISEASES OF THE URINARY SYSTEM 
and in others there is only a slight tenderness. In only 13 of the 21 
eases seen by the writer was any abnormality noted in the region of 
either kidney, and in only a few of the cases was there marked enlarge- 
ment. Tenderness is supposed to be a very suggestive sign of calculus, 
but it is very frequently absent. When the kidney is enlarged it is often 
difficult to differentiate between nephrolithiasis with pyonephrosis and 
renal tumor. The presence of pus in the urine is more common with 
calculus, but is also seen in tumor. Careful urinalysis, with estimation 
of urea, total solids, and the determination of the functional state of 
the kidneys is important. When the phthalein excretion is low cry- 
oscopy of the blood or preferably determination of the blood-urea should 
be performed. Before operation is attempted it is important to know 
the condition of the "other" kidney. The radiograph is of great cer- 
tainty, and almost all renal and ureteral calculi can be demonstrated 
in this way. The pure uric acid calculus is the most difficult to detect, 
and some competent radiographers claim that it cannot be shown. In 
suspected cases the passing of a wax-tipped catheter will almost invari- 
ably furnish evidence if a stone is present. The most deceptive shadows 
are those shown by phleboliths, which not infrequently occur in the 
pelvis adjacent to the lower portions of the ureter. The diagnosis is 
made all the more difficult owing to the fact that phleboliths are not 
infrequently associated with pain. In such cases a positive diagnosis 
can usually be made by taking an z-ray photograph with a stiletted 
catheter in the ureter, or by outlining the course of the ureter with 
an injection of coilargol. 
Differential Diagnosis.-The more common diseases which are to be 
considered are tumor of the kidney or ureter; tuberculosis; essential renal 
hematuria; stricture or torsion of the ureter, with hydronephrosis; 
vesical disease, such as stone, tuberculosis or tumor; prostatic hyper- 
trophy and carcinoma; chronic prostatitis; seminal vesiculitis. Disease 
of the spine, such as Pott's disease, bony exostoses, spinal-cord lesions, 
lumbago, neuralgia, etc., must be considered. We have not space to 
enter into a full discussion of all these diseases, many of which present 
certain symptoms similar to those of renal and ureteral calculus. 
The arrays alone are usually sufficient to make a diagnosis positive, and 
careful physical, urinary, and cystoscopic examinations are of great 
value. It is well to lay stress upon the fact that chronic prostatitis and 
seminal vesiculitis are very frequently associated with pain in the back 
of a dull, aching character, and localized in the region of one or both 
kidneys. Not infrequently crises of pain occur in these cases exactly 
simulating renal colic, even radiating to the groin and testicle, and not 
infrequently associated with hematuria, irritability of the bladder, 
frequency of urination, pyuria, etc. The writer has seen a number of 
such cases, in which an operation had been performed upon the 
kidney, which was found to be normal. In all of these cases rectal 
examination showed an extensive chronic inflammatory condition 
around the prostate and seminal vesicle on the affected side. The 
hematuria and pyuria came from an inflamed posterior urethra, thus 
making the simulation of renal colic complete. Rectal examination, URINARY LIT HI ASIS 
1023 
stripping of the prostate and seminal vesicles, and the microscopic 
study of the secretion obtained will generally clear up the question at 
once. In all cases of pyuria careful search should be made for the 
tubercle bacillus, as this sometimes occurs with renal calculus. The 
differentiation between tumor and stone has been discussed elsewhere. 
It is often difficult to make a positive diagnosis without the x-rays. The 
cystoscope will generally show if the disease is vesical in character 
and careful examination of the spine should always be made. 
Treatment.-When the urine of a patient is known to contain a con- 
siderable amount of certain salts, uric acid, oxalates, phosphates, etc., 
suitable treatment should be adopted to correct this condition. The use 
of water in abundance, and particularly certain mineral waters, such as 
those at Saratoga and Poland Springs, Vichy, Contrexeville, Evian, 
certain German spas, etc., is of value. Healthy exercise, with regular 
breathing and special diets, according to the salt present, are indicated, 
the use of hexamethylenamine, piperazine, benzoate and carbonate of 
lithia, etc., have been advised, as these may act as valuable solvents, 
but it is probable that diet, exercise, and water in abundance are the 
most valuable methods. When the calculus is formed and is apparently 
not too large to pass, the use of glycerin in large doses, 50 to 100 cc. daily, 
has been strongly advised; it is said to provoke painful crises and to be 
followed by expulsion of the calculus. The writer had success with 
this in one patient in whom a calculus lodged in the lower portion of the 
ureter. It is often surprising to find that very large calculi have been 
passed, and Leonard has taken the position that before operation is 
carried out every effort should be made to cause the passage of a small 
calculus. Casper has advised the injection of oil into the ureter, a method 
used by the writer with success in a few cases. 
Dilatation of the ureter below the site of the lodgment of the calculus 
has also been successful. When the stone is lodged in the very end of 
the ureter it is sometimes possible to dislodge it with the ureteral catheter, 
or it may be possible to slit up the ureter by means of an operating 
cystoscope, and thus facilitate the escape of a calculus. In the female, 
vaginal massage or stripping from above downward sometimes pushes 
the calculus into the bladder, and rectal massage has also been advised 
in the male. Although renal and ureteral calculi may often remain for 
years without producing severe symptoms, this is not the rule, and 
usually they lead to very destructive processes. Even when the cal- 
culus is small its extraction should be undertaken when it has not been 
evacuated by protracted treatment. It has now been demonstrated that 
the operation of nephro- or ureterolithotomy is practically free from 
danger in uncomplicated cases, and that all portions of ureter are alike 
amenable to surgical treatment by an extraperitoneal operation, with 
the exception of the intramural and intravesical incarceration of calculi, 
in which the intravesical route (suprapubic or cystoscopic) is to be 
preferred.1 
When the stone is lodged, and particularly when associated with 
1 See an article on the subject in the Annals of Surgery, May, 1903. 1024 
DISEASES OF THE URINARY SYSTEM 
secondary infection, pyonephrosis, perinephritis, etc., operation should 
not be delayed. If the kidney is found to be in fairly good condition, 
nephrectomy usually need not be performed, and it is remarkable that 
the kidney, which is apparently considerably diseased, may often become 
quite useful and give no trouble after the removal of the calculus. 
When, however, there is extensive suppuration and the cortex is largely 
destroyed, the kidney should be removed if the condition of the patient 
warrants, and if the other kidney is healthy. The use of water in great 
abundance before and after all operations upon the urinary tract is the 
first principle. With the taking of large amounts of water, with saline 
infusions and slowly introduced enemata, uremia can be prevented even 
in severe renal disease. With anuria energetic efforts should be adopted 
at once to bring on urinary secretion-water in abundance, infusions, 
enemata, transfusions, sweat baths, cupping, diuretics, etc. Watson 
has shown that delay is very dangerous, and if the anuria persists 
after the use of active medical measures from twenty-four to forty- 
eight hours, an immediate and rapid operation should be carried out, 
with the object of incising the kidney and draining the pelvis. If 
the condition of the patient is dangerous, no attempt should be made 
to remove the calculus, unless this is very easily accomplished; a second- 
ary lithotomy can be performed later. Casper has advised ureter cathe- 
terization and the injection of water or oil into the kidneys, with the 
idea of dislodging the stone and of stimulating renal secretion. This 
procedure has been successful, and may be used in appropriate cases; 
but it is not advisable to wait long before operation is carried out when 
the condition of anuria persists. 
One important object is to prevent recurrences and diet should play 
a large part in this. Bradford1 mentions three factors concerned in the 
formation of calculi: (1) Composition of food; (2) the amount of the 
particular calculus-forming ingredient in the urine and its chemical 
relationship with the other urinary constituents; (3) inflammation of 
the renal pelvis. 
The formation of uric and oxalic acid stones does not depend wholly 
on the amount of these substances present in the urine. Yet, the amount 
may influence the formation of stones to some degree. Hence, the 
regulation by diet of the amount secreted becomes important. Where 
it is desirable to modify the reaction of the urine for a prolonged period, 
dietetic measures are more suitable than the administration of drugs. 
The excretion of uric acid cannot be prevented by any system of dieting. 
Yet, the deposition can be influenced by dietetic measures by restricting 
the output of uric acid and by altering the reaction of the urine. Approxi- 
mately one-half the uric acid excreted is the result of metabolism of the 
tissues. For uric acid to remain in solution the urine must not be unduly 
acid and salts must be present to provide necessary bases to combine 
and form biurates. This is brought about by vegetable diet, inasmuch 
as vegetables are rich in alkaline salts, especially those of potassium. 
1 A System of Diet and Dietetics, edited by G. A. Sutherland, 1908, Chap. xxii. URINARY LI THIASIS 
1025 
In this way urine can be rendered less acid or even neutral and the 
deposition of uric acid hindered. The free ingestion of water is advised. 
Conditions are different with calcium oxalate stones, as the great 
bulk of it in the urine is derived from foods or products of decomposition 
in the alimentary canal. It is probable that only traces of oxalic acid 
are formed in the tissues during metabolism. The formation of calculi 
composed of oxalates depends on other factors than the mere quantity 
excreted, as the process lies in the formation of relatively insoluble 
calcium oxalate instead of excretion of the soluble oxalate. Rhubarb 
and tomatoes have a high oxalic acid content and the ingestion of large 
amounts produce oxaluria. Oxalic acid is also found in the stomach 
in cases of dilatation with diminished hydrochloric acid by fermentation 
and decomposition. The regulation of diet is more important in the 
prevention than in the cure. No dietetic measures can affect stones 
already formed but may prevent the formation of subsequent ones. The 
dietetic treatment for oxaluria consists in the exclusion of foods contain- 
ing abundance of oxalates. This must be combined with the treatment 
of the gastric disturbance. 
Kahn and Rosenbloom call attention to the treatment of giving 
alkaline solutions to patients with stone disease, and to the necessity 
of changing the therapeutics in renal calculi, since the majority of these 
calculi are composed of the insoluble salts of calcium and not of uric 
acid or urates. They insist that the treatment of insoluble calcium 
salts is entirely different from that of uric acid. The antacid treatment 
should not be used in calcium stones. They conclude that calculi obtained 
by operation or otherwise should be subjected to analysis and if composed 
of calcium salts no antacid treatment should be advised. They further 
conclude that the majority of renal stones are composed of calcium 
oxalate and that sometimes the calcium salt is the only component of 
the stones. CHAPTER XXI 
GENITO-URINARY DIAGNOSIS. DISEASES OF THE 
PROSTATE 
HUGH HAMPTON YOUNG, M.D. 
EXAMINATION OF URINE 
Methods ordinarily employed in the collection and examination of 
nrine may lead to very grave errors in diagnosis. When all the urine 
is voided into one receptacle it is impossible to say whether certain 
pathological constituents may have come from the urethra, prostate, 
or bladder, but by making use of three receptacles much important data 
can be obtained. In a case of acute gonorrhoea, which is confined to the 
anterior urethra, if the patient voids urine in only one receptacle it will 
be cloudly with pus, but if he voids in three receptacles it will be clear 
in the second and third, due to the fact that the purulent secretions in 
the anterior urethra have been washed out by the first urine voided. 
If, however, the inflammation has passed the external sphincter in the 
triangular ligament and involved the prostatic urethra, the secretion 
which cannot escape anteriorly through the tightly closed membranous 
urethra passes upward into the bladder and mixes with the bladder 
urine. In such cases the urine voided in three glasses shows pus in all 
three, and cannot, therefore, be differentiated from pus arising from 
the bladder or kidneys. Blood coming from the anterior or posterior 
urethra follows the same directions as purulent secretions. In some 
cases of hematuria from the prostatic urethra the bleeding does not 
occur except at the end of urination, when the final spasm squeezes out 
the blood from the inflamed or ulcerated verumontanum or middle 
prostatic lobe. In a similar way purulent secretions which lie in the 
prostatic ducts in chronic prostatitis often appear as shreds in the last 
urine voided. In cases of spermatorrhoea, spermatozoa likewise are 
present in large numbers in the last urine. By the use of the three 
glass tests a fairly accurate differentiation of the various portions of 
the urethra is obtained and the origin of many a case of albuminuria, 
hematuria, or pyuria is explained. 
It is important that the urine should be examined soon after voiding, 
and for this purpose every physician should have a centrifuge, micro- 
scope, two or three staining fluids, and the simple apparatus necessary for 
a fairly complete urinalysis. When the urine is allowed to stand there 
is a rapid growth of bacteria and in a short time a precipitate which 
often obscures the presence of tube casts or other pathological elements. 
On this account urinary infections are often completely overlooked. 
It is particularly important in cases in which instrumentation of the 
urethra or bladder has been carried out to watch the urine for bacterial 
1026 GENITO-URIN ARY DIAGNOSIS 
1027 
infection, and when, in such cases, the third glass of voided urine shows 
a cloudiness, it should be examined at once. The passage of urine through 
the urethra generally washes out all the bacteria which it contains, but 
if cultures are wanted, or if the diagnosis between the smegma bacillus 
and the tubercle bacillus is desirable, the anterior urethra should be 
thoroughly cleansed by irrigation with sterile water, and the penis 
(particularly the foreskin, glans, and coronal sulcus) cleansed with 
soap, water, and 1 to 1000 bichloride of mercury solution. If this is 
done and the urine is voided in three sterile receptacles, the third urine 
should always be free from extraneous bacterial infection, and if bacteria 
answering the description of the tubercle bacillus are found, one can be 
quite positive that tuberculosis is present.1 
The effect of bacteria upon the secretion of urine and the production 
of urinary precipitates is very great. Certain bacteria, particularly 
those of the proteus group, have a very marked alkalinizing effect and 
cause a rapid deposition of phosphates and the production of calculi. 
Most ammoniacal urines are due to this bacillus. Some of the staphylo- 
cocci render the urine alkaline, but they are generally less rapid and 
intense in their action. Other bacteria, notably those of the colon 
group, never lessen the acidity of the urine, but in some cases add to its 
acidity. When bacteria of different effect (alkalinizers and acidifiers) 
are present they seem to neutralize each other, and with the preponder- 
ance of one or the other the reaction of the urine is found to change. 
Bacteria are not infrequently present in the urine in large numbers 
in cases in which there is no pus to be found, and the writer has seen 
numerous cases of persistent bacteriuria in which no signs of inflammation 
developed, and only by immediate examination of the urine, voided in 
three glasses, would the condition have been detected. Such an examin- 
ation is important in many of the acute febrile conditions, owing to the 
not infrequent development of bacteriuria and pyuria, and is now well 
recognized in typhoid fever. 
Instrumental Examination.-It may not be amiss to say a few words 
in regard to the use of the simpler exploratory instruments. 
Fig. 14 
Bougie with olive-shaped ends. 
Bougies.-Bougies are of great value in detecting the presence of 
stricture of the urethra. The best instruments are made of silk or linen 
covered with gum and provided with an olive-shaped ball at one or 
both ends, as shown in Fig. 14. The general practitioner should have 
at least four of these instruments, varying in size from 14 to 26, French 
scale. They cannot be boiled, and should be cleansed with soap and 
water and by immersion in 1 to 1000 bichloride of mercury. For stricture 
of the deep urethra, curved metal sounds are necessary. One should 
have at least six of these varying in size from 20 to 30, French; they are 
1 For further discussion, see Johns Hopkins Hospital Reports, 1906, vol. xiii. 1028 
DISEASES OF THE URINARY SYSTEM 
sterilized by boiling. In their introduction care should be taken, par- 
ticularly in passing through the membranous urethra, not to produce 
traumatism, false passage, etc. After the beak has passed into the 
bladder the instrument may be used as a searcher for calculi. If a No. 
28 French passes, the urethra can generally be said to be free from 
stricture. 
Catheters.-There is probably no instrument with which more harm 
has been done than the catheter, and on this account a word of caution 
seems advisable. In. the great majority of cases in which a catheter is 
necessary, prostatic hypertrophy is producing the obstruction. In such 
cases the urethra is distorted not only by the pressure of the lateral 
lobes, but by the upward growth of a median lobe, which usually produces 
an acute flexure in the floor of the urethra. The size of the ordinary silver 
catheter or straight catheters of gum or rubber has led to the tunnelling 
of this median portion of the prostate in thousands of cases, and the 
pathological museums contain many beautiful specimens but sad 
reminders of disaster. By the use of the coude (or elbowed) gum-linen 
catheter, catheterization can be successfully performed without injury in 
almost all cases of obstruction to urination from prostatic hypertrophy. 
The acute bend in the instrument, shown in Fig. 15, enables it to ride 
Fig. 15 
Coud6 catheter. 
over the obstructing barrier in the median portion of the prostate. This 
instrument is indeed the most satisfactory for general use, and should 
be recognized by the profession as the standard catheter to be first 
employed in nearly all cases. The straight rubber catheter, which is 
now almost exclusively employed, is often difficult to introduce in 
normal cases, owing to the fact that its point becomes engaged either 
in the pouch of the bulb just at the external sphincter at the median 
portion of the prostate, or in front of the external sphincter. The 
shape of the coude catheter, on the other hand, enables it to escape 
being caught in either of these natural depressions. The straight rubber 
catheter, however, has its place, and is particularly useful in cases of 
cancer of the prostate, in which it is much more easy to introduce than 
the coude catheter. The silver catheter is also of importance, but should 
usually be employed only when the coude or the rubber catheter has 
failed,' and great care should be taken to avoid making a false route. 
In cases of prostatic hypertrophy a special silver catheter with a large 
" prostatic curve" is often of help, and the two stilets which were 
invented by Guyon, Fig. 16, enabling one to give almost any curve to 
gum or rubber catheters, are often of great assistance. 
For cases in which retention of urine is caused by a definite stricture, GENITO-URINARY DIAGNOSIS 
1029 
a catheter which can be attached to a filiform is often of great value, 
the filiform leading the catheter through the strictured portion of the 
urethra. As it is impossible in some cases to introduce any form of 
instrument, an aspirating apparatus should always be at hand. The 
needles employed should not be any larger than the average steel bonnet- 
pin. Aspiration may be repeatedly done with these without much danger 
and with practically no fear of extravasation. 
Fig. 16 
Guyon's stilet to facilitate introduction of catheter in prostatic hypertrophy. 
Asepsis.-Before attempting any urethral instrumentation great care 
should be taken to prevent infection. The penis should be thoroughly 
cleansed with soap and 1 to 1000 bichloride of mercury, and should be 
surrounded with a sterilized towel saturated with the same solution. 
The anterior urethra should be irrigated with 1 to 60,000 bichloride of 
mercury, and the operator's hands cleansed with soap, water, and 
bichloride of mercury, or other approved methods, before any attempt 
to introduce the previously sterilized instruments is made. Great care 
should be taken to avoid traumatism, and the bladder should be irrigated 
with a solution of 1 to 60,000 bichloride of mercury, or 1 to 10,000 
nitrate of silver before the instrument is withdrawn. Usually the patient 
should take some internal urinary antiseptic (such as hexamethylenamine, 
45 to 60 grains a day) for several days after the procedure (and if possible 
before also), and careful examinations of the urine, voided in three 
glasses, should be made on subsequent days in order to detect the occur- 
rence of infection. If this were done by all practitioners, many of the 
disastrous results of urethral instrumentation would never occur. It 
is the rarest thing to find physicians properly equipped with even the 
instruments absolutely necessary for emergencies, such as they are apt 
to meet at any time, and on this account it seems desirable to give a 
list of genito-urinary instruments which should be in the possession of 
every general practitioner.1 But if the physician is able to invest in only 
1 Glass urethral nozzles for antiseptic irrigation of the urethra and bladder. Sounds 
for dilatation of the urethra (Nos. 18, 20, 22, 24, 26, 28, French). Filiforms, for 
strictures of small calibre, with screws for attachment to dilating followers (Nos. 10, 
14, 18, 22, French). Catheters: coude prostatic gum silk catheters which can be 
boiled (Porges) (Nos. 14, 16, 18, French). Rubber straight "Nelaton" catheters 
(Nos. 10, 14, 16, 18, French). A silver van Buren curve (No. 16, French). Guyon's 
stilets, coude and Benique curves (to give a proper curve to gum and rubber catheters). 1030 
DISEASES OF THE URINARY SYSTEM 
one instrument, let it be a coude gum catheter, and one that can be 
thoroughly sterilized by boiling (such as the French make of Forges). 
Visual Exploration.-The use of the urethroscope and cystoscope has 
become so greatly popularized of late that a few words may not be 
amiss. Here, too, great care should be taken to avoid infection, and 
on this account a urethroscope, in which the light is not carried in the 
tube of the instrument, but is thrown in from without, is much to be 
preferred. By its use diagnoses of obscure urethral lesions can occa- 
sionally be made. The topical treatment of chronic gonorrhoea and 
diseases of the verumontanum is often of very great benefit. Cystoscopy 
is performed with the bladder distended with water or with air. 
It is impossible here to discuss the advantages and shortcomings of 
both these methods, but suffice it to say that, for general diagnostic 
work, thorough inspection of the entire bladder, study of the action of 
the two ureters and of the size and distribution of the prostatic lobes, 
the simple cystoscope of Nitze with the bladder distended with water 
is by far the best instrument. This little instrument, with its coude 
beak, is one of the easiest to introduce, and with the use of novocain in 
the urethra its employment is rendered extremely simple and free from 
pain. Its findings are usually so certain, and often so brilliant, that it 
seems remarkable that it is not now used with far greater frequency. 
With the simple cystoscope it is possible not only to distinguish between 
the various diseases of the prostate and bladder, but also by study of 
the ureteral orifices to give an accurate interpretation of the condition 
of the two kidneys in many cases. 
Renal hematuria or pyuria can easily be detected by watching the 
intermittent outflow of urine from the ureteral orifices, and in many 
cases of unilateral renal disease a pathological condition of the lower 
end of the ureter can be detected. 
For intravesical treatment in the female the use of an open tubular 
cystoscope and vesical distension with air is generally to be preferred, 
as successfully used by H. A. Kelly. Catheterization of the ureters is no 
longer a difficult procedure, and can usually be accomplished with very 
little pain after the use of novocain (5 per cent, solution) in the urethra. 
The writer's preference is for the catheterizing cystoscope, made by 
Wappler in New York, which is provided with two catheters, and at the 
same time is of small size, so that its introduction is not difficult. 
Ureteral catheterization has not become so easy that it is to be recom- 
mended as a routine procedure by all practitioners. It can be learned, 
however, without great difficulty, and it should be employed much more 
widely than it is. By the use of formalin vapors, thorough sterilization 
of the ureter cystoscope and catheters can be obtained and the dangers 
of vesical and ureteral infection can be reduced to almost nil. 
By the introduction of the phthalein test, Rowntree and Geraghty 
have given an accurate and simple method of determining the functional 
value of one or both kidneys. GENITO-URINARY DIAGNOSIS 
1031 
THE DIAGNOSIS OF CERTAIN GENITO URINARY AFFECTIONS 
Urethritis.-The characteristics of the gonococcus are so well known 
today that it would hardly seem necessary to say anything in regard 
to diagnosis; but very little is generally known about the so-called 
pseudogonococci and the persistence of gonorrhoea without gonococci. 
In an acute urethritis with a profuse discharge of pus the gonococcus 
is usually found so quickly and in such great numbers that a positive 
diagnosis is easy. When, however, the discharge is slight, or the only 
purulent secretion present is found in the shape of shreds in the urine, 
the detection of the gonococcus is often very difficult. This is due first 
to the presence of other organisms which closely simulate the gonococcus. 
Some of these do not decolorize by Gram, although they are typical in 
shape and intracellular; but there are others in which the organism is 
not only a biscuit-shaped diplococcus, but also decolorizes by Gram. 
Fortunately, the latter organism is found very rarely in the urethra 
(according to See, in a proportion of 2 per cent, of the bacteria found in 
the normal urethra). These pseudogonococci are non-pathogenic and 
are found only in very small numbers, so that if the rule is made to 
make a positive diagnosis of the gonococcus only when present in fair 
number, and when located within the pus cells, no mistake will be made, 
according to See. But the absence of the gonococcus is not sufficient 
to warrant the assertion that the case is non-infectious. In the majority 
of cases of chronic gonorrhoea it is almost impossible to find the gono- 
coccus or in fact any organism, but multitudes of cases of pelvic inflam- 
matory trouble in women prove the fallacy of the idea that these patients 
cannot transmit infection. 
The absence of the gonococcus is not the all-important question. 
Of course, whenever the gonococcus is present the condition is far from 
cured, but because it cannot be found or even because there is no evidence 
of a urethral discharge is no justification for the habit of telling the 
patient that he is cured. Before a gonorrhoeal patient is discharged as 
well he should undergo a careful routine examination, which should 
include examination for discharge at the meatus, and shreds in the 
urine, voided in three glasses; palpation of the prostate and seminal 
vesicles; expression of their contents for microscopic study and the 
examination of the urethra with a sound for infiltrations, strictures, 
etc. As long as urethral shreds composed largely of pus cells are present 
the patient cannot be considered well. As long as the prostate is enlarged, 
indurated, and the secretion contains pus cells in considerable number 
there is great danger to the opposite sex. The fact that a marked pros- 
tatitis may be present, when there is no evidence of chronic urethritis 
at the meatus or in the urine, shows the very great importance of a 
routine examination of the prostate and seminal vesicles, and even 
when the prostate feels normal it is important to examine its secretion, 
which can easily be made to appear at the meatus simply by vigorous 
massage. The normal secretion is largely composed of lecithin cells 
easily recognized, and the presence of a definite number of polynu- 
clear leukocytes, as shown by the addition of acetic acid, demonstrates 1032 
DISEASES OF THE URINARY SYSTEM 
at once the presence of a chronic inflammatory condition of the 
prostate. Fortunately, this condition is generally curable by a pro- 
longed course of prostatic massage and other local treatment, but until 
such cure is effected, marriage is generally a hazardous procedure, even 
if repeated careful examinations fail to show the gonococcus. The gono- 
coccus fixation test, if positive, should prevent marriage. If negative we 
cannot say that a gonococcus infection is not present. 
Chronic Prostatitis.-The importance of chronic prostatitis, which is 
one of the most common diseases with which the adult male is afflicted, 
and the fact that it is responsible for symptoms in regions far remote 
and simulates many other affections, is very little appreciated. The 
symptoms of chronic prostatitis may be sexual, urinary, or referred. 
Only the last is discussed here, as we have not space to write of the 
numerous sexual disorders or to the urinary irritations and obstructions 
produced by chronic prostatitis. The referred symptoms are of a 
painful nature, and may involve the back, hips, thigh, rectum, perineum, 
groins, and scrotum. They seem to occur in four distinct groups: (1) 
Those involving the rectum, perineum, and urethra; (2) those involving 
the groin and scrotum; (3) those following the course of the sciatic 
nerves and involving the legs, thighs, hips, and buttocks; and (4) those 
involving the back and region of the kidneys. 
These referred pains are generally of a dull, aching character, coming 
on at certain periods of the day; in some cases painful seizures of con- 
siderable intensity occur. This is particularly true of those cases which 
simulate renal colic, often being of such severity as to require morphine. 
They are often accompanied by hematuria and marked irritability of 
the bladder (both due to an inflamed prostate), and the simulation of 
the symptomatology of renal caculus is often perfect. Rectal examination 
in these cases usually shows a marked inflammatory infiltration, involv- 
ing the prostate, seminal vesicle, and surrounding structures in the 
pelvis on the side in which the pain occurs. The explanation of these 
referred pains is, according to Head, that a painful stimulus received 
at ah internal organ is directed upward to that segment of the cord from 
which its sensory fibres are given off; there it comes in close communica- 
tion with the fibres from the surface of the body which arise from the 
same segment, and thus the pain is referred to another region than 
that of the viscera actually affected. The prostate receives fibres from 
the tenth, eleventh and twelfth dorsal, the first, second and third sacral, 
and the fifth lumbar segment. With this varied distribution it is easy 
to see how the referred pains occurring as a result of chronic prostatitis 
may simulate, as they do, lumbago, nephrolithiasis, coxalgia, sciatica, 
varicocele, and other conditions in the various regions from the dia- 
phragm to the toes. It is safe to say that chronic prostatitis is responsible 
for many of the so-called neurasthenias in the male, and that many 
painful maladies which go untreated could easily be recognized if careful 
examination were made of the prostate and its secretion.1 
1 Those who are interested will find an extensive report of cases in the Johns Hopkins 
Hospital Reports, 1906, vol. xiii, and articles by McCrae and the writer in the Jour. 
Amer. Med. Assoc., 1913, vol. Ixi, pp. 477 and 822. GENITO-URINARY DIAGNOSIS 
1033 
McCrae, in drawing attention to the remote effects of lesions of the 
prostate, has emphasized the frequency of general nervous disturbance 
due to this cause. There are also many disturbances of the circulation. 
Some of these are evidently functional in character and specially 
characterized by attacks of palpitation of the heart and sometimes by 
pain so severe that angina pectoris is diagnosed. In many of the patients 
with chronic prostatic disease there is serious involvement of the myo- 
cardium, and the rapid improvement which may follow prostatectomy is 
remarkable. A phlebitis sometimes occurs, apparently secondary to pros- 
tatic infection. The possibility of the prostate being the source of 
infection in cases of arthritis deformans should be kept in mind. 
It is very important for practitioners to make a routine examination 
of the prostate as a regular part of physical examination in order that 
they may become adept in recognizing slight changes in the gland and 
its adnexa. With the patient bending forward with his elbows upon his 
knees, the index finger (covered with a rubber cot) is inserted into the 
rectum, and systemic examination of the membranous urethra, prostate, 
seminal vesicles, and vasa deferentia made. With practice, no difficulty 
is usually experienced in mapping out these structures and in determining 
pathological changes. In chronic prostatitis the prostate is often some- 
what enlarged, irregular, sometimes nodular, with induration in places, 
and at times great tenderness. It is apt to be associated with an 
induration along the vasa deferentia and lower portion of the seminal 
vesicles, and continuous with that of the prostate. In some cases the 
seminal vesicles are enlarged and indurated, and the space • between 
them may be filled up by a broad plateau of infiltration which con- 
nects the indurated vesicles. Adhesions to the pelvic wall on one 
or both sides, fixing the prostate and sometimes the seminal vesicles, 
are a fairly common finding, the periprostatic infiltration occasionally 
being very extensive. In some cases the prostate appears normal; it 
is impossible to make out any enlargement, irregularity, or induration, 
and the great importance of obtaining some of the secretion by massage 
or stripping of the seminal vesicles or prostate is evident. This stripping 
process, carried on systematically from above downward, soon empties 
considerable secretion into the prostatic urethra, from which it may 
be carried by a similar stripping movement through the external sphinc- 
ter, after which it runs down freely to the meatus, where it may be 
caught upon a slide for microscopic examination. In normal cases the 
prostatic secretion is composed largely of lecithin cells, which are small, 
translucent, non-nucleated bodies, varying in size from that of a blood- 
platelet to that of a red-blood corpuscle. Large granular cells, epithelial 
cells, and spermatozoa are also seen. If trauma has been produced, 
red and white corpuscles may be present. Often by the microscopic 
examination alone the presence of a prostatitis is recognized. The 
writer strongly urges the necessity of this examination as a routine. 
Chronic prostatitis is essentially a periacinous infiltration. The 
accompanying processes in the seminal vesicles and in the periprostatic 
and perivesical tissues are much the same. In these processes the nerve 
terminals, fibres, and ganglia are frequently involved, and to this is due 1034 
DISEASES OF THE URINARY SYSTEM 
the many referred pains which occur. The purely sexual symptoms 
are most often due to changes in the verumontanum, characterized by 
infiltration, enlargement, congestion, and dilatation of the ejaculatory 
ducts. The urine in these cases is apt to show fine comma shreds in the 
third urine voided, due to the squeezing out of purulent plugs or moulds 
from the lumina of the prostatic ducts during the last spasmodic efforts 
of urination. Spermatorrhoea may be present also. 
In a study of 358 cases of chronic prostatitis the symptoms were as 
follows: Frequency of urination, 90 cases; pain during urination, 46; 
urgency of urination, 25; difficulty of urination, 11; irritability of the 
deep urethra, 11; pain at the end of urination, 7; pain at the beginning 
of urination, 3; and dribbling after urination, 1. In 34 cases definite 
obstruction to urination was present, but in only two cases was the 
retention of urine complete. These men were thirty-two and thirty- 
seven years of age, and one had led a catheter life for twelve years. 
(These patients were cured by perineal prostatectomy.) The location 
of the referred pains was as follows: Lumbar region, 64; region 
of the kidney, 8; of a colicky nature simulating renal colic, 10; in the 
perineum, 35; suprapubic, 22; groin, 18; urethra, 14; rectum, 13; thighs, 
12; hips, 10; sacrum, 5; simulating sciatica, 5; knees, 4; and legs, 4. 
In some cases these painful seizures were of great intensity. This is 
particularly true of those cases which simulated renal colic, the attacks 
being of such great severity as to require morphine. These attacks 
are not infrequently accompanied by hematuria and marked irritability 
of the bladder (both due to posterior urethral inflammation), so that 
the simulation of renal colic due to calculus is often perfect, and in six 
of the ten cases exploratory operation had been performed on the kidney 
without finding a calculus. Rectal examination in these cases usually 
showed a marked prostatitis, with infiltration around the seminal vesicles 
and adhesions to the pelvic wall. The treatment of these cases is most 
satisfactory,. and consists in prostatic massage, very hot rectal douches 
given with Martin's rectal tube, local application of nitrate of silver 
to the verumontanum and posterior urethra, intravesical irrigations, 
dilatation, etc. Frequently extensive infiltration of very chronic 
character and involving apparently the whole floor of the pelvis dis- 
appears under this treatment, with an immediate amelioration and 
the final cure of symptoms of long duration. Drainage of the seminal 
vesicles (and prostate) has been shown to yield remarkably good results 
in severe chronic inflammatory conditions of these organs. Before a 
diagnosis of neurasthenia in the male is made a most careful examination 
of the prostate and seminal vesicles and their secretion should be made. 
Tuberculosis of the Genite-urinary Tract.-With an insidious 
hematuria or pyuria the suspicion of the presence of tuberculosis in 
some portion of the urinary tract generally arises. Owing to the fact 
that tuberculosis is very rarely primary in the bladder, it is important 
to recognize the original focus of the infection. Although the bladder 
is infected in the majority of cases, the primary site is generally in the 
kidney, the prostate and seminal vesicles, or the epididymis, and in 
many cases all of these structures ultimately become involved. In GENITO-URINARY DIAGNOSIS 
1035 
cases of tuberculosis of the epididymis, prostate, and seminal vesicles, 
palpation will generally make the diagnosis clear; but in some cases the 
differentiation between tuberculosis and a chronic inflammatory con- 
dition is not easy, and it is important to find the bacilli. As remarked 
above, if care be taken to cleanse the penis, irrigate the anterior urethra, 
and collect the urine in three sterile glasses, one can be positive that an 
organism obtained from the third urine which answers the proper stain- 
ing tests is the tubercle and not the smegma bacillus. In many cases 
it is advisable to determine the extent of vesical involvement and the 
presence of tuberculosis of either kidney, and for such the cystoscope 
is very necessary. Fortunately, by ureteral meatoscopy (a term invented 
by Fenwick to designate a simple inspection of the ureteral orifices) 
it is possible to form some idea of the condition of the kidney on 
that side. If tuberculosis is present the fluid ejected will be cloudy, 
and perhaps show a large amount of muco-pus, and the mucous mem- 
brane surrounding the orifice will usually show marked inflammatory 
changes, varying from hyperemia and cedematous swelling to severe 
ulceration. Ureteral catheterization should always be carried out if 
possible and can usually be done unless the bladder be too irritable or 
contracted. 
Before the performance of nephrectomy one should be absolutely 
certain that the other kidney is functionating. It is needless to say at 
this date that the various segregators are absolutely unreliable, especially 
in cases of tuberculosis. 
Hypertrophy of the Prostate.-According to Sir Henry Thompson, 
one man in every five over fifty years of age suffers from prostatic hyper- 
trophy. Many of these cases never cause much trouble, but the great 
frequency of the disease, and the fact that it is first seen by medical 
men, warrant a few words upon the subject. 
Prostatic hypertrophy usually consists of many spheroids of hyper- 
trophic gland tissue bound together in a fibrous stroma, the whole 
forming an encapsulated lobular mass, which presses against the urethra 
and may extend far into the bladder. In 120 specimens examined by 
us, 100 were of the glandular type, 14 of the fibromuscular, and 6 inflam- 
matory. Besides the enlargements of the lateral lobes, a more or less 
considerable hypertrophy of the median portion of the prostate, the 
so-called middle lobe, which lies beneath the urethral orifice at the vesical 
opening, is very commonly present. This produces by its growth a bar 
at the neck of the bladder, which acts not only as an obstruction to the 
outflow of urine but to the introduction of a catheter. In nearly all 
such cases there is an acute bend in the urethra, sometimes with a 
formation of a pouch in front of this median bar or lobe. This is also 
often associated with a contracted condition of the prostatic orifice, so 
that the introduction of a straight instrument is in many cases impos- 
sible. 
The usual results of prostatic obstruction are, at first, frequency of 
urination and a gradual contracture of the bladder, with progressive 
lessening of its capacity. Later, the bladder is not completely emptied, 
and the residual urine gradually increases. Complete retention 1036 
DISEASES OF THE URINARY SYSTEM 
of urine sets in, as a rule, without warning, and, in some cases, when 
there has been very little difficulty of urination. Often the passage of 
a catheter will be followed by a complete retention of urine, which may 
not disappear until operation is performed. The bladder usually becomes 
trabeculated, and pouches and diverticula form, in some cases reaching 
great size. Dilatation of the ureters and renal pelves is often present 
to a marked degree when the symptoms do not suggest any such changes, 
and if an ascending infection occurs the case at once assumes a desperate 
character. The symptoms are usually those due to gradually increasing 
obstruction, viz., hesitation, straining, increased frequency of urination, 
with smallness of the stream, and often several isolated attempts or 
efforts are required before the act of urination is completed. With 
increase in the residual urine, urination gradually becomes more frequent 
and difficult, and in most cases complete retention and a catheter life 
ultimately results. In rare instances the bladder may become very 
greatly distended, and although there is much residual urine (from 
1000 to 5000 cc.), the overdistended bladder may be able to functionate 
apparently quite normally, voiding large amounts of urine at long 
intervals, so that one is surprised to find a greatly distended bladder 
with a large amount of residual urine. In other cases incontinence, 
generally with considerable residual urine, is present. The varied 
symptomatology cannot be discussed in detail, but we wish to lay stress 
upon the fact that often with few symptoms present very serious de- 
structive processes are going on, and, almost without warning, the patient 
is often found to be in a desperate condition. The great importance 
of instituting treatment early, before the occurrence of a large amount 
of residual urine and before the formation of diverticula and hydro- 
nephrosis, is shown by the fact that in early cases operation is practically 
free from danger, whereas in the latter class of cases there is always 
danger of uremia, although it is possible with careful treatment to help 
nearly all of these patients. 
As remarked above, a special coude catheter should be employed 
in cases of prostatic hypertrophy, because the abrupt curve near the 
point of the instrument enables it to ride up over the median bar. The 
use of straight rubber catheters, and even the ordinary silver catheter, 
is, as a rule, dangerous, and the straight olive-tip pointed silk catheter 
should never be used. 
The question as to what is the proper treatment to follow when the 
patient comes into the hands of the practitioner is of great importance. 
It is well recognized that a large amount of residual urine should never 
be allowed to continue indefinitely, owing to the injurious effect upon 
the higher urinary organs, and on this account many have advised 
systematic catheterization when the amount of residual urine is larger 
than 150 cc. Unfortunately, the first catheterization is not infrequently 
followed by complete retention of urine, necessitating the beginning 
of a catheter life, and on this account, when one considers catheterizing 
for the first time, he must always be prepared for such a result. It is 
not safe to withdraw residual urine and leave the patient thinking that 
he will be able to void as before; and as frequent catheterization is almost GENITO-URINARY DIAGNOSIS 
1037 
always followed by infection of the bladder, cystitis, etc., the question 
of the employment of the catheter is a serious one. The use of a catheter, 
even in the hands of skilful patients, with abundant means at hand to 
perform it properly, is frequently beset with great difficulties and serious 
complications, such as false passages, catheter fever, prostatic abscess, 
unrelieved retention, with increased dilatation of the ureters and kidneys, 
ascending infection, etc. The breakdown of catheter life occurs in a 
large percentage of the cases before many months have passed, and a 
surgical operation is then often required in an emergency to save life. 
On the other hand, the surgical treatment of prostatic hypertrophy 
has progressed rapidly, and the operation of prostatectomy has now 
become remarkably simple and free from danger, even though the 
surgeon is still required to treat many patients who have suffered from 
the disease for a long time and are in serious condition on account of 
numerous complications. The operative mortality of perineal prostatec- 
tomy varies from 3 to 6 per cent, in the various statistics, and of supra- 
pubic prostatectomy from 6 to 10 per cent. 
Owing to the terrible suffering of some of these unfortunate patients, 
operators have been induced to do the operation upon desperately ill 
and very aged men, and this fact is largely responsible for the presence 
of any mortality. For example, the writer has had 12 deaths following 
350 cases of perineal prostatectomy. About 30 per cent, of these patients 
were over seventy years of age and 12 over eighty years of age, and 
among the 12 deaths, 5 were over eighty years. The writer had (from 
July 24, 1905, to March 20, 1908) 128 consecutive cases of perineal 
prostatectomy without a death, every patient leaving the hospital well 
or improved. Four of these patients were over eighty years of age, 19 
between seventy-five and seventy-nine, and 22 between seventy and 
seventy-four. Many of these patients, besides being very aged, were 
in poor physical condition. In 20 cases more or less severe organic 
heart disease was present (dilatation, endocarditis, myocarditis, and • 
arteriosclerosis). In 6 cases pyelitis or pyonephrosis, in one case renal 
calculi, and in another ureteral calculi were present. These statistics 
are mentioned to show that there was no choosing of the cases, and 
that the operation of conservative perineal prostatectomy is a satis- 
factory one. 
It seems evident, therefore, that all patients with prostatic hyper- 
trophy and gradual increasing obstructive symptoms should be subjected 
to operation before serious complications arise. The use of a catheter 
even for a protracted period is not to be advised, as it almost invariably 
results in infection, which is often very difficult to remove. When, 
however, the amount of residual urine is large, say 400 to 2000 cc., fre- 
quent catheterization should be carried out for a protracted period before 
operation, so as to allow the distension of the ureters and kidneys to be 
relieved. In some cases it may be advisable to fasten a retained catheter 
in the urethra, and it is remarkable how such drainage leads to a rapid 
improvement of the function of the kidneys. In numerous instances 
severe uremia has cleared under this treatment (water in large amounts 
by mouth, by rectum, or by infusion being given at the same time). 1038 
DISEASES OF THE URINARY SYSTEM 
In such cases rapid improvement in the urine is noted (the phthalein 
test is an accurate index of this) and, as a rule, operation should not 
be undertaken until this improvement has been sufficiently marked to 
indicate that there is very little danger of renal suppression after 
operation. When catheterization is necessary the patient should be 
instructed to do it with proper antiseptic precautions, and he should be 
provided with coude gum-silk catheters of various sizes. All such 
patients should take hexamethylenamine (from 15 to 40 grains daily 
-gm. 1 to 2.6) to prevent urinary infection. The medical man, how- 
ever, is not justified in allowing his patient to adopt a catheter life 
unless the patient refuses operative treatment. 
Cancer of the Prostate.-Recent statistics have shown that this 
disease is far more common than previously supposed. In five years 
in the writer's private practice there were about 250 cases of benign 
prostatic hypertrophy and 68 cases of carcinoma of the prostate-the 
proportion between cancer and hypertrophy wras therefore 1 to 4. The 
rectal findings in carcinoma are usually so different from those of hyper- 
trophy that there is no difficuly in diagnosis. In half of the cases 
cancer is not associated with hypertrophy of the prostate. The prostate 
is often much larger than normal, but it may not have any of the large 
rounded adenomatous lobes found in hypertrophy, and there is usually 
no intravesical outgrowth of lateral or median lobes unless there be a 
coexistent hypertrophy. The cancer begins most often beneath the 
urethra, and from here grows along the ejaculatory ducts, finally involving 
the space between the seminal vesicles beneath the trigone, from which 
it may in some cases invade the bladder. Slight elevation of the median 
portion of the prostate is not infrequently present, but rarely in the 
shape of a rounded intravesical lobe, as remarked above. In about 
50 per cent, of the cases adenomatous hypertrophy of the lateral lobes, 
which may project into the bladder, is present, with a layer of carcinoma 
behind it, and just beneath the capsule of the prostate. The so-called 
malignant degeneration in previously benign prostates occurs very 
seldom, in the writer's opinion, and one should almost always be able 
to recognize carcinoma either by examination or at operation before 
the prostate has been removed. 
The symptoms of cancer of the prostate are unfortunately very similar 
to those of hypertrophy. In a study of 87 cases seen by the writer, 50 
per cent, occurred during the seventh decade, and only one case before 
the age of fifty. The first symptoms were usually frequency of urination, 
sometimes associated with difficulty and occasionally burning in the 
urethra. In 13 cases the first symptom was pain, located in the penis 
in 5, in the bladder in 4, in the thigh in 4, in the testicle and groin in 3, 
in the hip in 3, in the pubes twice, rectum once, legs once, and back twice. 
The pain was usually slight, but in some cases severe, and in some the 
diagnosis of rheumatism, neuralgia, sciatica, and lumbago had been 
made. Hematuria was the symptom at onset in only 4 cases. In one 
case the only symptom was swelling of one leg. The frequency and 
difficulty of urination are similar to that seen in prostatic hypertrophy. 
Retention of urine with a catheter life not infrequently comes on. GEN ITO-URI NARY DIAGNOSIS 
1039 
Hematuria is no more marked than in hypertrophy, but, as a rule, pain 
is a much more prominent symptom, especially in the later stages. 
The diagnosis of carcinoma of the prostate is easy in the later stages, 
when the large stony mass of induration, involving the prostate, seminal 
vesicles, and intervesicular region, is present. When, however, the 
disease is still confined to the limits of the prostatic capsule, diagnosis 
is much more difficult. Examination of the writer's patients showed 
that cancer was almost always associated with a stony induration of 
part or all of the prostate. On cystoscopic examination there were 
generally no intravesical lobes, except when hypertrophy existed, and 
when the suburethral portion of the prostate was examined with the 
finger, while the cystoscope was still in the urethra, it was almost invari- 
ably found to be more thickened and indurated in carcinoma than in 
hypertrophy. A markedly indurated prostate in a man over fifty years 
of age should always be viewed with suspicion and, unless carcinoma can 
be excluded, should be subjected to an early exploratory prostatectomy. 
When the posterior surface of the prostate is exposed through the peri- 
neum it is usually possible, by palpation and inspection, to recognize 
carcinoma. In some cases, however, it has been necessary to make an 
incision into the prostatic lobes and excise a piece of tissue for frozen 
sections and microscopic examination. This procedure can be carried 
out in ten minutes, and if the disease is benign the ordinary enucleating 
prostatectomy can be carried out; but if malignant and no high infiltra- 
tion is to be felt, a radical excision should be adopted. 
A study of the pathology showed that in order to obtain radical cures 
it would be necessary to excise not only the prostate with its capsule 
and urethra but also the seminal vesicles and lower portion of the 
vesical trigone (the defect is easily closed by anastomosing the bladder 
with the membranous urethra). This operation the writer carried out 
in 9 patients. The results have been very gratifying and the prospects 
of a permanent cure are excellent in 6 patients, 2 of whom have lived 
over five years apparently without recurrence. The treatment of 
advanced cases may be divided into three classes: 
1. Those in whom urination is not extremely frequent or painful. 
Here a let-alone policy is usually advisable. The patient should be 
told not to let the bladder become overdistended. 
2. Those in whom urination is frequent and the amount of residual 
urine is large. In such cases the use of a catheter often gives great 
relief and removes the danger of renal complications from back pressure. 
A straight rubber Nelaton catheter (the ordinary red rubber catheter) 
is usually the best to employ, and several sizes should be at hand; but 
the largest that can be comfortably passed should be used so as to keep 
the posterior urethra somewhat dilated. In most cases the coude prostatic 
gum catheter does not pass easily-the beak catches in the prostatic 
urethra, which is usually strictured and not merely compressed, as in 
hypertrophy. A silver catheter should be employed only when others 
fail, and then with great care. 
3. Those in whom catheterization is difficult or painful. In these 
cases operative relief is generally necessary, and suprapubic drainage 1040 
DISEASES OF THE URINARY SYSTEM 
may be employed. This necessitates the wearing of some form of 
apparatus. In some cases the patient gets along fairly well. 
The Bottini electro-cautery operation may be used, and in some cases 
the results have been brilliant and permanent, the patient being able 
to void urine with fair comfort until the end. 
A conservative partial perineal prostatectomy may also be done, 
the object being to remove the obstructive pressure of the lateral and 
median portions of the prostate. The writer has employed this operation 
in more than 60 cases, with excellent results. Several patients have 
lived three years, and had no return of the obstruction to urination. 
In about 70 per cent, of the cases the functional results have been as 
good as are obtained in benign hypertrophy of the prostate, urination 
being practically normal, and continuing so as long as the patient lives. 
I now carry out a conservative perineal prostatectomy instead of sub- 
jecting these patients to a catheter life. INDEX 
A 
Abdomen in acute enteritis, 330 
peritonitis, 678, 680 
in ascites, 662 
in cholera nostras, 332 
in chronic enteritis, 335 
perihepatitis, 491 
peritonitis, 719 
in cirrhosis of liver, 522 
of stomach, 277 
in mesenteric embolism, 436 
thrombosis, 436 
in mucous colitis, 439 
in splanchnoptosis, 753 
in subphrenic pyopneumothorax, 712 
in tuberculosis of peritoneum, 724 
Abdominal aorta, aneurism of, diagnosis 
of, from carcinoma of stomach, 219 
distension in appendicitis, 371 
muscles, constipation and, 312 
operations, acute dilatation of stom- 
ach and, 249 
organs, anatomy of, 747 
embryology of, 747 
viscera, correlation of, through vagus 
and sympathetic, 35 
wall, perforation of, in gastric ulcer, 
187 
Abscess of Fallopian tubes, subphrenic 
abscess and, 701 
hepatppulmonary, 503 
of kidney, 937 
of liver, 496 
of mesentery, .696 
of omentum, 696 
of pancreas in calculus of pancreas, 
635 
paranephric, 970 
periappendicular, 364, 370 
pericolic, 697 
perigastric, 696 
perinephric, 970 
peritoneal, residual, 698 
retroperitoneal, 698 
of spleen, subphrenic abscess and, 700 
subphrenic, 699 
Achylia in chronic gastritis, 242 
gastrica, 29, 153 
course of, 155 
diagnosis of, 155 
from chronic gastritis, 244 
diarrhoea in, 155, 324 
etiology of, 153 
gastric contents in, 155 
vol. in-66 
Achylia gastrica, neurasthenia and, 153 
pain in, 154 
pathology of, 154 
prognosis of, 155 
symptoms of, 154 
treatment of, 156 
vomiting in, 154 
Acetic acid in carcinoma of stomach, 211 
Aceto-acetic acid in urine, 827 
Acetone bodies in urine, 826 
Acholic stools, 294 
Achroocytosis, 73 
Acidity, gastric, in cholelithiasis, 576 
I in duodenal ulcer, 192, 346 
I in gastric ulcer, 181 
Acne o^ mouth, 54 
pancreatica, 641- 
Acori 37156 
diagnosis of, 157* 
from bulimia, 133 
etiology of, 157" 
symptoms of, 157" 
treatment of, 157" 
Actinomyces, kidney infections and, 1)52 
Actinomycosis of appendix, 386 
of liver, 541 
of mouth, 59 
of oesophagus, 86 
Acute yellow atrophy of liver, 472 
Addison's disease, diagnosis of, from acute 
peritonitis, 689 
Adenitis in carcinoma of stomach, 208 
Adenoma of intestines, 433 
of kidney, 1003 
diagnosis of, from hyperneph- 
roma, 1000 
malignant papillary cyst, 1002 
of pancreas, 649 
Adhesions, peritoneal, intestinal obstruc- 
tion from, 407 
Adhesive tuberculosis of peritoneum, 724 
Aglossia; 60 / 
Agusia, 4&-* A" 
Albuminuria, 794,/ 
in acute nephritis, 862 
in appendicitis, 371 
in ascites, 664 
in chronic parenchymatous nephritis, 
882 
circulatory disturbances and, 795 
in cirrhosis of liver, 526 
cyclic, diagnosis of, from acute 
nephritis, 870 
diagnosis of, from chronic interstitial 
nephritis, 916 
1041 1042 
INDEX 
Albuminuria, febrile, 867 
diagnosis of, from acute nephritis, 
870 
of fevers, 795 
functional, 795 
jaundice and, 796 
kidney and, 774 
lesions and, 796 
of pregnancy and, 868 
in nephroptosis, 756 
physiological, 795 
proteins in, 794, 818 
in pyelonephritis, 958 
in tuberculosis of kidney, 982 
Albuminuric retinitis, 911 
Albumoses in Zarcinoma of stomach, 207 
Albumosurituf820 
Alcoholism/ticute hepatitis and, 494 
nephritis and, 866 
yellow atrophy of liver and, 473 
biliary cirrhosis of liver and, 536 
carcinoma of stomach and, 201 
chronic interstitial nephritis and, 891 
-pancreatitis and, 627 
parenchymatous nephritis and, 
880 
peritonitis and, 717 
cirrhosis of liver and, 508 
fatty liver and, 467 
tuberculosis of peritoneum and, 721 
Alimentary tract in uremia, 837 
Alkaptonuria, 817 
Amaurosis in acute nephritis, 865 
in chronic interstitial nephritis, 910 
in anemia, 836 
Amoeba in carcinoma of stomach, 213 
Ampulla of Vatey^^carcinoma of, 594 
^dSSgnosis of, 59X 
pathology of, 59a 
symptoms of, 59/ 
-treatment^ of^^gS 
Amyloid casts^799 " a 
degeneration, intestinal hemorrhage 
and, 307 
of liver, 469 
disease of intestines, 392 
diagnosis of, from tuberculosis, 
389 
kidney, 933 
diagnosis of, from chronic inter- 
titial nephritis, 916 
parenchymatous neph- 
ritis, 885 
liver, ascites and, 658 
diagnosis of, from fatty liver, 468 
tumors of tongpe, 66 
Amylopsin, 289 
Anacidity of stoma< h, 153. See Achylia 
gastrica. 
Anemia in amyloicH kidney, 935 
in carcinoma of intestines, 430 
of stomach, 208 
gastric ulcer and, 171, 176 
intestinal hemorrhage and, 307 
of kidney, 787 
infections and, 952 
pernicious, mouth in, 55 
Anemia, pernicious, pigmentation of liver 
and, 471 
splenic, diagnosis of, from cirrhosis of 
liver, 528 
in tuberculosis of kidney, 985 
Aneurism of abdominal aorta, diagnosis 
of, from carcinoma of stomach, 219 
of aorta, diagnosis of, from cyst of 
pancreas, 647 
of hepatic artery, 458 
miliary, hematemesis from, 283 
ruptured, diagnosis of, from necrosis 
of pancreas, 620 
Angina, Ludwig's, 75 
Angioma of lips, 45 
of liver, 546 
of peritoneum, 733 
Angioneurotic oedema of mouth, 53 
Anomalies of biliary ducts, 547 
of gall-bladder, 547 
of kidney, 785 
of tongue, 60 
Anorexia in carcinoma of stomach, 205 
in chronic gastritis, 241 
nervous, 157 
appetite in, 158 
diagnosis of, 158 
dyspepsia and, 165 
etiology of, 157 
inanition in, 158 
symptoms of, 158 
treatment of, 158 
Anthracosis, hepatic, 470 
Antiperistalsis of intestines, 287, 288 
Anuria, 841 
in acute nephritis, 861 
diagnosis of, from chronic interstitial 
nephritis, 919 
Aorta, aneurism of, diagnosis of, from 
cyst of pancreas, 647 
Aphthae, Bednar's, 52 
Aphthous stomatitis, 46 
Apoplexy, pancreatic, 610 
Appendicitis, 355 
abdominal distension in, 371 
abscess from, 364, 370, 377 
of liver and, 497 
adhesions from, 365 
albuminuria in, 371 
ascaris lumbricoides in, 360 
bacillus coli communis in, 361 
capsulatus aerogenes in, 361 
lactis aerogenes in, 361 
pyocyaneus in, 361 
bacteriology of, 361 
catarrhal, 372 
chills in, 369 
cholelithiasis and, 571 
chronic, 365, 375 
peritonitis and, 714 
relapsing, 375 
treatment of, 385 
constipation in, 368 
contents of appendix in, 363 
cystitis in, 371 
definition of, 355 
diagnosis of, 376 INDEX 
1043 
Appendicitis, diagnosis of character and 
stage of, 376 
differential, 377 
from acute colitis, 378 
enteritis, 378 
gastritis, 377 
peritonitis, 381 
pyelitis, 380 
from biliary colic, 380 
from cholecystitis, 379, 567 
from cholelithiasis, 380 
from cholera nostras, 332 
from duodenal ulcer, 347 
from intestinal colic, 378 
obstruction, 379 
from malarial fever, 379 
from movable kidney, 380 
from nephrolithiasis, 380 
from nervous conditions, 381 
from oophoritis, 381 
from ovarian neuralgia, 381 
from pancreatitis, 379 
from pneumonia, 379 
from renal colic, 380 
from rupture of duodenal ulcer, 
379 
of gastric ulcer, 379 
from salpingitis, 381 
from typhoid fever, 378 
diarrhoea in, 368 
digestive disturbances in, 359 
etiology of, 358 
structure and, 359 
fecal concretions in, 360 
fever in, 369 
foreign bodies in, 360 
gangrene in, 363 
gangrenous, 372 
heredity in, 359 
hyperacidity and, 114 
hyperalgesia in, 367 
involvement of whole appendix in, 
374 
kidney infections and, 952 
leukocytosis in, 369 
lymphoid tissue and, 361 
McBurney's point in, 367 
mild, 373 
nationality in, 359 
nausea in, 368 
nephroptosis and, 757 
occupation in, 359 
oxyuris vermicularis in, 360 
pain in, 366 
parasites and, 360 
pathology of, 361 
peritonitis in, 364, 372, 374 
prognosis of, 381 
pulse in, 369 
rigidity in, 368 
septicemia in, 372 
sex in, 359 
signs of, 370 
simple, 372 
streptococcus pyogenes in, 361 
subphrenic abscess and, 700 
surrounding structures in, 374 
Appendicitis, symptoms of, 366 
infection in, 368 
reflex, 368 
vesical, 371 
treatment of, 383 • 
diet in, 384 
medical, 383 
trichiurus trichiura in, 360 
tumor in, 370 
urine in, 371 
varieties of, 372 
vomiting in, 368 
Appendicular abscess, subphrenic pyo- 
pneumothorax and, 711 
colic, 373 
Appendix, actinomycosis of, 386 
anatomy of, 356 
carcinoma of, 386 
circulation of, 358 
coats of, 357 
contents of, 363 
cystic distension of, 386 
diseases of, acute peritonitis and, 672 
gangrene of, 363 
inflammation of, 355. See Appendi- 
citis. 
mesentery of, anatomy of, 357 
mucocele of, 386 
myoma of, 386 
myxoma of, 386 
necrosis of, 363 
nerve supply of, 358 
obliteration of, 366 
palpation of, 371 
polyps of, 386 
sarcoma of, 387 
tuberculosis of, 385 
tumors of, 386 
Appetite in chronic nephritis, 904 
in constipation, 315 
in duodenal ulcer, 346 
in hyperacidity, 116 
in nervous anorexia, 158 
Aptyalism, 68 
Arterial spasm, gastric ulcer and, 171 
Arteries in chronic nephritis, 898, 903 
renal, anomalies of, 786 
Arteriosclerosis, diagnosis of, from chronic 
interstitial nephritis, 915 
interstitial nephritis and, 893 
of intestines, 437 
peritonitis and, 716 
Arthracotic cirrhosis of liver, 531 
Ascaris lumbricoides, appendicitis and, 
360 
Ascites, 657 
abdomen in, 662 
in acute perihepatitis, 487 
albuminuria in, 664 
amyloid liver and, 658 
backward pressure and, 657 
bacteriology of, 660 
in carcinoma of gall-bladder, 596 
of liver, 542 
cells in, 660 
in chronic perihepatitis, 491 
peritonitis 658, 720 1044 
INDEX 
Ascites, chyliform, 661 
chylous, 660 
in cirrhosis of liver, 523 
of stomach, 278 
in congestion of liver, 484 
constipation in, 663 
in cyst of pancreas, 645 
diagnosis of, 664 
as to cause, 665 
from intestinal obstruction, 665 
from ovarian cyst, 664 
varieties of, 528 
dyspepsia in, 663 
etiology of, 657 
exudates in, 659 
fatty, 661 
in hypernephroma, 997 
lactescent, 662 
milky, 662 
non-fatty, 662 
palpation in, 663 
pathology of, 659 
percussion in, 663 
peritonitis and, 659 
prognosis of, 666 
renal dropsy and, 659 
results of, 663 
signs of, 662 
syphilis of liver and, 658 
in thrombosis of portal vein, 462, 659 
transudates in, 659 
treatment of, 667 
diuretics in, 668 
operative, 668 
paracentesis in, 667 
purgation in, 668 
in tuberculosis of peritoneum, 725 
Ascitic fluid, character of, 659, 665 
Asepsis in genito-urinary diagnosis, 1029 
Asiatic cholera, acute nephritis in, 867 
Atonic constipation, 313 
Atony, gastro-intestinal, hyperacidity and, 
114 
of stomach, 160. See Stomach, atony 
of. 
diagnosis of, from hyperacidity, 
117 
Atresia of intestine, diagnosis of, from 
hypertrophic stenosis of pylorus, 271 
Atrophy of liver, 465 
acute yellow, 472 
of mucous membrane, diagnosis of, 
from carcinoma of stomach, 217 
of salivary gland, 74 
of tongue, 66 
Auto-inoculation in carcinoma of stomach, 
201 
Automatic mechanism in intestinal pro- 
cesses, 291 
Autonomic system, 24, 35, 106 
Azotorrhoea in calculus of pancreas, 635 
in disease of pancreas, 602 
B 
Bacillus aerogencs capsulatus in acute 
peritonitis, 676 
Bacillus aerogenes in intestines, 296 
bifidus communis in intestines, 296 
Boas-Oppler, in carcinoma of stomach, 
212 
capsulatus aerogenes in appendicitis, 
361. 
coli in acute peritonitis, 674 
in appendicitis, 361 
in chronic peritonitis, 717 
in diarrhoea, 325 
in fat necrosis, 607 
in intestines, 296 
in jaundice, 448 
diphtheria in mouth, 40 
enteritidis in diarrhoea, 325 
fusiformis in mouth, 41 
gangrenae pulpae in mouth, 40 
lac is aerogenes in appendicitis, 361 
in intestines, 296 
leprae in mouth, 41 
maximus in mouth, 40 
necrodentalis in mouth, 40 
proteus in jaundice, 448 
pseudodiphtheria in mouth, 40 
putrificus in intestines, 296 
pyocyaneus in acute peritonitis, 675 
in appendicitis, 361 
in diarrhoea, 325 
in mouth, 40 
tuberculosis in mouth, 41 
typhosus in peritonitis, 675, 717 
Bacteria in acute enteritis, 329 
in constipation, 312 
in intestines, distribution of, 295 
necrosis of pancreas and, 612 
suppurative cholangeitis and, 556 
in urethra, 943 
Bacteriology of acute cholecystitis, 561 
peritonitis, 674 
of appendicitis, 361 
of ascites, 660 
of biliary infections, 549 
of cholelithiasis, 570 
of cystitis, 944 
of diarrhoea, 324 
of gangrenous stomatitis, 49 
of infections, of kidney, 947, 950, 951 
of intestinal tract, 295 
of mouth, 39 
of pyelitis, 947, 950 
of pyelonephritis, 947, 950 
of subphrenic abscess, 706 
of suppurative pancreatitis, 623 
of tuberculosis of peritoneum, 721 
of ulcerative stomatitis, 48 
of urethritis, 943, 946 
of urine, 943 
Bacterium gingivitidis in mouth, 40, 55 
Bacteriuria, 948 
Baelz's disease, 45 
Bands from chronic peritonitis, 715 
Banti's disease, diagnosis of, from cirrhosis 
of liver, 528 
Bednar's aphthae, 52 
Belt test in splanchnoptosis, 753 
Bence-Jones proteins in urine, 819 
Bile, 289 INDEX 
1045 
Bilharzia haematobia, portal cirrhosis and, 
510 
kidney infections and, 952 
Bihary calculi, diagnosis of, from calculi 
of pancreas, 636 
cirrhosis of liver, 535 
diagnosis of, from acute yellow 
atrophy of liver, 477 
from carcinoma of liver, 545 
from portal cirrhosis, 527 
colic, diagnosis of, from appendicitis, 
380 
from necrosis of pancreas, 
620 
from obstruction of intes- 
tines, 401 
ducts, abscess of Ever and, 498 
anomalies of, 547 
carcinoma of, 593 
diagnosis of, 598 
etiology of, 594 
pathology of, 594 
primary, 593 
prognosis of, 598 
treatment of, 598 
common, obstruction of, 581 
congenital obliteration of, 547 
extrahepatic, carcinoma of, 594 
fistulae in cholelithiasis, 584 
infection, treatment of, 588 
intermittent fever, diagnosis of, from 
abscess of liver, 504 
tract, digestion and, 34 
infections of, 548 
bacteriology of, 549 
colon bacillus and, 551 
through common bile duct, 
550 
lymphatic circulation, 
551 
portal circulation, 550 
systemic circulation, 551 
wall of gall-bladder, 551 
Bilirubin in liver, 470 
Biliverdin in liver, 470 
Black tongue, 61 
Bladder, paralysis of, kidney infections 
and, 952 
in renal calculi, 1021 
rupture of periappendicular abscess 
into, 365 
in tuberculosis of kidney, 981 
Blindness in uremia, 836 
Blood in abscess of liver, 502 
in acute nephritis, 864 
peritonitis, 683 
yellow atrophy of liver, 476 
in carcinoma of stomach, 204 
in cirrhosis of liver, 525, 539 
cultures in acute peritonitis, 684 
in jaundice, 452 
"occult," tests for, 180 
pressure, in nephritis, 903, 904, 921, 
927 
renal function and, 770 
in tuberculosis of peritoneum, 726 
in uremia, 831 
Blood in urine, 802. See Hematuria. 
Bloodvessels in chronic interstitial neph- 
ritis, 896 
parenchymatous nephritis, 884 
in jaundice, 453 
Boas-Oppler bacillus in carcinoma of 
stomach, 212 
Bougies in genito-urinary diagnosis, 1027 
Bowels, congestion of, constipation and, 
312 
incarceration of, intestinal obstruc- 
tion from, 406 
infarction of, intestinal hemorrhage 
and, 307 
strangulation of, intestinal hemor- 
rhage and, 307 
ulceration of, 343 
Bowman's capsule in acute nephritis, 858 
/?-oxybutyric acid in urine, 826 
Bradycardia in jaundice, 453 
Brain, tumor of, diagnosis of, from chronic 
interstitial nephritis, 918 
Breath in chronic interstitial nephritis, 
904 
offensive, 42 
in abscess of lung, 42 
in atony of stomach, 42 
in carcinoma of larynx, 42 
in diabetes, 42 
in dilatation of stomach, 42 
in diverticulum of oesophagus, 
42, 94 
in gangrene of lung, 42 
in hemoptysis, 42 
in septicemia, 42 
treatment of, 42 
in tuberculosis, 42 
in uremia, 42 
Bright's disease, 778, 845. See Nephritis. 
Bronchitis in acute nephritis, 870 
in chronic interstitial nephritis, 905 
Bronzed diabetes, 529 
Budd's non-alcoholic cirrhosis of liver, 509 
Bulimia, 132 
diagnosis of, 133 
from acoria, 133, 157 
from polyphagia, 133 
etiology of, 133 
prognosis of, 133 
symptoms of, 133 
treatment of, 133 
Burns, nephritis and, 853 
Butyric acid in carcinoma of stomach, 211 
C 
Cachectic splanchnoptosis, 754 
Cachexia in tuberculosis of kidney, 985 
Calcium carbonate calculus, 1009 
origin of, 1015 
oxalate calculus, 1008, 1025 
phosphate calculus, origin of, 1015 
Calculus, biliary, composition of, 573 
kidney infections and, 952 
of pancreas, 632 
renal, 1007 1046 
INDEX 
Calculus, renal, age and, 1011 
anuria in, 1020 
bilaterality of, 1010 
bladder in, 1021 
calcium carbonate, 1009 
oxalate, 1008, 1025 
character of, 1008 
classification of, 1007 
color of, 1010 
crystallization of, 1014 
cystin, 1009, 1015 
definition of, 1007 
diagnosis of, 1021 
differential, 1022 
from hypernephroma, 999 
from phleboliths, 1022 
from prostatitis, 1022 
from tuberculosis of kidney, 
989 
x-rays in, 1022 
diet and, 1012, 1024 
disintegration of, 1011 
distribution of, 1012 
etiology of, 1011 
form of, 1010 
• formation of, 1017 
heredity and, 1011 
hydronephrosis in, 1018 
inorganic, matrix of, 1016 
jackstone, 1009 
kidney in, 1017 
location of, 1018 
mulberry, 1009 
nucleus of, 1009 
number of, 1010, 1018 
occupation and, 1011 
organic, matrix of, 1015 
oxalate, diet in, 1025 
pain in, 1019 
pathology of, 1017 
pebble, 1009 
prevention of, 1024 
previous disease and, 1012 
primary, composition of, 1008 
pyonephrosis and, 1018 
renal colic in, 1019 
sex and, 1011 
size of, 1010 
staghorn, 1009 
symptoms of, 1019 
treatment of, 1023 
in ureter, 1017, 1021 
uric acid, diet in, 1024 
urinary reaction and, 1013 
xanthin, 1009, 1014 
salivary, 71 
tartar, 71 
tuberculosis of kidney and, 978 
ureteral, 1007 
Cancrum oris, 49 
Carbohydrates, absorption of, in intestines, 
290 
Carcinoma of ampulla of Vater, 594 
of appendix, 386 
of biliary ducts, 593 
of choledochopancreatic duct, 594 
of colon, 429 
Carcinoma of duodenum, 427 
diagnosis of, from carcinoma of 
stomach, 217 
of gall-bladder, 593 
of ileum, 428 
of intestines, 424 
of jejunum, 428 
of kidney, 1001 
diagnosis of, from hyperneph- 
roma, 1000 
from tuberculosis, 989 
of lips, 45 
of liver, 541 
ascites and, 658 
diagnosis of, from carcinoma of 
gall-bladder, 598 
of stomach, 218 
of mouth, 52 
of oesophagus, 98 
diagnosis of, from hematemesis, 
282 
of pancreas, 648 
of prostate, 1038 
of stomach, 199 
diagnosis of, from achylia gas- 
trica, 155 
from chronic gastritis, 244 
from cirrhosis of liver, 528 
from gastralgia, 136 
from gastric ulcer, 184 
from nervous dyspepsia, 166 
hematemesis from, 284 
of tongue, 66 
Cardiac failure in uremia, 839 
stenosis, gastric ulcer and, 189 
Cardioptosis, incidence of, 752 
Cardiospasm, 147 
acute dilatation and, 251 
diagnosis of, 148 
dysphagia in, 148 
etiology of, 147 
hysteria and, 147 
neurasthenia and, 147 
pain in, 148 
symptoms of, 147 
treatment of, 149 
Casts in chronic parenchymatous neph- 
ritis, 882 
kidney and, 774 
of pregnancy and, 868 
renal, 798 
Catarrhal appendicitis, 372 
cholangeitis, acute, 552 
, chronic, 559 
cholecystitis, 562 
jaundice, 448, 552 
pyelitis, 953 
stomatitis, 45 
ulcers, 351 
Catheters in genito-urinary diagnosis, 1028 
Cecum, rupture of periappendicular ab- 
scess into, 365 
Cerebrospinal vomiting, 143 
Cheek, actinomycosis of, 59 
Chemical process in intestines, 288 
Cheyne-Stokes respiration in chronic 
interstitial nephritis, 905 INDEX 
1047 
Chills in abscess of liver, 501 
in acute pyelitis, 961 
in appendicitis, 369 
Chloroform poisoning, acute yellow 
atrophy of liver and, 473 
Chlorosis, gastric ulcer and, 171 
hyperacidity and, 114 
Cholangeitis, catarrhal, acute, 552 
diagnosis of, 554 
etiology of, 552 
feces in, 553 
gall-bladder in, 554 
jaundice in, 553 
liver in, 554 
pathology of, 552 
prognosis of, 555 
pruritus in, 553 
pulse in, 553 
skin in, 553 
spleen in, 554 
symptoms of, 553 
treatment of, 555 
urine in, 553 
chronic, 559 
diagnosis of, 560 
etiology of, 559 
gall-stones and, 559 
jaundice in, 560 
pathology of, 560 
prognosis of, 560 
symptoms of, 560 
treatment of, 560 
cholelithiasis and, 570, 574, 583 
suppurative, 556 
bacteria and, 556 
diagnosis of, 558 
from malarial fevers, 559 
from suppurative pylephle- 
bitis, 558 
etiology of, 556 
gall-bladder in, 557 
jaundice in, 557 
leukocytosis in, 558 
liver in, 557 
onset of, 557 
pathology of, 557 
prognosis of, 559 
symptoms of, 557 
treatment' of, 559 
treatment of, 588 
Cholecystitis, abscess of liver and, 497 
acute, 561 
bacteriology of, 561 
catarrhal, 562 
diagnosis of, 567 
from appendicitis, 567 
etiology of, 561 
fever in, 564 
gangrenous, 562 
jaundice in, 565 
leukocytosis in, 565 
membranous, 563 
nausea in, 564 
pain in, 564 
pathology of, 562 
perforation in, 566 
phlegmonous, 563 
Cholecystitis, acute, prognosis of, 567 
pulse in, 565 
results of, 565 
suppurative, 563 
symptoms of, 564 
treatment of, 568 
typhoid bacillus in, 561 
vomiting in, 564 
chronic, 568 
diagnosis of, 569 
from gall-stones, 569 
etiology of, 568 
gall-stones and, 568 
pathology of, 568 
peritonitis and, 714 
prognosis of, 569 
symptoms of, 569 
treatment of, 569 
ulcerative, 563 
diagnosis of, from appendicitis, 379 
from carcinoma of gall-bladder, 
597 
from cyst of pancreas, 646 
Choledochopancreatic duct, carcinoma of, 
594 
pathology of, 595 
symptoms of, 597 
Cholelithiasis, 569. See also Gall-stones. 
acidity in, 576 
appendicitis and, 571 
associated lesions of, 574 
atony of stomach and, 161 
bacteriology of, 570 
biliary fistulas in, 584 
carcinoma of gall-bladder and, 593 
cholangeitis and, 570, 574, 583 
common duct in, 581 
complications of, 582 
crepitus in, 580 
cystic duct in, 580 
diagnosis of, 585 
from abscess of fiver, 504 
from aneurism of hepatic artery, 
459 
from appendicitis, 380 
from carcinoma of gall-bladder, 
597 
of pancreas, 653 
from duodenal ulcer, 586 
from gastric ulcer, 586 
from hyperacidity, 117 
x-rays in, 585 
diet and, 571 
etiology of, 569 
fever in, 580 
gall-bladder in, 579 
hyperacidity and, 114 
indigestion in, 575 
interstitial pancreatitis and, 627 
intestinal obstruction in, 584 
. aundice in, 579 
metabolism and, 571 
necrosis of pancreas and, 613 
pain in, 576 
pathogenesis of, 574 
pathology of, 572 
pericholecystic adhesions and, 583 1048 
INDEX 
Cholelithiasis, pregnancy and, 571 
prognosis of, 586 
sequelae of, 582 
symptoms of, 575 
treatment of, 587 
diet in, 590 
prophylactic, 587 
surgical, 591 
vomiting in, 576 
Cholemia, 454 
Choleperitoneum, 670 
Cholera infantum, 341 
prognosis of, 342 
symptoms of, 341 
treatment of, 343 
morbus, 331. See Cholera nostras. 
nostras, 331 
abdomen in, 332 
diagnosis of, 332 
from appendicitis, 332 
diarrhoea in, 332 
etiology of, 331 
fever in, 332 
onset of, 331 
pain in, 331 
pathology of, 331 
prognosis of, 333 
symptoms of, 331 
treatment of, 334 
vomiting in, 331 
Choluria, 828 
Chorea, nephritis and, 850 
Chyliform ascites, 661 
Chylous ascites, 660 - 
Chyluria, 805 
Cicatricial stenosis of pylorus, 262 
Circulation, nephritis and, 780 
Circulatory disturbances of kidney, 787 
albuminuria and, 795 
system, gastric ulcer and, 171 
in uremia, 838 
Cirrhosis, biliary, diagnosis of, from acute 
yellow atrophy of liver, 
477 
from carcinoma of liver, 545 
from portal cirrhosis, 527 
of liver, 505. See Liver, cirrhosis of. 
arthracotic, 531 
cardiac, 483 
diagnosis of, from fatty liver, 468 
from passive congestion, 485 
from perihepatitis, 493 
from tuberculosis of peri- 
toneum, 727 
malarial, 530 
portal, diagnosis of, from biliary cir- 
rhosis, 539 
from carcinoma of liver, 545 
of stomach, 273 
Cladothrix buccalis in mouth, 40 
Colic, appendicular, 373 
biliary, 576 
diagnosis of, from appendicitis, 
380 
from necrosis of pancreas, 
620 
in calculus of pancreas, 634 
Colic, gall-stone, 576 
intestinal, 303 
diagnosis of, from appendicitis, 
378 
from gastralgia, 136 
lead, 306 
mucous, 437 
renal calculus and, 1019 
diagnosis of, from appendicitis, 
380 
from gastralgia, 136 
Colitis, 336 
diagnosis of, 337 
from appendicitis, 378 
diarrhoea in, 336 
etiology of, 336 
fever in, 337 
hemorrhage in, 336 
membranous, 437 
mucous, 33, 437 
abdomen in, 439 
•complications of, 440 
constipation in, 439 
definition of, 437 
in descent of intestines, 757 
diagnosis of, 440 
diarrhoea in, 439 
etiology of, 438 
intestinal sand in, 440 
neurasthenia in, 439 
pathology of, 438 
prognosis of, 440 
symptoms of, 438 
treatment of, 440 
pain in, 336 
pathology of, 336 
prognosis of, 337 
simple, 336 
symptoms of, 336 
treatment of, 337 
Collapse in acute peritonitis, 678 
in diarrhoea, 326 
in hemoperitoneum, 669 
in obstruction of intestines, 400 
in suppurative pancreatitis, 624 
Colon, carcinoma of, 429 
dilatation of, congenital, 321 
diagnosis of, from dilatation of 
stomach, 261 
idiopathic, 320 
diseases of, acute peritonitis and, 673 
displaced, incidence of, 752 
distension of, kidney infections and, 
952 
transverse, perforation of, in necrosis 
of pancreas, 619 
tumors of, diagnosis of, from carcin- 
oma of stomach, 218 
Colorless stools, 294 
Coma in chronic interstitial nephritis, 909 
diagnosis of, 919 
Compression of intestines, 394 
obstruction from, 408 
Concretions, intestinal, obstruction from, 
404 
Congenital anomalies of liver, 455 
chronic interstitial nephritis, 891 INDEX 
1049 
Congenital cystic kidney, 786 
diverticula of intestines, 421 
hypertrophic stenosis of pylorus, 269 
malformations of oesophagus, 78 
obliteration of biliary ducts, 547 
pylorospasm, 269 
stenosis of intestine, obstruction 
from, 408 
of oesophagus, 96 
Congestion of bowels, constipation and, 
312 
of kidney, diagnosis of, from acute 
nephritis, 870 
from chronic interstitial 
nephritis, 914 
parenchymatous neph- 
ritis, 885 
infections and, 952 
of liver, 478 
diagnosis of, from fatty liver, 468 
Constipation, 309 
abdominal muscles and, 312 
in active congestion of liver, 479 
in acute dilatation of stomach, 252 
enteritis, 330 
hepatitis, 495 
peritonitis, 682 
in appendicitis, 368 
appetite in, 315 
in ascites, 663 
atonic, 313 
in atony of stomach, 161 
bacteria in, 312 
in carcinoma of pancreas, 651 
in chronic enteritis, 334 
interstitial nephritis, 905 
peritonitis, 715, 720 
in cirrhosis of liver, 520 
complications of, 316 
congestion of bowels and, 312 
definition of, 309 
in descent of intestines, 757 
diagnosis of, 316 
diarrhoea in, 315 
dilatation of stomach and, 254, 256 
diseases of stomach and, 311 
dress and, 312 
in duodenal ulcer, 346 
etiology of, 309 
dietetic, 311 
functional, 310 
organic, 313 
fever in, 315 
fluoroscopic findings in, 313 
functional types of, 313 
headache in, 314 
in hepatoptosis, 757 
in hyperacidity, 116 
hypochondriasis in, 314 
idiopathic dilatation of colon and, 321 
in intestinal colic, 305 
kidney infections and, 952 
in mucous colitis, 439 
in necrosis of pancreas, 617 
in nervous dyspepsia, 165 
neurasthenia and, 315 
in obstruction of intestines, 398 
Constipation, pain in, 314 
in paranephritis, 972 
pathology of, 314 
in pericolitis, 355 
in phlegmonous gastritis, 232 
in pylorospasm, 150 
sedentary life and, 313 
skiagraphic findings in, 313 
spastic, 313 
in splanchnoptosis, 753 
in suppurative pancreatitis, 624 
symptoms of, 314 
synonyms of, 309 
treatment of, 317 
diet, 318 
exercise, 317 
medical, 319 
surgical, 320 
in volvulus, 414 
vomiting in, 315 
Constriction of intestines, 394 
Continuous gastromyxorrhcea, 131 
Convulsions in acute nephritis, 865 
in chronic interstitial nephritis, 908 
in uremia, 835 
Corrosive oesophagitis, 81 
Courvoisier's law, 579 
Creatinin, excretion of, 813 
Croupous pyelitis, 954 
Cryoscopy of urine, 792 
Crystallization of renal calculi, 1014 
Crystals in urine, 800 
Cutaneous burns, duodenal ulcer and, 349 
lesions in uremia, 840 
Cyanotic induration of kidney, chronic 
parachymatous nephritis and, 880 
Cyclic albuminuria, diagnosis of, from 
acute nephritis, 870 
Cylindroids in urine, 800 
Cystic distension of appendix, 386 
duct, cholelithiasis and, 580 
obstruction of, 580 
kidney, congenital, 786 
pyelitis, 954 
Cysticercus cellulosae of peritoneum, 736 
Cystin calculus, 1009 
origin of, 1015 
in urine, 817 
Cystinuria, 817 
Cystitis in appendicitis, 371 
bacteriology of, 944 
kidney infections and, 952 
tuberculosis of kidney and, 978 
Cystoscopy, 938 
in hypernephroma, 998 
Cysts of kidney, diagnosis of, from chronic 
interstitial nephritis, 918 
of liver, 547 
of mesentery, diagnosis of, from cyst 
of pancreas, 646 
of mouth, 52 
necrosis of pancreas and, 619 
ovarian, acute peritonitis and, 673 
diagnosis of, from ascites, 664 
from cyst of pancreas, 646 
of peritoneum, 733 
cysticercus cellulosae, 736 1050 
INDEX 
Cysts of peritoneum, dermoid, 739 
hydatid, 733 
mesenteric, 736 
non-parasitic, 733 
omental, 737 
parasitic, 733 
retroperitoneal, 739 
sanguineous, 738 
urachal, 739 
D 
Decubital ulcers, 351 
of oesophagus, 84 
Deforming perihepatitis, 488 
Deformities of spine, acute dilatation of 
stomach and, 251 
Degeneration, parenchymatous, of liver, 
466 
Delirium in uremia, 837 
Dermatoses of mouth, 53 
Dermoid cyst of mouth, 53 
of peritoneum, 739 
Diabetes, breath in, 42 
insipidus, diagnosis of, from chronic 
interstitial nephritis, 918 
in calculus of pancreas, 635 
in carcinoma of pancreas, 650, 
652 
diagnosis of, from chronic inter- 
stitial nephritis, 917 
mellitus in cyst of pancreas, 645 
diseases of pancreas and, 604 
interstitial pancreatitis and, 630 
mouth in, 55 
in necrosis of pancreas, 619 
Diaphragmatic hernia, diagnosis of, from 
subphrenic pyopneumothorax, 713 
Diarrhoea, 322 
in achylia gastrica, 155, 324 
in active congestion of liver, 479 
in acute enteritis, 330 
hepatitis, ' 95 
pyelitis, 961 
yellow atrophy of liver, 475 
in amyloid kidney, 935 
liver, 469 
in appendicitis, 368 
bacillus coli communis in, 325 
enteritidis in, 325 
pyocyaneus in, 325 
bacteriology of, 324 
in carcinoma of pancreas, 651 
iit childhood, 337 
age and, 339 
choleraic, 341 
dyspeptic, 340 
enterocolitis, 340 
diagnosis of, 341 
fever in, 341 
onset in, 340 
pain in, 340 
prognosis of, 341 
stools in, 340 
vomiting in, 340 
environment and, 339 
Diarrhoea in childhood, etiology of, 337 
food and, 337 
pathology of, 339 
season and, 339 
simple, 340 
symptoms of, 340 
treatment of, 342 
in cholera nostras, 332 
in chronic enteritis, 334 
interstitial nephritis, 905 
pyelitis, 961 
in cirrhosis of liver, 520 
in colitis, 336 
mucous, 439 
collapse in, 326 
in constipation, 315 
definition of, 322 
diagnosis of, 326 
in dilatation of colon, 321 
of stomach, 256 
enterocolitis and, 324 
etiology of, 322 
excessive ingestion of fluids and, 322 
food and, 323 
in hyperacidity, 116, 324 
infections and, 324 
in intestinal colic, 305 
hemorrhage, 308 
indigestion, 301, 324 
tuberculosis, 389 
in mesenteric embolism, 435 
thrombosis, 435 
mucous, 437 
nervous influences and, 323 
treatment of, 328 
in obstruction of intestines, 399 
pain in, 326 
in pericolitis, 355 
in phlegmonous gastritis, 232 
in portal thrombosis, 462 
protozoa and, 325 
purgatives and, 323 
renal disease and, 323 
in sprue, 393 
in suppurative pancreatitis, 624 
pylephlebitis, 464 
symptoms of, 325 
tenesmus in, 326 
treatment of, 326 
diet in, 327 
medicinal, 327 
in ulcer of intestines, 352 
in uremia, 838 
in volvulus, 414 
Diet, acute dilatation of stomach and, 251 
gastric ulcer and, 170 
hyperacidity and, 114 
renal calculus and, 1012 
Dietl's crises in nephroptosis, 756, 759 
Digestion, adaptability in, 20 
adhesions and, 36 
biliary tract in, 34 
blood supply and, 32 
functional disturbances of, 21 
structural changes from, 24 
disease ami, 23 
general relations of, 17 INDEX 
1051 
Digestion, individuality in disease of, 18 
infection and, 32 
interrelation of functions in, 19, 30 
intestinal flora and, 37 
motor functions in, 20 
peptic disturbance of, 30 
psychoneuroses and, 37 
splanchnoptosis and, 35 
vicarious action in, 20 
Digestive gastrosuccorrhoea, 128 
Dilatation of colon, diagnosis of, from 
dilatation of stomach, 261 
of hepatic artery, 458 
veins, 459 
idiopathic, 320 
of oesophagus, 90 
idiopathic, 85, 91 
in stenosis of pylorus, 271 
Diphtheria, nephritis and, 849 
Diphtheritic gastritis, 236 
pyelitis, 954 
Diplopia in chronic nephritis, 910 
Distension in intestinal indigestion, 301 
Diverticula of intestines, 420 
of oesophagus, 92 
Diverticulitis, 423 
Diverticulum of Vater, biliary infections 
through, 550 
Dropsy, renal, ascites and, 659 
Drugs, nephritis and, 852 
Duct, choledochopancreatic, carcinoma of, 
594 
Duodenal ulcer, 191, 344 
acidity in, 192, 346 
appetite in, 346 
burns and, 349 
chronic peritonitis and, 714 
complications of, 193, 347 
constipation in, 346 
diagnosis of, 347 
from acute pancreatitis, 348 
from aneurism of hepatic 
artery, 459 
from appendicitis, 348 
from cholelithiasis, 586 
from cirrhosis of liver, 527 
from gall-stones, 348 
from hyperacidity, 117 
from intestinal obstruction, 
348, 401 
etiology of, 344 
hemorrhage in, 192, 347 
hyperacidity in, 346 
intestinal hemorrhage and, 307 
number of, 192 
pain in, 346 
pathology of, 344 
perforation in, 193, 347 
rupture of, diagnosis of, from 
appendicitis, 379 
secondary changes in, 345 
subphrenic abscess and, 701 
pyopneumothorax and, 710 
symptoms of, 192, 345 
tenderness in, 192 
treatment of, 348 
vomiting in, 192, 346 
Duodenitis, necrosis of pancreas and, 612 
Duodenum, carcinoma of, 427 
circumpapillary, 427 
diagnosis of, from carcinoma of 
stomach, 217 
infrapapillary, 428 
suprapapillary, 427 
perforation of, in necrosis of pancreas, 
619 
st eno-is of, 262 
diagnosis of, from hypertrophic 
stenosis of pylorus, 271 
traction on, acute dilatation of' stom- 
ach and, 250 
Dysentery, abscess of liver and, 497 
acute hepatitis and, 494 
nephritis and, 850 
Dyspepsia in ascites, 663 
in biliary cirrhosis of liver, 538 
in descent of intestines, 757 
in gastric ulcer, 176 
nervous, 164 
abdomen in, 165 
anorexia in, 165 
appetite in, 165 
constipation in, 165 
diagnosis of, 165 
from atony of stomach, 162 
from carcinoma of stomach, 
166 
from chronic gastritis, 166 
from dilatation of stomach, 
261 
from ulcer of stomach, 166 
etiology of, 164 
neurasthenia in, 165 
pathology of, 165 
prognosis of, 166 
symptoms of, 165 
treatment of, 166 
Dyspeptic cirrhosis of liver, 509 
Dysphagia in acute oesophagitis, 81 
in carcinoma of oesophagus, 102 
in cardiospasm, 148 
Dyspnoea in acute dilatation of stomach, 
251 
nephritis, 864 
in chronic interstitial nephritis, 905 
in perforation of gastric ulcer, 187 
in uremia, 839 
Dyspragia, intermittent angiosclerotic, 437 
E 
Echinococcus cyst, diagnosis of, from 
cyst of pancreas, 646 
kidney infections and, 952 
Eclampsia, acute yellow atrophy of liver 
and, 473 
in kidney of pregnancy, 869 
Eczema of lips, 45 
of mouth, 54 
Emaciation in pancreatitis, 625 
in tuberculosis of kidney, 985 
Embolic ulcers, 350 
Embolism, gastric ulcer and, 171 1052 
INDEX 
Embolism of hepatic artery, 458 
of mesenteric arteries, 434 
intestinal hemorrhage and, 
307 
of portal vein, 463 
Embryonic tumors of kidney, 1003 
Emphysematous liver, 466 
Empyema, diagnosis of, from subphrenic 
abscess, 708 
of gall-bladder, 563, 566 
of renal pelvis, 937 
subphrenic abscess and, 701 
Encysted tuberculosis of peritoneum, 723 
Endocarditis, mesenteric embolism and, 
435 
Endophlebitis of portal veins, 465 
obliterating, 460 
Enlargement of spleen in cirrhosis of 
liver, 517, 523 
diagnosis of, from carcinoma of 
stomach, 219 
in thrombosis of portal vein, 462 
Enteralgia, 305 
Enteritis, acute, 328 
abdomen in, 330 
bacteria in, 329 
constipation in, 330 
definition of, 328 
diagnosis of, from appendicitis, 
378 
diarrhoea in, 330 
etiology of, 329 
fever in, 331 
jaundice in, 330 
pain in, 330 
pathology of, 329 
prognosis of, 333 
stools in, 330 
symptoms of, 329 
treatment of, 333 
vomiting in, 330 
chronic, 334 
abdomen in, 335 
constipation in, 334 
diagnosis of, 335 
diarrhoea in, 334 
etiology of, 334 
pathology of, 334 
• prognosis of, 335 
symptoms of, 334 
treatment of, 335 
Enterocolitis, diarrhoea and, 324 
Enterokinase, 290 
Enteroptosis, 747. See Splanchnoptosis. 
in atony of stomach, 162 
Enterostenosis, 753 
Enzymes, inverting, 290 
Epinephritis, 970 
Epiploitis, 695 
symptoms of, 695 
treatment of, 696 
Epistaxis in chronic nephritis, 906 
Epithelial casts, 799 
cells in tuberculosis of kidney, 984 
Epithelioma, leukoplakia and, 65 
Erepsin, 290 
Erosins, gastric, hematemesis from, 283 
Eructation, nervous, 141 
Erysipelas of mouth, 54 
nephritis and, 850 
Erythema nodosum, nephritis and, 850 
Eustrongylus gigas, kidney infections and, 
952 
Extraperitoneal subphrenic abscess, 705 
Exudate in ascites, 659 
F 
Facies in acute peritonitis, 679 
Fallopian tubes, abscess of, subphrenic 
abscess and, 701 
Fat necrosis, 606 
bacillus coli in, 607 
clinical significance of, 609 
etiology of, 607 
experimental, 607 
incidence of, 607 
pathology of, 608 
urine in, 609 
Fats, absorption of, in intestines, 290 
Fatty acids, cirrhosis of liver and, 509 
ascites, 661 
casts, 800 
liver, 466 
stools, 294 
Febrile albuminuria, diagnosis of, from 
acute nephritis, 870 
Fecal concretions in appendicitis, 360 
masses, intestinal obstruction from, 
403 
Feces, 292 
in abscess of liver, 502 
acholic, 294 
in carcinoma of intestines, 430 
in catarrhal cholangeitis, 553 
chemical composition of, 293 
color of, 292 
colorless, 294 
consistency of, 292 
in diseases of pancreas, 600, 602 
fatty, 294 
in gangrenous pancreatitis, 618 
inorganic constituents of, 293 
microscopic examination of, 293 
mucus in, 293 
in necrosis of pancreas, 617 
odor of, 292 
quantity of, 292 
reaction of, 293 
in tuberculosis of peritoneum, 726 
Ferments in carcinoma of stomach, 211 
Fever in abscess of liver, 501 
in acute cholecystitis, 564 
enteritis, 331 
hepatitis, 495 
nephritis, 863 
peritonitis, 683 
pyelitis, 961 
yellow atrophy of liver, 475 
in aneurism of hepatic artery, 459 
in appendicitis, 369 
in carcinoma of gall-bladder, 597 
of pancreas, 653 INDEX 
1053 
Fever in carcinoma of stomach, 208 
in cholelithiasis, 580 
in cholera nostras, 332 
in chronic pyelitis, 961 
in cirrhosis of liver, 520, 538 
in constipation, 315 
in gangrenous pancreatitis, 618 
in infections of kidney, 962 
in necrosis of pancreas, 617 
in paranephritis, 972 
in subphrenic pyopneumothorax, 712 
in suppurative pancreatitis, 624 
in tuberculosis of kidney, 985 
of peritoneum, 726 
in ulcer of intestines, 353 
in uremia, 840 
Fibrinous pyelitis, 954 
Fibroma of peritoneum, 731 
of tongue, 66 
Fibromyoma of peritoneum, 730 
Fibrous stenosis of oesophagus, 96 
Filaria, kidney infections and, 952 
Fistuke, biliary, in cholelithiasis, 584 
Flatulence in intestinal indigestion, 301 
Fluoroscopic findings in constipation, 313 
Follicular ulcers, 351 
Foods, absorption of, in intestines, 290 
Foreign bodies in appendicitis, 360 
intestinal obstruction from, 404 
stenosis of pylorus and, 263 
Frenum of tongue, deformities of, 61 
ulcer of, 63 
Fulminating uremia, 842 
Functional disturbances, intestinal colic 
and, 303 
G 
Gall-bladder, anomalies of, 547 
ascites in, 596 
carcinoma of, 593 
diagnosis of, 597 
from carcinoma of liver, 598 
from cholecystitis, 597 
from cholelithiasis, 586, 597 
of liver and, 543 
pain in, 596 
of pancreas and, 652 
treatment of, 598 
in catarrhal cholangeitis, 554 
in cholelithiasis, 579 
in chronic peritonitis, 719 
diseases of, acute peritonitis and, 673 
empyema of, 563, 566 
in suppurative cholangeitis, 557 
tumors of, diagnosis of, from carcin- 
oma of stomach, 218 
wall of, biliary infection through, 551 
Gall-stones, character of, 572 
chronic cholangeitis and, 559 
cholecystitis and, 568 
colic, 576 
Causes of, 578 
diagnosis of, 585 
infection and, 578 
nausea in, 577 
Gall-stone colic, pain in, 576 
treatment of, 589 
vomiting in, 577 
in common duct, 581 
in cystic duct, 580 
diagnosis of, from cholecystitis, 569 
from duodenal ulcer, 347 
from gastralgia, 136 
from gastric ulcer, 184 
discharge of, 588 
in diverticulum of Vater, 582 
intestinal obstruction from, 403 
latency of, 576 
situation of, 573 
solution of, 588 
varieties of, 573 
Ganglionated neuroma of peritoneum, 731 
Gangrene of appendix, 363 
of pancreas, necrosis and, 615 
Gangrenous appendicitis, 372 
cholecystitis, 563 
pyelitis, 954 
stomatitis, 49 
Gaseous distension of intestines, 298 
liver, 466 
Gastralgia, nervous, 135 
diagnosis of, 136 
from gastric ulcer, 184 
etiology of, 135 
in mycotic gastritis, 236 
nausea in, 135 
pain in, 135 
symptoms of, 135 
treatment of, 136 
vomiting in, 135 
Gastralgokenosis, 134 
Gastrectasis, 247. See Stomach, dilata- 
tion of. 
diagnosis of, from atony of stomach, 
162 
Gastric anacidity, 153. See Achylia gas- 
trica. 
analysis in carcinoma of stomach, 
210 
in gastric ulcer, 181 
contents in atony of stomach, 162 
in chronic gastritis, 242 
crises, diagnosis of, from dilatation 
of stomach, 261 
disease, carcinoma and, 200 
emptiness, painful, 134 
hyperesthesia, 137 
idiosyncrasies, 138 
juice, hypersecretion of, 122. See 
Gastrosuccorrhoea. 
neurasthenia, 164 
neuroses, 106 
age in, 109 
classification of, 110 
definition of, 106 
diagnosis of, 111 
from chronic gastritis, 244 
etiology of, 108 
prognosis of, 111 
occurrence of, 109 
treatment of, 112 
regurgitation, 140 1054 
INDEX 
Gastric ulcer, 168. See also Stomach, 
ulcer of. 
age in, 169 
anemia and, 171, 176 
treatment of, 196 
arterial spasm and, 171 
carcinoma developing upon, 188 
diagnosis of, 188, 205 
symptoms of, 188 
of stomach and, 188, 200, 
205 
cardiac stenosis and, 189 
chlorosis and, 171 
chronic peritonitis and, 714 
circulatory system and, 171 
complications of, 185 
constipation in, treatment of, 
196 
course of, 193 
definition of, 168 
diagnosis of, 183 
from carcinoma, 184 
from cholelithiasis, 586 
from cirrhosis of liver, 527 
from gall-stones, 185 
from gastralgia, 184 
from gastritis, 184 
from hyperacidity, 117 
from hypersecretion, 184 
from nervous dyspepsia, 166 
from obstruction of intes- 
tines, 401 
diet and, 170 
distribution of, 168 
dyspepsia in, 176 
embolism and, 171 
etiology of, 169 
function and, 26 
gastric analysis in, 181 
healing of, 175 
hematemesis in, 176, 178 
hemorrhage in treatment of, 
196 
histology of, 175 
hour-glass stomach and, 182, 
189 
etiology of, 189 
symptoms of, 190 
treatment of, 199 
hyperacidity and, 171, 172 
hypermotility in, 182 
hypersecretion and, 171, 172 
infarction and, 172 
infections and, 170 
intestinal hemorrhage and, 307 
latent, 176 
nervous system and, 172 
number of, 173 
"occult blood" in, 179 
occupation in, 170 
pain in, 176 
treatment of, 196 
parotitis and, 189 
pathogenesis of, 169 
pathology of, 173 
perforation of, 186 
course of, 186 
Gastric ulcer, perforation of, into intes- 
tines, 186 
pain in, 187 
signs of, 187 
symptoms of, 187 
treatment of, 198 
perigastritis in, 185 
symptoms of, 186 
prognosis of, 193 
pseudoperforation of, 188 
pyloric stenosis and, 189 
rupture of, diagnosis of, from 
appendicitis, 379 
secretion in, 28 
sequelae of, 185 
sex in, 170 
shape of, 174 
signs in, 181 
situation of, 173 
size of, 175 
statistics of, 168 
subphrenic abscess and, 701 
pyopneumothorax and, 710 
symptoms of, 176 
synonyms of, 168 
tetany and, 189 
trauma and, 170 
treatment of, 194 
diet in, 194 
lavage in, 196 
Leube's, 196 
Lenhartz's, 196 
medicinal, 195 
Rosenheim's, 197 
Senator's, 197 
surgical, 197 
tuberculosis and, 170 
urine in, 176 
vomiting in, 176, 177 
treatment of, 196 
x-ray examination in, 181, 183 
Gastritis, acid, diagnosis of, from hyper- 
acidity, 117 
acute, 226 
classification of, 226 
diagnosis of, from appendicitis, 
377 
simple, 226 
constipation in, treatment of, 
230 
definition of, 226 
diagnosis of, 229 
etiology of, 227 
jaundice in, 229 
nausea in, 228 
treatment of, 230 
pain in, 228 
pathology of, 228 
primary, 227 
prognosis in, 228 
pyrosis of, 229 
secondary, 228 
signs of, 228 
symptoms of, 228 
treatment of, 230 
vomiting in, 228 
chronic, 237 INDEX 
1055 
Gastritis, chronic, achylia in, 242 
anorexia in, 241 
atrophic, 240 
classification of, 238 
course of, 243 
definition of, 237 
diagnosis of, 243 
from achylia gastrica, 244 
from carcinoma of stomach, 
216, 244 
from dilatation of stomach, 
261 
from gastralgia, 136 
from gastric neuroses, 244 
from nervous dyspepsia, 166 
etiology of, 239 
gastric contents in, 242 
hyperacidity in, 242 
incidence of, 237 
intestines in, 241 
nutrition in, 241 
pathology of, 240 
productive, 240 
prognosis of, 243 
symptoms of, 241 
treatment of, 244 
vomiting in, 241 
diagnosis of, from chronic interstitial 
nephritis, 918 
from gastric ulcer, 184 
from stenosis of pylorus, 271 
diphtheritic, 236 
etiology of, 236 
pathology of, 237 
symptoms of, 237 
etiology of, 25 
interstitial purulent, 231 
mucous, 238 
mycotic, 235 
etiology of, 235 
gastralgia in, 236 
hyperchlorhydria in, 236 
symptoms of, 236 
treatment of, 236 
vomiting in, 236 
necrosis of pancreas and, 612 
phlegmonous, 231 
age in, 231 
circumscribed, 231 
constipation in, 232 
course of, 232 
definition of, 231 
diagnosis of, 233 
diarrhoea in, 232 
diffuse, 231 
etiology of, 231 
fever in, 232 
nausea in, 232 
pain in, 232 
pathology of, 231 
prognosis of, 233 
sex in, 231 
symptoms of, 232 
synonyms of, 231 
treatment of, 233 
vomiting in, 232 
proliferative, 238 
Gastritis, secondary, 239 
toxic, 233 
diagnosis of, 235 
diarrhoea in, 234 
etiology of, 233 
jaundice in, 234 
pain in, 234 
petechia; in, 234 
prognosis of, 235 
symptoms of, 234 
treatment of, 235 
vomiting in, 234 
Gastrohemorrhagia, 279 
Gastro-intestinal disturbances, chronic 
interstitial nephritis and, 892 
disease, kidney infections and, 
952 
splanchnoptosis, 754 
tract in cirrhosis of liver, 517 
in jaundice, 455 
Gastromyxorrhoea, 130 
continuous, 131 
intermittent, 130 
Gastroptosis, 754 
in atony of stomach, 162 
diagnosis of, 758 
from dilatation of stomach, 261 
gastrectasis and, 254 
incidence of, 752 
symptoms of, 755 
treatment of, 763 
Gastrosuccorrhoea, 122 
continua chronica, 125 
diagnosis of, 127 
etiology of, 125 
pathology of, 125 
prognosis of, 127 
sequelae of, 126 
symptoms of, 126 
treatment of, 127 
periodica, 123 
diagnosis of, 124 
etiology of, 123 
prognosis of, 124 
symptoms of, 123 
treatment of, 124 
vomiting in, 123 
digestive, 128 
diagnosis of, 129 
etiology of, 128 
gastric contents in, 129 
prognosis of, 129 
symptoms of, 128 
treatment of, 129 
in pylorospasm, 150 
Genito-urinary diagnosis, 1026 
asepsis in, 1029 
bougies in, 1027 
catheters in, 1028 
instrumental, 1027 
visual, 1030 
tract, tuberculosis of, diagnosis of, 
1034 
Geographical tongue, 63 
Glenard's disease, 747. See Splanchnop- 
tosis. 
Glomerular changes in kidney, 776 1056 
INDEX 
Glossitis, 62 
chronic superficial, 63 
Moeller's, 63 
papillosa, 63 
Glossodynia, 64 
exfoliativa, 63 
Glossoplegia, 62 
Glucose in urine, 821 
Glycosuria, 821 
in calculus of pancreas, 635 
in carcinoma of pancreas, 652 
disease of pancreas and, 604, 606 
in gangrenous pancreatitis, 619 
in interstitial pancreatitis, 630 
in necrosis of pancreas, 617 
in suppurative pancreatitis, 625 
Glycuronic acid in urine, 823 
Gonococcic infections, chronic peritonitis 
and, 714 
kidney infections and, 952 
tuberculosis of kidney and, 978 
Gonococcus, chronic parenchymatous 
nephritis and, 880 
peritonitis from, 686 
Gonorrhoeal stomatitis, 51 
Gout, nephritis and, 854, 891 
Granular casts, 799 
pyelitis, 954 
Granulomata of oesophagus, 85 
Gravel, sediment, origin of, 1017 
Gumma of liver, diagnosis of, from carci- 
noma of stomach, 219 
Gums in ulcerative stomatitis, 48 
tuberculosis of, 57 
H 
Hanot's cirrhosis, 535 
Harelip, 45 
Headache in acute nephritis, 864 
in chronic interstitial nephritis, 908 
in constipation, 314 
in dilatation of colon, 321 
in uremia, 837 
Hearing in uremia, 836 
Heart in amyloid kidney, 935 
in chronic interstitial nephritis, 898, 
902, 926 
parenchymatous nephritis, 884 
in cirrhosis of liver, 518, 525 
in congestion of liver, 481 
disease of, diagnosis of, from chronic 
interstitial nephritis, 914 
intestinal hemorrhage and, 307 
in jaundice, 453 
Heartburn in hyperacidity, 115 
Hemangioma of intestines, 434 
Hematemesis, 279 
in acute yellow atrophy of liver, 475 
age in, 280 
in carcinoma of stomach, 206 
in cirrhosis of liver, 520 
definition of, 279 
diagnosis of, 281 
from carcinoma of oesophagus, 
282 
Hematemesis, diagnosis of, from carcin- 
oma of stomach, 284 
from duodenal hemorrhage, 282 
from erosions, 283 
from hemorrhage from oesoph- 
agus, 282 
from miliary aneurisms, 283 
from ulcer of stomach, 283 
from varices in stomach, 283 
from venous stasis, 283 
from vicarious hemorrhages, 283 
etiology of, 279 
extragastric, 280 
gastric, 279 
in gastric ulcer, 176, 178 
in hypernephroma, 998 
neuropathic, 282 
pathology of, 280 
prognosis of, 284 
sex in, 280 
in suppurative pylephlebitis, 464 
symptoms of, 280 
in thrombosis of portal vein, 462 
treatment of, 285, 534 
Hematogenous jaundice, 447 
Hematoma, retroperitoneal, 738 
Hematoporphyrinuria, 809 
Hematuria, 802 
in carcinoma of prostate, 1038 
in chronic nephritis, 901 
in embryonic tumors of kidney, 1005 
etiology of, 804 
in hypernephroma, 996 
in nephroptosis, 756 
in sarcoma of kidney, 1003 
in tuberculosis of kidney, 984 
Hemofuscin in liver, 470 
Hemochromatosis, 529, 606 
interstitial pancreatitis and, 630 
portal cirrhosis of liver and, 510 
Hemoglobinuria, 818 
Hemoperitoneum, 669 
collapse in, 669 
diagnosis of, 669 
pain in, 669 
prognosis of, 670 
sequelae of, 669 
symptoms of, 669 
treatment of, 670 
vomiting in, 669 
Hemoptysis, breath in, 42 
Hemorrhage in acute yellow atrophy of 
liver, 474, 475 
in aneurism of hepatic artery, 459 
cerebral, in chronic nephritis, 913 
in chronic interstitial nephritis, 906 
in colitis, 336 
in duodenal ulcer, 192, 347 
intestinal, 307 
in portal thrombosis, 462 
in mesenteric thrombosis, 436 
into pancreas, 610 
retinal, in chronic nephritis, 911 
from tongue, 62 
in ulcer of intestines, 353 
vicarious, diagnosis of, from hema- 
temesis, 283 INDEX 
1057 
Hemorrhagic erosions of stomach in 
uremia, 838 
necrosis of pancreas, 610 
pancreatitis, diagnosis of, from sup- 
purative pane eatitis, 626 
Hemorrhoids, intestinal hemorrhage and, 
307 
Hemosiderin in liver, 470 
Hepatic artery, abscess of liver and, 497 
aneurism of, 458 
diagnosis of, 459 
from cholelithiasis, 459 
, from duodenal ulcer, 
459 
fever in, 459 
hemorrhage in, 459 
jaundice in, 459 
pain in, 459 
pathology of, 458 
symptoms of, 459 
treatment of, 459 
dilatation of, 458 
diseases of, 458 
embolism of, 458 
thrombosis of, 458 
intermittent fever, 582 
splanchnoptosis, 754 
veins, abscess of liver and, 497 
dilatation of, 459 
diseases of, 459 
embolism of, 460 
thrombosis of, 460 
Hepatitis, acute, 494 
non-suppurative, 494 
alcoholism and, 494 
constipation in, 495 
diagnosis of, 496 
diarrhoea in, 495 
dysentery and, 494 
etiology of, 494 
fever in, 495 
jaundice in, 495 
kala-azar and, 494 
liver in, 495 
malarial fever and, 494 
pain in, 495 
pathology of, 494 
prognosis of, 496 
spleen in, 495 
symptoms of, 495 
treatment of, 496 
urine in, 495 
vomiting in, 495 
parenchymatous, 494 
chronic interstitial, 505. See Liver, 
cirrhosis of. 
suppurative, 496. See Liver, abscess 
of. 
Hepatogenous jaundice, 447 
Hepatoptosis, 458, 757 
constipation in, 757 
diagnosis of, 759 
meteorism in, 757 
pain in, 757 
symptoms of, 757 
Hernia, diaphragmatic, diagnosis of, from 
subphrenic pyopneumothorax, 713 . 
vol. in- 67 
Hernia, internal, intestinal obstruction 
from, 405 
intestinal hemorrhage and, 307 
Herpes buccalis, 51 
labialis, 45 
of oesophagus, 90 
Herpetic stomatitis, 51 
Hiccough in acute perihepatitis, 487 
peritonitis, G82 
in uremia, 838 
Hippocratic fingers in biliary cirrhosis of 
liver, 539 
Homogentisic acid in urine, 824 
Horner's complex, 103 
Hour-glass stomach, 182 
gastric ulcer and, 182, 189 
Hutchinson's teeth, 59 
Hyaline casts, 799 
perihepatitis, 488 
Hydatid cyst of liver, subphrenic pyo- 
pneumothorax and, 711 
of peritoneum, 733 
disease, diagnosis of, from carcinoma 
of liver, 545 
Hydronephrosis, diagnosis of, from cyst of 
pancreas, 646 
from hypernephroma, 999 
renal calculus and, 1018 
tuberculosis of kidney and, 978 
Hyperacidity, 112 
appendicitis and, 114 
appetite in, 116 
atony and, 114 
chlorosis and, 114 
cholelithiasis and, 114 
in chronic gastritis, 242 
constipation in, 116 
diagnosis of, 117 
from acid gastritis, 117 
from atony of stomach, 117 
from cholelithiasis, 117 
from chronic hypersecretion, 117 
from ulcer of stomach, 117 
diarrhoea in, 116, 324 
diet and, 114 
in duodenal ulcer, 643 
eructations in, 115 
etiology of, 114 
gastric juice in, 116 
heartburn in, 115 
larval, 121 
diagnosis of, 122 
treatment of, 122 
mental strain and, 114 
pain in, 115 
pathology of, 115 
prognosis of, 117 
symptoms of, 115 
treatment of, 118 
diet in, 118 
hygienic, 120 
medicinal, 120 
ulcer of stomach and, 114, 171, 172 
urine in, 117 
vomiting in, 116 
Hyperalgesia in appendicitis, 367 
Hypcrchlorhydria, 112. See Hyperacidity. 1058 
INDEX 
Hyperemia of kidney, 788 
Hyperesthesia gastrica, 137. See Gastric 
hyperesthesia. 
1 lyperkeratosis of tongue, 61 
Hypernephroma, 994 
ascites in, 997 
cystoscopy in, 998 
diagnosis of, 998 
from adenoma, 1000 
from carcinoma, 1000 
from fibroma, 1000 
from hydronephrosis, 999 
from lipoma, KMX) 
from perinephritis, 999 
from polycystic disease, l(M)0 
from pyonephrosis, 999 
from renal calculus, 999 
from rhabdomyoma, 1000 
from sarcoma, 1000 
from teratoma, 1000 
from tuberculosis, 989, 998 
duration of, 998 
etiology of, 994 
hematemesis in, 998 
hematuria in, 996 
histology of, 995 
invasion of, 995 
jaundice in, 997 
oedema in, 997 
pain in, 996 
pathology of, 994 
symptoms of, 996 
treatment of, 1000 
results of, 1001 
tuberculosis and, 978 
tumor in, 996 
urine in, 997 
varicocele in, 997 
vomiting in, 998 
Hyperplastic intestinal tuberculosis, 390 
Hyperptyalism, 68 
Hypersecretion, diagnosis of, from dilata- 
tion of stomach, 261 
from gastric ulcer, 184 
from hyperacidity, 117 
of gastric juice, 122. See Gastro- 
succorrhoea. 
Hypertrophic biliary cirrhosis, 535 
stenosis of pylorus, 263 
diagnosis of, from carcinoma 
of stomach, 219 
Hypertrophy of prostate, 1035 
kidney infections and, 952 
Hyphomycetic stomatitis, 50 
Hypochlorhydria, 152 
diagnosis of, 152 
symptoms of, 152 
treatment of, 152 
Hypochondriasis in constipation, 314 
Hypotyalism, 68 
Hysteria, cardiospasm and, 147 
nervous anorexia and, 157 
I 
Ichthyosis buccalis, 64 
Icterus neonatorum, 450 
Idiopathic dilatation-of colon, 320 
Ileum, carcinoma of, 428 
Ileus, 394 
Incarceration of intestines, 394 
obstruction from, 406 
Incontinence of pylorus, 159 
Indicanuria, 811 
Indigestion in cholelithiasis, 575 
intestinal, 301 
diarrhoea and, 324 
in splanchnoptosis, 753 
Infarct of kidney, 789 
Infarction, gastric ulcer and, 172 
intestinal hemorrhage and, 307 
Infection, digestion and, 32, 34 
Infectious diseases, nephritis and, 848, 
866, 880, 892 
Infective oesophagitis, 81 
Inflammation of labial glands, 45 
of mouth, 45 
of oesophagus, 79 
of parotid gland, 69 
of ureter, 974 
Influenza, nephritis and, 851 
Interacinar pancreatitis, 629 
Intercostal neuralgia, diagnosis of, from 
gastralgia, 136 
Interlobular pancreatitis, 629 
Intermittent gastromyxorrhoea, 130 
Interstitial changes in kidney, 777 
pancreatitis, 626 
Intestinal colic, 303 
constipation in, 305 
definition of, 303 
diagnosis of, 305 
from appendicitis, 378 
from gastralgia, 136 
diarrhoea in, 305 
etiology of, 303 
functional disturbances and, 303 
nausea in, 305 
organic conditions and, 304 
pain in, 304 
peristalsis in, 304 
symptoms of, 304 
treatment of, 306 
vomiting in, 305 
flora, digestion and, 37 
hemorrhage, 307 
amyloid degeneration and, 307 
anemia and, 307 
ankylostoma and, 308 
cardiac disease and, 307 
cirrhosis of liver and, 307 
congestive conditions of bowels 
and, 307 
diarrhoea in, 308 
diseases of bloodvessels and, 
307 
duodenal ulcer and, 307 
embolism of mesenteric vessels 
and, 307 
etiology of, 307 
gastric ulcer and, 307 
hemorrhoids and, 307 
hernia and, 307 
. infarction of bowel and, 307 INDEX 
1059 
Intestinal hemorrhage, inflammatory con- 
ditions of bowel and, 307 
intussusception and, 307 
prognosis of, 308 
stools in, 308 
strangulation of bowel and, 307 
symptoms of, 308 
thrombosis of mesenteric vessels 
and, 309 
of portal vein and, 462 
treatment of, 308 
ulcerative conditions of bowel 
and, 307 
unassociated with pathological 
conditions of bowel, 307 
indigestion, 301 
diagnosis of, 302 
diarrhoea and, 324 
etiology of, 301 
fermentative, 302 
symptoms of, 301 
treatment of, 302 
processes, automatic mechanism in, 
291 
sand, 295 
in mucous colitis, 440 
tract, bacteriology of, 295 
physiology of, 286 
Intestines, absorption of carbohydrates 
in, 290 
of fats in, 290 
of food in, 290 
adenoma of, 433 
amyloid disease of, 392 
treatment of, 393 
antiperistalsis of, 287 
arteriosclerosis of, 437 
atresia of, diagnosis of, from hyper- 
trophic stenosis of pylorus, 271 
bacillus aerogenes in, 296 
bifidus communis in, 296 
coli in, 296 
lactis aerogenes in, 296 
putrificus in, 296 
bacteria in, distribution of, 295 
growth of, 297 
significance of, 296 
treatment of, 298 
types of, diagnosis of, 297 
virulence of, 297 
carcinoma of, 424 
adhesions and, 426 
blood in, 430 
complications of, 431 
dilatation and, 426 
distension in, 430 
feces in, 430 
metastasis and, 427 
obstruction and, 425 
pathology of, 425 
perforation in, 426 
peritonitis and, 426 
pus in, 430 
symptoms of, 427 
treatment of, 431 
tumors in, 429 
chemical processes in, 288 
Intestines, compression of, 394 
constriction of, 394 
descent of, 757 
constipation in, 757 
diagnosis of, 759 
dyspepsia in, 757 
mucous colitis in, 757 
diseases of, 286 
acute peritonitis and, 672 
diverticula of, 420 
acquired, 422 
congenital, 421 
false, 420 
symptoms of, 423 
treatment of, 424 
true, 420 
as excretory organs, 291 
gaseous distension of, 298 
diagnosis of, 300 
symptoms of, 299 
treatment of, 300 
hemangioma of, 434 
incarceration of, 394 
lipoma of, 433 
lymphangioma of, 434 
lymphosarcoma of, 431 
symptoms of, 432 
treatment of, 433 
motor functions of, 286 
movements of, mechanism of, 287 
nervous, 287 
myxoma of, 433 
neuralgia of, 305 
obstruction of, 394 
acute, 396 
from adhesions, 407 
pathology of, 407 
symptoms of, 407 
from bands, 404, 414 
symptoms of, 405 
in cholelithiasis, 584 
chronic, 395, 397 
collapse in, 400 
from compression, 408 
from concretions, 404 
from congenital stenosis, 408 
constipation in, 398 
definition of, 394 
diagnosis of, 401, 414 
fluoroscopic, 403 
from acute peritonitis, 688 
from appendicitis, 379 
from ascites, 665 
from duodenal ulcer, 348, 
401 
from gall-stones, 401 
from gastric ulcer, 401 
from movable kidney, 401 
spleen, 401 
from pancreatitis, 401 
from renal colic, 401 
situation of, 402 
skiagraphic, 403 
urine in, 403 
diarrhoea in, 399 
from fecal masses, 403, 415 
from foreign bodies, 404, 414 1060 
INDEX 
Intestines, obstruction of, from gall-stones, 
403 
symptoms of, 404 
from incarceration of bowels, 406 
from internal hernia, 405 
symptoms of, 406 
from intussusception, 409, 414 
age and, 409 
etiology of, 409 
location of, 410 
pain in, 411 
pathology of, 410 
prognosis of, 412 
symptoms of, 411 
tenesmus in, 411 
treatment of, 412 
from knotting, 412 See Volvu- 
lus. 
meteorism in, 398 
pain in, 397 
from paralysis of bowel, 418 
functional, 419 
symptoms of, 420 
treatment of, 420 
with organic disease, 
419 
pathology of, 395 
in portal thrombosis, 462 
prognosis of, 416 
prostration in, 400 
from stenosis, 408 
from stricture, 407 
diagnosis of, 408 
symptoms of, 408 
treatment of, 408 
symptoms of, 397 
treatment of, 416 
surgical, 418 
from twisting, 412. See Volvulus. 
vomiting in, 399 
obturation of, 394 
occlusion of, 394 
paralysis of, in acute peritonitis, 681 
perforation of, in gastric ulcer, 186 
peristalsis of, 286 
pathological, 287 
varieties of, 288 
physiology of, 296 
rhythmic segmentation of, 286 
sarcoma of, 431 
blood in, 432 
fever in, 432 
symptoms of, 432 
treatment of, 433 
strangulation of, 394 
stricture of, 394 
syphilis of, 391 
symptoms of, 392 
treatment of, 392 
tuberculosis of, 387 
chronic hyperplastic, 390 
stenosing, 390 
treatment of, 390 
ulcerative, 388 
diagnosis of, 389 
from amyloid disease, 
389 
Intestines, tuberculosis of, ulcerative, di- 
arrhoea in, 389 
symptoms of, 389 
terminal changes in, 388 
tumors of, benign, 433 
symptoms of, 434 
treatment of, 434 
malignant, 424 
ulcer of, 343 
catarrhal, 351 
decubital, 351 
diagnosis of, 353 
diarrhoea in, 352 
duodenal, 344 
embolic, 350 
fever in, 353 
follicular, 351 
hemorrhage in, 353 
jejunal peptic, 349 
leukemic, 352 
pain in, 353 
prognosis of, 354 
stercoral, 351 
symptoms of, 352 
thrombotic, 350 
treatment of, 354 
trophic, 352 
uremic, 350, 83S 
Intoxications, chronic nephritis and, 880 
Intraperitoneal subphrenic abscess, 703 
Intussusception, intestinal hemorrhage 
and, 307 
obstruction from, 409 
Inverting enzymes, 290 
lodiococcus vaginatus in mouth, 40 
Ischemia of kidney, 787 
j Ischuria, 791, 806 
Itching in uremia, 840 
J 
Jackstone calculus, 1009 
Jaundice, 446, 552 
in abscess of liver, 500 
in acute cholangeit is, 553 
cholecystitis, 565 
enteritis, 330 
gastritis, 229 
hepatitis, 495 
yellow atrdphy of liver, 475 
albuminuria and, 796 
in aneurism of hepatic artery, 459 
bacillus coli communis in, 448 
proteus in, 448 
in biliary cirrhosis of liver, 538 
blood in, 452 
bloodvessels in, 453 
bradycardia in, 453 
in calculus of pancreas, 635 
in carcinoma of gall-bladder, 596 
of liver, 542 
of pancreas, 650, 652 
catarrhal, 448, 552 
causes of, 446 
in cholelithiasis, 579 
cholcmia in, 454 INDEX 
1061 
Jaundice in chronic cholangeitis, 560 
peritonitis, 714 
splenomegalic hemolytic, 450 
in cirrhosis of liver, 520 
of stomach, 278 
in congestion of liver, 479, 484 
in cyst of pancreas, 645 
effects of, 451 
in gangrenous pancreatitis, 619 
in gastritis, 234 
gastro-intestinal tract in, 455 
heart in, 453 
hematogenous, 447 
hepatogenous, 447 
in hypernephroma, 997 
liver in, 454 
mechanism of, 449 
mucous membrane in, 451 
necrosis of pancreas and, 612, 616, 
617 
nephritis and, 854 
nervous system in, 454 
in new-born, 450 
nutrition in, 455 
obstructive, 447 
pathogenesis of, 449 
pruritus in, 452 
simple, 448 
skin in, 451 
in suppurative cholangeitis, 557 
pancreatitis, 624 
in tuberculosis of peritoneum, 726 
types of, 447 
urine in, 453 
urobilinuria in, 454 
urticaria in, 452 
xanthelasma in, 452 
Jaw, actinomycosis of, 59 
Jejunal peptic ulcer, 349 
Jejunum, carcinoma of, 428 
Juvenile vomiting, 145 
K 
Kala-azar, acute hepatitis and, 494 
Keratosis buccalis, 64 
Kidney, abscess of, diagnosis of, 964 
prognosis of, 966 
urine in, 959 
absence of, 785, 937 
acute dilatation of stomach and, 251 
nephritis and, 857 
adenoma of, 1003 
diagnosis of, from hyperneph- 
roma, 1000 
malignant papillary cyst, 1002 
albuminuria and, 774 
amyloid, 933 
age and, 933 
anemia in, 935 
diagnosis of, 935 
from chronic interstitial 
nephritis, 916 
parenchymatous neph- 
ritis, 885 
diarrhoea in, 935 
Kidney, amyloid, etiology of, 933 
heart in, 935 
liver in, 935 
oedema in, 935 
pathology of, 934 
prognosis of, 936 
sex and, 933 
spleen in, 935 
symptoms of, 935 
syphilis and, 933 
treatment of, 936 
tuberculosis and, 933 
uremia in, 935 
urine in, 935 
anemia of, 787 
arteries of, anomalies of, 786 
arteriosclerotic, 847, 897 
capillaries of glomerulus in, 776 
capsular space in, 776 
carcinoma of, 1001 
diagnosis of, 1002 
from hypernephroma, 1000 
from tuberculosis, 989 
pathology of, 1002 
symptoms of, 1002 
treatment of, 1002 
casts and, 774 
circulatory disturbances of, 787 
in cirrhosis of liver, 518, 526 
in chronic interstitial nephritis, 895 
congestion of, diagnosis of, from 
acute nephritis, 870 
from chronic nephritis, 885, 
914 
cyanotic induration of, chronic par- 
enchymatous nephritis and, 880 
cystic congenital, 786 
signs of, 787 
cysts of, diagnosis of, from chronic 
interstitial nephritis, 918 
diseases of, changes in urine and, 791 
displacements of, 786 
drink and, 783 
effects of age on, 773 
excretion of solids by, 768 
of water by, 767 
fibroma of, diagnosis of, from hyper- 
nephroma, 1000 
food and, 783 
function of, 766 
blood and, 770 
functional activity of, 942 
competence of, 781 
test of, 781 
glomerular changes in, 776 
glomerulus of, in acute nephritis, 858 
hyperemia of, 788 
hypernephroma of, 994. See Hyper- 
nephroma. 
diagnosis of, from tuberculosis, 
989, 998 
infarct of, 789 
infections of, actinomyces and, 952 
anemia and, 952 
appendicitis and, 952 
ascending, bacteriology of, 951 
bilharzia and, 952 1062 
INDEX 
Kidney, infections of, calculus and, 952 
chronic passive congestion and, 
952 
constipation and, 952 
by contiguity, pathology of, 956 
swelling in, 960 
urine in, 959 
cystitis and, 952 
diagnosis of, 962 
distension of colon and, 952 
echinococcus and, 952 
eustrongylus gigas and, 952 
fever in, 962 
filaria and, 952 
gastro-intestinal diseases and, 
952 
gonorrhoea and, 952 
hematogenous, bacteriology of, 
951 
pathology of, 956 
hypertrophy of prostate and, 952 
injuries of rectum and, 952 
malnutrition and, 952 
metastastic, bacteriology of, 951 
nephritis and, 952 
nephroptosis and, 952 
paralysis of bladder and, 952 
parasites and, 952 
pelvic peritonitis and, 952 
periureteritis and, 952 
phimosis and, 952 
pregnancy and, 952 
pyogenic, 937 
bacteriology of, 943, 947, 
950 
cystoscopy in, 938, 988 
etiology of, 949 
pain in, 959 
prophylaxis in, 966 
swelling in, 960 
symptoms of, 956 
treatment of, 966 
ureteral catheterization in, 
939 
urinary examination in, 941 
urine in, 940, 958 
segregators in, 944 
retention of urine and, 952 
stricture of ureter and, 952 
of urethra and, 952 
trauma and, 952 
traumatic, pathology of, 956 
tuberculosis and, 952 
tumors and, 952 
ureteritis and, 952 
urogenous, bacteriology of, 951 
internal secretion of, 769, 833 
interstitial changes in, 777 
tissue of, in acute nephritis, 
859 
in chronic interstitial neph- 
ritis, 897 
ischemia of, 787 
large red, 882 
white, 881 
lipoma of, diagnosis of, from hyper- 
nephroma, 1000 
Kidney, malformations of, 785 
mobility of, 786 
movable, diagnosis of, from appendi- 
citis, 380 
from carcinoma of stomach, 
219 
from obstruction of intes- 
tines, 401 
parenchymatous changes in, 774 
pelvis of, tumors of, 1006 
phthalein test of, 781 
physiology of, 765 
pathological, 770 
polycystic disease of, diagnosis of, 
from hypernephroma, 1000 
position of, anomalies of, 786 
of pregnancy, 867 
albuminuria in, 868 
casts in, 868 
chronic nephritis and, 893 
diagnosis of, 869 
eclampsia in, 869 
(edema in, 868 
prognosis of, 869 
theories of, 868 
treatment of, 869 
urine in, 868 
in renal calculus, 1017 
rhabdomyoma of, diagnosis of, from 
hypernephroma, 1000 
sarcoma of, 1003 
diagnosis of, from hyperneph- 
roma, 1000 
hematuria in, 1003 
pain in, 1003 
symptoms of, 1003 
tumor in, 1003 
secondary contracted, 882, 884 
shape of, anomalies of, 786 
small white, 882 
surgical, 937 
teratoma of, diagnosis of from hyper- 
nephroma,- 1000 
toxins and, 773 
tuberculosis of, 976 
acute miliary, 979 
age and, 978 
albuminuria in, 982, 983 
anemia in, 985 
bilateral, 981 
bladder in, 981 
cachexia in, 985 
calculus and, 978 
chronic pyelitis and, 978 
congenital deformities and, 
978 
course of, 986 
cystitis and, 978 
diagnosis of, 987 
from calculus, 989 
from carcinoma, 989 
from hypernephroma, 989, 
998 
from pyelitis, 989 
from pyelonephritis, 989 
emaciation in, 985 
epithelial cells in, 984 INDEX 
1063 
Kidney, tuberculosis of, etiology of, 977 
fever in, 985 
gonorrhoea and, 978 
hematuria in, 984 
hydronephrosis and, 978 
hypernephroma and, 978 
infection in, 977 
nephroptosis and, 978 
oliguria in, 982 
pain in, 985 
paranephritis in, 980 
pathology of, 979 
perinephritis in, 980 
pregnancy and, 978 
primary, 979 
prognosis of, 989 
pulse in, 986 
pus cells in, 984 
pyogenic infections and, 952 
sex and, 979 
swelling in, 985 
symptoms of, 982 
treatment of, 990 
climatic, 993 
hygienic, 993 
medicinal, 993 
prophylactic, 990 
surgical, 991 
symptomatic, 993 
tubercle bacilli in, 984, 987 
tuberculin in, 988, 993 
unilateral, 981 
ureter in, 980 
urethritis and, 978 
urine in, 983 
tubules of, in acute nephritis, 859 
changes in, 777 
in chronic interstitial nephritis, 
896 
disturbances of, 772 
function of, 771 
tumors of, 994 
benign, 1005 
diagnosis of, 1005 
symptoms of, 1005 
embryonic, 1003 
diagnosis of, 1005 
duration of, 1005 
hematuria in, 1005 
pain in, 1005 
pathology of, 1004 
symptoms of, 1005 
treatment of, 1005 
infections and, 952 
variegated, 882 
L 
Labial glands, inflammation of, 45 
Lacrimal glands, enlargement of, 73 
Lactescent ascites, 662 
Lactic acid in carcinoma of stomach, 211 
Lactosuria, 822 
Larval hyperacidity, 121 
Larynx, carcinoma of, breath in, 42 
Lavage in acute dilatation of stomach, 252 
Lead colic, 306 
Leprosy of mouth, 59 
Leptothrix buccalis maxima in mouth, 40 
innominata in mouth, 40 
Leucin in urine, 816 
Leukemic enlargement of liver, diagnosis 
of, from fatty liver, 468 
infiltration of liver, 471 
ulcers, 352 
Leukocytosis in abscess of liver, 502 
in acute cholecystitis, 565 
in appendicitis, 369 
in gangrenous pancreatitis, 618 
in necrosis of pancreas, 617 
in subphrenic pyopneumothorax, 712 
in suppurative cholangeitis, 558 
pancreatitis, 625 
in tuberculosis of peritoneum, 726 
Leukoplakia, 64 
epithelioma and, 65 
etiology of, 64 
pathology of, 65 
symptoms of, 65 
syphilis and, 64 
treatment of, 65 
Leukoplasia, 64 
Levulosuria, 821 » 
in hepatic disease, 445 
Lichen planus of mouth, 54 
Lingua nigra, 61 
Linguopapillitis, 62 
Linitis, plastic, 273 
Lipase, 289 
Lipoma of intestines, 433 
of kidney, diagnosis of, from hyper- 
nephroma, 1000 
of peritoneum, 732 
Lips, actinomycosis of, 59 
color of, 45 
double, 44 
dryness of, 44 
eczema of, 45 
eruptions of, 45 
treatment of, 45 
fissure of, 44 
shape of, 44 
tremor of, 45 
tuberculosis of, 57 
tumors of, 45 
Lithemic splanchnoptosis, 754 
Lithuria, 812 
Liver, abscess of, 496 
amoebic, 496, 503 
appendicitis and, 497 
biliary ducts and, 498 
blood in, 502 
chills in, 501 
cholecystitis and, 497 
diagnosis of, 504 
from biliary intermittent 
fever, 504 
from cholelithiasis, 504 
from malarial fever, 504 
dysentery and, 497 
etiology of, 496 
feces in, 502 1064 
INDEX 
Liver, abscess of, fever in, 501 
hepatic artery and, 497 
veins and, 497 
jaundice in, 500 
leukocytosis in, 502 
liver in, 501 
lymphatics and, 498 
multiple septicopyemic, 499 
pain in, 500 
pathology of, 498 
portal vein and, 497 
prognosis of, 504 
rupture of, 503 
spleen in, 502 
subphrenic abscess and, 700 
sweating in, 500 
symptoms of, 498 
traumatic, 497, 499 
treatment of, 505 
tropical, 500 
urine in, 502 
vomiting in, 502 
actinomycosis of, 541 
in acute hepatitis, 495 
yellow atrophy of, 472 
alcoholism and, 473 
blood in, 476 
chemistry of, 474 
chloroform poisoning 
and, 473 
diagnosis of, 476 
from biliary cir- 
rhosis, 477 
from phosphorus 
poisoning, 476 
diarrhoea in, 475 
etiology of, 472 
fever in, 475 
hematemesis in, 475 
hemorrhages in, 474,475 
jaundice in, 475 
liver in, 475 
nephritis and, 850 
pain in, 475 
pathogenesis of, 474 
pathology of, 473 
phosphorus poisoning 
and, 473 
pregnancy and, 472 
prognosis of, 477 
puerperal eclampsia and, 
473 
pulse in, 475 
septicopyemia and, 473 
spleen in, 476 
symptoms of, 475 
syphilis and, 473 
treatment of, 477 
urine in, 476 
vomiting in, 475 
amyloid, 469 
anemia in, 469 
ascites and, 658 
diagnosis of, 470 
from fatty liver, 468, 
470 
diarrhoea in, 469 
Liver, amyloid, etiology of, 469 
pathology of, 469 
prognosis of, 470 
spleen in, 469 
symptoms of, 469 
treatment of, 470 
angioma of, 546 
anomalies of, acquired, 456, 457 
diagnosis of, 457 
symptoms of, 457 
treatment of, 457 
congenital, 455 
atrophy of, 465 
general, 465 
localized, 465 
pathology of, 466 
symptoms of, 466 
carcinoma of, 541 
ascites and, 542, 658 
diagnosis of, 544 
from biliary cirrhosis, 545 
from carcinoma of gall- 
bladder, 598 
of stomach, 218 
from hydatid disease, 545 
from portal cirrhosis, 545 
from syphilis of liver, 545 
etiology of, 541 
gall-bladder in, 543 
hydronephrosis in, 543 
jaundice in, 542 
liver in, 543 
lungs in, 543 
onset of, 542 
pain in, 542 
pathology of, 541 
primary, 541 
prognosis of, 545 
secondary, 541 
spleen in, 544 
symptoms of, 542 
treatment of, 546 
vomiting in, 543 
cardiac, 481 
in catarrhal cholangeitis, 554 
in chronic interstitial nephritis, 899 
perihepatitis, 490, 492 
peritonitis, 718 
circulation in, 514 
cirrhosis of, 505 
anastomosis in, 512 
arthracotic, 531 
ascites and, 658 
autoserotherapy in, 534 
biliary, 535 
alcohol and, 536 
blood in, 539 
diagnosis of, 539 
from portal cirrhosis, 
539 
dyspepsia in, 538 
fever in, 538 
hippocratic fingers in, 539 
jaundice in, 538 
liver in, 538 
onset of, 537 
pain in, 538 INDEX 
1065 
Liver, cirrhosis of, biliary, pathology of, 
536 
prognosis of, 540 
spleen in, 538 
symptoms of, 537 
treatment of, 540 
types of, 539 
urine in, 539 
varieties of, 507 
vomiting in, 538 
Budd's non-alcoholic, 509 
in children, 531 
circulation in, 512, 514, 525 
connective tissue in, 516 
diagnosis of, from fatty liver, 468 
from passive congestion, 485 
from perihepatitis, 493 
from tuberculosis of peri- 
toneum, 727 
dyspeptic, 509 
elastic tissue in, 517 
epigastric murmur in, 525 
experimental, 510 
gall-bladder in, 513 
hemochromatosis and, 529 
diagnosis of, 530 
prognosis of, 530 
symptoms of, 530 
treatment of, 530 
hyperplasia in, 515 
intestinal hemorrhage and, 307 
malarial, 530 
mesenteric thrombosis and, 435 
portal, 508 
abdomen in, 522 
albuminuria in, 526 
alcohol and, 508 
ascites in, 523 
treatment of, 534 
bilharzia hematobia in, 510 
blood in, 525 
complications of, 526 
constipation in, 520 
diagnosis of, 527 
from Banti's disease, 
528 
from biliary cirrhosis, 
527 
from carcinoma of 
stomach, 528 
from duodenal ulcer, 
527 
from gastric ulcer, 527 
from portal thrombosis, 
528 
from splenic anemia, 
528 
from tuberculous peri- 
tonitis, 528 
from tumors of peri- 
toneum, 528 
diarrhoea in, 520 
etiology of, 508 
fatty acids and, 509 
fever in, 520 
gastro-intestinal tract in, 
517 
Liver, cirrhosis of, portal, heart in, 518, 
525 
hematemesis in, 520 
treatment of, 534 
hemorrhages in, 521 
histology of, 513 
infections and, 509 
jaundice in, 520, 521 
kidneys in, 518, 526 
liver in, 523 
lungs in, 518 
malarial fevers and, 509 
nausea in, 520 
nephritis in, 526 
neuritis in, 527 
oedema in, 525 
pain in, 520 
pathogenesis of, 519 
pathology of, 510 
peritoneum in, 518 
pleuritis in, 526 
pneumokoniosis and, 510 
prognosis of, 531 
signs in, 522 
spleen in, 517, 523 
symptoms of, 520 
syphilis and, 509 
tapping in, 524 
toxemia in, 522 
treatment of, 532 
surgical, 535 
tuberculosis and, 509, 526 
types of, 529 
typhoid fever and, 509 
uncinaria duodenalis in, 510 
urine in, 526 
vomiting in, 520 
tuberculosis of peritoneum and, 
526, 721 
varieties of, 506 
congestion of, 478 
active? 478 
diagnosis of, 480 
etiology of, 478 
jaundice in, 479 
pain in, 479 
pathology of, 479 
prognosis of, 480 
symptoms of, 479 
treatment of, 480 
vomiting in, 479 
passive, 481 
ascites in, 484 
diagnosis of, 485 
from cirrhosis, 485 
from fatty Ever, 468 
etiology of, 481 
heart in, 481 
jaundice in, 484 
oedema in, 484 
pain in, 484 
pathology of, 481 
prognosis of, 485 
symptoms of, 483 
treatment of, 485 
urine in, 485 
constricted, 456 1066 
INDEX 
Liver, corset, 456 
cysts of, 547 
hydatid, subphrenic pyoneumo- 
thorax and, 711 
deformities of, 456 
diseases of, 442 
acute peritonitis and, 673 
levulosuria in, 445 
disorders of, retrogressive, 465 
displacement of, diagnosis of, from 
fatty liver, 468 
incidence of, 752 
emphysematous, 466 
fatty, 466 
alcohol and, 467 
diagnosis of, 468 
from amyloid liver, 468, 470 
from cirrhosis of liver, 468 
from displacement, 468 
from leukemia, 468 
from passive congestion, 
468 
etiology of, 467 
metabolism and, 467 
pathology of, 467 
poisoning and, 467 
prognosis of, 468 
symptoms of, 468 
treatment of, 469 
tuberculosis and, 467 
vomiting in, 468 
functions of, detoxifying, 444 
disturbance of, 31 
glycogenic, 445 
lipogenic, 444 
urea-forming, 445 
functional disorders of, 442 
gaseous, 466 
gumma of, diagnosis of, from carci- 
noma of stomach, 219 
in jaundice, 454 
leukemic enlargement of, diagnosis of, 
from fatty liver, 468 
infiltration of, 471 
malignant disease of, diagnosis of, 
from perihepatitis, 493 
necrosis of, 471 
parenchymatous degeneration of, 466 
pericarditic pseudocirrhosis of, 488, 
716 
pigmentation of, 470 
in anthracosis, 470 
bilirubin in, 470 
biliverdin in, 470 
in hemochromatosis, 471 
hemofuscin in, 470 
hemosiderin in, 470 
in malarial fevers, 470 
in pernicious anemia, 471 
red atrophy in, 471 
silicosis in, 470 
sarcoma of, 546 
sugar-iced, 488, 718 
in suppurative cholangeitis, 557 
syphilis of, 541 
ascites and, 658 
chronic peritonitis and, 717 
Liver, syphilis of, diagnosis of, from car- 
cinoma of liver, 545 
from perihepatitis, 493 
in thrombosis of portal vein, 462 
tropical, 494 
tuberculosis of, 541 
of peritoneum and, 726 
tumors of, benign, 546 
malignant, 541 
Locomotor ataxia, mouth in, 55 
Loculated tuberculosis of peritoneum, 723 
Ludwig's angina, 75 
Lung, abscess of, breath in, 42 
in carcinoma of liver, 543 
in cirrhosis of liver, 518 
gangrene of, breath in, 42 
Lupus erythematosus of mouth, 53 
Lymphangioma of intestines, 434 
of lips, 45 
Lymphatic circulation, biliary infection 
and, 551 
Lymphatics in carcinoma of stomach, 204 
Lymphoid tissue, appendicitis and, 361 
Lymphosarcoma of intestines, 431 
M 
McBurney's point in appendicitis, 367 
Macroglossia, 60 
macrochelia and, 61 
Magnesium phosphate calculus, origin of, 
1015 
Malarial fevers, acute hepatitis and, 494 
cirrhosis of liver and, 509, 530 
diagnosis of, from abscess of 
liver, 504 
from acute peritonitis, 689 
from appendicitis, 379 
from suppurative cholan- 
geitis, 559 
nephritis and, 850 
pigmentation of liver and, 470 
Malformations of kidney, 785 
Malnutrition, kidney infections and, 952 
Malpighian bodies in acute nephritis, 858 
in chronic nephritis, 896 
Mania in uremia, 837 
Measles, nephritis and, 849 
Meckel's diverticulum, 421 
Megastoma entericum in carcinoma of 
stomach, 213 
Melanoglossia, 61 
Melanuria, 811 
Membranous cholecystitis, 563 
colitis, 437 
Mercurial stomatitis, 48 
Merycism, 138 
diagnosis of, 139 
etiology of, 139 
prognosis of, 139 
symptoms of, 139 
treatment of, 139 
Mesenteric cysts of peritoneum, 736 
embolism, 434 
abdomen in, 436 
diagnosis of, 436 INDEX 
1067 
Mesenteric embolism, diarrhoea in, 435 
etiology of, 435 
hemorrhage in, 307, 436 
pain in, 435 
pathology of, 435 
prognosis of, 437 
symptoms of, 435 
treatment of, 437 
vomiting in, 435 
glands, disease of, acute peritonitis 
and, 673 
thrombosis, 434 
abdomen in, 436 
cirrhosis of liver and, 435 
diagnosis of, 436 
diarrhoea in, 435 
etiology of, 435 
hemorrhage in, 307, 436 
pain in, 435 
pathology of, 435 
prognosis of, 437 
symptoms of, 435 
treatment of, 437 
vomiting in, 435 
Mesentery, cyst of, diagnosis of, from 
cyst of pancreas, 646 
suppuration in, 696 
Metabolism, cholelithiasis and, 571 
fatty liver and, 467 
nephritis and, 854, 892 
Meteorism, 298 
in hepatoptosis, 757 
Micrococcus gingivae in mouth, 40 
Microglossia, 60 
Mikulicz's disease, 73 
varieties of, 74 
Miliary aneurisms, hematemesis from, 283 
Milky ascites, 662 
Mixed tumor of salivary glands, 72 
Moeller's glossitis, 63 
Motor functions of intestines, 286 
insufficiency of stomach, 247 
paralysis of intestines, obstruction 
from, 418 
Mouth, acne of, 54 
actinomycosis of, 59 
angioneurotic oedema of, 53 
bacillus diphtheriae in, 40 
fusiformis in, 41 
gangrenae pulpae in, 40 
leprae in, 41 
maximus in, 40 
necrodentalis in, 40 
pseudodiphtheria in, 40 
pyocyaneus in, 40 
tuberculosis in, 41 
bacterium gingivitidis in, 40, 55 
bacteriology of, 39 
carcinoma of, 52 
cladothrix buccalis in, 40 
cysts of, 52 
dermoid, 53 
dermatoses of, 53 
in diabetes, 55 
diseases of, 39 
dry, 68 
eczema of, 54 
Mouth, erysipelas of, 54 
.inflammation of, 45 
iodiococcus vaginatus in, 40 
leprosy of, 59 
leptothrix buccalis maxima in, 40 
innominata in, 40 
in leukemia, 55 
lichen planus of, 54 
in locomotor ataxia, 55 
lupus erythematosus of, 53 
micrococcus gingivae in, 40 
pemphigus of, 54 
in pernicious anemia, 55 
in pregnancy, 56 
psoriasis of, 53 
scleroderma of, 54 
scleroma of, 60 
in scurvy, 55 
sepsis of, 41 
spirillum sputigenum in, 41 
spirochetes in, 41 
in sprue, 393 
staphylococcus pyogenes in, 40 
streptococcus brevis in, 40 
pyogenes in, 40 
syphilis of, 58 
primary sore in, 58 
secondary lesions in, 58 
tertiary lesions in, 58 
tinea circinata of, 54 
tuberculosis of, 57 
diagnosis of, 58 
treatment of, 58 
tumors of, 52 
mixed, 53 
in typhoid fever, 54 
in uremia, 55 
urticaria of, 53 
in varicella, 56 
in variola, 56 
Movable kidney, diagnosis of, from 
appendicitis, 380 
from carcinoma of stomach, 
219 
from obstruction of intes- 
tines, 401 
Mucocele of appendix, 386 
Mucous colic, 437 
colitis, 437 
diarrhoea, 437 
gastritis, 238 
membrane, atrophy of, diagnosis of, 
from carcinoma of stomach, 217 
in jaundice, 451 
Mucus in feces, 293 
Mulberry calculus, 1009 
Muscles, abdominal, constipation and, 
312 
Myasthenia, dilatation of stomach and, 
255 
Mycotic gastritis, 235 
stomatitis, 50 
Myoma of appendix, 386 
of peritoneum, 730 
Myxoma of appendix, 386 
of intestines, 433 
I of peritoneum, 733 1068 
INDEX 
N 
Nausea in acute cholecystitis, 564 
gastritis, 228 
nephritis, 863 
pyelitis, 961 
in appendicitis, 368 
in cholera nostras, 331 
in gall-stone colic, 577 
in intestinal indigestion, 301 
in mesenteric embolism, 435 
in necrosis of pancreas, 616 
in nephroptosis, 756 
nervous, 146 
diagnosis of, 147 
etiology of, 146 
symptoms of, 147 
treatment of, 147 
in phlegmonous gastritis, 232 
in portal cirrhosis of liver, 520 
in uremia, 837 
Necrosis of appendix, 363 
fat, 606 
hemorrhagic, of pancreas, 610 
of liver, 471 
of pancreas, diagnosis of, from suppu- 
rative pancreatitis, 626 
Nephritic colic, diagnosis of, from gastral- 
gia, 136 
Nephritis, 778, 845 
acid theory of, 855 
acute, 857 
albuminuria in, 861 
alcoholism and, 866 
amaurosis in, 865 
in Asiatic cholera, 867 
blood in, 864 
bowels in, 876 
Bowman's capsule in, 858 
bronchitis in, 870 
in chronic nephritis, 912 
complications of, 870 
convulsions in, 865 
diagnosis of, 870 
from chronic interstitial, 915 
parenchymatous, 871, 
883 
from congestion of kidney, 
870 
from cyclic albuminuria, 870 
from febrile albuminuria, 
870 
diet in, 874 
diuretics in, 876 
drugs in, 873 
dyspnoea in, 864 
elimination in, 876 
etiology of, 857 
fever in, 863. 
from cold, 865 
glomerulus in, 858 
headache in, 864 
hyposthenia in, 862 
interstitial tissue in, 859 
kidney in, 857 
malaise in, 865 
Malpighian bodies in, 858 
Nephritis, acute, milk in, 875 
nausea in, 863 
cedema in, 860 
pain in, treatment of, 879 
pathology of, 857 
pneumonia in, 870 
primary, 867 
prognosis of, 871 
pulse in, 863 
skin in, 864, 877 
sweats in, 877 
symptoms of, 860 
termination of, 871 
treatment of, 872 
tubules in, 859 ' 
types of, 860 
in typhoid fever, 867 
uremia in, 830, 903 
urine in, 861 
vomiting in, 863 
water in, 873, 875 
yellow atrophy of liver and, 850 
age and, 856 
burns and, 853 
cholera and, 849 
chorea and, 850 
chronic, arteriosclerotic form, 897 
chronic perihepatitis and, 489 
diffuse, 847 
diagnosis of, from chronic 
interstitial, 916 
from, chronic paren- 
chymatous, 885 
interstitial, 890 
acute nephritis in, 912 
alcoholism and, 891, 923 
amaurosis in, 910 
appetite in, 904 
arteries in, 898, 903 
arteriosclerosis and, 893 
blood in, 904 
pressure in, 903, 921, 
927 
bloodvessels in, 896 
breath in, 904 
bronchitis in, 905 
cardiac disease and, 893 
cardiovascular changes in, 
902 
cerebral hemorrhage in, 913 
Cheyne-Stokes respiration 
in, 905 
in childhood, 891 
climate in, 925 
coma in, 909 
complications of, 912 
treatment of, 930 
congenital, 891 
constipation in, 905 
convulsions in, 908 
diagnosis of, 913 
from acutenephritis,915, 
916 
from albuminuria, 916 
from amyloid kidney, 
916 
from anuria, 919 INDEX 
1069 
Nephritis, chronic interstitial,from arterio- 
sclerosis, 915 
diagnosis of, from brain 
tumor, 918 
from chronic diffuse, 916 
parenchymatous, 
885, 915 
from congestion of kid- 
ney, 914 
from cystic kidney, 918 
from diabetes, 917 
from diseases of heart, 
914 
from gastritis, 918 
from malignant disease, 
918 
from neuralgias, 918 
from neurasthenia, 918 
from prostatitis, 918 
from secondary con- 
traction, 916 
diarrhoea in, 905 
diet in, 922 
diplopia in, 910 
dyspnoea in, 905 
elimination in, 928 
epistaxis in, 906 
etiology of, 890 
exercise in, 925 
experimental, 894 
gastro-intestinal disturb- 
ances and, 892 
gout and, 891 
headache in, 908 
treatment of, 931 
heart in, 898, 902, 926 
hematoma in, 901 
hemorrhages in, 906 
heredity and, 891 
infectious diseases and, 892 
interstitial tissue in, 897 
kidney in, 895 
of pregnancy and, 893 
lead and, 891 
liver in, 899 
Malpighian bodies in, 896 
metabolism and, 892 
milk in, 922 
nausea in, 904 
nervous symptoms in, 907 
neuralgia in, 907 
oedema in, 907 
treatment of, 930 
onset of, 900 
pain in, 904, 907 
palsies in, 908 
pathology of, 895 
pigmentation in, 906 
polyuria in, 900 
primary, 895 
prognosis of, 919 
retina in, 910 
retinal hemorrhages in, 911 
secondary, 897 
skin in, 906 
stomatitis in, 904 
suprarenal gland in, 899 
Nephritis, chronic interstitial, symptoms 
of, 900 
toxemia in, 907 
treatment of, 921 
active, 922 
prophylactic, 921 
surgical, 931 
symptomatic, 930 
tubules in, 896 
uremia in, 903 
treatment of, 929 
uremic ulcers in, 899 
urine in, 900 
vomiting in, 904 
parenchymatous, 880 
albuminuria in, 882 
alcoholism and, 880 
bloodvessels in, 884 
casts in, 882 
cold and, 880 
complications of, 884 
cyanotic induration and, 880 
diagnosis of, 884 
from acute nephritis, 
874, 885 
from amyloid kidney, 
885 
from chronic intersti- 
tial, 885, 915 
from congestion of kid- 
ney, 885 
etiology of, 880 
gonococcus and, 880 
heart in, 884, 912 
infectious diseases and, 880 
intoxications and, 880 
Malpighian bodies in, 881 
oedema in, 883 
pathology of, 881 
prognosis of, 886 
secondary ' contraction in, 
882, 884 
symptoms of, 882 
treatment of, 886 
anemia in, 888 
diet in, 886 
salt in, 887 
sweats in, 888 
tapping in, 889 
water in, 887 
tuberculosis and, 880 
uremia in, 884 
urine in, 882 
circulation and, 780 
classification of, 778, 845 
cold and, 855 
diarrhoea and, 323 
diphtheria and, 849 
drugs and, 852 
dysentery and, 850 
erythema nodosum and, 850 
erysipelas and, 850 
etiology of, 848 
gout and, 854 
heredity and, 856 
infectious diseases and, 848, 866 
influenza and, 851 1070 
INDEX 
Nephritis, intestinal conditions and, 854 
jaundice and, 854 
kidney infections and, 952 
malarial fevers and, 850 
measles and, 849 
metabolism and, 854 
in nephroptosis, 756 
occupation and, 856 
pneumonia and, 849 
in portal cirrhosis of liver, 526 
pregnancy and, 856 
ptomaine poisoning and, 853 
purpura and, 850 
purulent, diagnosis of, 964 
pyemia and, 850 
rheumatic fever and, 850 
scarlet fever and, 849 
septicemia and, 850 
sera and, 852 
sex and, 856 
smallpox and, 849 
suppurative, 937 
pain in, 960 
prognosis of, 966 
symptoms of, 957 
traumatic, prognosis of, 966 
treatment of, 969 
urine in, 959 
syphilis and, 851 
tonsillitis and, 850 
toxins and, 852 
traumatic, urine in, 959 
tuberculosis and, 850 
typhoid fever and, 849 
typhus fever and, 849 
vaccinia and, 849 
varieties of, 779, 846 
x-rays and, 853 
yellow fever and, 850 
Nephrolithiasis, diagnosis of, from appen- 
dicitis, 380 
Nephrolysins, 834 
Nephroptosis, 750, 755 
age and, 751 
albuminuria in, 756 
appendicitis and, 757 
diagnosis of, 759 
Dietl's crises in, 756 
dilatation of stomach and, 756 
gastrectasia in, 757 
grades of, 751 
hematuria in, 756 
incidence of, 750 
kidney infections and, 952 
nausea in, 756 
nephritis in, 756 
pain in, 756 
pregnancy and, 751 
symptoms of, 756 
treatment of, 763 
tuberculosis of kidney and, 978 
urine in, 756 
vomiting in, 756 
Nervous anorexia, 157 
dyspepsia, 164 
diagnosis of, from atony of 
stomach, 162 
Nervous dyspepsia, diagnosis of, from 
dilatation of stomach, 261 
eructation, 141 
gastralgia, 135 
nausea, 146 
system, gastric ulcer and, 172 
in jaundice, 454 
in motor insufficiency of stomach, 
248 
in uremia, 835 
vomiting, 142 
Neuralgia in chronic interstitial nephritis, 
907 
diagnosis of, from chronic interstitial 
nephritis, 918 
intercostal, diagnosis of, from gas- 
tralgia, 136 
of intestines, 305 
ovarian, diagnosis of, from appen- 
dicitis, 381 
Neurasthenia, achylia gastrica and, 153 
cardiospasm and, 147 
in constipation, 315 
diagnosis of, from chronic interstitial 
nephritis, 918 
gastric, 164 
in mucous colitis, 439 
nervous anorexia and, 157 
dyspepsia and, 165 
in splanchnoptosis, 753, 754 
Neuroma, gangliated, of peritoneum, 731 
Neuropathic hematemesis, 282 
Neuroses, gastric, 106 
diagnosis of, from chronic gas- 
tritis, 244 
of oesophagus, 86 
polysymptomatic, 164 
Noma, 49 
Nutrition in carcinoma of stomach, 207 
in jaundice, 455 
O 
Obliterative tuberculosis of peritoneum, 
724 
Obstipation, 309 
Obstruction of intestine, 394 
Obturation of intestines, 394 
Occlusion of intestines, 394 
"Occult blood" in carcinoma of stomach, 
207, 211 
in gastric ulcer, 179 
tests for, 180 
Ochronosis, 817 
(Edema in acute nephritis, 860 
in amyloid kidney, 935 
angioneurotic, of mouth, 53 
in chronic interstitial nephritis, 907 
parenchymatous nephritis, 883 
perihepatitis, 492 
peritonitis, 720 
in cirrhosis of liver, 525 
in congestion of liver, 484 
in hypernephroma, 997 
in kidney of pregnancy, 868 
(Esophagitis, acute, 79 INDEX 
1071 
(Esophagitis, acute, diagnosis of, 82 
etiology of, 79 
pathology of, 79 
sequelae of, 82 
symptoms of, 81 
treatment of, 82 
chronic, 82 
pathology of, 82 
sequelae of, 83 
symptoms of, 83 
treatment of, 83 
corrosive, 81 
infective, 81 
phlegmonous, 80 
purulent, 80 
(Esophagus, actinomycosis of, 86 
auscultation of, 77 
carcinoma of, 98 
diagnosis of, 103 
from hematemesis, 282 
dysphagia in, 102 
etiology of, 99 
extension in, 101 
fixation of tongue in, 102 
Horner's complex in, 103 
pain in, 102 
pathology of, 99 
perforation in, 101 
prognosis of, 103 
site of, 100 
symptoms of, 102 
treatment of, 104 
congenital malformations of, 78 
description of, 76 
dilatation of, 90 
diagnosis of, 92 
etiology of, 90 
idiopathic, 85, 91 
prognosis of, 92 
symptoms of, 91 
treatment of, 92 
diseases of, 76 
diverticula of, 92 
breath in, 42, 94 
diagnosis of, 94 
etiology of, 92 
pathology of, 92 
pressure, 93 
symptoms of, 94 
traction, 93 
treatment of, 95 
vomiting in, 94 
examination of, 77 
bougies in, 77 
fluoroscope in, 78 
cesophagoscope in, 78 
sounds in, 77 
stomach tube in, 77 
herpes of, 90 
inflammation of, 79 
neuroses of, 86 
motor, 87 
diagnosis of, 89 
dysphagia in, 88 
dyspnoea in, 88 
etiology of, 87 
symptoms of, 88 
(Esophagus, neuroses of, motor, treat- 
ment of, 89 
sensory, 86 
diagnosis of, 87 
treatment of, 87 
non-malignant growths of, 105 
palpation of, 77 
paralysis of, 90 
percussion of, 77 
rupture of, 85 
sarcoma of, 105 
stenosis of, non-malignant, 96 
congenital, 96 
diagnosis of, 97 
etiology of, 96 
fibrous, 96 
prognosis of, 97 
sequelae of, 96 
symptoms of, 96 
treatment of, 97 
stricture of, non-malignant, 96 
syphilis of, 86 
tuberculosis of, 85 
ulcers of, 84 
decubitus, 84 
peptic, 84 
pressure, 84 
uremic, 84 
Oidium albicans, 46, 50 
Oliguria in tuberculosis of kidney, 982 
Omental cysts of peritoneum, 737 
Omentum, abscess of, 696 
inflammation of, 695 
tumors of, diagnosis of, from carci- 
noma of stomach, 218 
volvulus of, 418 
Oophoritis, diagnosis of, from appendicitis, 
381 
Oral sepsis, 41 
Oxalic acid calculus, origin of, 1015 
Oxaluria, 815 
diet in, 1025 
treatment of, 815 
Oxyuris vermicularis, appendicitis and, 
360 
Ovarian cyst, acute peritonitis and, 673 
diagnosis of, from ascites, 664 
from cyst of pancreas, 646 
neuralgia, diagnosis of, from appen- 
dicitis, 381 
P 
Pain in abscess of liver, 500 
in achylia gastrica, 154 
in acute cholecystitis, 564 
circumscribed peritonitis, 693 
dilatation of stomach, 251 
enteritis, 330 
gastritis, 228 
hepatitis, 495 
peritonitis, 678, 680 
yellow atrophy of Ever, 475 
in aneurism of hepatic artery, 459 
in appendicitis, 366 
in biliary cirrhosis of liver, 538 1072 
INDEX 
Pain in calculus of pancreas, 634 
in carcinoma of gall-bladder, 596 
of liver, 542 
of oesophagus, 102 
of pancreas, 651 
of prostate, 1038 
of stomach, 207 
in cardiospasm, 148 
in cholelithiasis, 576 
in cholera nostras, 331 
in chronic nephritis, 904, 907 
peritonitis, 715 
in cirrhosis of liver, 520 
of stomach, 277 
in colitis, 336 
in congestion of liver, 479, 484 
in constipation, 314 
in cysts of pancreas, 644 
in diarrhoea, 326 
in dilatation of stomach, 256 
in duodenal ulcer, 346 
in embryonic tumors of kidney, 1005 
in gall-stone colic, 576 
in gastric ulcer, 176 
in hemoperitoneum, 669 
in hemorrhagic necrosis of pancreas, 
616 
in hepatoptosis, 757 
in hyperacidity, 115 
in hypernephroma, 996 
in interstitial pancreatitis, 630 
in intestinal colic, 304 
indigestion, 301 
in intussusception, 411 
in mesenteric embolism, 435 
thrombosis, 435 
in nephroptosis, 756 
in nervous gastralgia, 135 
in obstruction of intestines, 397 
in paranephritis, 972 
in perforation of gastric ulcer, 187 
in phlegmonous gastritis, 232 
in pyelonephritis, 960 
in pyogenic infections of kidney, 959 
in pyonephrosis, 960 
in renal calculus, 1019 
in sarcoma of kidney, 1003 
in splanchnoptosis, 753 
in stenosis of pylorus, 270 
in subphrenic abscess, 707 
pyopneumothorax, 712 
in suppurative nephritis, 960 
pancreatitis, 624 
in toxic gastritis, 234 
in tuberculosis of kidney, 985 
of peritoneum, 725 
in ulcer of intestines, 353 
in volvulus, 414 
Palate, soft, paralysis of, 62 
tuberculosis of, 57 
Palsies in chronic interstitial nephritis, 908 
Pancreas, abscess of, calculus and, 635 
subphrenic abscess and, 701 
acute dilatation of stomach and, 251 
adenoma of, 649 
arteriosclerosis of, 605 
calculus of, 632 
Pancreas, calculus of, abscess of pancreas 
in, 635 
azotorrhcea in, 635 
carcinoma of pancreas and, 636 
colic in, 634- 
complications of, 635 
diabetes mellitus in, 635 
diagnosis of, 636 
from biliary colic, 636 
etiology of, 632 
glycosuria in, 635 
jaundice in, 635 
loss of weight in, 635 
pain in, 634 
pathology of, 633 
steatorrhoea in, 635 
symptoms of, 634 
treatment of, 636 
carcinoma of, 648 
calculus of pancreas and, 636 
constipation in, 651 
diabetes mellitus in, 650, 652 
diagnosis of, 653 
from cholelithiasis, 653 
* diarrhoea in, 651 
fatty stools in, 651 
gall-bladder in, 652 
glycosuria in, 652 
incidence of, 648 
jaundice in, 650, 652 
liver in, 652 
pain in, 651 
pathology of, 649 
secondary, 648 
symptoms of, 650 
treatment of, 654 
tumor in, 651 
vomiting in, 651 
cyst of, 637 
ascites in, 645 
classification of, 637 
contents of, 642 
diabetes mellitus and, 645 
diagnosis of, 645 
from aortic aneurism, 647 
from cholecystitis, 646 
from cysts of mesentery, 646 
from echinococcus cysts, 646 
from hydronephrosis, 646 
from ovarian cysts, 646 
etiology of, 640 
jaundice in, 645 
loss of weight in, 645 
necrosis of pancreas and, 619 
pain in, 644 
pathology of, 640 
position of, 638 
proliferation, 641 
pressure signs of, 644 
pseudocysts, 637 
relations of, 643 
retention, 640 
steatorrhoea in, 645 
symptoms of, 643 
traumatic, 641 
treatment of, 647 
true, 637 INDEX 
1073 
Pancreas, cyst of, tumor in, 643 
disappearance of, 644 
descent of, 758 
diseases of, 599 
azotorrhcea in, 602 
diabetes mellitus and, 604 
feces in, 600, 602 
glycosuria and, 604, 606 
metabolic function and, 604 
pancreatic secretion and, 599 
pathology of, 599 
steatorrhoea in, 599 
symptoms of, 599 
displaced, incidence of, 752 
fat necrosis and, 606 
gangrene of, 615 
hemorrhagic necrosis of, 610 
bacteria and, 612 
cholelithiasis and, 613 
complications of, 619 
constipation in, 617 
course of, 615 
cysts of pancreas in, 619 
diabetes mellitus in, 619 
diagnosis of, 620 
from biliary colic, 620 
from ruptured aneur- 
ism, 620 
from suppurative pan- 
creatitis, 626 
duodenitis and, 612 
etiology of, 611 
feces in, 617 
fever in, 617 
gangrene in, feces in, 618 
fever in, 618 
glycosuria in, 619 
jaundice in, 619 
leukocytosis in, 618 
of pancreas and, 615 
tumor in, 618 
gastritis and, 612 
glycosuria in, 617 
jaundice and, 612, 616, 617 
leukocytosis in, 617 
nausea in, 616 
necrotic stage of, 616 
onset of, 616 
operation in, 621 
pain in, 616 
pathogenesis of, 614 
pathology of, 614 
perforation of colon in, 619 
of duodenum in, 619 
of stomach in, 619 
pregnancy and, 612 
sequelae of, 619 
shock in, 616 
splenic thrombosis in, 619 
symptoms of, 615 
treatment of, 621 
urine in, 617 
vomiting in, 616 
sarcoma of, 650 
syphilis of, 632 
tuberculosis of, 631 
Pancreatic apoplexy, 610 
vol. in-68 
Pancreatic juice, ferments of, 289 
secretion of, 288 
Pancreatitis, acute, diagnosis of, from 
acute peritonitis, 688 
from appendicitis, 379 
from duodenal ulcer, 348 
from obstruction of intes- 
tines, 401 
chronic interacinar, 629 
interlobular, 629 
interstitial, 626 
alcoholism and, 628 
cholelithiasis and, 627 
diabetes mellitus and, 630 
etiology of, 627 
glycosuria in, 630 
hemochromatosis and, 630 
pain in, 630 
pathology of, 628 
symptoms of, 630 
vomiting in, 630 
experimental, 612 
suppurative, 622 
bacteriology of, 623 
collapse in, 624 
constipation in, 624 
diagnosis of, 625 
from hemorrhagic necrosis, 
626 
diarrhoea in, 624 
emaciation in, 625 
etiology of, 623 
fever in, 624 
glycosuria in, 625 
jaundice in, 624 
leukocytosis in, 625 
onset of, 624 
pain in, 624 
pathology of, 623 
peritonitis in, 625 
sequelae of, 625 
symptoms of, 624 
treatment of, 626 
tumor in, 624 
vomiting in, 624 
traumatic, 612 
Papillary cyst adenoma of kidney, 1002 
Papillitis lingualis, 62 
Paracentesis abdominis, 667 
in cirrhosis of liver, 524, 534 
Paragusia, 43 
Paralysis of bladder, kidney infections 
and, 952 
of intestines in acute peritonitis, 681 
obstruction from, 418 
of oesophagus, 90 
of soft palate, 62 
of tongue, 62 
in uremia, 836 
Paranephric abscess, 970 
Paranephritis, 970 
constipation in, 972 
course of, 972 
diagnosis of, 973 
etiology of, 970 
fever in, 972 
pain in, 972 1074 
INDEX 
Paranephritis, pathology of, 971 
prognosis of, 973 
swelling in, 972 
symptoms of, 972 
treatment of, 973 
in tuberculosis of kidney, 980 
urine in, 972 
vomiting in, 972 
Parasites, appendicitis and, 360 
kidney infections and, 952 
Parasitic cysts of peritoneum, 733 
Parenchymatous changes in kidney, 774 
degeneration of liver, 466 
hepatitis, 494 
Parorexia, 134 
Parotid gland, inflammation of, 69 
Parotitis, acute, 69 
chronic, 69 
gastric ulcer and, 189 
in subphrenic pyopneumothorax, 712 
Pebble calculus, 1009 
Pelvic peritonitis, kidney infections and, 
952 
Pelvis of kidney, tumors of, 1006 
Pemphigus of mouth, 54 
Pentosuria, 822 
Peptic ulcer, 168 
jejunal, 349 
of oesophagus, 84 
Peptonuria, 820 
Perforation in duodenal ulcer, 347 
Periappendicular abscess, 364, 370, 377 
rupture of, into bladder, 365 
into cecum, 365 
into uterus, 365 
peritonitis from, 365 
through abdominal wall, 
365 
Pericarditic pseudocirrhosis of liver, 488, 
716 
Pericarditis, chronic perihepatitis and, 492 
peritonitis and, 716 
in uremia, 839 
Pericholecystic adhesions, cholelithiasis 
and, 583 
Pericolic abscesses, 697 
diagnosis of, 698 
subphrenic abscess and, 701 
symptoms of, 698 
treatment of, 698 
Pericolitis, 354 
acute, 694 
etiology of, 694 
symptoms of, 695 
treatment of, 695 
diagnosis of, 355 
etiology of, 354 
pathology of, 354 
sinistra, 355, 695 
symptoms of, 355 
treatment of, 355 
Perigastric abscess, 696 
diagnosis of, 697 
etiology of, 697 
signs of, 697 
symptoms of, 697 
adhesions in stenosis of pylorus, 262 
Perigastritis, diagnosis of, from carcinoma 
of stomach, 217 
in gastric ulcer, 815 
Perihepatitis, 486 
acute, 486 
ascites in, 487 
diagnosis of, 487 
etiology of, 486 
hiccough in, 487 
pain in, 487 
pathology of, 486 
prognosis of, 487 
symptoms of, 487 
treatment of, 487 
vomiting in, 487 
chronic, general, 488, 718 
abdomen in, 491 
ascites in, 491 
chronic nephritis and, 489 
diagnosis of, 492 
from cirrhosis, 493 
from malignant disease, 
493 
from syphilis, 493 
from tubercidous peri- 
tonitis, 493 
etiology of, 488 
infections and, 489 
liver in, 490, 492 
oedema in, 492 
pathology of, 489 
pericarditis in, 492 
pleuritis in, 492 
prognosis of, 493 
symptoms of, 491 
syphilis and, 489 
treatment of, 493 
urine in, 492 
hyperplastic, 488 
local, 488 
deforming, 488 
hyaline, 488 
Perimesosigmoiditis, 715 
Perinephric abscess, 970 
Perinephritis, 970 
diagnosis of, from hypernephroma, 
999 
in tuberculosis of kidney, 980 
Periodical vomiting, 144 
Periodontitis, 56 
Periostitis alveolaris dentalis, 56 
Perisigmoiditis, 695 
Peristalsis in cirrhosis of stomach, 277 
in intestinal colic, 304 
of intestines, 286 
increased, 288 
pathological, 287 
in stenosis of pylorus, 271 
Peristaltic unrest, 151 
Peritoneal abscesses, 698 
Peritoneum, absorption from, 655 
angioma of, 733 
in cirrhosis of liver, 518 
comparison of, with other serous 
membranes, 656 
cysts of, 733 
conditions simulating, 740 INDEX 
1075 
Peritoneum, cysts of, cysticercus cellu- 
losae, 736 
dermoid, 739 
hydatid, 733 
clinical aspects of, 735 
diagnosis of, 735 
pathology of, 734 
treatment of, 735 
mesenteric, 736 
pathology of, 736 
signs of, 737 
symptoms of, 737 
omental, 737 
diagnosis of, 738 
symptoms of, 737 
retroperitoneal, 739 
sanguineous, 738 
urachal, 739 
treatment of, 740 
diseases of, 655 
hemorrhage into, diagnosis of, from 
acute peritonitis, 688 
fibroma of, 730 
treatment of, 731 
fibromyoma of, 730 
gangliated neuroma of, 731 
immunity of, 657 
lipoma of, 732 
diagnosis of, 733 
etiology of, 732 
prognosis of, 733 
signs of, 732 
symptoms of, 733 
treatment of, 733 
myoma of, 730 
myxoma of, 733 
pseudomyxoma of, 740 
retroperitoneal hematoma of, 738 
tuberculosis of, 720 
abdomen in, 724 
adhesive, 724 
age and, 721 
alcoholism and, 721 
ascitic, 723, 724 
bacteriology of, 721 
blood in, 726 
chronic fibroid, 724 
cirrhosis of liver and, 526, 721 
complications of, 726 
diagnosis of, 727 
from carcinoma of stomach, 
218 
from cirrhosis of liver, 528, 
727 
from perihepatitis, 493 
from tumor, 727 
from typhoid fever, 727 
encysted, 723, 725 
etiology of, 721 
feces in, 726 
fever in, 726 
incidence of, 721 
jaundice in, 726 
leukocytosis in, 726 
liver in, 726 
loculated, 723, 725 
obliterative, 724, 725 
Peritoneum, tuberculosis of, onset of, 724 
pain in, 725 
pathology of, 722 
paths of infection in, 722 
pregnancy and, 721 
prognosis of, 728 
sex and, 721 
spleen in, 726 
symptoms of, 724 
treatment of, 729 
urine in, 726 
tumors of,/730 
diagnosis of, from carcinoma of 
stomach, 218 
from cirrhosis of liver, 528 
from tuberculosis, 727 
malignant, 740 
primary, 741 
diagnosis of, 743 
etiology of, 742 
pathology of, 741 
signs of, 742 
treatment of, 744 
secondary, 744 
diagnosis of, 746 
pathology of, 744 
prognosis of, 746 
signs of, 745 
symptoms of, 745 
treatment of, 746 
non-malignant, 730 
Peritonitis, acute circumscribed, 693 
non-suppurative, 693 
pain in, 694 
symptoms of, 694 
treatment of, 694 
diffuse, 670 
abdomen in, 678, 680 
abscess and, 673 
age and, 673 
bacillus acrogenes capsula- 
tus in, 676 
coli in, 674 
pyocyaneus in, 675 
typhosus in, 675 
bacteriology of, 674 
blood in, 683 
cultures in, 684 
collapse in, 678 
constipation in, 682 
cytology in, 677 
diagnosis of, 687 
age in, 689 
from acute pancreatitis, 
688 
from Addison's disease, 
689 
from appendicitis, 381 
from hemorrhage into 
peritoneum, 688 
from intestinal obstruc- 
tion, 688 
from pneumonia, 688 
from pernicious malaria, 
689 
from pleursy, 688 
from tympanites, 688 1076 
INDEX 
Peritonitis, acute diffuse, diagnosis of, 
from uremia, 689 
history in, 689 
sex in, 689 
diseases of appendix and, 
672 
of colon and, 673 
of gall-bladder and, 673 
of intestines and, 672 
of liver and, 673 
of mesenteric glands 
and, 673 
of spleen and, 673 
of stomach and, 672 
distension in, 681 
duration of, 684 
etiology of, 671 
facies in, 679 
fever in, 683 
hiccough in, 682 
histology of, 677 
intestinal paralysis in, 681 
onset in, 679 
ovarian cysts and, 673 
pain in, 678, 680 
pathogeny of, 671 
pathology of, 675 
percussion in, 681 
perforation of uterus and, 
673 
position in, 679 
primary, 671 
prognosis of, 690 
pulse in, 678, 683 
pyosalpinx and, 673 
respiration in, 682 
rigors in, 682 
secondary, 672 
sequelae of, 678 
sex and, 673 
staphylococcus epidermidis 
albus in, 674 
pyogenes albus in, 674 
aureus in, 675 
streptococcus pyogenes in, 
674 
symptoms of, 678 
tenderness in, 680 
thirst in, 679 
treatment of, 691 
medical, 692 
prophylactic, 691 
serum, 693 
surgical, 691 
transfusion in, 692 
urine in, 684 
vomiting in, 678, 682 
in appendicitis, 364, 372, 374 
ascites and, 659 
chronic, adhesions in, 718 
appendicitis and, 714 
ascites and, 658 
cholecystitis and, 714 
constipation in, 715 
diffuse, 715 
duodenal ulcer and, 714 
gastric ulcer and, 714 
Peritonitis, chronic, gonococcic infections 
and, 714 
jaundice in, 714 
localized, 714 
bands from, 715 
mesenteric, 715 
pain in, 715 
puerperal infection and, 714 
simple, 713 
abdomen in, 719 
age in, 719 
alcoholism and, 717 
arteriosclerosis and, 716 
ascites in, 720 
bacillus coli in, 717 
typhosus in, 717 
classes of, 715 
constipation in, 720 
diagnosis of, 720 
gall-bladder in, 719 
liver in, 718 
oedema in, 720 
onset of, 719 
pathogeny of, 717 
pathology of, 717 
pericarditis and, 716 
pleuritis and, 716 
prognosis of, 720 
respiration in, 720 
sex in, 719 
spleen in, 718 
symptoms of, 719 
syphilis of liver and, 717 
treatment of, 720 
tuberculosis and, 717 
symptoms of, 714 
deformans, 718 
fibrosa, 718 
gonococcic, 686 
from intussusception, 410 
pelvic, kidney infections and, 952 
pneumococcic, 685 
prognosis of, 686 
symptoms of, 685 
progressive fibrinopurulent, 676 
puerperal, 686 
in suppurative pancreatitis, 625 
tuberculous, 720. See Peritoneum, 
tuberculosis of. 
Perityphlitis, 355 
Periureteritis, 974 
course of, 974 
diagnosis of, 975 
kidney infections and, 952 
in pyelitis, 954 
symptoms of, 974 
treatment of, 975 
Pernicious anemia, mouth in, 55 
pigmentation of liver and, 471 
malaria, diagnosis of, from acute 
peritonitis, 689 
Petechiae in toxic gastritis, 234 
Phantom tumor, 299 
Phimosis, kidney infections and, 952 
Phlebitis, suppurative, of hepatic veins, 460 
Phlegmonous cholecystitis, 563 
oesophagitis, 80 INDEX 
1077 
Phosphaturia, 814 
Phosphorus poisoning, acute yellow 
atrophy of liver and, 473 
diagnosis of, from acute yellow 
atrophy of liver, 476 
Pick's disease, 488, 716 
Pleural effusion, diagnosis of, from sub- 
phrenic abscess, 708 
Pleuritis, chronic perihepatitis and, 492 
peritonitis and, 716 
in cirrhosis of liver, 526 
diagnosis of, from acute peritonitis, 
688 
in subphrenic pyopneumothorax, 712 
Pneumatosis, 150 
diagnosis of, 151 
etiology of, 150 
symptoms of, 150 
treatment of, 151 
Pneumaturia, 806 
Pneumococcus, peritonitis from, 685 
Pneumokoniosis, cirrhosis of liver and, 510 
Pneumonia, diagnosis of, from acute peri- 
tonitis, 688 
from appendicitis, 379 
nephritis and, 849 
Poisoning, chloroform,acute yellow atrophy 
of liver and, 473 
phosphorus, acute yellow atrophy of 
liver and, 473, 476 
Polycystic disease of kidney, diagnosis of, 
from hypernephroma, 1000 
Polyorrhymenitis, 488 
Polyphagia, diagnosis of, from acoria, 157 
Polyps of appendix, 386 
Polysymptomatic neuroses, 164 
Polyuria, 791, 806 
in chronic interstitial nephritis, 900 
pyelitis, 961 
Portal circulation, biliary infections 
through, 550 
cirrhosis of liver, 508 
diagnosis of, from biliary 
cirrliosis, 539 
from carcinoma 545 
pyemia, 463 
vein, abscess of liver and, 497 
diseases of, 460 
embolism of, 463 
perforation of, in gastric ulcer, 
186 
thrombosis of, 460 
ascites in, 462, 659 
diagnosis of, 462 
from cirrhosis of liver, 
528 
diarrhoea in, 462 
enlargement of spleen in, 
462 
etiology of, 460 
hematemesis in, 462 
intestinal hemorrhage in, 
462 
obstruction in, 462 
liver in, 462 
prognosis of, 463 
pathology of, 461 
Portal vein, thrombosis of, symptoms of, 
462 
treatment of, 463 
vomiting in, 462 
Pregnancy, acute yellow atrophy of liver 
and, 472 
cholelithiasis and, 571 
kidney of, 867 
chronic nephritis and, 893 
infections and, 952 
mouth in, 56 
necrosis of pancreas and, 612 
nephritis and, 856 
pyelitis of, prognosis of, 965 
symptoms of, 961 
treatment of, 968 
pyelonephritis of, symptoms of, 961 
tuberculosis of kidney and, 978 
of peritoneum and, 721 
Pressure ulcers of oesophagus, 84 
Proliferation cysts of pancreas, 641 
Prostate, carcinoma of, 1038 
diagnosis of, 1039 
hematuria in, 1038 
pain in, 1038 
pathology of, 1038 
symptoms of, 1038 
treatment of, 1039 
diseases of, 1026 
hypertrophy of, 1035 
kidney infections and, 952 
results of, 1035 
symptoms of, 1036 
treatment of, 1036 
surgical, 1037 
Prostatitis, chronic, 1032 
diagnosis of, 1032 
from nephritis, 918 
pain in, 1032 
signs of, 1033 
symptoms of, 1032, 1034 
treatment of, 1034 
Proteins in urine, 818 
Protozoa, diarrhoea and, 325 
Pruritus in catarrhal cholangeitis, 553 
in jaundice, 452 
Pseudocirrhosis, pericardial, 488, 716 
Pseudomembranous pyelitis, 954 
Pseudomyxoma of peritoneum, 740 
Pseudoperforation of gastric ulcer, 188 
Psilosis, 393 
Psoriasis linguae, 64 
of mouth, 53 
Psychic vomiting, 144 
Psychoneuroses, digestion and, 37 
Ptomaine poisoning, nephritis and, 853 
Ptyalism, 68 
Puerperal eclampsia, acute yellow atrophy 
of liver and, 473 
infections, chronic peritonitis and, 714 
peritonitis, 686 
Purpura, nephritis and, 850 
Pus in carcinoma of intestines, 430 
of stomach, 207 
cells in tuberculosis of kidney, 984 
Pyelitis, 937 
acute catarrhal, 953 1078 
INDEX 
Pyelitis, acute, chills in, 961 
diagnosis of, 964 
from appendicitis, 380 
diarrhoea in, 961 
fever in, 961 
nausea in, 961 
prognosis of, 965 
pulse in, 961 
swelling in, 960 
symptoms of, 957 
treatment of, 967 
urine in, 958 
vomiting in, 961 
age and, 953 
bacteriology of, 947, 950 
in children, symptoms of, 961 
chronic, 954 
diarrhoea in, 961 
fever in, 961 
polyuria in, 961 
prognosis of, 965 
pulse in, 961 
swelling in, 960 
symptoms of, 957 
treatment of, 968 
tuberculosis of kidney and, 978 
urine in, 958 
croupous, 954 
cystic, 954 
diagnosis of, from tuberculosis of 
kidney, 989 
diphtheritic, 954 
etiology of, 949 
fibrinous, 954 
gangrenous, 954 
granular, 954 
pathology of, 953 
periureteritis in, 954 
of pregnancy, prognosis of, 965 
symptoms of, 961 
treatment of, 968 
pseudomembranous, 954 
simple, prognosis of, 965 
treatment of, 966 
ureter in, 954 
ureteritis in, 954 
Pyemia, nephritis and, 850 
portal, 463 
Pyelonephritis, 937 
age and, 953 
albuminuria in, 958 
ascending, pathology of, 955 
bacteriology of, 947, 950 
diagnosis of, 964 
from tuberculosis of kidney, 
989 
etiology of, 949 
pain in, 960 
of pregnancy, symptoms of, 961 
treatment of, 968 
suppurative, 937 
swelling in, 960 
treatment of, 967 
urine in, 958 
Pyelonephrosis, 937 
Pylephlebitis, suppurative, 463 
diagnosis of, 464 
Pylephlebitis, suppurative, diagnosis of, 
from suppurative cholangeitis, 
.558 
diarrhoea in, 464 
hematemesis in, 464 
pathology of, 464 
prognosis of, 464 
symptoms of, 464 
treatment of, 465 
vomiting in, 464 
Pylorospasm, 149, 262 
acute dilatation and, 25 
congenital, 269 
hypertrophic stenosis of pylorus 
and, 269 
diagnosis of, 150 
from carcinoma of stomach, 219 
from hypertrophic stenosis of 
pylorus, 271 
etiology of, 149 
gastrosuccorrhoea in, 150 
symptoms of, 149 
tetany in, 150 
treatment of, 150 
vomiting in, 149 
Pylorus, incontinence of, 159 
stenosis of, 262 
benign, 260 
from carcinoma of stomach, 263 
cicatricial, 262 
dilatation of stomach and, 260 
from external pressure, 262 
foreign bodies and, 263 
gastric ulcer and, 189 
hypertrophic, 263 
congenital, 269 
diagnosis of, 271 
from atresia of 
intestine, 271 
from congenital 
atresia, 271 
from gastritis, 271 
from habit vomit- 
ing, 271 
from pylorospasm, 
271 
from regurgitation, 
271 
from stenosis of 
duodenum, 271 
dilatation in, 271 
hypertrophy and, 269 
pain in, 270 
pathology of, 269 
pathogenesis of, 269 
peristalsis in, 271 
prognosis of, 271 
pylorospasm and, 269 
signs in, 270 
symptoms of, 270 
synonyms of, 269 
treatment of, 272 
tumor in, 271 
vomiting in, 270 
perigastric adhesions in, 262 
ulcer of, diagnosis of, from carcinoma 
of stomach, 217, 219 INDEX 
1079 
Pylorus, ulcer of, varieties of, 262 
diagnosis of, 261 
Pyogenic infections of kidney, 937 
Pyonephrosis, diagnosis of, 965 
from hypernephroma, 999 
pain in, 960 
prognosis of, 966 
renal calculus and, 1018 
swelling in, 960 
symptoms of, 957 
urine in, 959 
Pyorrhoea alveolaris, 56 
diagnosis of, 56 
treatment of, 57 
Pyopneumothorax, subphrenic, 710 
Pyrosis in acute gastritis, 228 
Pyuria, 805 
tests for, 805 
R 
Ranula, 52 
pancreatica, 640 
Rectum, injuries of, kidney infections and, 
952 
Reflex vomiting, 145 
Regurgitation, gastric, 140. See Gastric 
regurgitation. 
Renal arteries, anomalies of, 786 
calculus, 1007. See Calculus, renal. 
diagnosis of, from hyperneph- 
roma, 999 
casts, 798 
colic, diagnosis of, from appendicitis, 
380 
from obstruction of intes- 
tines, 401 
renal calculus and, 1019 
pelvis, empyema of, 937 
suppuration, diagnosis of, 964 
vessels, thrombosis of, 789 
Residual peritoneal abscesses, 698 
Respiration in chronic peritonitis, 720 
Respiratory system in uremia, 839 
Retina in chronic interstitial nephritis, 910 
Retinal hemorrhages in chronic interstitial 
nephritis, 911 
Retinitis, albuminuric, 911 
Retrogressive disorders of liver, 465 
Retroperitoneal abscesses, 698 
subphrenic abscess and, 701 
symptoms of, 699 
treatment of, 699 
cysts of peritoneum, 738 
hematoma, 738 
sarcoma, 742 
Rhabdomyoma of kidney, diagnosis of, 
from hypernephroma, 1000 
Rheumatic fever, nephritis and, 850 
Rhythmic segmentation of intestines, 286 
Riga's disease, 66 
Rigg's disease, 56 
Rigors in acute peritonitis, 682 
Round ulcer, 168 
Rumination, 138 
Rupture of oesophagus, 85 
s 
Saliva, chorda, 67 
composition of, 67 
paralytic, 67 
secretion of, 67 
sympathetic, 67 
Salivary calculi, 71 
etiology of, 71 
symptoms of, 71 
treatment of, 72 
gland, atrophy of, 74 
diseases of, 39, 67 
enlargement of, 73 
stone in, 71 
swelling of, 70 
syphilis of, 71 
tuberculosis of, 70 
tumors of, 72 
treatment of, 73 
secretion, absence of, 68 
diminution of, 68 
increase of, 68 
Salivation, 48, 68 
in children, 68 
Salpingitis, diagnosis of, from appendicitis, 
381 
Sand, intestinal, 295 
Sanguineous cysts of peritoneum, 738 
Sarcinse in carcinoma of stomach, 213 
Sarcoma of appendix, 387 
of intestines, 431 
of kidney, 1003 
diagnosis of, from hyperneph- 
roma, 1000 
of liver, 546 
of oesophagus, 105 
of pancreas, 650 
retroperitoneal, 742 
Scarlet fever, nephritis and, 849 
Scleroderma of mouth 54, 60 
Scurvy, mouth in, 55 
Secretion, 19, 30, 290 
disharmony in, 33 
false combinations of, 33 
of saliva, 67 
Sedentary life, constipation and, 313 
Sensation, oral, disturbances of, 43 
Sepsis, oral, 41 
Septicemia in appendicitis, 372 
breath in, 42 
nephritis and, 850 
Septicopyemia, acute yellow atrophy of 
liver and, 473 
Septicopyemic abscess of liver, 499 
Sera, nephritis and, 852 
Serositis, multiple, 488 
Serum test in carcinoma of stomach, 215 
Shock in necrosis of pancreas, 616 
Sialodochitis fibrinosa, 70 
Sialorrhoea, 35, 68 
Sialosis, 68 
Silicosis, hepatic, 470 
Sitophobia, 158 
etiology of, 159 
in nervous dyspepsia, 165 
symptoms of, 159 1080 
INDEX 
Skiagraphic findings in constipation, 313 
Skin in acute nephritis, 864 
catarrhal cholangeitis, 553 
in chronic interstitial nephritis, 906 
in jaundice, 451 
Smallpox, nephritis and, 849 
Smoker's patch, 64 
Spasm of pylorus, diagnosis of, from car- 
cinoma of stomach, 219 
of tongue, 62 
Spastic constipat ion, 313 
Spine, deformities of, acute dilatation of 
stomach and, 251 
tuberculosis of, subphrenic abscess 
and, 701 
Spirochetes in, mouth, 41 
Splanchnoptosis, 747 
abdomen in, 753 
age in, 751 
belt test in, 753 
cachectic, 754 
constipation in, 753 
diagnosis of, 758 
digestion and, 35 
etiology of, 748 
frequency of, 750 
gastro-intest inal, 754 
hepatic, 754 
incidence of, 750 
indigestion in, 753 
lithemic, 754 
neurasthenia in, 753, 754 
pain in, 753 
pathogenesis of, 748 
pregnancy and, 751 
prognosis of, 760 
symptoms of, 753 
treatment of, 760 
general, 761 
mechanical, 762 
medical, 762 
operative, 763 
prophylactic, 760 
vomiting in, 753 
Spleen in abscess of liver, 502 
abscess of, subphrenic abscess and, 
700 
in acute hepatitis, 495 
yellow atrophy of liver, 476 
in amyloid kidney, 935 
liver, 469 
in carcinoma of liver, 544 
in catarrhal cholangeitis, 554 
in chronic peritonitis, 718 
in cirrhosis of liver, 517, 523, 538 
descent of, 758 
diagnosis of, 760 
diseases of, acute peritonitis and, 
673 
enlargement of, diagnosis of, from car- 
cinoma of stomach, 219 
in thrombosis of portal vein, 
462 
movable, diagnosis of, from obstruc- 
tion of intestines, 401 
incidence of, 752 
.in tuberculosis of peritoneum, 726 
Splenic anemia, diagnosis of, from cirrhosis 
of liver, 528 
vein, thrombosis of, in necrosis of 
pancreas, 619 
Sprue, 393 
diarrhoea in, 393 
etiology of, 393 
mouth in, 393 
pathology of, 393 
prognosis of, 394 
symptoms of, 393 
treatment of, 394 
Staghorn calculus, 1009 
Staphylococcus epidermidis albus in acute 
peritonitis, 674 
pyogenes albus in acute peritonitis, 
674 
aureus in acute peritonitis, 675 
in mouth, 40 
Steapsin, 289 
Steatorrhoea in calculus of pancreas, 635 
in cyst of pancreas, 645 
in diseases of pancreas, 599 
feces in, 600 
Stenosis, cardiac, gastric ulcer and, 189 
of duodenum, 262 
of intestine, congenital, obstruct ion 
from, 408 
of oesophagus, congenital, 96 
fibrous, 96 
non-malignant, 96 
pyloric, dilatation of stomach and, 
260 
gastric ulcer and, 189 
of pylorus, 262 
congenital hypertrophic, 269 
Stenosing tuberculosis of intestines, 390 
Stercoral ulcers, 351 
Stomach, anacidity of, 153. See Achylia 
gastrica. 
atony of, 160 
appetite in, 161 
breath in, 42 
cholelithiasis and, 161 
constipation in, 161 
gastric contents in, 162 
diagnosis of, 162 
from gastrectasis, 162 
from hyperacidity, 117 
from nervous dyspepsia, 162 
enteroptosis in, 162 
etiology of, 160 
gastroptosis in, 612 
prognosis of, 162 
treatment of, 163 
vertigo in, 162 
carcinoma of, 199 
acetic acid in, 211 
adenitis in, 208 
adenocarcinamatous, 203 
age in, 200 
albumoses in, 207 
alcoholism and, 201 
amoebae in, 213 
anemia in, 208 
anorexia in, 205 
auscultation in, 209 INDEX 
1081 
Stomach, carcinoma of, auto-inoculation 
and, 201 
blood stream in, 204 
Boas-Oppler bacillus in, 212 
bowels in, 207 
butyric acid in, 211 
colloid, 203 
course of, 219 
diagnosis of, 213 
from achylia gastrica, 155 
from atrophy, 217 
from carcinoma of duo- 
denum, 217 
of liver, 218 
from chronic gastritis, 216, 
244 
from cirrhosis of liver, 528 
from disease of pancreas, 
218 
from gastralgia, 136 
from gastric ulcer, 184 
from nervous dyspepsia, 166 
from perigastritis, 217 
from spasm of pylorus, 219 
from stenosis of pylorus, 
263 
from tuberculosis of peri- 
toneum, 218 
from tumors of colon, 218 
of gall-bladder, 218 
of omentum, 218 
of peritoneum, 218 
from ulcer of pylorus, 217, 
219 
serum test in, 215 
of tumor, 214 
x-rays in, 215 
dissemination of, 203 
duration of, 219 
etiology of, 200 
extension of, 203 
ferments in, 211 
fever in, 208 
functional signs of, 210 
gastrectomy in, 224 
gastric analysis in, 210 
disease and, 200 
rigidity in, 209 
ulcer and, 188, 200 
hematemesis in, 206, 284 
heredity in, 200 
incidence of, 199 
inflation in, 209 
inspection in, 208 
lactic acid in, 211 
latent, 205 
lymphatics in, 204 
medullary, 203 
megastoma entericum in, 213 
metastases in, 204 
motor insufficiency in, 210 
mucosa in, 202 
multiple, 202 
nutrition in, 207 
"occult blood" in, 207, 211 
onset of, 205 
pain in, 207 
Stomach, carcinoma of, pain in, treatment 
of, 223 
palpation in, 209 
pathology of, 201 
percussion in, 209 
prognosis of, 221 
pus in, 207 
race in, 200 
sarcinae in, 213 
scirrhus, 203 
secondary, 201 
secretory power in, 210 
sex in, 200 
simplex, 203 
site of, 201 
squamous-celled, 203 
stomach contents in, 212 
symptoms of, 205 
trauma and, 201 
treatment of, 221 
medical, 221, 222 
palliative, 225 
results of, 225 
surgical, 223 
trichomonas in, 213 
urine in, 207 
vomiting in, 206 
cardia of, carcinoma of, diagnosis of, 
220 
symptoms of, 220 
treatment of, 221 
spasm of, 147. See Cardiospasm. 
cirrhosis of, 241, 273 
abdomen in, 277 
ascites in, 278 
circumscribed, 276 
course of, 278 
definition of, 273 
diagnosis of, 278 
from syphilis, 278 
histology of, 276 
history of, 273 
jaundice in, 278 
lymphatics in, 276 
mucosa in, 275 
muscularis in, 275 
nomenclature of, 273 
pain in, 277 
pathogenesis of, 274 
pathology of, 275 
peristalsis in, 277 
sex in, 274 
symptoms of, 277 
treatment of, 279 
tumor in, 277 
vomiting in, 277 
dilatation of, acute, 24, 248 
cardiospasm and, 251 
constipation in, 252 
debilitating conditions in, 
249 
deformities of spine and, 
251 
diagnosis of, 252 
dietetic errors and, 251 
dyspnoea in, 251 
etiology of, 249 1082 
INDEX 
Stomach, dilatation of, acute, kidney and, 
251 
lavage in, 252 
operations and, 249 
pain in, 251 
pancreas and, 251 
pathology of, 251 
prognosis of, 252 
pylorospasm and, 251 
signs in, 252 
symptoms of, 251 
traction on duodenum and, 
250 
trauma in, 249 
treatment of, 252 
urine in, 252 
vomiting in, 251 
chronic, 253 
auscultation in, 259 
benign pyloric stenosis in, 
260 
course of, 263 
diagnosis of, 261 
from chronic gastritis, 
261 
from dilated colon, 261 
from gastric crises, 261 
from gastroptosis, 261 
from hypersecretion, 
261 
from nervous dyspepsia, 
261 
palpation in, 259 
percussion in, 259 
prognosis of, 264 
prophylaxis in, 264 
stomach contents in, 259 
treatment of, 265 
diet in, 265 
drugs in, 267 
electricity in, 267 
hydrotherapy in, 267 
mechanical, 266 
surgical, 268 
vomiting in, treatment of, 
268 
definition of, 247 
gastroptosis and, 254 
idiopathic, 253 
constipation and, 254 
etiology of, 254 
myasthenia and, 255 
mechanical factors in, 248 
nephroptosis and, 756 
nervous system in, 248 
obstructive, 255 
constipation in, 256 
diarrhoea in, 256 
inspection in, 258 
pain in, 256 
pathology of, 255 
signs in, 258 
symptoms of, 256 
nervous, 257 
tetany in, 257 
prognosis of, 258 
treatment of, 258 
Stomach, dilatation of, obstructive, urine 
in, 257 
vomiting in, 256 
relative, 255 
symptomatic, 255 
diseases of, acute peritonitis and, 
672 
constipation and, 311 
functional, 106 
organic, 168 
distension of, 150. See Pneumatosis. 
disturbance of function of, 23 
hemorrhagic erosions of, in uremia, 
838 
hour-glass, gastric ulcer and, 182, 
189 
hyperacidity of, 112. See Hyper- 
acidity. 
hyperchlorhydria of, 112. See Hyper- 
acidity. 
hypersecretion in, 122 
hypochlorhydria of, 152. See Hypo- 
chlorhydria. 
lesser curvature of, carcinoma of, 
diagnosis of, 219 
motor insufficiency of, forms of, 
247 
neuroses of, 106. See Gastric neu- 
roses. 
perforation of, in necrosis of pancreas, 
619 
pylorus of, incontinence of, 159 
spasm of, 149. See Pylorospasm. 
stenosis of, 262. See Pylorus, 
stenosis of. 
secretion in, 29 
subacidity of, 152. See Hypochlor- 
hydria. 
ulcer of, 168. See also Gastric ulcer, 
diagnosis of, from hyperacidity, 
117 
varices in, hematemesis from, 283 
Stomatitis, aphthous, 46 
confluent, 47 
etiology of, 46 
symptoms of, 46 
treatment of, 47 
catarrhal, 45 
in chronic interstitial nephritis, 
904 
gangrenous, 49 
bacteriology of, 49 
symptoms of, 49 
treatment of, 50 
gonorrhoeal, 51 
treatment of, 52 
herpetic, 51 
hypoinycetic, 50 
mercurial, 48 
treatment of, 49 
mycotic, 50 
ulcerative, 47 
in uremia, 838 
Strangulation of intestines, 394 
hemorrhage and, 307 
Streptococcus brevis in mouth, 40 
pyogenes in acute peritonitis, 674 1083 
INDEX 
Streptococcus pyogenes in appendicitis, 
361 
in mouth, 40 
Stricture of intestines, 394 
obstruction from, 407 
of oesophagus, non-malignant, 96 
of ureter, kidney infections and, 952 
of urethra, kidney infections and, 
952 
Subacidity, 152. See Hypochlorhydria. 
Subphrenic abscess, 699 
boundaries of, 702 
left anterior intraperitoneal, 703 
extraperitoneal, 705 
posterior intraperitoneal, 
705 
position of, 702 
right anterior, 703 
extrahepatic, 705 
rupture of, 706 
without gaseous contents, 699 
abscess of liver and, 
700 
pancreas and, 
701 
of spleen and, 
700 
age in, 702 
appendicitis and, 
700 
bacteriology of, 706 
diagnosis of, 708 
from empyema 
708 
from pleural 
effusion, 708 
duodenal ulcer and, 
701 • 
empyema and, 701 
etiology of, 699 
fever in, 707 
gastric ulcer and, 
701 
onset of, 706 
pain in, 707 
pathology of, 702 
pericolic abscess 
and, 701 
prognosis of, 709 
pulmonary embol- 
ism in, 708 
pulse in, 707 
pyosalpinx and, 701 
retroperitoneal ab- 
scess and, 701 
sex in, 702 
signs of, 707 
symptoms of, 706 
treatment of, 710 
tuberculosis of spine 
and,701 
pyopneumothorax, 710 
abdomen in, 712 
age and, 711 
appendicular abscess and, 711 
complications of, 712 
diagnosis of, 712 
Subphrenic pyopneumothorax, diagnosis 
of, from diaphragmatic 
hernia, 713 
from pleural effusion, 713 
duodenal ulcer and, 710 
etiology of, 710 
fever in, 712 
gastric ulcer and, 710 
hydatid cyst of liver and, 711 
leukocytosis in, 712 
onset of, 712 
pain in, 712 
parotitis in, 712 
pathology of, 711 
pleuritis in, 712 
prognosis of, 713 
sex and, 711 
signs in, 712 
symptoms of, 712 
treatment of, 713 
vomiting in, 712 
Succus entericus, 290 
Sugar in urine, 821 
tests for, 823 
Sugar-iced liver, 488 
Suppurative cholangeitis, 556 
nephritis, 937 
pancreatitis, 622 
phlebitis of hepatic veins, 460 
pyelonephritis, 937 
pylephlebitis, 463 
diagnosis of, from suppurative 
cholangeitis, 558 
Suprarenal gland in chronic interstitial 
nephritis, 899 
Surgical kidney, 937 
Sweating in abscess of liver, 501 
Sympathetic system, 24, 35, 107 
Syphilis, acute yellow atrophy of liver and, 
473 
amyloid kidney and, 933 
chronic perihepatitis and, 489 
cirrhosis of liver and, 509 
diagnosis of, from cirrhosis of stomach, 
278 
of intestines, 391 
leukoplakia and, 64 
of liver, 541 
diagnosis of, from carcinoma, 554 
from perihepatitis, 493 
of mouth, 58 
nephritis and, 851 
of oesophagus, 86 
of pancreas, 632 
of salivary glands, 71 
Systemic circulation, biliary infections 
through, 551 
T 
Tartar, 71 
treatment of, 71 
Taste, disturbances of, 43 
Teeth, Hutchinson's, 59 
Tenesmus in diarrhoea, 326 
in intussusception, 411 1084 
JNDEX 
Teratoma of kidney, diagnosis of, from 
hypernephroma, 1000 
Tetany in dilatation of stomach, 257 
gastric ulcer and, 189 
in pylorospasm, 150 
Thirst in acute peritonitis, 679 
Thrombosis of hepatic artery, 458 
of mesenteric arteries, 434 
intestinal hemorrhage and, 
307 
of portal vein, 460 
ascites and, 659 
diagnosis of, from cirrhosis 
of liver, 528 
of renal vessels, 789 
Thrombotic ulcers, 350 
Thrush, 50 
diagnosis of, 51 
treatment of, 51 
Thyroid tumors of tongue, 66 
Tinea circinata of mouth, 54 
Tongue, actinomycosis of, 59 
anomalies of, 60 
atrophy of, 66 
black, 61 
carcinoma of, 66 
doubling of, 61 
fibroma of, 66 
fixation of, in carcinoma of oesophagus, 
102 
frenum of, deformities of, 61 
ulcer of, 63 
geographical, 63 
hyperkeratosis of, 61 
melanotrichia of, 61 
Riga's disease of, 66 
spasm of, 62 
in sprue, 393 
sucking, 61 
swallowing, 61 
tuberculosis of, 59 
tumors of, 66 
wandering rash of, 63 
Tonsillitis, nephritis and, 850 
Toxemia in chronic nephritis, 907 
Toxins, kidney and, 773 
nephritis and, 852 
Traction on duodenum, acute dilatation 
of stomach and, 250 
Transudates in ascites, 659 
Trauma, abscess of liver and, 497 
acute dilatation of stomach and, 249 
carcinoma of stomach and, 201 
in gastric ulcer, 170 
kidney infections and, 952 
Traumatic cysts of pancreas, 641 
pancreatitis, 612 
Trichiurus, appendicitis and, 360 
Trichomonas in carcinoma of stomach, 213 
Trophic ulcers, 352 
Tropical abscess of liver, 500 
liver, 494 
Trypsin, 289 
Tubercle bacilli in tuberculosis of kidney, 
984, 987 
Tuberculin in tuberculosis of kidney, 988, 
993 
Tuberculosis, amyloid kidney and, 933 
of appendix, 385 
breath in, 42 
chronic hyperplastic intestinal, 717 
parenchymatous nephritis and 
880 
peritonitis and, 717 
cirrhosis of liver and, 509, 526 
fatty liver and, 467 
gastric ulcer and, 170 
of genito-urinary tract, diagnosis of, 
1034 
of gums, 57 
of intestines, 387 
of kidney, pyogenic infections and, 
952 
of lips, 57 
of liver, 541 
of mouth, 57 
nephritis and, 850 
of oesophagus, 85 
of pancreas, 631 
of peritoneum, 720 
diagnosis of, from carcinoma of 
stomach, 218 
from cirrhosis of liver, 528 
from perihepatitis, 493 
of salivary glands, 70 
of soft palate, 57 
of spine, subphrenic abscess and, 701 
of tongue, 57 
Tuberculous pleuritis in cirrhosis of liver, 
526 
Tumor in appendicitis, 370 
of appendix, 386 
of brain, diagnosis of, from chronic 
interstitial nephritis, 918 
in carcinoma of intestines, 429 
of pancreas, 651 
in cirrhosis of stomach, 277 
of colon, diagnosis of, from carcinoma 
of stomach, 218 
in cysts of pancreas, 643 
of gall-bladder, diagnosis of, from 
carcinoma of stomach, 218 
in gangrenous pancreatitis, 618 
in hypertrophic stenosis of pylorus, 
271 
of intestine, benign, 433 
malignant, 424 
of kidney, 994 
benign, 1005 
embryonic, 1003 
of lips, 45 
of liver, benign, 546 
malignant, 541 
mixed, of salivary glands, 72 
of mouth, 52 
of omentum, diagnosis of, from carci- 
noma of stomach, 218 
of pelvis of kidney, 1006 
of peritoneum, 730 
diagnosis of, from carcinoma of 
stomach, 218 
from cirrhosis of liver, 528 
from tuberculosis, 727 
malignant, 740 INDEX 
1085 
Tumor of peritoneum, malignant, pri- 
mary, 740 
secondary, 744 
non-malignant, 730 
phantom, 299 
of salivary glands, 72 
in suppurative pancreatitis, 624 
of tongue, 66 
Tympanites, 298 
in acute peritonitis, 681 
diagnosis of, from acute peritonitis, 
688 
Typhlitis, 355 
Typhoid bacillus, acute cholecystitis and, 
561 
fever, acute nephritis in, 867 
carriers of, 562 
cirrhosis of liver and, 509 
cholecystitis in, 561 
diagnosis of, from appendicitis, 
378 
from tuberculosis of peri- 
toneum, 727 
mouth in, 54 
nephritis and, 849 
Typhus fever, nephritis and, 849 
Tyrosin in urine, 816 
U 
Ulcek, duodenal, 191, 344 
chronic peritonitis and, 714 
diagnosis of, from aneurism of 
hepatic artery, 459 
from cholelithiasis, 586 
from cirrhosis of liver, 527 
from hyperacidity, 117 
from obstruction of intes- 
tines, 401 
intestinal hemorrhage and, 307 
subphrenic abscess and, 701 
pyopneumothorax and, 710 
gastric, 168 
chronic peritonitis and, 714 
diagnosis of, from cholelithiasis, 
586 
from cirrhosis of liver, 527 
from obstruction of intes- 
tines, 401 
intestinal hemorrhage and, 307 
subphrenic abscess and, 701 
pyopneumothorax and, 710 
of frenum of tongue, 63 
of intestine, 343 
catarrhal, 331 
decubital, 351 
embolic, 350 
follicular, 351 
leukemic, 352 
stercoral, 351 
syphilitic, 391 
thrombotic, 350 
tuberculous, 388 
uremic, 350, 838 
of oesophagus, 84 
decubital, 84 
Ulcer of oesophagus, peptic, 84 
pressure, 84 
uremic, 84 
peptic, 168 
jejunal, 349 
of pylorus, diagnosis of, from carci- 
noma of stomach, 217, 219 
of stomach, diagnosis of, from nervous 
dyspepsia, 166 
hematemesis from, 283 
hyperacidity and, 114 
trophic, 352 
uremic, in chronic nephritis, 899 
Ulcerative cholecystitis, 563 
stomatitis, 47 
Uncinaria duodenalis, cirrhosis of liver 
and, 510 
Urachal cysts of peritoneum, 739 
Uremia, 830 
acute, 841 
alimentary tract in, 837 
amaurosis in, 836 
in amyloid kidney, 935 
anuria in, 841 
blindness in, 836 
blood in, 831 
breath in, 42 
cardiac failure in, 839 
chronic, 842 
in chronic interstitial nephritis, 
903 
parenchymatous nephritis, 
884 
circulatory system in, 838 
classification of, 841 
coma in, 837 
convulsions in, 835 
cutaneous lesions in, 840 
delirium in, 837 
diagnosis of, 842 
from acute peritonitis, 689 
from other coma, 919 
diaphoresis in, 843 
diarrhoea in, 838 
dyspnoea in, 839 
fever in, 840 
fulminating, 842 
headache in, 837 
hearing in, 836 
hemorrhagic erosions of stomach in, 
838 
hiccough in, 838 
internal secretion in, 833 
itching in, 840 
mania in, 837 
mouth in, 55 
nausea in, 837 
nephrolysins in, 834 
nervous system in, 835 
paralyses in, 836 
pathology of, 830 
pericarditis in, 839 
prognosis of, 842 
pupils in, 837 
respiratory system in, 839 
special senses in, 836 
stomatitis in, 838 1086 
INDEX 
Uremia, symptoms of, 835 
theories of, 831 
toxin in, 831 
treatment of, 843, 929 
ulceration of intestines in, 838 
urine in, 830 
venesection in, 844 
vomiting in, 837 
Uremic ulcers, 350 
in chronic nephritis, 899 
of oesophagus, 84 
Ureter, inflammation of, 974 
in pyelitis, 954 •* 
in renal calculus, 1017 
stricture of, kidney infections and, 952 
in tuberculosis of kidney, 980 
Ureteral catheterization, 939 
Ureteritis, 974 
bacteriology of, 946 
course of, 974 
diagnosis of, 975 
kidney infections and, 952 
in pyelitis, 954 
symptoms of, 974 
treatment of, 975 
Urethra, bacteria in, 943 
stricture of, kidney infections and, 952 
Urethritis, bacteriology of, 943 
diagnosis of, 1031 
tuberculosis of kidney and, 978 
Uric acid calculus, origin of, 1014 
Urinary excretion, anomalies of, 791 
litniasis, 1007 
sediments, examination of, 797 
tract, diseases of, changes in urine 
and, 791 
Urine in abscess of liver, 502 
of kidney, 959 
aceto-acetic acid in, 827 
acetone bodies in, 826 
in acute catarrhal cholangeitis, 553 
dilatation of stomach, 252 
hepatitis, 495 
nephritis, 861 
peritonitis, 684 
yellow atrophy of liver, 476 
air in, 806. See Pneumaturia. 
albumin in, 794. See also Albumin- 
uria. 
detection of, 796 
tests for, 797 
ammoniacal, 793 
in amyloid kidney, 935 
in appendicitis, 371 
bile in, 828 
blood in, 280. See Hematuria. 
/3-oxybutyric acid in, 826 
in carcinoma of stomach, 207 
casts in, 798 
amyloid, 799 
epithelial, 799 
fatty, 800 
granular, 799 
hyaline, 799 
waxy, 799 
changes in, diseases of urinary tract 
and, 791 
Urine in chronic nephritis, 882, 900 
perihepatitis, 492 
chyle in, 805. See Chyluria. 
in cirrhosis of liver, 526, 539 
color of, 807 
in congestion of liver, 479, 485 
creatinin in, 813 
cylindroids in, 800 
cryoscopy of, 792 
crystals in, 800 
cystin in, 817 
in dilatation of stomach, 252, 257 
electrical conductivity of, 793 
examination of, 1026 
fat in, 827 
in fat necrosis, 609 
fat-splitting ferment in, 609 
fibrin in, 806. See Fibrinuria. 
in gastric ulcer, 176 
glucose in, 821 
glycuronic acid in, 823 
homogentisic acid in, 824 
in hyperacidity, 117 
in hypernephroma, 997 
in jaundice, 453 
in kidney of pregnancy, 868 
lactose in, 822 
leucin in, 816 
levulose in, 821 
in necrosis of pancreas, 617 
in nephroptosis, 756 
in paranephritis, 972 
pentoses in, 822 
proteins in, 794, 818 
Bence-Jones, 819 
albumoses, 820 
hemoglobin, 818 
peptones, 821 
pus in, 805. See Pyuria, 
in pyelitis, 958 
in pyelonephritis, 958 
in pyogenic infections of kidney, 958 
in pyonephrosis, 959 
racemic arabinose in, 822 
reaction of, 793 
retention of, kidney infections and, 
952 
segregators, 940 
specific gravity of, 792 
spermatozoa in, 800 
sugars in, 821 
recognition of, 823 
in suppurative nephritis, 959 
in traumatic nephritis, 959 
in tuberculosis of kidney, 983 
of peritoneum, 726 
tyrosin in, 816 
in uremia, 830 
Urobilinuria, 810 
in jaundice, 454 
Uro-erythrinuria, 810 
Urostealiths, 1009 
Urticaria of mouth, 53 
Uterus, perforation of, acute diffuse peri- 
tonitis and, 673 
rupture of periappendicular abscess 
into, 365 INDEX 
1087 
Vomiting in hemoperitoneum, 669 
in hyperacidity, 116 
in hypernephroma, 998 
in intermittent gastromyxorrhoea, 131 
in interstitial pancreatitis, 630 
in intestinal colic, 305 
indigestion, 301 
juvenile, 145 
in mesenteric embolism, 435 
thrombosis, 435 
in mycotic gastritis, 236 
in necrosis of pancreas, 616 
in nephroptosis, 756 
nervous, 142 
diagnosis of, 145 
etiology of, 143 
gastralgia, 135 
prognosis of, 145 
treatment of, 146 
in obstruction of intestines, 399 
in paranephritis, 972 
periodical, 144 
in children, 145 
in phlegmonous gastritis, 232 . 
psychic, 144 * 
in pylorospasm, 149 
reflex, 145 
in splanchnoptosis, 753 
in stenosis of pylorus, 270 
in subphrenic pyopneumothorax, 712 
in suppurative pancreatitis, 624 
pylephlebitis, 464 
in thrombosis of portal vein, 462 
in toxic gastritis, 234 
in uremia, 837 
in volvulus, 414 
W 
Wandering rash of tongue, 63 
Waxy casts, 799 
X 
Xanthelasma in jaundice, 452 
Xanthin calculus, 1009 
origin of, 1014 
Xerostomia, 68 
X-rays in carcinoma of stomach, 215 
in diagnosis of cholelithiasis, 585 
examination in gastric ulcer, 181 
nephritis and, 853 
¥ 
Yellow fever, nephritis and, 849 
Vaccine, nephritis and, 849 
Varicella, mouth in, 56 
Varices in stomach, hematemesis from, 283 
Varicocele in hypernephroma, 997 
Variola, mouth in, 56 
Venous stasis, hematemesis from, 283 
Vertigo in atony of stomach, 162 
Vicarious hemorrhages, diagnosis of, from 
hematemesis, 283 
Visceroptosis, 747. See Splanchnoptosis. 
Volvulus, 412 
constipation in, 414 
diagnosis of, 415 
diarrhoea in, 414 
etiology of, 412 
of omentum, 418 
pain in, 414 
pathology of, 413 
prognosis of, 414 
seats of, 413 
symptoms of, 414 
vomiting in, 414 
Vomiting in abscess of liver, 502 
in achylia gastrica, 154 
in active congestion of liver, 479 
in acute cholecystitis, 564 
dilatation of stomach, 251 
enteritis, 330 
gastritis, 228 
hepatitis, 495 
nephritis, 863 
perihepatitis, 487 
peritonitis, 678, 682, 
pyelitis, 961 
yellow atrophy of liver, 475 
in appendicitis, 368 
in biliary cirrhosis of liver, 538 
in carcinoma of liver, 543 
of pancreas, 651 
of stomach, 206 
cerebrospinal, 145 
in cholelithiasis, 576 
in cholera nostras, 331 
in chronic gastritis, 241 
interstitial nephritis, 904 
in cirrhosis of liver, 520 
of stomach, 277 
in constipation, 315 
in dilatation of stomach, 256 
in diverticula of oesophagus, 94 
in duodenal ulcer, 192, 346 
in fatty liver, 468 
in gall-stone colic, 577 
in gastric ulcer, 176, 177 
in gastrosuccorrhcea, 123 
habit, diagnosis of, from hypertrophic 
stenosis of pylorus, 271