Pathological and practical observations on diseases of the abdomen : comprising those of the stomach and other parts of the alimentary canal, oesophagus, caecum, intestines and peritoneum

Preface

Diseases of the Stomach have, during the last few years, received considerable attention, and our medical literature has been enriched by the labours of Budd, Handheld Jones, Chambers, Brinton, Wilson Fox, Leared, Fenwick, and others. Much, however, still remains to be done ; and whilst some of the facts contained in the present volume will tend to confirm what is already known, other new ones will be found, which, we trust, will repay an attentive perusal of its pages.

The design in this work has been to illustrate the diseases treated upon, by cases which have come under our personal observation, with a few remarks upon them, and some general deductions. During the period of my curatorship of the Museum at Guy's, and of my demonstratorship of Morbid Anatomy for several years, very numerous opportunities were presented of noticing diseases of the stomach and intestines in their varied phases ; and I would tender sincere thanks to those of my colleagues who have permitted the mention of instances under their care. Although I have sought definitely to distinguish some classes of diseased conditions, I should be very unwilling to regard them as entities superadded to the human frame, but rather, to quote the words of Sir John Forbes, "as new phases of vital manifestations.".

Life may be considered as the resultant of certain forces, manifested in the performance of functions, which are combined harmoniously for one purpose ; it has received varied appellations, each indicative of our inability to discover its vi

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real character ; thus we have had vital force, power of growth, nutrition, development, organization, nature, &c, each new observer considering himself more clear-sighted than his predecessor, although he has merely substituted one term for another.. This Living force is in close correlative relation with other physical forces, and the fuller investigations of physiological science show that the same forces are in operation, namely, gravitation, chemical action, &c, in the living organism, as external to it ; modified, it is true, by another force, namely, life. And as in the science of physics generally, so in the study of living phenomena, we must ever bear in mind that a like cause always produces a like effect. Yague observation, and the superficial remarks of some writers, would lead us to suppose, that, in living phenomena, the same cause is followed, at first by one effect, then by another ; interpreting fixed realities by prejudice rather than by reason.

Some phraseology is necessary to express our meaning and ideas, and one great difficulty is overcome, if we can understand that the same words convey to each the same thought. It may be convenient, as we have mentioned, to regard life as the resultant of certain forces, and disease as a deviation from the normal direction. If any of the forces which are in natural operation be modified in intensity, a deviation is the result, and diseased action is produced, the resultant being necessarily changed ; still the tendency is such that on the withdrawal of the modifying force, the normal course is reassumed. Not only may it be natural force which has led to this departure from the healthy state, but new force may be added, as much as when the earth in its orbit is disturbed by the attraction of some other celestial body.

In diseases, many sources of change arise — modifying forces — thus syphilitic or miasmatic poison, small-pox &c, alter the character of every function ; a new substance is added as much as in the voltaic battery, when the fluid in one or other cell is changed by the admixture of any substance ; this may

PREFACE.

vii be merely of the kind already existing, or a foreign substance may have been introduced ; in any case, the phenomena are modified. Such, to some extent, is the case in pathological changes. These changes, produced by perverted nutrition, or altered vital forces, are in many instances of such a character, that no examination of the structure itself could discern the state which had been produced ; as fruitless would it be to search in the nerve of a limb for the altered force which had led to spasm, as to expect to find a telegraphic message by a microscopical examination of the wire, although the structure of both had been transiently modified by the disturbance of the forces they transmitted. If the character of the disturbance in disease is one, which, like a polar force, reverts to its former condition, no trace can be found on inspection, but, in many instances, obvious structural modifications are the result.

Diseased action, however, as generally manifested, is the resultant, not of one, but of several changes in the normal condition, and very few persons are literally in perfect health. The living forces are modified by hereditary tendency, as struma ; to this, perhaps, is added, syphilis, to that miasm ; still further, sudden changes of temperature, improper supply of nourishment, of heat, and light, may be causes of disease ; each of these may act as fresh sources of deviation from the normal healthy direction of living action, superadded to the resultant produced by the previous combination.

Some have supposed that acute disease quickly passes off, and that with the subsidence of the more marked symptoms no trace is left behind, but very generally this is not the case ; the attentive study of pathology will soon convince us of the contrary ; new exciting causes of disease arise, perhaps of a different character, but the resultant (to revert to the previous phraseology of forces) is not precisely the same, the former diseased state acts as a modifying force. This course may be often repeated, and if the changes have been such as to entail vni

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discomfort or weakness, chronic disease is said to exist ; but if without these, the patient generally passes for one in sound health. It is the acumen of the practical physician that detects the traces of previous morbid action, and he alone knows how rightly to estimate the course likely to be assumed by any new addition to a state widely diverse to that of health ; hence, also, the variety of diseases by which the same organ is affected, the causes are different and so of necessity their effect.

It is the province of medical science, rightly to estimate the effects produced on vital action by any disturbing causes, and to study their almost endless varieties ; several general characters lead us to group these effects into classes ; and although in this volume we have spoken of diseased action as manifesting itself especially in the alimentary canal in the changes described, and the symptoms detailed, it will be found that these parts are in many cases only affected in common with the whole economy, whilst in others, that the special manifestation of morbid action is in the abdomen.

Numerous means are available for checking and modifying diseased action, and we must protest against the ignorance of those who regard the draught of medicine as the only important agent. The skill of the physician is often most manifest in the suggestion of hygienic measures which by many may be assumed as of trifling moment ; and whilst it is perfectly true that many morbid conditions cease after a time, or that the frame becomes so accustomed to perverted action that the balance of functions is apparently maintained without cognizance on the paTt of the patient, still the aid of medical science is most important. The first agents to which we must refer are those which are in constant operation in the maintenance of life — in one state preservative of health, in another the the cause of disease — as the character of the air breathed, whether saturated with moisture, poisoned with miasm, or with the decomposing effluvia of crowded cities, as compared

PREFACE.

IX with that found in more elevated situations, on the sea or its coasts, &c; so also with reference to diet, to light, to clothing, to temperature, to habits of mental or bodily training or exercise; the right use of all these is not less important in the restoration to health, than in the maintenance of it, and in both cases alike, is within the province of medical science.

Too frequently medicine is taxed to obviate the disease whilst its cause is pertinaciously adhered to. It is in vain to recommend to the dyspeptic patient remedies which would certainly mitigate his disease, whilst intense anxiety remains, and hurried, half masticated meals, are taken at irregular hours and without due moderation — or, again, it is useless to direct means to relieve a disturbed brain, whilst excitement is added to excitement, the senses stimulated by light, noise, animated conversation, and active thought — or to give opium to check peritonitis, to quiet muscular movement, when the patient is allowed to move from the recumbent position.

The consideration of the fundamental conditions of life demands strict attention, not only as indicating the tendency vital action has to assume its natural direction, but also in enabling us to use and apply effective means for the removal of morbid processes ; and we are at no great loss to understand the intellectual power and acumen of those who, because everything is not known in the pathology and treatment of disease, would contemptuously discard that which is known and established. We deplore the ignorance of those who know not the value of opium in peritonitis, &c, of iodide of potassium in secondary syphilis, of purgatives and mercurials in hepatic engorgement, of preparations of steel in many forms of anaemia, of quinine and arsenic in intermittents ; our object is not to confute errors which arise from wilfully closing the eye to light already attained, but to seek to add facts upon which science may safely advance.

We have generally divided the chapters according to the anatomical divisions, rather than in a strictly pathological

X

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manner. The first chapter is on diseases of the Mouth and Throat, and the next on those of the Pharynx, but I have not dwelt upon those maladies which more especially come under the care of the Surgeon. The chapter on disease of the (Esophagus, contains many interesting cases, some of them obscure in their pathology, and very insidious in their origin ; some instances of ulceration, perforating the trachea or bronchi, which we have described, have generally, and we believe incorrectly, been considered as instances of cancerous disease. The diseases of the stomach constitute the subject of the next section, and have obtained from authors very considerable attention ; we believe that there are forms of ulceration, superficial and evanescent, which leave scarcely more trace in the mucous membrane of the stomach than the aphthous ulceration of the mucous membrane of the mouth, whilst others are permanent, and are manifest after death ; and indeed we find the same forms of diseased action in the mouth as in the stomach ; thus both are affected by inflammatory congestion, perverted epithelial growth and secretion, sluggish condition of the circulation, acute inflammatory disease, as well as by fibroid and cancerous disease. Ulceration of the stomach is probably a more common condition than is generally supposed, and in many instances yields to judicious treatment ; the instances we have adduced show that there are several distinguishing marks by which it may be known from cancer. Fibroid degeneration of the pylorus has generally been considered as of a cancerous nature ; and whilst we are unable to remove this almost certainly fatal form of disease, we may, as in cancer, do much to mitigate the symptoms and to prolong life.

In the so-called functional disease of the stomach, chemical research has removed much that was obscure, and will do still more to explain the pathological changes which are induced ; the investigation of the physiological connections of the pneumogastric nerve, as well as of the sympathetic nerve rivKFACE.

XI and the branches of the semilunar ganglia will enable us more correctly to estimate the very diverse symptoms produced in dyspepsia, many of which have their origin in this source. The right estimate of such symptoms as pain in the region of the stomach and vomiting are most important in the diagnosis, and equally so in the treatment of gastric affections.

The chapter on the Duodenum presents us with instances of disease which closely simulate maladies of the pyloric extremity of the stomach.

The next chapter is on Grastro- Enteritis and Enteritis, diseases in which correct diagnosis is very important ; in the latter class of diseases especially, life may be easily sacrificed by time being thrown away, and by improper treatment ; in the former with judicious diet, warmth, demulcents, &c, recovery generally takes place. Whilst we strongly recommend, in many of these instances of gastro-enteritis, the avoidance of mercurials, the value of salines, as of bicarbonate and chlorate of potash, and carbonate of soda, are well known to those who have carefully watched the effect that has followed their administration.

In the chapter on Strumous Disease of the Intestine and Peritoneum we have sought to show that these diseases are only part of a general perverted nutrition, and that, in many instances, disease in other organs is entirely obscured by the more marked affection of the abdominal viscera ; here, also, we should strongly urge the avoidance of mercurial medicines and of drastic purgatives; the lives of many delicate children are sacrificed by worm powders and quack nostrums administered in these diseases.

The diseases of the Caecum and its Appendix are next dwelt upon. We have shown that unusual freedom of the C33cal attachments may determine intestinal obstruction from rotatory movements of the intestine ; the symptoms and treatment of caacal distension and of local enteritis are described, as well as the more serious consequences of perforaxii

I'KKFACE.

tion of the appendix j we have given numerous instances of these forms of affection, and their perusal will show the great similarity in the symptoms and their general course. Dr. Burns, in a valuable paper in the ' Medico- Chirurgical Transactions/ described, several years ago, some of these affections. It would appear that the symptoms of cancerous disease of the cascum are different from simple cascal enteritis and perforation ; and that in many cases we may discriminate the character of the complaint. It will be found that treatment may do much to relieve and to assist the cure of csecal disease ; the pain demands rest, and it is well after the acute pain has subsided, still to maintain absolute repose for several days. The bowels are often confined, but the use of purgatives generally aggravates the disease without effecting the desired operation ; this is better obtained by the application of warmth and by opium ; those remedies, which diminish the enteric inflammation lead most speedily to the subsidence of the morbid symptoms.

We have next pointed out the characters of the several forms of Diarrhoea, but we are well aware that diarrhoea is merely a symptom of very different conditions, and that in many instances it passes almost imperceptibly into dysentery.

Dysentery and Catarrh of the Colon are the subjects afterwards considered, and the instances we have adduced show that inflammation of the colon, of a most severe form, arises in our own country. Most of the writers on this subject are those who have observed it in its worst forms abroad or in Ireland. In some of the cases typhoid fever was simulated; in others, perforation of the colon had taken place ; in one there was pyasmia and commencing suppuration in the liver ; in several chronic cases the secondary effects were shown in producing contraction of the intestine, perforation, and artificial anus, &c. ; as regards abscess in the liver, in one case the abscess had dried and contracted ; in another, fresh diseased action was set up around it, and abscess in the brain was the result.

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Xlll

We must confess, that in some of the most severe forms all treatment is ineffectual to cure, whilst it partially soothes and relieves ; but in the great majority of instances means may be used which effectually combat the symptoms of disease.

We had intended to give some observations on Asiatic cholera, but for several reasons have not done so ; first, because although the disease manifests itself more apparently in the disturbed functions of the alimentary canal, it has not been clearly shown that the disease is really one affecting alone or even principally the abdomen • and secondly, all the facts known in reference to this disease are better and more clearly given in the report drawn up by Dr. Baly and Sir W. Gull.

In the chapter on Typhoid Fever, we have merely described the condition of the abdominal affection, without entering into the general question of fever, and its treatment ; in the latter, it is well to guard against the danger of so freely administering opiates to check diarrhoea as to lead to cerebral oppression, and excessive engorgement of the lungs, from imperfect performance of the respiratory function.

In the chapter on Colic I have cursorily spoken of the simpler forms of the disease, and have separated the more severe varieties of ileus — internal strangulation, intussusception, and cancerous disease of the colon. It will be found that whilst the latter conditions bear a strong general resemblance in producing fatal constipation, they may, in many instances, be distinguished the one from the other ; intussusception closely simulates simple colic, but, in not a few instances, it is accompanied by discharge of bloody mucus, or with actual diarrhoea ; and this latter symptom sometimes arises even with cancerons disease of the sigmoid flexure. Wo have very strongly urged the avoidance of drastic purgatives, calomel, colocynth, and even milder purgatives, and as xiv

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strongly recommended the free administration of opium ; the cases detailed almost uniformly show that, where purgatives were given, vomiting, pain, and distress were increased, whilst these and other symptoms were, on the contrary, relieved by opium. Opium, in such cases, appears to be the best means of procuring relief to the bowels, if an action be possible. In the chapter on Worms, we have designedly been very brief in our remarks.

The cases of Suppuration in the Abdominal Parietes, and of Perforation of the Intestine from Without, are an interesting series ; many of them are obscure in their diagnosis, and different in their course. Great care is required in watching the symptoms as they become fully developed' and in avoiding the aggravation of them by too active treatment.

The serous membrane of the intestines, the peritoneum, is so intimately connected with the morbid conditions of the alimentary canal, that we have appended some remarks on its diseases. In very many instances the serous membrane is implicated by direct extension of disease ; in other cases, the peritoneal change is the expression of a general morbid condition of the whole system ; in addition to a chapter on Peritonitis, I have appended remarks on Ascites, and also on Abdominal Tumours.

The cases I have recorded might have been given at greater length, and on each, one fuller remarks might have been made ; but the design of the work has been, in a very few words to point out the peculiarities of each instance, embodying in more general deductions the apparent conclusions derived from the whole. My desire is to shed some light on the difficulties which often present themselves in the daily practice of the profession, and to suggest means whereby the alleviation of disease may be promoted.

The former editions of my work on ' Diseases of the Abdomen ' have been exhausted for several years, and I regret that so long a time has elapsed in the preparation of

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XV the present edition. The whole work has been carefully revised ; several chapters on important subjects have been added; and, I trust, that it will be found helpful in clinical study, as well as in the treatment of disease. I have derived valuable assistance from my friend and colleague, Dr. Goodhart, both in examining the later records of the Guy's pathological department, and also in the revision of the work.

70, Brook Street,

Grosvenor Square.

Chapter I

Introduction. — Digestion and Indigestion contrasted ; general remarks upon and summary of the various Structures involved — glandular, muscular, serous, connecting, nervous, vascular; preliminary remarks upon Treatment; the action of Remedies modified by the condition of the recipient ; by the co-existence of other independent Diseases — The antagonism of Disease . . . 1 — 13

CHAPTER n.

On Diseases of the Tongue and Mouth. — Paralysis of the Tongue — Deficient epithelium — Irregular growth of the Papillae — Stomatitis— Thrush — Ulcerative Stomatitis — Cancrum oris — Glossitis, acute and chronic — phthisical and syphilitic; Neuralgia of the Tongue — Spasm — Ringworm — Parotitis — Tonsillitis, acute and chronic — (Edema— Cancer — Paralysis of the Soft Palate — Bulbar Paralysis 14—39

Chapter III

On Diseases of the Pharynx. — Spasm — Inflammation, catarrhal, membranous, phlegmonous — Syphilitic ulceration— Cancer — Suppuration behind the Pharynx, Cysts, and Pouches . . . 40 — 50

Chapter IV

On Diseases of the CEsophagus. — Anatomical relations — Diseases of the Mucous Membrane — Inflammation — Ulceration — Abscesses — Cysts — Warty Growths — Muscular Spasm — Paralysis — Hypertrophy — Dilatation — Pouches — Strictures — The effects of Corrosives — Foreign bodies — Hasmorrhage in the Coats — Rupture— Gastric Solution 51—129 b xviii

TABLE OF CONTENTS.

Chapter V

On Organic Diseases of the Stomach. —Post- mortem Solution — Atrophy of the Mucous Membrane — Hypertrophy — Mammillation — Dilatation of Stomach — Hour-glass contraction — Lardaceous Disease — Inflammation — Ulceration — Sloughing of the Mucous Membrane— Fibroid Degeneration of the Pylorus— Polypoid growths— Cancer 130—253

Chapter VI

On Functional Diseases of the Stomach. — Forms of Dyspepsia, from altered conditions of the Mucous Membrane and of the Gastric Juice — Atonic Dyspepsia — Exhaustion of Cerebro-Spinal System of Nerves — Dyspepsia in Chronic Disease — At different periods of life — Excessive Secretion of Gastric Juice — Irregular Secretion — Morbid Secretion — Pyrosis — Dyspepsia in Rheumatism and Gout ; in Albuminuria — Dyspepsia from altered Vascular Supply ; from the state of the Nervous System ; from impeded movements of the Stomach ; from Fermentation ; Haematemesis — Pain and Vomiting as signs of Gastric Disease .... 254 — 310

Chapter VII

On Diseases of the Duodenum. — Position of — State of Secretion — Malformation— Congestion, acute and chronic — Duodenal Dyspepsia — Inflammation — Ulceration — Cancerous Disease — Mechanical Obstruction— Hydatid— Perforation 311—341

Chapter VIII

On Muco- Enteritis and Enteritis. — Varieties — Pathological Changes — Symptoms — Diagnosis — Prognosis — Treatment . . 342 — 359

Chapter IX

On Strumous and Tubercular Disease of the Alimentary Canal. Lardaceous Disease. — Various forms of Diarrhoea in Strumous Children — Disease of Mesenteric Glands — Tubercles in the Peritoneum and Strumous Peritonitis — Disease of Intestine in Phthisis — Lardaceous Disease . . . . . . . 360 — 390

Chapter X

On Diseases of the Ccecwn and Appendix Caci. — Changes in position — Atrophy — Distension — GEdema — Congestion — Typhlitis — Ulceration— Cancerous Disease — Trichocephalus Dispar. — Appendix — Increase of length— Atrophy — Dilatation — Concretions — Results of — Symptoms of Disease — Diagnosis — Prognosis — Causes — Treatment— Cases 391 — 434

TABLE OF CONTENTS.

xix

On Organic Obstruction, Internal Strangulation, Intussusception, and Carcinoma of Intestine. — Classification of — Causes — Symptoms — Diagnosis — Treatment — Cases of 535 — 599

Chapter XVII

On Suppuration of the Abdominal Parietes, Perforation of the Intestine from without, and Abscess in the Abdominal Parietes, extending into the Intestine — Feecal Abscess. — Causes of External Perforation — symptoms — Treatment — Cases of 600 — 617

On Ascites. Dropsy. — Varieties — Asthenic — Mechanical — Inflammatory— Glandular— Tubercular — Cancerous — 0 varian — Symptoms- Diagnosis — Treatment 656 — 67*

Chapter XXI

On Abdominal Tumours. — Abdominal Spaces — Tumours found in each region — Diagnostic Signs 675 — 685

DESCRIPTION OF PLATES.

PLATE I.

Stomach presenting a chronic nicer; at its upper margin the pneumogastric nerve is shown extending into dense fibrous tissue. The pancreas and the left lobe of the liver formed tbe base of the ulcer ; the latter presented fibroid degeneration of its structure. — Case XLIII.

PLATE II.

Stomach exceedingly contracted from chronic ulceration, with villous growth Simulating cancer. — Case LYIII.

1. External view, resembling the colon in appearance.

2. Internal surface, showing ulceration near the pylorus, and

villous growth near the centre of the stomach.

PLATE III.

Fig. I. Section of the mucous membrane of a portion of the ileum in acute inflammation of the colon and ileum, showing the surface covered with false membrane (diphtherite) and continuous with the mucous follicles. — Case CXXIX.

Fig. II. Section of a solitary gland from the cascum, from the same Case, CXXIX, showing (a) the edges of a raised portion intensely injected from distended capillaries ; (b) surface of mucous membrane covered with diphtheritic granular membrane; (c) opening into the gland ; (ci) small phosphatic crpstals.

Fig. III. Appearance of inflamed colon in Case CXXXIX ; (a) false membrane composed of granule cells ; (6) surface of a portion of the colon beneath the false membrane ; (e) follicle or crypt containing cells similar to those composing the false membrane.

Fig. IV. Colloid cancer of the sigmoid flexure X 400 diam.; (a b) columnar epithelium; (c) nuclei with granular blastema; (d) large cells, with large nuclei, and some with several nuclei in them ; (e) intervening delicate tissue ; (/) elongated fibre cells. —Case CLXIV.

Fig. V. Obstruction of the sigmoid flexure by cancerous growth; (a) columnar epithelium and nuclei; (b) fibrous tissue beneath tbe mucous membrane ; (e) interspaces filled with nuclei ; (c) surface of mucous membrane composed of dense fibre tissue. — Case CLX.

c xxn

DESCRIPTION OF J'LATES.

PLATE IV.

Fig. I. Ca3cum inverted, appendix towards the pelvis, where it was adherent; ascending colon commencing opposite the ileum. — Case CV.

Fig. II. Caecum inverted and twisted on its own axis into the left hypochondriac region, appendix close to the spleen; ascending colon constricted; constriction increased by band of adhesion to the sigmoid flexure, which appeared to have been the primary cause of the fatal twist and obstruction. — Case CVL

Fig. III. Position of intestines in a case of intussusception of caecum and ascending colon into descending colon and sigmoid flexure ; the commencement of the rectum is drawn from its position, to show the strangulated bowel within. Dr. Hughes' case, No. CLII.

PLATE V,

Dissection showing the distribution of the pneumogastric nerve on the anterior surface of the stomach, its extension to the pancreas and pylorus, and its connection with the semilunar ganglia, &c. (a) oesophageal extremity of the stomach ; (&) pylorus ; (c c) pneumogastric nerves ; (e e) branch of the pneumogastric to the pancreas, connected also with the sympathetic, and then passing onwards to the pylorus; (//) other branches to the pylorus; (9 9 9 9) branches of the pneumogastric nerve distributed on the anterior surface of the stomach, presenting a peculiar dichotomous division, and repeated union of its branches; (h h li h h 7i) splanchnic nerves; (i) aorta; (j) diaphragmatic artery, with a filament of nerve upon it; (hk) coronary artery; (I) splenic artery; (m) hepatic artery turned aside from its position in front of the aorta, and from its origin at the cceliac axis ; and thus it appears to be behind the aorta; the large branches of the sympathetic nerve upon it are continuous with the portion of ganglion («•*) close to the coronary artery; (n) vena portae; (0 0) supra-renal capsules receiving numerous nerve filaments ; (r r) semilunar ganglia, and descending branches to the mesenteric artery and renal plexus, &c. ; (s) mesenteric artery drawn aside.

In this distribution of nerves, the close sympathy of the stomach with the parts supplied by the semilunar ganglion is explained ; thus, it is brought into connection with the liver by its hepatic branches with the pancreas, with the diaphragm and phrenic nerve, with the supra-renal capsules, and by its descending branches with other abdominal viscera.

PLATE III.

ON

DISEASES OE THE STOMACH.

CHAPTER L