Diseases of the intestines, their special pathology, diagnosis, and treatment : with sections on anatomy and physiology, microscopic and chemic examination of the intestinal contents, secretions, feces and urine intestinal bacteria and parasites; surgery of the intestines; dietetics, diseases of the rectum, etc

Front matter

DISEASES

of the

INTESTINES.

Preface

In the second volume of “ Diseases of the Intestines ” are embraced those pathological conditions that occupy the border-land between internal medicine and surgery. The modern evolution of the exact methods of clinical diagnosis, relating to many diseases of the human body, can not but command universal admiration ; but the technics of the microscope, and chemical as well as physiological investigation, have as yet left large vacancies in the pathology of the intestinal function ; and where these exact methods desert us, there is but one beacon light for the general practitioner, and that is clinical experience.

The comprehensive subject of Intestinal Obstruction has been presented mainly under two headings : (i) the enterostenoses, and (2) the obstructions. Under the latter there are many sub-types, which it was necessary to consider separately. Clinically, the enterostenoses are quite distinctive from the obstructions, although pathologically and anatomically the obstruction and the stenosis may be due to the same cause. In the introduction to the chapter on Intestinal Obstruction will be found a special consideration of the pathogenesis and the mechanism whereby they are brought about.

In this connection it is often difficult to emphasize the difference between truth and mere facts. These two are often, unfortunately, considered synonymous. Facts are the little truths that our senses are capable for the present of comprehending ; but back of and beyond these facts later experience often reveals the higher and greater truth. Accordingly, it was not considered advisable to argue in all cases of doubtful pathogenesis and diagnosis. The reader will, however, find that the facts and truths are presented for his consideration as thoroughly as possible in the light of our

IX

X

PREFACE.

present knowledge, when it is not safe to be dogmatic in conclusions pertaining to clinical or pathological questions. The author has endeavored, when the discussion is in debatable territory, to suggest to the reader the proper solution of a given diagnostic problem.

To a large number of American surgeons and clinicians mentioned in the text I am under obligations for personal expression of their opinions concerning the treatment to be pursued in the conditions embraced in the border-land between medicine and surgery. More especially it becomes my duty to express my thanks to Dr. Charles Warded Stiles, of the Bureau of Animal Industry, U. S. Department of Agriculture, for reading the proof of the chapter on Intestinal Parasites, and for making numerous valuable suggestions thereto. Also to Dr. William Sydney Thayer for his generous aid given to the section devoted to Strongyloid.es intestinalis.

If this work, in addition to being an aid to the practitioner, as well as the specialist, will prove an inspiration to exact and objective clinical observation, as well as experimental investigation, the most heartfelt wish of the author will be fulfilled. Many masterly minds have concentrated their energies upon the solution of problems concerning intestinal pathology, and with a more enlightened understanding will come a more effective treatment.

'0/j.ev Ppaxv( V i?£ Ttxv7l pciKpa. (“ Life is short, but Art is long.")

— Hippocrates.

John C. Hemmeter.

February, i()02.

TABLE OF CONTENTS. — VOL. II

CHAPTER I. Appendicitis

Synonyms. — Simple or Catarrhal Form. — Nature, Description, and Etiology.— Pathological Anatomy.— Symptomatology. — Relapses. — Prognosis. — Diagnosis. — Therapeutics. — Diet.

Suppurative Inflammation of the Vermiform Appendix (Suppurative Appendicitis with or without Perforation). Synonyms.— Nature, Description, and Etiology. — Bacteriology. — Pathological Anatomy. Symptomatology. — Prognosis. — Diagnosis. — Differential Diagnosis. Treatment.

Chronic Appendicitis (Recurrent and Relapsing Appendicitis). Symptomatology. — Diagnosis. — Method of Palpating the Appendix. Prognosis.

Literature on Appendicitis.

Chapter II

Infectious Granulomata of the Intestine. Tuberculosis

of the Intestine,

Tuberculous Enteritis. — Tubercular Intestinal Tumors. — Treatment. Syphilis of the Intestines. Acute Syphilitic Enteritis. — Chronic Syphilitic Enteritis. — Syphilitic Tumors of the Intestine.

Actinomycosis of the Intestine. Parenchymatous Form. — Symptomatology.— Diagnosis. — Treatment.

Literature on Tuberculosis of Intestines will be found in Addendum, page 666.

Literature on Syphilis of the Intestines.

CHAPTER III. Intestinal Occlusion

Introduction to the Study of Intestinal Occlusion.

Enterostenosis — Narrowing of the Lumen and Occlusion of the Intestines. Synonyms.

I. Enterostenosis. Symptomatology. — General Symptomatology of

Enterostenoses. — Prognosis.

II. Acute and Chronic Intestinal Occlusions. Synonyms.— Nature and Concept, Description and Etiology. — Pathological Anatomy of Acute Occlusion. — Pathological Anatomy of Chronic Occlusion. — Symptomatology. — Individual Symptoms. — Results of Examination of the Abdomen in Intestinal Occlusion. — Course, Duration, and Termination of Occlusion. — Perforation. — Diagnosis. — Differentiation of Occlusion from Other Diseases. — Diagnosis of Chronic Intestinal Stenosis. — Prognosis. — Therapeutics.

Strangulation and Internal Ilerniaform Incarceration of the Intestine. Age. — Sex. — I. Strangulation and Incarceration by Peritonitic Bands or Adhesions. — II. Strangulation and Incarceration by Omphalomes-

PAGE

17-86

87-114

XI

XU TABLE OF CONTENTS. VOL. II.

enteric (Vitelline') Remains (Meckel’s Diverticula). — III. Strangulation and Incarceration by Mesenteric and Omental Slits. — IV. Strangulation and Incarceration of Internal Hernias into Peritoneal Pouches and Openings. — Pathological Physiology and Etiology. — Symptomatology.— Prognosis and Course. — Diagnosis.

Obturations, i. Obturation by Gall-stones. — 2. Obturation by Intestinal Calculi (Enteroliths). — 3. Obturation by Foreign Bodies. 4.

.Obturation by Fecal Masses. — 5. Obturation by Entozoa. — Characteristic Subjective and Objective Signs of Obturation, as Distinct from Other Forms of Obstruction.

Invagination or Intussusception. Physiological (Nothnagel) or Agonal Form (Leichtenstern) of Invagination. — Pathological Invagination (Nothnagel). Vital, Persistent, or Inflammatory Form (Leichtenstern). Obstructive Form (Treves).. — Terminology. — Age. — Sex. — Pathogenesis.— Etiology. — Symptomatology. — Individual Symptoms. — Clinical History. — Cause of Death. — Course of the Chronic Forms. — Diagnosis. Volvulus and Axial Twists of the Intestine. Sex.— Age. — Torsions of the Mesenteric Axis of the Small Intestine. — Rotations of the Intestine Around its Own Axis. — Knot Formations Between Two or More Intestinal Loops. — Etiology. — Pathological Anatomy. — Individual Symptoms. — Recurrent and Consecutive Attacks. — Course. — Diagnosis.

Internal Strictures of the Intestine. Llypertrophies and Chronic Inflammatory Thickenings of the Intestinal Wall. — Strictures Due to Cicatrices from Dysenteric Ulcers. — Intestinal Strictures after Traumas, Incarcerated Hernias, and Intussusceptions. — Rectal Strictures. — Tuberculous Strictures of the Intestine.. — Multiple Tubercular Strictures.— Diagnosis.

External Constriction of the Intestine. External Peritonitic Strictures and Adhesions. — Symptomatology.— Diagnosis.

Intestinal Compression. Symptomatology. — Diagnosis.

Paralysis, Spastic Occlusion, and Motor Insufficiency of the Intestine. — Synonyms.— Intestinal Occlusion without Mechanical Obstruction of the Lumen. — Pathological Physiology of Intestinal Paralysis. — Symptomatology. — Diagnosis. — Prognosis.

Diagnosis of Various Forms of Stenosis and Occlusion of the Intestine. Does an Enteros/enosis or Occlusion of the Intestine Actually Exist ? — What is the Location of the Obstruction ? — What is the Pathological Nature of the Condition Causing the Obstruction ? — Acute Intestinal Occlusions. — Chronically Developing Occlusions.

Medical Treatment of the Various Forms of Intestinal Occlusion. I. Therapeutic Methods Applied Through the Mouth and Stomach. — II. Therapeutic Methods Applied from the Rectum. — III. Applications Direct to or through the Abdominal Wall.

Schema or Synopsis for Recording Clinical History of Intestinal Occlusion.

Literature.

CHAPTER IV. Contusions, Rupture, Perforation (Trauma) of the Intestine

Rupture of the Intestines. — Traumatic Rupture of Intestine by Forcible Distention. — Perforation of the Intestine (Gunshot and Stab Wounds).

CHAPTER V. Enterorrhagia

Synonym. — Symptomatology. — Pathological Anatomy. — Diagnosis. — Treatment.

PAGE

360-370

371-382

TABLE OF CONTENTS. VOL. II.

Xlll

Chapter VI

The Clinical Aspect of Intestinal Surgery ; Borderlines between Medicine and Surgery,

Surgical Treatment of Appendicitis. •

Nature, Concept, and Course of these Various Forms. I. Appendicular Colic. — II. Simple or Catarrhal Appendicitis. — III. Ulcerative Appendicitis with Exudation. — Group IV. — V. Appendicitis with the Symptoms of Acute Intestinal Occlusion. — VI. Appendicitis with the Clinical Picture of Diffuse Peritonitis. — VII. Returning and Relapsing Forms. — VIII. Chronic Appendicitis. — The Pulse. — Fever. — Tumor. — Leukocytosis.

Operative Treatment of Intestinal Obstruction. Peritonitis. — Treatment of Individual Forms of Obstruction. — Relapses after Operation for Intestinal Obstruction.

The Clinical Aspects for Operative Treatment of Chronic Enteros ten oses.

The Surgical Treatment of Intestinal Neoplasms.

CHAPTER VII. Intestinal Atrophy

State of the Columnar Surface Epithelium. — The Mucosa. — Measurements of the Breadths of the Various Layers and Structures in the Intestinal Wall — Normal, Hypertrophic, and Atrophic. — The Muscular Layer. — Fatty Degeneration of the Muscularis.

Progressive Gastro-intestinal Atrophy — Atrophic and Degenerative Changes in the Nerve Plexuses of the Intestine — Atrophia Gastro-intestinalis Progressiva. Clinical History.

CHAPTER VIII. Abnormalities of Form and Position

Idiopathic Dilation of the Colon.

Literature.

Intestinal Diverticula. Persistent Omphalmomesenteric (Vitelline) Remains. Intestinal Duplications. Displacements of the Intestine. Enteroptosis. Coloptosis.

Chapter IX

Diseases of the Intestinal Blood-vessels and Influence of Intestinal Affections upon the Blood, .

Embolism and Thrombosis of the Mesenteric Artery. Symptomatology. — Diagnosis. — Course and Prognosis. — Treatment.

Thrombosis of the Mesenteric Vein. Symptomatology. — Treatment.

P enarteritis Nodosa Intestinalis.

Venous Hyperemia of the Intestines.

Dilation of the Hemorrhoidal Veins (Phlebectasia ; Hemorrlioidalis).

Amyloidosis of the Intestine. Synonym. — Nature and Concept.

Amyloidosis of the Intestinal Blood-vessels. — Symptomatology.

Diagnosis. — Prognosis — Treatment.

Influence of Intestinal Affections upon the Blood. Anemia —Leukocytosis.

CHAPTER X. Intestinal Neuroses, Nervous Diseases of the Intestines

Motor Neuroses of the Intestine. Enterospasm.

Peristaltic Unrest of the Intestines. Paralysis of the Intestinal Musculans. — Insufficiency or Paralysis of the Sphincters.

PAGE

383-437

438-445

446-470

503-534 xiv

TABLE OF CONTENTS. VOL. II.

PAGE

Sensory Neuroses of the Intestines. Enteralgia, Mesenteric Neuralgia.

— Neuralgia Hypogastrica (Ronrberg).

Secretory Intestinal Neuroses.

Literature on Intestinal Neuroses.

Introduction

Protozoa. Rhizopods. — I n fusoria.

Animal Parasite (Helminthiasis). Cestodes (Tapeworms) — Trematodes (Flukeworms). — Nematodes (Roundworm). — Oxyuris vermicularis (Seatworm, Pinworm). — Trichotrachelidte (Leuckart) (Whipworm). Trichuris trichiura (old name, Trichocephalus dispar). — Trichinella spiralis. Trichina spiralis Owen, 1835 ; Tricliinella spiralis (Owen) Railliet. Trichinosis. — Strongylides. Ankylostomuin duo-

denale. — Correct name : Uncinaria duodenalis (Dubini, 1843) Railliet,

18S5 (Hook-worm). — Strongyloides intestinalis.

CHAPTER XII. Diseases of the Rectum, 606-665

Examination of the Rectum.

Rectitis or Proctitis.

Hypertrophic Rectitis and Stricture of the Rectum.

Periproctitis.

Rectal and Anal Abscess.

Fistula.

Anal Ulcer or Fissure.

Ulceration of the Rectum.

Pruritus.

Acute Inflammation and Prolapse of the Anal Mucous Membrane.

Chronic Noninflammatory Prolapse of the Anal Mucous Membrane.

Nonmalignant Anal Growths.

Anal Hemorrhage.

Nonmalignant Rectal Growths.

Malignant Disease of the Rectum.

Foreign Bodies in the Rectum.

Arrested Development of the Anus and Rectum.

Addendum (Literature on Tuberculous Cecal Tumor), .

Index of Authors,

Index of Subjects,

LIST OF ILLUSTRATIONS

1. Pelvic Cavity of Male (Superior View). (From Deaver’s “Surgical

Anatomy.”) . .

2. Ileocolic Fossa. (Deaver.)

3. Ileocecal Fossa, (Deaver.)

4. Subcecal Fossa. (Deaver.)

5. Histology of Tubercular Ulcer. (Pathol. Laboratory of Univ. of Maryland.)

6. Adhesions of Ascending, Transverse, and Descending Colon to Abdominal

Wall and Other Organs. (From Author’s Clinic.) .

7. A. Showing the Steel Sound Introduced through the Sphincter Ani, ... 2S5 B. Showing the Bismuth Emulsion Accumulated in the Dilatation or Pouch

above the Obstruction, 2S5

8. Superior Mesenteric Vessels. (From “ Deaver’s Surgical Anatomy.”) . . . 473

9. Inferior Mesenteric Vessels. AspectA. (From “ Deaver’s Surgical Anatomy.”) 477

10. Inferior Mesenteric Vessels. Aspect B. (From “ Deaver’s Surgical Anatomy.” ) 481

11. Right Side of Mesentery, Cecum, and Ascending Colon, 485

12. Chronic Hyperplastic Rectitis and Stricture of the Rectum of Luetic Origin.

A Gumma Has Taken the Place of the Anal Pilaster. (From Professor Hemmeter’s Clinic. ) 621

13. Carcinomatous Stricture of the Rectum, 657

PAGE

FIG.

1. Ileocecal Valve, Cecum, and Appendix. (From Deaver.)

2. Ileocecal Valve, Opening of Appendix. (From dissection in Anatomical

Laboratory of the University of Maryland. )

3. Ascending and Descending Colon, Sigmoid Flexure. (From dissection in Ana-

tomical Laboratory of the University of Maryland.)

4. Strangulation of Intestine by Meckel’s Diverticulum. (Regnault. ) . . . .

5. Showing Interior of Invagination. (From preparation in Anatomical Labora-

tory, University of Maryland.)

6. Exterior of Invagination. (From preparation in Anatomical Laboratory, Uni-

versity of Maryland. )

7. Volvulus of Sigmoid Flexure. (According to Potain. )

8. Volvulus of Small Intestine. (Leichtenstern.)

9. Dilation of Colon from Adult Twenty-nine Years Old (Dr. Formad’s Case).

(From Tyson’s “Practice of Medicine.”)

10. Multiple Acquired Diverticula of Colon. View from Peritoneal Surface, . . .

11. Chronic Passive Congestion of Colon

12. Amoeba coli,

13. Cercomonas intestinalis. (According to Davaine.)

14. Cercomonas coli hominis. (According to May. )

15. Trichomonas intestinalis. (According to Zunker.)

16. Megastoma entericum. (According to Grassi and Scliewiakoff.)

17. Balantidium coli. (According to Malmsten.)

18. Taenia solium. (From Author’s Collection.)

19. Taenia saginata. (From Author’s Collection.)

20. Dibothriocephalus latus, Head and Egg,

21. Gravid Segment of Beef-measle Tapeworm (Taenia saginata), Showing Lateral

Branches of the Uterus, Enlarged (Original). (After Chas. W. Stiles, United States Department of Agriculture, Bureau of Animal Industry, Bulletin No. 19.)

PAGE

XV

XVI

LIST OF ILLUSTRATIONS.

FIG. PAGE

22. Gravid Segment of Pork-measle Tapeworm (Taenia solium), Showing the Lat-

eral Branches of the Uterus, Enlarged (Original). ( After Chas. W. Stiles,

United States Department of Agriculture, Bureau of Animal Industry.) . . 558

23. Ascaris lumbricoides, 5^9

24. Oxyuris vermicularis, 57b

25. Development of Ova of Oxyuris vermicularis. (After Heller.) 577

26. Trichuris trichiura (Old Name, Trichocephalus dispar), 5*1

27. Uncinaria duodenalis, or Anchylostoma duodenale 5°9

28. Adult Strongyloides intestinalis (Parasitic Form). (After Richard P. Strong,

Johns Hopkins Hospital Reports, vol. x, Plate II. ) . ...... 600

29. Rhabditiform Embryo of Adult Fig. 28. (After Richard P. Strong, Johns

Hopkins Hospital Reports, vol. x, Plate II.) ...... . . . 600

30. Adult Male of Free-living Generation. (After Richard P. Strong, Johns Flop-

kins Hospital Reports, vol. x, Plate II. ) .... ••••••■ °01

31. Adult Female of Free-living Generation. (After Richard P. Strong, Johns

Hopkins Hospital Reports, vol. x, Plate II.) °01

32. The Position of the Hands for Noninstrumental Proctoscopy 007

33. The Position of the Fingers after their Introduction into the Anus, °oS

34. The First Position of the Patient for Martin’s Proctoscopy, o°9

35. The Second Position of the Patient, Illuminating Apparatus, etc., bio

36. Putting the Patient into the Third Position, **

37. Martin’s Posture for Proctoscopy,

38. Martin’s Proctoscope, •>

39. The Obturator for Anoscopes and Proctoscopes °*4

40. Martin’s Test-hook,

42. Interior View of the Left Half of the Rectum of an Adult, Previously Filled

with Melted Paraffin, , “

43 A Rectal Valve Drawn as Seen under the Microscope, . . ...... • °24

44. A Longitudinal Vertical Section Showing the Position of the Pelvic Organs in

Martin’s Posture, -*

45. A Longitudinal Vertical Section Showing the Position of the Pelvic Organs in ^

Martin’s Posture, • ■ • • . • ;r ‘ • ‘

46. Shows the Method of Using the Test-hook; an Obstructing Valve can not be

Effaced under Its Pressure, 6zg

47. Martin’s Curved Test-hook, g

48. Martin’s Over- and Under- valvotomy Scalpels ?

49. Illustrates the Method of Cutting the Valve .. . . . 3

to A Transverse View of the Rectum Showing Two Normal Rectal \ alses on the

Left and the Healed Operated Valve on the Right . • J

51. A Set of Martin’s Graduated Proctoscopes ; the Smallest is l ,{ Inches in D . ^

5- Tffi^Pa tien t i n'.Shn s’" Postu re 'w i tli MaVtin’s Table and ‘illumination Apparatus

Adjusted for Examination and Operation upon the Anus, . . . • • • •

53. The Patient in Martin’s Posture with Table and Ulummation Appara us

5 Adjusted for Examination and Operation within the Rectum, rhe Passive

Patient is Supported by the Shoulder-suspender and Knee-piece, »34

54. Shows a Method of Spraying the Rectum and Sigmoid Fiexure, . • ^ • • 4

55. Shows a Prolapse of Connective-tissue Hemorrhoids and Anal Mucous Met . ^

56. Shows a Prolapse of Connective-tissue Internal Hemorrhoid 648

Martin’* Kffid Clamp for SeSoval of Hemorrhoids under Locai Anesthesia, 650 49. Martin’s Conoid Clamp Opened, ••.•••. 651

I?: for 0.e if taW ^

62. A Composite Proctoscopic View of a Rectal Polypus, Papillomas, and a Hyper- ^

trophied Rectal Valve, • 656

63. A Method for the Removal of a Rectal Polypus, . •••• „, 0' ‘ 661

64. A Method for the Removal of a Foreign Body from a Recta Chamber, . .

65. A Method for the Removal of a Foreign Body from a Rectal Chamber, . .

Diseases of the Intestines.

VOLUME II.