William Osler.

Modern medicine : its theory and practice, in original contributions by American and foreign authors (Volume v. 5) online

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CONTRIBUTORS TO VOLUME V.

BROWN. THOMAS R., M.D.

FRIEDENWALD, JULIUS, M.D.

KELLY, A. O. J., M.D.

McCRAE, JOHN, M.B. (Tor.), M.R.C.P. (Lond.).

MARTIN, CHARLES F., M.D.

OPIE, EUGENE L., M.D.

RIESMAN, DAVID, M.D.

ROLLESTON, HUMPHRY DAVY, M.A., M.D. (Cantab.j, F.R.C.P.

STENGEL, ALFRED, M.D.

STOCKTON, CHARLES G., M.D.



MODERN MEDICINE



ITS THEOEY AND PEAGTICE



^^



■irJ



IN OEIGINAL CONTRIBUTIONS BY AMERICAN AND
FOREIGN AUTHORS

EDITED BY

WILLIAM OSLEE, M.D.

REGIUS PROFESSOR OP 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 OP MEDICINE

IN MC GILL UNIVERSITY, MONTREAL, CANADA



ASSISTED BY



THOMAS MCCRAE, M.D.



associate professor of medicine and clinical therapeutics in the johns hopkins university,
Baltimore; fellow of the royal college op physicians, london



VOLUME V
DISEASES OF THE ALIMENTARY TRACT

ILLUSTRATED




PHILADELPHIA AND NEW YORK

LEA & FEBIGER
1908



Entorrd aooording to the Act of Congress, in the year 1008, by

LEA & FEBIGER
in the Office of the Libriiriiiu of Congress. All rights reserved.



'vlC4\



^](]f>1






CONTEIBUTOES TO VOLUME V.



THOMAS R. BROWN, M.D.,

Associate in Medicine in the Johns Hopkins Medical Rchool, Baltimore, Md.

JULIUS FRIEDENWALU, M.D.,

Professor of Diseases of the Stomach in the College of Physicians and Surgeons,
Baltimore, Md.

A. O. J. KELLY, M.D.,

Assistant Professor of Medicine in the University of Pennsyh'ania; 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.B. (Tor.), M.R.C.P. (Lond.),

Lecturer in Pathology, McGill University, Montreal, Canada.

C. F. MARTIN, M.D.,

Assistant Professor of Medicine and Clinical Medicine, McGill Universitj^,
Montreal, Canada.

EUGENE L. OPIE, M.D.,

Member of the Rockefeller Institute for Medical Research, New York City;
Visiting Physician to the Presbyterian Hospital, New York City.

DAVID RIESMAN, M.D.,

Associate in Medicine in the Medical Department of the University of Pennsyl-
vania; Professor of Clinical Medicine in the Philadelphia 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 Clinical Medicine in the Medical Department of the Universit}^ 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.



(V)



CONTENTS OF VOLUME V.



DISEASES OF THE ALIMENTARY TRACT.



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 III.

DISEASES OF THE (ESOPHAGUS 77

By John McCkae, M.B. (Tor.), M.R.C.P. (Lond.)

CHAPTER IV.

FUNCTIONAL DISEASES OF THE STOMACH 105

By Julius Friedenwald, M.D.

CHAPTER V.

ORGANIC DISEASES OF THE STOMACH 175

By Charles F. Martin, M.D.

CHAPTER VI.

DISEASES OF THE INTESTINES 327

By Alfred Stengel, M.D.

CHAPTER VII.

DISEASES OF THE PERITONEUM 495

By Humphry Davy Rolleston, M.A., M.D. (Cantab.), F.R.C.P.

(vii)



viii CONTENTS OF VOLUME V

CIIAITEK \III.

SPLANCHNOI>TOSIS— ENTER01>1\)SIS— GLENARD'S DISEASE . . 599
Bv Thomas K. Buown, M.D.

CHAPTER IX.

DISE.\SES OF THE P.\NCREAS 021

By Eugene L. Opie, M.D.

CHAPTER X.

DISEASES OF THE LIVER, GALL-BLADDER, AND BILIARY DUCTS 683
By a. O J. Kelly, M.D.



DISEASES OP THE ALIMENTAEY TRACT.



CHAPTER I.



liNTRODUCTORY DISCUSSION ON THE DISEASES OF 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 divided under
the following headings:

1. The Whole and the Part.

2. Individuality in Disease.

3. The Interrelation of Digestive Functions.

4. Adaptability and Vicarious Action of the Digestive Functions.

5. The Relatively Great Importance of Motor Functions.

6. The Nature of Functional Disturbances of Digestion.

7. Functional Disturbances in Relation to Structural Disease,

8. Structural Changes Resulting from Functional Disorders.

9. Structure and Function in Relation to Peptic Ulcer.

10. The Question of Secretion.

11. Infection in Relation to Digestion.

12. Visceral Blood Supply in Relation to Digestion.

13. False Combinations of Secretion — Disharmony.

14. The Place of the Biliary Tract in Digestive Pathology.

15. Some Peculiarities of Pancreatitis.

16. Possible Correlation of the Abdominal Viscera through the Sympa-

thetic.

17. Splanchnoptosis and Overtension of the Peritoneum.
18- Psychoneuroses in Relation to Digestion.

19. Variations in the Intestinal Flora in their Relation to Diseases of
the Digestive Tract.

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 the
digestion has no part and from which it 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
VOL. v.— 2 ( 17 )



18 DISEASE;S OF THE ALIMEXTAIiY TRACT

advancement of digestion ; hut as absorption and assimilation, on the one hand,
and the formation and withih-awal of catal)oHe and waste j)r(KhK'ts, on the
other, are soinnnechately rehitetl to the jjreHniinary (Hgestion, 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. AVhile it makes for simplicity in description to exclude from
imj)lication those organs not connnonly grouped with the digestive apparatus,
this does not result in a correct unilerstaiuling, 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 state of the nervous system, including its
psychical manifestations, to the fluids of the body, to the blood pressure,
the metabolism of the tissue, and to the state of the emunctories. The
importance of these matters is perhaj)s imconsciously recognized when we
declare that good digestion depentls upon restful sleep, fresh air, sunlight,
physical exercise, and the jjroper activity of the bowels, kidneys, and skin.
When we disregard these essential matters, it is difficult to form a just con-
ception of the nature of digestive disturbances, or to prescribe successfully
therapeutic 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 (juestion, "^Yhere is the dis-
ease?" 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
they lead to functional disturbance, both local and general, and it will there-
fore be understood that 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.

^lany 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 importance, and by arranging our
data with a view to answering such inquiries we throw most light upon the
subject as a whole.



THE INTERRELATION OF DIGESTIVE FUNCTIONS 19

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 care-
fully weighed, so that we may avoid the feudality of classification and the
tyranny of established rule. For instance, von Noorden has shown that
certain starches are comparatively successful foods in particular 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, invariably excites intense gastro-intestinal distress in
an occasional individual. This principle applies to other matters than food.
The sensitiveness of some persons 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. Doubtless there are many individual factors that are
at times active in producing physiological derangements which are as yet
undetected.

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 happi-
ness 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 intestine are excited by proper psychical
stimulation, and some of them are inhibited, others overexcited, by dis-
tress. 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 other secretions,
stimulates the secretion of pancreatic juice, bile, and succus entericus ; there-
upon the pylorus again opens and the rhythmic movements of the stomach
expel a further portion of the gastric juice into the duodenum, w^hich, in
turn, leads again to the closure of the pylorus. This reciprocal action demon-
strates 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 sup-
posed 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. It is by a combination of these two that trypsin is formed.

Attention has been called to the fact that the psychical condition may
influence salivation and gastric secretion; then there follows a stimulation
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.



20 DISEASES OF THE ALIMEXTARY TRACT

But (he impulse starting in u psychic state does not end in its effects
upon the Hver and pancreas. The functional activity of the small intestine
is greatly influenced bv the presence therein of the right proportion of secre-
tion from the liver, pancreas, and other glands, and intestinal digestion would
suffer in case Of ilecrease or derangement in this supj)ly. Under such con-
ditions irritation ofthe 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 the bacterial life, especially within the gut,
would be multiplied, fermentation occur, and infection of the organism
would 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 main-
tain a proper balance of the organism. W^hen there exists a marked dis-
turbance of intestinal digestion we have reason to sujjpose that it interferes
with this absor|)ti()n. While the liver may be cml)arrassed through not
receiving by way of the |X)rtal circulation the usual supply of recovered sub-
stances, it suffers at the same time because of the absorption of the products
of j)utrcfaction. It has also been shown by Adami that Hving bacteria
reach the liver from the intestine.

Wlien the liver is thus overtaxed, a general toxcTmia supervenes, the whole
body is injured, and hiemolysis is often exaggerated. There exists a remark-
able, although somewhat obscure, relationship between the liver and the
kidneys, and under conditions that are herein described renal elimination
may be decreased or otherwise deranged. To these evils others may be
added when the colon, suffering in turn, contributes to the general toxaemia.
Drlaficld has emphasized the frequency of chronic colitis as the result of
interstitial ne])hritis, and others have recognized the injurious effects of colitis
upon the kidneys.

Relatively great importance attaches to that portion of the digestive
apparatus which includes the pylorus, duodenum, and pancreas. 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 that may result
from any great disturl)aiice 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 portion
of the alimentary tract is able to dispense with the assistance which it ordi-
narily 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 functionlcss through chronic inflam-
mation, 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
accompanicfl by as serious results as ensue from lowering of vitality in the
apparatus generally, such as follow grave diseases of the nervous system,
or the chronic intoxications and infections. In other words, the organism
seems capable of sustaining almost in entirety the loss of function of certain
of the digestive organs. Nutrition sometimes fails as the result of depression,
affecting all parts of the apparatus at one time. But to reiterate, it would
be a misapprehension to suppose that health can be perfect after the loss



NATURE OF FUNCTIONAL DISTURBANCES OF DIGESTION 21

of function of any one of the important digestive organs, or after tlie re-
moval of parts, as, for instance, the stomach, hy surgical intervention.

5. The Relatively Great Importance of Motor Functions. — Our

understanding 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 be necessary secretion, she immediately
resents, and dangerous symptoms supervene upon, 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 stagnation of gastro-intestinal contents or the interruption of
the flow of secretion from the great digestive glands. In the latter case the
mischief is not so much from the retention of secretion as from the mere
fact 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
of even moderate stagnation, for constipation in certain individuals is
immediately succeeded by general digestive derangement as well as by
important constitutional symptoms. This is especially true of those un-
accustomed to constipation or those in whom there is inadequate activity
of the lungs, liver, and kidneys. In relation to the kidneys and liver, this
statement is likely to pass unchallenged by some who would doubt its applica-
bility to the lungs, but we probably fail to recognize the full importance of
elimination by way of the lungs. In sufferers from emphysema, chronic
fibroid pneumonia, or continued pulmonary congestion, the patient is strik-
ingly relieved by timely stimulation of the skin, bowels, and kidneys. Doubt-
less 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. Individuals long accustomed to atony
of the colon may acquire a tolerance, and experience little inconvenience
from prolonged constipation. This is but another illustration of the success
with which the organism adapts itself to untoward conditions. At the same
time it shows how intimate is the relationship between the digestive functions
and those of remote apparatuses like the genito-urinary and the respiratory.
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 thrown upon certain digestive derangements as a result.

6. The Nature of Functional Disturbances of Digestion.— The
nature of the so-called functional diseases is better apprehended by studying
them along more general lines such as those already 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



22 DISEASES OF THE ALIMEXTARY TRACT

was then seen that the state giving rise to a coinj)lex of symi:)toms formerly
-deseribeil as "indigestion" was not a single patliologieal entity, that it was
in fact not one thing, hnt a varied derangement of gastric activity, the
more or less tlirect result of irritation or depression of the sympathetic
nervous system. Theri'fore, these functional affections were early divided
into two classes: first, functional disease from excitation, and second, from
depression. This division, while in a sense well justified, is not so simple
as it appears; for, in point of fact, it is not always practicable to decide in
which group a given disturbance shall be placed. Besides, in not a few
patients we may discover evidences of an irritative character at one time
and dei)ressive at another. Nevertheless, the classification is useful and
helpful to understanding. It was soon perceived that symptoms from
excitement might not materially diil'er from those following depression,
and that both are manifestations of ])hysi()logical fatigue, whether arising
from particular or general sources of exhaustion. These difl'crent, varying
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 sup-
plemented in order to make it of value in the understanding of the actual
disease. True, we do occasionally meet with a disturbance that seems to be
wholly motor, secretory, or sensory, as, for instance, cardiospasm or gastralgia;
but, as a rule, and with relatively few exceptions, we find a complex in which
two or all of these divisions of symptoms occur simultaneously. Illustration
may be found in most of the cases of so-called gastrc atony.

The trend of events that makes 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. Tliis study must not be limited to the mere
investigation of the functional behavior of the stomach. Commonly, indeed
almost invariably, the etiology of the trouble will be found in some remote
and perhaps unexpected region of the organism, to some leak of general
energy, if the exj>ression is permissible, to some undiscovered irritation of
the nervous system. Thus a retroverted uterus, proctitis, or a displaced
kidney may indirectly lead to important digestive disturbances, but more
frequently causes of gastric asthenia are to be found in eyestrain. 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 disregarded. 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
commonly 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 especially active
when the vitreous body begins from age to lose in pliability. We are in-
debted to Gould for insisting upon the reality of the nuitter.

Formerly our text-books referred to but few gastric disorders save the well-
established structural processes. With the advent of newer methods of



Online LibraryWilliam OslerModern medicine : its theory and practice, in original contributions by American and foreign authors (Volume v. 5) → online text (page 1 of 126)