eases. The results go to show that here is a field, the further cultivation of which may lead to highly important additions to our pathological knowledge.

Of the 100 examinations, in 72 the appearances denoted more or less degenerative change. Of these 72 cases, in 47 the degeneration was limited to a portion of the stomach, usually the pyloric portion, the tubules in the remainder of the organ being healthy. In 11 cases the extent of the affection was greater, but still moderate. In 14 cases the appearances denoted destructive changes extending over the greater part of the stomach. The appearances denoting degeneration within the tubules consisted of the deposit of black pigment and fatty granules, the presence of granular matter in the place of the normal epithelium, supposed to be the debris of the latter, and atrophy or loss of the epithelium. These changes are analogous to those observed in the degenerative changes which take place within the convoluted tubes of the kidney in cases of the chronic affections of these organs embraced under the name of Bright's disease.

In the 14 cases in which the gastric tubules were extensively degenerated, the patients died with a variety of diseases, and it is not easy in so limited a number of cases to determine what symptoms were attributable to the affections of the stomach. It is not improbable that further researches will show these glands to be the seat of morbid conditions of great importance, as occurring alone or in association with other affections. There is room for the conjecture that the impairment of digestive power, the anæmia, debility, etc., which sometimes occur without being connected with any obvious disease, as in the so-called idiopathic anæmia described by Addison, and which are sometimes superadded to various diseases, may be due to morbid conditions seated in the gastric tubules. Further explorations in this new field of research may lead to developments of as much pathological importance as those which have resulted within the past few years, from the study of the morbid conditions of the kidney.

The study of the secretory apparatus of the small intestine, or the follicles of Lieberkuhn, may afford a similar field for fruitful research, which, as yet, appears to have hardly been begun.

The points which it is desirable to settle by a sufficient number of observations are: First, the variations in appearances which occur within the limits of health, and the appearances which denote disease, and not cadaveric changes. Second, the different kinds of morbid change, together with their pathological character and import. Third, the gross appearances corresponding to the changes ascertained by the microscope. Fourth, the symptoms associated with different anatomical changes.

'Medico-Chirurgical Transactions, vol. xxxvii. London, 1854.

CHAPTER IV.

Structural Affections of the Intestinal Canal involving Obstruction-Invagination-Strangulated Hernia within the Abdomen-Rotation or Twisting of Intestine-Compression and Stricture of Intestine-Obstruction from Impaction of Feces, Enterolithes, and Foreign Bodies-Functional Obstruction.

STRUCTURAL affections of the intestines are important, measurably or chiefly, as giving rise to obstipation due to mechanical obstruction to the passage of the intestinal contents. Hence, we may consider these affections under the head of obstruction of the bowels. And, having considered the important structural affections involving obstruction, it will be convenient to consider, in this chapter, obstipation (meaning by this term obstruction as distinguished from constipation) dependent on causes other than lesions of structure, viz., on the impaction of feces, the formation of concretions called enterolithes, the introduction of foreign bodies, and on merely functional disorder. The term ilens or iliac passion, and other names, have been applied to cases of obstipation with the ejection from the mouth of the intestinal contents, or so-called stercoraceous vomiting. As the latter symptom occurs in connection with obstruction from various causes, the names based upon it have no special pathological significance, and tend to produce confusion.

Obstruction from structural affections is happily not of frequent occurAccording to the statistical researches of Benjamin Phillips, it is met with in a proportion of one per cent. in post-mortem examinations.1 The lesions involving obstruction are the following: Intussusception, invagination or volvulus; strangulation from hernia within the abdomen; rotation of a portion of intestine upon its own axis, or upon the mesentery, and, according to Rokitansky, twisting of a portion of intestine around another coil of intestine; compression of one portion of intestine by another portion, or by a tumor situated exterior to the canal, and stricture produced by morbid growth within the canal or by the contraction following the cicatrization of ulcers. The symptoms attending these several affections are not, in all respects, the same, although obstipation is a common feature They will therefore claim separate consideration. But it will be seen that it is not always easy to determine, by means of the symptoms in individual cases, the particular lesion which occasions the obstruction.

INVAGINATION.

Invagination, intussusception, or volvulus, is the reception of a portion of the intestines into another portion. Generally the invagination is from above downward, but sometimes the lower portion is received into the upper. It is certain that it may occur as a temporary condition, giving rise to no symptoms. In post-mortem examinations, especially in children, innocuous invaginations of the small intestine are not infrequently found; the invaginated portion is restored without difficulty, and, aside from the displace

1 Trans. Royal Med. and Surg. Society of London, vol. xiii. 1848.

ment, there are no morbid appearances. In such instances, they have probably occurred in the last moments of life. I counted as many as fifteen of such invaginations in the body of a child dead with the typhoid fever. It is not unlikely that they occur frequently in connection with various diseases and even in health. It is only when the invagination becomes fixed, giving rise to congestion, inflammation, etc., that it occasions obstruction and other symptoms. It is then a lesion of very great gravity, in the great majority of cases ending fatally. This is the most frequent of the lesions causing fatal obstruction. Of 169 cases of obstruction from various lesions collected by Phillips, 63 were of this class.

Invagination brings into apposition three layers of intestine, viz., an entering, a returning, and a receiving layer. In the relation of the entering and receiving layer, mucous surfaces are in contact, and these do not become adherent. But serous surfaces are in contact in the relation of the entering and returning layer, and inflammation, excited at the point of entrance, leads to adhesion of these surfaces, extending more or less beyond the point of entrance. In this way the invagination becomes fixed. The vessels of the portion of the mesentery connected with the invaginated intestine are obstructed by tension. Congestion and swelling of the invaginated intestine ensue, and, at length, it becomes gangrenous, as if strangulated, and sloughs away, if life be sufficiently prolonged. The obstruction is due to the swelling from congestion and the exudation of lymph. Usually the obstruction is complete, but exceptional cases have been reported, in which the intestinal passage remained pervious, but much contracted. Peritonitis is apt to extend more or less around the seat of the invagination, leading to morbid attachment to the adjacent parts.

The invagination may occur at any point in the intestinal tract. Its most frequent seat, by far, is at the junction of the ileum and cæcum. This is shown, in cases of children, by the valuable statistical researches of Dr. J. Lewis Smith. Dr. Smith's account of the mode in which it generally occurs is as follows: "The intussusception not infrequently begins in the prolapse of the ileum through the ileo-cæcal valve, in the same way that prolapse of the rectum occurs through the sphincter ani. If death take place early, only a small portion of the ileum may have passed the valve. If the case be protracted, the tenesmus brings down more and more of the ileum with its accompanying mesentery. The constriction of the valve, which acts as a ligature, prevents the further descent of the ileum, and the tenesmus continuing, the next step is the inversion of the caput coli, which is drawn into the colon by the descending mass; and unless the case terminate by sloughing or death, the ascending and transverse portions of the colon are successively invaginated. Not infrequently, the cæcum is the part primarily inverted and invaginated, and descending along the colon, it draws after it the ileum which sustains its natural relation to the ileo-cæcal valve. These two forms of invagination-that in which the ileum, passing through the ileo-cæcal valve, successively inverts and draws after it the caput coli and the divisions of the colon, and that in which the caput coli is primarily invaginated, and descending along the large intestine, inverts the latter, and draws after it the ileum-constitute the vast majority of cases of this disease in childhood." It is however, to be borne in mind that the invagination may occur at any point in either the large or small intestine. The invaginated portion may descend so low as to be felt and seen at the anus, and it may even protrude from the body.

1 Statistical Researches Relative to the Seat, Symptoms, Pathological Anatomy, etc., of Intussusception in Children. Am. Jour. of Med. Sciences, Jan. 1862.

Invagination causing obstruction, as already stated, proves fatal in the great majority of cases; yet cases are by no means absolutely hopeless. The manner in which recovery usually takes place is of importance in its bearing on the treatment. The invaginated portion of intestine sloughs away and is evacuated, the entering and receiving portion at the point of entrance remaining adherent, and the perviousness of the canal being restored. Cases have been reported in which a large portion of invaginated intestine was thrown off, and recovery followed. Prof. Van Buren reported a case to the New York Pathological Society, in 1855, in which five feet of intestine were passed per anum, the patient recovering. Prof. Peaslee exhibited at a meeting of the New York Academy of Medicine, 1865, five feet of intestine which had been passed per anum four months before the death of the patient. He also exhibited the intestines removed from the body of this patient after death. The small intestine was only 16 feet in length, the length of the large intestine being 5 feet and 10 inches. The invagination and sloughing had taken place in the small intestine at a distance of six feet from the duodenum. A stricture existed at this point; the intestine above was much dilated, and that below greatly reduced in size. The patient died from inanition dependent on the stricture of the intestine.1 Dr. William Thomson, of Edinburgh, collected 43 cases ending in recovery. This is the mode of recovery, it is to be borne in mind, which is to be hoped for after permanent incarceration of the invaginated intestine has taken place.

The prominent local symptoms which enter into the clinical history of invagination are as follows: Pain is more or less prominent, at first paroxysmal as in colic, and after a time becoming constant, with frequent exacerbations. The pain, if the patient be old enough to describe it, appears to emanate from a certain fixed point. Tenderness at first may not be marked, but becomes developed, being either limited to or greatest at the point whence the pain emanates. The tenderness and constant pain denote the occurrence of peritonitis at the seat of the invagination. Vomiting soon becomes a prominent and persisting symptom, with a very few exceptions. The vomited matter, after a time, may have the odor of feces, and is then said to be stercoraceous. A truly stercoraceous vomiting, however, very rarely, if ever, takes place that is, the contents of the large intestine are not ejected. This could, of course, only happen when the obstruction commences below the cæcum, which is extremely rare; but, even if the cæcum be above the seat of the invagination, the ileo-cæcal valve certainly, in the great majority of cases, effectually prevents regurgitation of the contents of the large into the small intestine. Experiments and clinical observation show that the ileo cæcal valve will sustain an amount of pressure sufficient to cause rupture of the intestinal walls. It is not, however, improbable, as has been conjectured, that regurgitation may sometimes take place to some extent, provided the ileum as well as the cæcum at the point of junction be ⚫ distended. The accumulation of ingesta and gas above the obstruction occasions more or less abdominal distension, provided the invagination be not situated in the upper portion of the small intestine. Frequently the accumulation of intestinal contents at the seat of the invagination gives rise to a tumor appreciable by the eye and touch, and dulness on percussion. After the contents of the intestinal canal below the point of obstruction have been evacuated, there is persisting obstipation, save in a very few exceptional cases. If the invaginated portion of intestine descend to the rectum, tenesmus is

1 Vide Bulletin of the New York Academy of Medicine, vol. 11, Nos. 25-29. * Vide article on Internal Strangulated Intestine, by Elisha Harris, M. D., in New York Journal of Medicine, 1853.

felt, and the patient is led to make straining efforts. Under these circumstances bloody mucus is expelled, as in dysentery.

The general symptoms at first may not be marked, but soon they denote a grave affection. The pulse becomes accelerated, the frequency progressively increases, and it becomes proportionately feeble or compressible. Progressive prostration, hiccough, coolness or coldness of the surface, an anxious or haggard expression, denote the progress toward a fatal termination. The mode of dying is by asthenia, the pain and tenderness frequently diminishing or ceasing for some time before death.

A favorable progress is denoted by the occurrence of free evacuations from the bowels, the discharge of the invaginated portion of intestine, together with improvement in all the local and in the general symptoms.

Invagination is to be discriminated from functional colic, acute peritonitis, and, obstruction from other causes. The symptoms at first may denote nothing more than colic. The persistency of pain, the development of tenderness, the acceleration of the pulse, the vomiting, etc., however, soon point to an affection of greater gravity than colic. Acute peritonitis is to be excluded by the gradual development of the local and general symptoms, by the absence of diffused tenderness over the abdomen, of rigidity of the abdominal muscles, by the localization of pain and tenderness within a circumscribed space, and by the signs of a tumor in some cases. Acute peritonitis sometimes supervenes in cases of invagination from rupture of the intestine above the obstruction. From obstruction caused by hernia within the abdomen, and rotation or twisting of the intestine, the discrimination is more difficult, and, indeed, cannot always be made with positiveness. The age of the patient has a bearing on the diagnosis. Invagination occurs. most frequently in infancy. According to Dr. Smith's statistics, it is most apt to occur between the second and third month of infantile life. Of fortyseven cases, only eighteen occurred between the ages of one year and twelve years. Male children, more than female, are liable to it, the relative proportion, in Dr. Smith's cases, being thirty-two to twenty-two. On the other hand, hernial obstruction occurs oftener after infancy and childhood, and cases occur oftener in females than in males. The discharge of blood and mucus is distinctive of invagination involving the large intestine.

A point in diagnosis is to determine the probable seat of the invagination. The chances are that it is seated at the junction of the large and small intestine. The probability of this being the seat is increased, if the pain, tenderness, and swelling are situated in the neighborhood of the right iliac fossa. Tenesmus, with the discharge of blood and mucus, shows that the large intestine is involved. The invaginated portion may sometimes be felt and seen within the rectum. If seated in the small intestine, the constitutional disturbance is greater, and, if the point of obstruction be toward the upper portion of the small intestine, there will be little or no abdominal distension. Barlow considers the quantity of urine as furnishing a guide to the situation of the obstruction. If the small intestine be unobstructed, liquids ingested are abundantly absorbed, and the urine is proportionately abundant, but if the obstruction be situated high up in the small intestine, the diminished absorbing surface involves a scanty secretion of urine.1 It is doubtful if much reliance is to be placed on this test.

The prognosis is extremely unfavorable. The usual mode of recovery in the exceptional cases in which the affection does not end fatally, has been stated, viz., by sloughing away of the invaginated portion of intestine, the adhesions at the point of entrance being permanent. It is possible that the

Practice of Medicine.