CHRONIC INTESTINAL CATARRH.
BY W. W. JOHNSTON, M.D.
ETIOLOGY.—Chronic intestinal catarrh has many of the same causes as the acute form; it is the expression of a large number of different pathological states and complicates many general and local diseases.
It is very common in children under two years of age, and is associated with change in diet in weaning and with the irritability of all the tissues during dentition. It is also a frequent disease in old persons, being due to imperfect mastication, the weakness of digestion, portal congestion, the gouty diathesis, and other causes.1 Men have the disease more frequently than women. Hereditary influence and idiosyncrasy predispose to chronic catarrh of the bowel as to catarrh of the bronchi. Bad hygiene, want of cleanliness with an unhealthy condition of the skin, constant breathing of foul air due to want of proper ventilation, animal decomposition, or overcrowding predisposes to chronic diarrhoea. The chronic diarrhoeas among soldiers in camps,2 among the inmates of prisons, workhouses, and asylums, are examples of these influences. Overwork, especially mental overwork with anxiety, and privation of sleep act in the same direction. In the chronic constitutional diseases and in many chronic diseases of organs diarrhoea sooner or later appears, and very generally is the immediate cause of death. In phthisis pulmonum, whether tubercular or not, simple catarrh of the bowel is nearly always present.
1 La Diarrhée chez les Viellards, Paris, Thèsis, 1865, No. 112. See also works of Durand-Fardel and Charcot and Loomis.
2 According to the statistics prepared in 1871 by T. B. Hood of the U.S. Pension Office, chronic diarrhoea was the disease for which a pension was granted in 20 per cent. of all cases of disability from disease and in 75 per cent. of all the diseases of the digestive system (Report of Commissioner of Pensions, 1871).
During the course of chronic Bright's disease, more frequently in the cirrhotic form, lesions are developed in the intestine which cause obstinate diarrhoea. The discharge of urea into the intestine, and its conversion into carbonate of ammonium, which acts as an irritant to the mucous membrane, is the reason of the diarrhoea in this disease, according to Luton and Treitz;3 and in so far as the discharge represents the escape of urea by the bowel, it may be regarded as salutary. In gout, especially in old persons, periodical diarrhoea gives relief. Chronic gouty subjects assert that they are not benefited by colchicum until it has purged them. The lithic-acid diathesis, pyæmia, septicæmia, scurvy,4 diabetes, leucocythæmia, Addison's disease, and syphilis5 have diarrhoea during some part of their progress. The malarial cachexia is often attended with a diarrhoea which quinia alone will relieve; this symptom may occur periodically or be constant.
3 A. Luton, Des Séries morbides, Affections urémiques de l'Intestin, Paris, Thèsis, 1859, No. 38, p. 45; also, Treitz, "Ueber urämische Darmaffectionen," Prager Vierteljahrschrift, Bd. 64, 1859, S. 143.
4 See testimony as to the influence of scurvy in promoting diarrhoea (Woodward, Med. and Surg. History of the War, Part 2, Medical Volume, p. 638).
5 A. Trousseau, "Comments on a Case of Syphilitic Diarrhoea cured by Mercury," Clinique méd., Paris, 1868, t. iii. p. 123.
Disease of the liver, heart, or lungs, by retarding the circulation in the portal system, causes venous stasis and catarrh in the gastro-intestinal mucous membrane. The chief conditions which bring this about are tumors compressing the mesenteric veins, cirrhosis of the liver, tumors pressing on the ascending vena cava, valvular disease of the right and left heart, fatty degeneration or dilatation of the heart, cardiac debility from chronic exhausting diseases, fibroid phthisis, chronic pneumonic phthisis, chronic pleurisy, and pulmonary emphysema.
An unsuitable diet may not set up an acute catarrh, but may slowly induce changes of a chronic nature in the mucous membrane. This is the case in infants fed upon artificial food instead of breast-milk, or when the digestion is overtaxed after weaning. In adults food difficult of digestion and over-eating bring about the same result. Alcohol, spices, and condiments, if taken in excess, and the habitual use of purgatives, lead to chronic inflammation of the intestine.
Foreign bodies, such as fecal concretions, gall-stones, stones of fruit, bones, coins, and pins, by remaining in contact with the mucous membrane for a length of time, determine inflammation and ulceration.6
6 Lothrop, "Case of a Child in whom seventeen plum-stones, three cherry-stones, and seven small bones were impacted In the cæcum and ileum for a year. Inflammation, ulceration, and perforation of the bowel resulted" (Buffalo Med. and Surg. Journ., March, 1882, p. 346).
Neglect in the treatment of acute catarrh, the prolongation of an acute attack, from its intensity and the incurability of the lesions, establish chronic disease.
All chronic lesions of the bowel are complicated with chronic catarrh, as chronic tubercular ulcer, neoplasms in the wall, pressure of a tumor from without, etc.
PATHOLOGICAL ANATOMY.—The alterations in the intestines in chronic catarrh involve the walls to a much greater extent than in the acute form.
The intestinal tube is dilated, contracted, or irregularly dilated and contracted. When the calibre is increased the walls are thinned. Hypertrophy and hardening of the tunics, chiefly of the muscular and submucous tissue, are accompanied by a narrowing of the canal, and this change, most common in the rectum and sigmoid flexure, sometimes involves a very considerable extent of the colon. Lebert records the case of a woman who had diarrhoea for six weeks; constipation and vomiting with abdominal tenderness ensued. There was hypertrophy of all the coats of the stomach and of the ascending colon and rectum. The rectum was so narrowed by the thickening of its wall that a female catheter could not be passed through it.7 In chronic catarrh the mucous membrane of the colon and of the lower part of the ileum is the seat of the most characteristic lesions. The colon was alone the seat of disease in 9 out of 99 cases analyzed by Woodward; in the remaining 90 the two were involved together. In these the lesions in the colon (especially in the rectum and sigmoid flexure) were always more advanced and more serious than in the small intestine.
7 Lebert, Path. Anat., t. ii. pp. 247, 248; another case, Laboulbène, Anat. path., Paris, 1879, p. 194.
Gastric catarrh may by extension become duodenal catarrh, and from the duodenum the disease may extend into the common bile-duct and its branches. The duodenitis and catarrh of the ducts may persist, and become chronic after the stomach lesion is gone.
The mucous lining of the intestine is changed in color, form, thickness, consistence, and in the appearance of its glandular structures. The shades of color in chronic inflammation are dark red, livid, brown, drab, or slate-color, light blue, and greenish. The coloration is not uniform. Dark-red and gray spots are seen on a pale and uniform red ground; grayish streaks and patches are mingled with red or whitish areas, giving rise to a mottled or marbled appearance.8 In some cases red predominates, in others the slate-color.9 Dark-brown, almost black, patches are also seen. These different tints depend upon the intensity and character of the inflammation and the stage which it has reached. Diffused bright-red discolorations belong to acute inflammation, and are rarely seen in the chronic form. Acute hyperæmic patches appearing in the midst of a slate-colored membrane indicate intercurrent acute attacks. Dark-red streaks or spots are caused by extravasations. Brown and slate-colored areas represent the changes in old extravasations or pigment-deposits where inflammation or ulceration has existed. Where the inflammation is progressing toward the destruction of tissue the membrane is dark-purplish or black in color, mottled with patches of dull reddish hue and minute spots of bright red. Black dots are seen in the small and large intestine isolated or in close proximity. They are due to minute specks of black pigment deposited in the apices of the villi, in the centres of solitary glands, in rings around them, or in the glands of a Peyer's patch. The juxtaposition of pinhead black points gives rise to the shaven-beard appearance10 of the mucous membrane. Dark streaks or wavy lines of pigment are also seen.11
8 For illustration of color of mucous membrane in chronic inflammation see the following illustrations in color: Med. and Surg. Hist. of the War, Part 2, Medical Volume—plates facing pp. 308, 518, and 520; also, Illustrations of Morbid Anatomy, J. Hope, London, 1834, figs. 128, 129.
9 For an excellent illustration of slate-color of chronic inflammation, with supervening acute inflammation and hemorrhagic patches, see Carswell, Path. Anat., Plate ii. fig. 4; also, Lebert, Path. Anat., t. ii. Pl. cxiv. fig. 7.
10 For an excellent illustration of this change see Med. and Surg. Hist. of the War, volume cited, plates facing pp. 298, 304; also, Atlas d'Anatomie path., Lancereaux, Paris, 1871, Pl. iii. figs. 3 and 4.
11 See colored plates Med. and Surg. History of the War, volume cited, facing p. 308.
In the ileum the mucous folds are obliterated or swollen and thickened. Obliteration of the folds occurs in connection with a dilated intestine; when the intestine is contracted they are elevated, tortuous, and close together. The villi are hypertrophied, looking often like minute polypi. The mucous coat is usually thickened, measuring from one-fifth to one-fourth of an inch. It is softened, and more easily scraped off,12 but quite frequently there is induration instead of softening. The solitary glands of the ileum are hypertrophied and appear scattered over the mucous surface as small rounded elevations. They are quite numerous or a few only may be seen. A ring of vascular injection usually surrounds each enlarged follicle. Peyer's patches may be unchanged or from swelling of the follicles are more prominent than is normal, but relatively the enlargement of the solitary glands is greater. In chronic catarrh the follicles acquire greater size than in the acute form. The apices of the solitary glands in the small intestine may be broken down, leaving small follicular ulcers, with swollen rings around them formed of the undestroyed and hypertrophied gland-structure. Here and there one or two of the follicles in the Peyer's patch may have its centre indented by ulceration. These changes are usually in the lower part of the ileum near the cæcum.
12 The mucous membrane is often tumefied and softened in cases where there are thickening and contraction of the intestine with great reduction of its calibre (Elliot Coues, Med. and Surg. Rep., Philada., 1863, vol. x. p. 207).
In the colon the enlarged solitary glands are in greater number, and are dotted about more closely in the descending colon and sigmoid flexure.13 When there is ulceration the large intestine has many more ulcers than the ileum, and they are more numerous in the lower part of the colon. They appear as sharply-punched openings, and give to the mucous surface a honeycombed look; their diameter varies from one-tenth to one-fourth of an inch. Large ulcers formed by the confluence of smaller ones measure from one-fourth to one inch in diameter; they may be so deep as to have the muscular tunic for their base, and quite often the bottom of the ulcers is black. A ragged or uneven appearance is given to the surface by the ulcers being close together. Such extensive destruction sometimes takes place that no normal mucous membrane seems to be left. Perforating ulcers are occasionally seen in the large intestine or ileum. Perforation occurred in two of Woodward's ninety-nine cases. Healing ulcers14 are found by the side of others which are growing. Healed follicular ulcers are known by a puckered, stellated appearance15 of the mucous membrane, which is pigmented and of a slate-gray or marbled-brown color16 if the process has been long completed. Larger dense cicatrices, pigmented also, mark the site of more extensive ulcerations.
13 Illustration, Kupfertafeln zu DR. LESSER über die Entzündung und Verschwärung du Schleimhaut des Verdauungskanales, Berlin, 1830, Bei Enslin, Tab. ii. fig. 4.
14 Illustration, J. Hope, Illustrations of Morbid Anatomy, figs. 168, 169.
15 Illustration, Med. and Surg. Hist. of the War, tom. cit., p. 528.
16 Illustration, Cruveilhier, Anat. path., xxx. livraison, Pl. iii.; also, J. Hope, Illustrations of Morbid Anatomy, figs. 128, 129.
Besides follicular ulcers the mucous membrane is disorganized by ulcers which have their origin in a loss of epithelium and superficial erosion. These deepen and may attain considerable size.
In addition to the lesions already described, the inflamed and ulcerated surface is sometimes covered with a pseudo-membranous layer of greenish-yellow color.
Chronic catarrh of the duodenum is the cause of dilatation of the vessels and thickening of the coats. A varicose condition of the veins may give rise to hemorrhage without ulceration.17 The orifice of the common bile-duct and the ducts for some distance are narrowed by swelling of their lining membrane.18 Ulcer of the upper part of the duodenum is found rarely in connection with external burns and chronic Bright's disease. It is more common in men between thirty and forty years of age. An embolized artery is the starting-point of the lesion. The mucous layer, deprived of its nutrition in a limited area, dies or is destroyed by the acid gastric juice; a round ulcer with terraced edges is left, its base being the muscular or serous coat. Adhesions may form between the peritoneum near the ulcer and the liver, gall-bladder, or pancreas, or an opening may take place posteriorly in the right seventh intercostal space or into the peritoneal cavity. Cicatrization of the ulcer may lead to narrowing of the canal of the bowel or of the pancreatic and common bile-ducts.19
17 G. Coulon, Bull. de la Soc. Anat. de Paris, 1879, p. 690.
18 Duodenitis was made much of by Broussais and his followers, and a great deal has been written about it. (See Boudin, Paris, Thèsis, 1837, No. 76, Essai sur la Duodenite chronique.)
19 Ziemssen's Cyclopædia, Amer. ed., vol. vii. p. 404.
Suppuration in the wall of the duodenum is still rarer. One case only is on record of pus being found in the intestinal wall.20
20 Picard, Bull. de la Soc. Anat. Paris, t. xv., 1840-41, p. 393. See also microscopic view of suppuration in wall of duodenum, Thierfelder, Atlas d. path. Histologie, 2 lief., Tab. x. fig. 6.
Chronic proctitis or inflammation of the rectum may exist by itself. The mucous membrane is swollen, hyperæmic, and the walls may be indurated and thickened so as to reduce the calibre of the tube. Superficial erosions or deep ulcers and perforation are due to the retention of hard fecal matter in the distended pouches of the rectum. Inflammation in the tissue around the rectum (periproctitis) is excited by inflammation of the wall without perforation; abscesses form and burst externally or into the bowel, thus establishing fistulæ.
PATHOLOGICAL HISTOLOGY.—The essential primary feature of chronic catarrh is the increase and persistence of cell-accumulation in the reticular connective tissue of the mucous and submucous layer. After an acute or subacute attack some time elapses before the large number of cell-elements are disintegrated or absorbed. By remaining they offer a constant invitation to causes of irritation, hence the necessity for prolonged care in diet after acute attacks. Fresh causes—imprudence in eating, etc.—induce additions to the number of cells, and the tissue becomes overcharged with active elements of growth. Hypertrophy of tissues results, the mucous and submucous tissues thicken, and the glandular structures are stimulated to a condition of morbid activity. The glands of Lieberkühn elongate, the number of acini increases, and the contained cells multiply. Accidental closure of the gland-openings from outside pressure or over-accumulation of the contents leads to cyst-formations. The lymph-cells in the reticular tissue of the closed follicles undergo rapid increase; the follicle is over-distended, projects above the surface, bursts, and a small ulcerating cavity is left. This is now enlarged by the breaking down of the remaining tissue of the follicle, then of the submucosa. The overhanging roof of mucous membrane, deprived of its nutrition, sloughs off at the edges and the exposed ulcerated surface is increased. By the confluence of two or more burrowing ulcers more extensive destruction of the mucous and submucous layers is brought about. The large deepened ulcers have the mucous layer for their base. Cicatrization of the ulcers takes place by the formation of cicatricial tissue at their base; the excavation is filled up partially, by contraction the edges are brought together, and the tissue solidifies. No villi or epithelium covers these cicatrices.
There are rarer pathological changes. In catarrh of long duration cysts are found, especially in the large intestine. They are about the size of a small pea, projecting above the mucous surface. They have a yellow or amber color, and contain a jelly-like yellow fluid which can be pressed out. They originate in the distension of the dilating glands of Lieberkühn; according to Woodward, they find a favorable nidus for their growth in the softening tissue of the solitary glands; hence the cystic forms are seen occupying the interior of follicles undergoing disintegration.21 The presence of the glands of Lieberkühn in the interior of the closed follicles has been observed by other pathologists, some of whom are unable to explain so remarkable a lesion.22 Around the edges or in the midst of healing ulcers in the intestine granulation-like excrescences or polypoid growths are observed as a rare lesion. These seem to be projections from undestroyed islands of mucous membrane, being surrounded by the ulcerated surface. The minute polypi originate in a process of growth of the undestroyed mucous tissue. Cicatricial contractions around their bases give them peculiar forms; they are club-shaped, simple, or branched. This lesion has been described by Johann Wagner,23 Carl Rokitansky,24 and J. J. Woodward25 from original specimens. According to Woodward, the growths (pseudo-polypi he calls them) are composed of a central portion of connective tissue continuous with the submucous connective tissue of the intestine and a peripheral portion of diseased mucous membrane. The central connective tissue was filled with large and numerous cells, and the glands of Lieberkühn in the mucous covering were elongated and branched and showed evidences of an active hyperplasia.
21 J. J. Woodward, op. cit., pp. 570, 571.
22 A. Laboulbène, Anat. path., Paris, 1879, p. 186.
23 "Einige Formen von Darmgeschwüren; iii., die Dysenterische Darmverschwärung," Med. Jahrb. des k. k. öst. Staates, Bd. xi., 1832, S. 274.
24 "Der dysenterische Prozess auf dem Dickdarme und der ihm gleiche am Uterus, vom anatomischen Gesichtspuncte, beleuchtet," ibid., Bd. xxix., 1839, S. 88.
25 "Pseudo-polypi of the Colon," Am. Journ. Med. Sci., Jan., 1881, p. 142.
Polypi of the colon have been seen and figured by other pathologists, but they were not connected with ulceration and cicatrization of ulcers. Luschka26 saw the mucous membrane from the ileo-cæcal valve to the end of the rectum covered with polypi, club-shaped, the size of a hempseed or bean, and made up of glandular tubes simple or branched. Other cases have been described by Lebert, Heuriet, and others,27 in which polypi were distributed in the rectum, colon, cæcum, or about the ileo-cæcal valve. This is the condition described by Virchow as colitis polyposa.
26 Virchow's Archiv, vol. xx. p. 133.
27 Heuriet, Bull. de la Soc. Anat. Paris, t. xlviii., 1873, p. 250; Tr. N.Y. Path. Soc., vol. ii., 1877, p. 172. For illustration of multiple polypi of colon and rectum, Lebert, Path. Anat., tome ii., Pl. cxxii. figs. 1 and 2; granular elevations in ileum, idem, Pl. cxxi. fig. 1. Also, mucous polypi of rectum, Thierfelder, Tab. xiii. figs. 3, 3a, 3c; also, intestinal polypi of rectum, Lancereaux, Atlas Path. anat., 1871, Paris, Pl. iv. fig. 4. Polypi are rarely seen in the small intestine; see Böttcher, "Polypöses Myom des Ileums," Archiv der Heilkunde, xi. Jahrgang, 1870, p. 125.
Atrophy of the wall of the intestine, chiefly of the mucous layer, supervenes upon catarrh. It is confined to certain areas, the rest being normal or in a state of chronic catarrh. It is found in 80 per cent. of the cases examined either in the large or small intestine. The cæcum is the most frequent seat; next in the order of frequency it is seen in the ascending colon, the lower part of the ileum, the other parts of the colon, and is least common in the upper part of the ileum. In children the lesion is more common in the small intestine than in adults. The changes in the mucous membrane of the colon are a diminution in its thickness and disappearance of the glands of Lieberkühn. The mucous layer is reduced to one-fifth of its normal size, and no trace of the glands may be left; a layer of connective tissue with imbedded round cells is all that remains. The surface of the membrane is irregular and colored with yellowish pigment. In the ileum the villi are shrunken, with few cells; in some cases they disappear altogether. The muscular tunic may share in the atrophy.28
28 Nothnägel, "Zur Klinik der Darmkrankheiten," iii. Abtheilung, Darmatrophie, Zeitschr. f. klin. Med., Berlin, 1882, iv. p. 422; Virchow, "Ueber den Gang der amyloiden Degenerationen," Virchow's Archiv, Bd. viii. S. 364; E. Neumann, "Neue Beobachtungen über amyloide Degeneration," Deutsche Klinik, Bd. xii., 1860, S. 337, 353, and 373; Lambl, "Ueber amyloide und colloide Degeneration im Allgemeinen und die des Darmsinsbesondere," Beob. und Studien (aus dem Prager Kinder-Spitale), Prag., 1860, S. 319; Frerichs, "Diseases of the Liver," New York, 1879 (Wood's Library), vol. ii. p. 180; M. G. Hayem, "Note sur la Dégénérescence amyloide du Tube digestif," Compte Rend. des Séances de la Soc. de Biologie, Nov., 1865, 4me Série, t. ii. p. 191; also, Gaz. méd. de Paris, t. xxi. p. 99.
Lardaceous (amyloid or waxy) degeneration of the intestinal mucous membrane is met with in chronic catarrh. The small arteries of the villi and submucous layer, the muscular and other tissues, are infiltrated with a new material allied to fibrin. The membrane to the eye is paler than normal. When iodine is applied, a characteristic red staining of the infiltrated parts is noticed. This lesion is a cause of diarrhoea and of hemorrhage,29 from the greater permeability and greater fragility of the arteries. It is also associated with follicular ulceration, and is probably a cause of disintegration of the mucous membrane.30
29 T. Grainger Stewart, "On Hemorrhage from Waxy or Amyloid Degeneration," Br. and Foreign Med.-Chir. Rev., vol. xli. p. 201.
30 Frerichs, "Diseases of the Liver," New York, 1859 (Wood's Library), vol. ii. p. 180; also, E. Aufrecht, Berl. klin. Woch., 1869, p. 315.
The abdominal organs present other lesions in chronic intestinal catarrh, few of which have any distinctive character. The peritoneum shows signs of old or recent inflammation. The former is subacute or chronic, and is recognized by the adhesions of opposed surfaces in a limited area, frequently corresponding to the seat of intense intestinal inflammation. Fatal perforations are delayed or prevented by these adhesions. General peritonitis with soft lymph or sero-purulent effusion is found with perforation. The mesenteric glands may be enlarged. The liver is larger or sometimes smaller than normal, and its tissue is softened and may be fatty. Abscess of the liver31 is a very rare result of chronic intestinal catarrh, with ulceration. The gall-bladder is usually filled with bile. The spleen is small and firm in texture; less commonly it is soft and friable. The pancreas is healthy. The kidneys are large and pale; the cortical substance is relatively increased and the tubules contain granular epithelium.
31 It occurred in 4 per cent. of Woodward's cases of chronic follicular ulceration. See case reported by the writer in which the ulcers healed before the death of the patient from hepatic abscess (Maryland Med. Journ., March 15, 1883, p. 562).
In the thorax the heart is flabby, pale, and small; clots are found in the right and left side extending into the pulmonary artery and aorta. Sudden death has been attributed to cardiac thrombosis. That coagula do form in the heart during life is shown by the sudden occurrence of cerebral embolism with aphasia.32
32 The writer has seen one case of this kind occurring during the effort at stool in a patient who was very feeble and very anæmic from chronic intestinal inflammation with ulceration.
Pneumonia is the most frequent pulmonary lesion; it may be single or double. It was found in 18 of the 99 cases of Woodward, and in 21 out of H. A. Allen's 41 cases. Inflammation of the pleura is not infrequent. The brain and its membranes may be congested, and fluid is found in the subarachnoid space, in some instances in cases which have had a sudden termination. The cornea is ulcerated, and the eye destroyed by opening of the anterior chamber in a small proportion of cases. The sloughing process begins in the lower part of the cornea and in the sclerotic.
SYMPTOMS.—When chronic intestinal catarrh succeeds the acute form, the transition is marked by the disappearance of fever and an amelioration of all the symptoms, with apparent recovery. The patient begins to go about, but diarrhoea returns whenever there is any unusual fatigue or excess in eating. In some cases there is no improvement in the diarrhoea, but in the general symptoms only. When the malady is chronic from the beginning, the onset is characterized by symptoms of indigestion and occasional diarrhoea, which become more and more pronounced according to the severity of the illness.
Mild forms of catarrh have constipation, or diarrhoea alternates with a normal or constipated state of the bowels. The form in which constipation is continuous is associated with mechanical stasis from liver and heart lesions and with the gouty and uric-acid diathesis. The mucous membrane is in a state of passive hyperæmia, an excess of mucus being the product of the inflammatory process. Mucus coats the lining tunic, lessens its irritability, interferes with digestion and absorption, and acts as a ferment, exciting decomposition in the food. The bowel is atonic and is distended with contained gas; there is great feebleness of peristaltic contractions.
Intestinal indigestion and constipation are therefore the symptoms of this form. The signs of indigestion occur one to three hours after eating, according to the location of the maximum of catarrh and the time taken by the food to reach this point. They are a sense of fulness or distress in the abdomen from gaseous distension, slight colicky pains, and a rumbling of gas, which may be prolonged during several hours after a meal. The constipation is indicated by the spontaneous passage of dry masses or scybalæ coated with layers of mucus which are clear or cloudy, or the mucus may be intimately mixed with solid matter. Pure mucus is also expelled without fecal matter. There may be no stool without a purgative, and then softened matter with scybalæ and mucus is passed. Altered mucus in the form of membraniform shreds or cylinders occasionally pass in the so-called membranous enteritis.
The abdomen is full and not sensitive to pressure. The tongue is coated and usually pale and flabby. In appearance the patient exhibits a general want of tone; the skin is white or muddy, the muscles are soft, and the expression indicates the depression of spirits, the lassitude, and the inertia which he feels. Hemorrhoids are very likely to exist. Such a condition may last for months or years without much change. Under proper treatment recovery may take place, but if entirely neglected or improperly treated the disease inevitably becomes worse.
In a second mild form there is no permanent disease, only an impressionability of the mucous membrane of the bowel to causes which induce hyperæmia and excessive secretion ending in diarrhoea. Exposure to cold, fatigue, or slight indiscretions in diet may bring it on; even an emotional cause may do it. The attacks last one or several days, and may at times assume some gravity. This predisposition to diarrhoea lasting through a lifetime is analogous to the tendency to inflammation of the nasal and other mucous membranes.
In severer and typical forms the symptoms point to permanent lesions. The tongue is smooth, shining, or glazed, sometimes with a central brown streak, but it may be also pale and covered with a white coat. The appetite is diminished or lost, or it is capricious, craving unsuitable food. If there is no gastric catarrh, the chief distress does not come until some hours after eating, but the taking of food sometimes excites pain and brings on an evacuation of the bowels through reflex influence.
There may be slight tympanites or a retracted abdomen. The imperfect digestion of food and the fermentation of the intestinal contents develop gas which keeps the abdomen distended and causes slight pains and borborygmi. Pain may, however, be entirely absent. A feeling of abdominal soreness is not unusual; it is increased by coughing, sneezing, or any sudden movement. Sensibility to pressure is usually wanting; when it exists it is found along the line of the colon in most cases.
The diarrhoea is the characteristic symptom. The number of the stools varies from one to eight in twenty-four hours; four is about the average number. They occur usually in the early morning hours, from two to six o'clock, but food may at any time bring on peristaltic contraction, so that a motion after every meal is not uncommon. In quantity there is much variability; two to four ounces of fluid matter is the rule perhaps, but a very much larger amount than this is often passed with each evacuation. As a rule, the larger the quantity of fluid the more extensive is the catarrh and the more advanced are the lesions. The matters passed are composed chiefly of fecal matter varying in consistence from a solid or semi-solid mass to a watery fluid. In the soft stool, like thickened gruel, the consistence is due to the presence of mucus; in the thinner evacuation water is the chief element. Liquid stools are sometimes frothy. In color the dejecta are brown, yellow, red, green, slate-color, or white. They may be colored dark by medicines, as iron or bismuth, or by blood. The presence of blood gives a pinkish, bright-red, dark-brown, or black color, depending upon the amount of blood and the changes it has undergone in the bowel from a longer or shorter retention. Blood, when it comes from the rectum, is in bright-red streaks or small coagula. When its source is higher up, it is much altered, being dark and granular. Coffee-ground sediment in a fluid stool is blood from the upper part of the intestine or stomach. The spreading of an ulcer may open a vessel of some size, and a fatal hemorrhage follow. A yellow tint like that of a child's movement may arise from a mixture of pus and fecal matter. Pus, as a milky or creamy fluid which may be streaked with blood, is a frequent appearance in disease of the rectum and sigmoid flexure. The odor of the stools is fecal, sour, or sickening from fermentation or offensive from decomposition. In bad forms of chronic diarrhoea in children the black watery stools have a most offensive odor.
Mucus is the most constant ingredient of the diarrhoeal stool, and is in itself a sufficient evidence of catarrh, as it is not seen in normal stools except as a temporary phenomenon. It is present in flakes in watery evacuations, giving a jelly-like character to the fluid if it is in excess, or it is mixed with semi-solid feces. Pure mucus may be passed, if the catarrh is low down, in clear, glairy, or opaque masses. The frog's-egg or boiled-sago particles supposed by Niemeyer and others to point to follicular ulceration, and by Traube to be the swallowed bronchial secretion, are said by Virchow to be partly-digested starch, and also by Nothnägel to be of vegetable nature.33 The stools may contain small yellow or brownish masses which are mucoid in nature, being yellow from bile-staining. Pavement epithelial cells are found in the coating of mucus around a hard fecal lump. Cylindrical epithelium is passed uncolored or stained with bile. These cells are separated, and are deformed and shrunken, with a granular protoplasm and indistinct nucleus. Goblet-cells are also seen. Round cells in the form of mucus-corpuscles or giant-cells are mixed with shreds of mucus or float in the thin stools. Crystals of triple phosphate, of neutral phosphate, oxalate of lime, and other lime salts, and of cholesterin, are also seen.
33 Virchow's Archiv, v. S. 329; Nothnägel, "Zur Klinik der Darmkrankheiten," Zeitschrift für klin. Med., iii., 1881, p. 241.
Micrococci and bacteria have no pathological importance; they are seen in different diseases and in health.
Unaltered food may be expelled (lientery) by rapid peristaltic movements. But the microscope will detect what cannot be seen by the eye—unaltered starch-granules, filaments of meat-fibre, or fat in drops or in needle-shaped or feathery crystals.
The nervous system is disturbed after a certain time. There is languor, with depression of spirits, mental weariness, and inaptitude for work of any kind. The patient is querulous, morose; his sleep is restless, but sometimes profound until disturbed by the demand to empty the bowel. Melancholia is attributed to this as to other diseases of the abdomen, but their influence in producing insanity is doubtful.34
34 Griesinger, Mental Path. and Therap., Am. ed., New York, 1882, pp. 137, 138.
No decided symptoms are exhibited in the respiratory and circulatory systems. Even slight exertion will cause shortness of breath and increased frequency or palpitation of the heart. This irritability of the heart is a marked feature of the disease.35
35 DaCosta found that of 200 cases of irritable heart, 61 were in patients who had suffered from or still had diarrhoea (Am. Journ. Med. Sci., vol. lxi., 1871, p. 37).
The appearance of the urine is normal; it may be abundant, with phosphatic deposit, or it is scanty and high-colored. In bad cases albumen and casts have been found.36
36 Alonzo Clark, "Proc. of New York Path. Soc.," Med. and Surg. Reports, vol. ix., 1862-63, p. 312.
The symptom indicative of atrophy of the mucous membrane is believed by Nothnägel to be the persistent passage of one soft, unformed stool daily. Mucus and fat, which diminish the consistence of the stool, are excluded by microscopical examination. One stool daily shows that there is no exaggerated peristalsis which hurries the food along so rapidly that water cannot be absorbed.37
37 Nothnägel, "Zur Klinik der Darmkrankheiten," Zeitschrift für klin. Med., iv., 1882, p. 422.
PROGRESS AND TERMINATION.—As the disease advances it is marked by progressive emaciation and debility. The skin gradually acquires great pallor, indicating profound anæmia. The loss of flesh is very rapid. An exacerbation of the disease will in a few days cause the cheeks to grow hollow, the eyes to appear sunken with dark rings around them. In all cases of long duration the progress is intermittent; frequent relapses occur from which the patient may rally and regain a moderate degree of flesh. Recovery may take place in weeks or months—eighteen months is the average duration38—but in most instances a tendency to a recurrence of the diarrhoea from cold, fatigue, or indiscretions in diet will continue throughout life. An incomplete recovery may take place by the cessation of the diarrhoea and formation of a stricture from the healing of an intestinal ulcer. In the worst cases there is no rule as to the rapidity or regularity of the march of the disease.
38 C. H. Ralfe, Seamen's Hospital, London: see Aitken's Handbook of Treatment, New York, 1882, p. 116.
When the advance is toward a fatal issue the emaciation progresses until it becomes extreme; nothing but skin and bone are left. The cuticle is hard and dry, pale or brownish in color. The muscular strength is so reduced that the patient is unable to move from bed. The voice may sink to a whisper. The nervous depression and moroseness assumes a more marked character. Among the soldiers during the Civil War who had undergone great privations with insufficient or improper diet the mental phenomena were those of dementia.39 In them the disease was modified also by the symptoms of scurvy and malarial poisoning.
39 W. Kempler, "Entero-Colitis," Am. Journ. of Med. Sci., vol. lii., 1866, p. 337.
Fever is seen in the late stages; it is nocturnal at first, and later assumes the features of hectic. The pulse grows more frequent and thready; aphthous deposits appear on the inside of the mouth and pharynx. Toward the end the discharges may become more frequent and very abundant; they are more fluid, lighter colored or black, with floating particles of blood and mucus. There may be a loss of odor or they may have a cadaveric smell.
Death takes place in a few weeks or after years of alternate suffering and relief. The immediate causes of death are exhaustion, marasmus from starvation, collapse from perforation of an intestinal ulcer and consecutive peritonitis, syncope from sudden exertion, pneumonia, or acute pulmonary congestion, pleurisy, or subarachnoid effusion in the brain, with coma and convulsions.
COMPLICATIONS.—General dropsy results from the hydræmia and languid circulation of the late period of the disease. Other causes of this symptom are coincident diseases of the liver, kidney, or the malarial cachexia. Oedema of one extremity follows a thrombus in the crural vein. Chronic bronchitis and pulmonary phthisis are sometimes met with. Acute pneumonia40 and acute pulmonary congestion are occasional causes of death. Peritonitis may occur with and without perforation. The latter variety begins as a local inflammation of subacute or chronic nature, and spreads slowly until it becomes general. Extensive adhesions and abundant accumulations of serous, sero-purulent, or purulent fluid in the abdominal cavity result.
40 Pneumonia (8 double and 12 single) occurred in 20 out of 41 fatal cases reported by Harrison Allen, Tr. Path. Soc. Philada., 1867, vol. ii. p. 161.
The causal conditions which have been enumerated may be considered as complications. They are tuberculosis, Bright's disease, cirrhosis of the liver, abdominal tumors, scurvy, tubercular and other neoplasms in the wall of the intestine; attacks of intercurrent, intermittent, or remittent fever arise from the malarial influence to which the intestinal catarrh is due. These fevers and rheumatism and pseudo-rheumatism are complications in soldiers from the exposure to malarial influences and to cold and dampness.41
41 Woodward, op. cit., p. 495.
Ulceration of the cornea, escape of the aqueous humor, and collapse of the eye were observed in quite a number of cases occurring among soldiers.42
42 Elliot Coues, Med. and Surg. Reporter, Philada., 1863, vol. x. p. 207, and H. Allen, Tr. Path. Soc. Philada., 1867, vol. ii. p. 161.
SEQUELÆ.—The alteration of structure from long-standing inflammation leaves the mucous membrane prone to recurrence of inflammation. Chronic intestinal indigestion and permanent malnutrition come from the same cause. The glandular and lymphatic structures of the intestine and the mesenteric glands are so changed by disease that they imperfectly perform their function. Tabes mesenterica is the ultimate phase of this change. Constipation succeeds chronic diarrhoea, and is due to atony of the muscular wall from long-continued distension, and probably from degeneration of the muscular structure. A more serious cause of constipation, and sometimes of intestinal obstruction, is found in stenosis of the bowel from the healing of the ulcers of long-standing chronic catarrh. Stricture is more common in the colon, sigmoid flexure, and rectum. How frequently such a result follows the cicatrization of intestinal ulcers is not definitely known. Woodward concludes from a careful search of books and pathological museums that stenosis from this cause is very rare.43 Syphilis is the most common cause of ulcer. Local or general peritonitis leads to the formation of adhesions or fibrous bands uniting neighboring links of intestine. By the contracting of these narrowing of the intestinal canal may result. Paralysis, hemiplegia, paraplegia, etc. have been found to follow upon diarrhoea of long standing.44
43 Woodward, op. cit., p. 504.
44 Potain, "Parésie des Membres inférieurs ayant succedé à un Catarrhe gastro-intestinal," Rev. de thérap. Med.-Chir., Paris, 1880, xlvii. p. 562; "Paralysis spinale sécondaire à une Diarrhée chronique," Journ. des Conn. méd. Prat., Paris, 1880, 3, S. ii. p. 57.
DIAGNOSIS.—The mild form of chronic catarrh of the intestines associated with constipation has been confounded with hepatic disorders, and the obscure symptoms attending it have been attributed to excess or diminution of bile, and medicines to regulate the liver have been given accordingly. In the absence of lesions in the liver, in cases where symptoms such as have been described have preceded death, the opinion is not justified that disease of this organ has existed. On the contrary, alteration in the mucous membrane is almost always found, which points to the true nature of the disease. The diagnosis is based upon the accompanying gastric catarrh and upon the symptoms of intestinal indigestion and malnutrition. Greater sensibility to pressure over the right hypochondrium and along the line of the colon, pain one to two hours after eating, with distension of the abdomen, the passage of well-formed and somewhat indurated feces mixed or coated with mucus, are symptoms peculiar to these mild forms.
The tendency to diarrhoea from cold, indigestible food, etc. which marks the second form of mild catarrh is easily recognized.
The characteristic symptom of the severe form is the persistent diarrhoea. Paroxysmal pains, tympanites and rumbling of gas, tenderness on pressure over the colon, the alternate periods of improvement and relapse, with the constitutional signs of impaired nutrition and progressive anæmia and debility, point out the nature and the seat of the lesion with sufficient clearness. It is futile to attempt to distinguish chronic intestinal diarrhoea from chronic dysentery. The lesions of the two conditions are essentially the same; it depends upon the fancy as to which name is given to the lesions described here under the title chronic intestinal catarrh. A greater amount of blood and mucus in the stool with tenesmus would more properly be called dysenteric, but the same case may present at one time diarrhoeal, at another dysenteric, symptoms.
Primary must be distinguished from secondary diarrhoea. Therefore the liver, heart, and lungs must be examined to discover diseases which might cause portal congestion. Any constitutional malady may be a cause and an explanation: tuberculosis or pulmonary phthisis stands first in its influence; next, chronic Bright's disease, septicæmia, scurvy, syphilis, and gout are attended by intercurrent diarrhoea. If all general disease can be excluded and the morbid process be located in the intestine alone, its cause may be known by studying the habits, occupation, and diet of the patient. Foreign bodies—hardened feces, gall-stones, fruit-stones, etc.—are possible causes which the history of the case may point to.
Having located the disease in the intestine and decided upon its primary or secondary nature, it remains to determine more precisely (a) the locality of the lesion, and (b) the stage of the inflammatory process.
(a) In what part of the intestinal canal is the disease located? It must be remembered that in typical and fatal cases the large intestine is the home par excellence of the lesions of chronic catarrh, and that the lower part of the ileum is often associated in the morbid processes, but limited areas of the small or large intestine are affected in mild forms which yield readily to treatment.
Icterus, clay-colored stools, and bile in the urine show that the catarrh is in the duodenum and involves the opening of the common bile-duct. The absence of diarrhoea, with flatulence and colics, limits the area of inflammation to the duodenum. Symptoms of duodenal indigestion accompany this form of catarrh; the failure of bile to neutralize the acid chyme impairs the effect of the pancreatic secretion. Fats are not digested and there is fatty diarrhoea. To this may be added tenderness in the right hypochondrium, and pain and oppression in the epigastrium and to the right one hour after eating. There may be wasting and hypochondriasis.
The lower part of the duodenum below the opening of the bile-duct, the jejunum, and the ileum can be taken together as forming the small intestine. Chronic catarrh of the small intestine is attended with pain about the umbilicus, which comes on immediately or in one hour after taking food. Tympanitic distension gives a full, rounded prominence to the abdomen, which is more central than lateral, and greater below the umbilicus than above it. It is accompanied by a sense of oppression, which is greater after eating. Inability to digest food consisting largely of starch or sugar, as well as tardiness in the digestion of all foods, with resulting loss of flesh, are signs of intestinal indigestion. There may be no diarrhoea; if there is, important help to diagnosis can be gained by examining the stools. They contain undigested or partly-altered meat-fibre and starch-granules, discoverable only by the microscope. The discharges are soft and pulpy from an intimate admixture of mucus. To the naked eye no mucus is visible, but a thin layer under the microscope shows clear islets of pure mucus, or mucus may only be detected by the adhesion of the covering-glass to the slide. Bile-stained epithelium and globules of stained mucus are seen in the liquid stools from catarrh of the small intestine and of the ascending colon. There is the characteristic reaction and play of color on testing for bile-pigment. These are evidences that the stool with the bile has been hurried along the ileum and colon, and expelled before the transformation in the coloring matter has had time to take place.45
45 "II. Abtheilung, Diagnostische Bemerkungen zur Localisation der Catarrhe," Zeitschrift für klinische Medicin, Berlin, 1882, iv. p. 223.
In catarrh of the large intestine there is sensitiveness to pressure along the line of the colon; the distension of the abdomen is not uniform, depending upon the prominence of the transverse or descending colon. The pains are more severe and precede the stools, which are more frequent and larger than in catarrh of the ileum. The discharges are pulpy or watery. Globules of mucus are visible to the naked eye, and mucus is intimately mixed with fecal matter.
If the lower half of the colon is chiefly the seat of the disease, pure mucus coats the more solid stool and is in its substance. With catarrh limited to the descending colon scybalæ are imbedded in mucus. From the sigmoid flexure and rectum larger masses of mucus, without fecal matter or with it, are expelled. Pure lumps of mucus, mixed or stained with red blood and without fecal matter, indicate catarrh of the rectum—proctitis.
(b) The stage of the process of inflammation is diagnosed by the condition of the patient, the course of the disease, and the character of the stools. As long as there is a pulpy fecal diarrhoea, with no blood, pus, or fragments of tissue and no marked emaciation or fever, and with a tendency to improvement under favorable conditions, there is every reason to believe that there is no ulceration.
In follicular ulceration the course of the disease is essentially chronic, and is marked by periods of improvement under careful treatment, with exacerbations and relapses from slight causes of irritation. There is progressive emaciation and debility, with fever of hectic character, which is worse in the later stages. The abdomen may be retracted. The movements are frequent and liquid, and are without odor or fetid. They contain mucus, glassy-gray or green, pus-cells imbedded in masses of mucus, blood in small amount, but sometimes abundant, and shreds of the tissue of the mucous membrane. This last is an important aid to diagnosis.
The higher the ulcer the less marked is the diarrhoea. The lower its situation the greater is the frequency of the stools and the more liable are they to be accompanied by tenesmus and to contain blood and pus. Toward the last, ulceration is accompanied by rapid emaciation, fever, sweats, a feeble circulation, a dry tongue, great thirst, and oedema of the feet and ankles. Death takes place by gradual exhaustion, more rarely from perforation and peritonitis or from intestinal hemorrhage.46
46 Nothnägel, "Die Symptomatologie der Darmgeschwüre," Klinische Vorträge Volkmann, No. 200, Aug. 24, 1881.
Duodenal ulcer is with difficulty recognized during life.47 The following are the symptoms which have preceded death from this lesion: Profuse hemorrhage from the bowel, vomiting of food as well as blood, icterus, dysphagia, hiccough, oppression in the epigastrium after eating, attacks of cardialgia with tenderness on pressure in the right hypochondrium, and sudden death with symptoms of collapse. If these symptoms follow an extensive burn of the skin, they are easily referred to a duodenal ulcer.
47 W. L. Loomis, "Perforating Ulcer of Duodenum and Sudden Death." For two years the patient had suffered with dyspepsia and epigastric pain after eating, was gouty, and had lost flesh. Autopsy: atheroma of arteries, beginning cirrhosis of kidneys, walls of stomach thickened, perforated ulcer one inch below pylorus (Med. Record New York, 1879, vol. xv. p. 188; also Boston City Hospital Report, 1882, p. 374).
Tuberculous ulcers are distinguished from follicular ulcers by the history of hereditary predisposition, the existence of pulmonary tuberculosis, higher fever, and more rapid emaciation and debility.
A cancerous ulcer may be the cause of bloody stools; it is usually within reach of the finger in the rectum; the mass exercises pressure upon the prostate, and at times occludes the bowel, causing obstruction. The cachexia and rapid decline are not seen in catarrhal ulceration.
PROGNOSIS.—Chronic catarrh of the intestine is most fatal in children. Among infants artificially fed, when the illness develops and continues during hot weather, the mortality is very great. Recovery in the young is rendered less probable if chronic diarrhoea is associated with rickets, scrofula, or tuberculosis.
If the catarrh in adults is a complication of some previously existing constitutional disease, as Bright's disease or scurvy, or is connected with lesions of the liver, spleen, heart, or lungs, there is less hope of cure. In old persons this disease has a special gravity.
The longer the disease has lasted before treatment is begun, and the longer it continues without being influenced by treatment, the more unfavorable will be the prognosis. Discouraging symptoms are an uninterrupted loss of flesh and strength, lientery, hectic fever, relapses notwithstanding care in diet, and the signs of ulceration—blood, pus, and tissue-shreds in the stools, with an odor of decomposition.
Favorable promises may be based upon a hearty willingness of the patient to submit to the strictest regimen and to subordinate his life to the plans of treatment, the absence of other diseases, early improvement in his general condition and local symptoms under rest and diet. A complete cure cannot be assumed to exist unless the patient has passed one or more years without a relapse.
TREATMENT.—As chronic intestinal catarrh is a complication of so many conditions, the prevention of it becomes a matter of great importance and of very general application. All rules for preserving health—temperance in eating and drinking, bathing, exercise, good ventilation, the avoidance of overwork, both mental and physical—are so many means for escaping an intestinal catarrh which may present itself as an indigestion with constipation or as a diarrhoea.
The special liability of infants and children, and to a less extent of very old persons, and the greater dangers they run, call for the most careful selection of appropriate diet at these periods of life.
Where there is hereditary predisposition, idiosyncrasy, chronic diseases of organs, or constitutional diseases, an easily-digested dietary should be supplemented by precautions against chilling of the surface by the wearing of flannel underclothing and woollen socks.
The etiology of each case may at once suggest a line of treatment. Among the causes which point to appropriate measures are—the continued presence in the bowel of indigestible or undigested food, constant exposure to cold or to changes of temperature, chronic cardiac disease and portal congestion from any cause, chronic cachexiæ, as syphilis, malaria, tuberculosis, or Bright's disease, the crowding together of individuals in prisons, asylums, etc.
1. The mildest form of intestinal catarrh characterized by intestinal indigestion and constipation or by the passage of fecal matter more or less solid, mixed or coated with mucus, is best treated by a diet such as is advised for intestinal indigestion, bathing with friction, outdoor life, exercise on horseback or by walking, pleasurable occupations, and travel. Iron if there is anæmia, and strychnia if there is a sluggish capillary circulation, with cold hands and feet, are available and useful in many cases. Massage and the Swedish movement treatment find useful application in feeble men and in women who are not strong enough for outdoor exercise. To aid the digestion the liquor pancreaticus as advised by Roberts, a teaspoonful one hour and a half to two hours after each meal, with ten to twenty grains of the bicarbonate of sodium, is, theoretically at least, to be warmly recommended. The Rockbridge alum water, a small glass three times daily between meals, has astringency enough for the hyperæmic membrane and is of good service without increasing constipation.
Purgatives should be avoided as much as possible. An enema of cool water, not more than a tumblerful, taken each morning after breakfast if persevered in, may do all that is needed in this direction. If it fails to empty the bowel completely, a larger enema of warm water—one pint—holding in solution sulphate of zinc or alum in the strength of one grain to three or four ounces, can be thrown high up with a rubber tube once daily. This acts upon the mucous surface, constringes mildly the congested vessels, and when expelled brings away the retained fecal matter. These astringent rectal injections offer promise of cure in many obstinate cases where the colon is chiefly the seat of disease. Belladonna is advised for cases of this kind in combination with strychnia for the constipation. Mild laxatives are often necessary. Bedford mineral water, Hunyadi water, or other salines and the less active vegetable cathartics, can be given alternately. Ipecacuanha has had quite a reputation in combination with purgatives in intestinal catarrh. Aloin pills empty the bowel without much attendant irritation.
2. The form of catarrh which shows itself in a tendency to diarrhoea from indiscretions in diet or from exposure to cold must receive prophylactic treatment. Especially in this form is it important to improve the activity of the skin by bathing and friction, and to lead a temperate life in all things, regulating the diet according to the rules already stated. Tonics are called for in such cases. Fowler's solution of arsenic (one drop before each meal, Ringer), the potassio-tartrate or the tincture of the chloride of iron, dilute sulphuric acid, nitro-muriatic or hydrochloric acid, are efficient in improving digestive activity or in opposing the anæmia which is nearly always present. Quinia is indicated in malarial anæmia with a disposition to loose bowels. Quassia or other vegetable bitters can be given if the appetite is languid; the bitters are, as a rule, of little benefit, and may do harm if diarrhoea exists. Strychnia with quassia or columbo stimulates the appetite and the gastric digestion. When intercurrent attacks of diarrhoea come on with coated tongue, flatulence, distress about the umbilicus after eating, bismuth given on an empty stomach in full doses is serviceable. Small doses of morphia or of opium in some form can be added to the bismuth if there is much pain or when the stools are frequent.
In this and in other forms of intestinal catarrh mineral waters are profitably employed. They are best taken at their sources; and here, as in the case of sea-bathing, the benefit is largely due to the change of air and scene and to the more simple mode of life. Any of the watering-places where alkaline-saline waters or ferruginous waters are found may be of benefit. A trip to Europe and a stay at Carlsbad will break up many an obstinate case of chronic abdominal disorder; but other beneficial waters in Europe are Tarosp, Rohitsch, Marienbad, Kissengen, and Plombières.
In this country the comfort and conveniences of the summer hotels and climate are as much to be considered as the chemical composition of the waters. For milder forms of catarrh with constipation a season at Saratoga, with a life of temperance there, is a wise procedure. Bedford Springs, Pa., offer the same advantages in part, but the waters are best suited to catarrh with constipation. Many of the Virginia springs benefit health-seekers who do not place too much reliance upon the virtues of the waters, and who trust to the value of pure air, exercise, diversion, and rest.
3. All plans of treatment for the more severe form of catarrh with chronic diarrhoea (follicular enteritis) must be based upon a knowledge of the lesions. Bearing in mind the alterations in the mucous and submucous tissues, it is clear that no treatment can be successful which is not carried out with the most careful attention to details, and which is not continued for some time after all the symptoms of the disease have ceased. The complete resolution of hypertrophied glandular tissue, the scattering of cell-accumulations, and the healing of ulcers can only be secured in this way. It is best to present the whole case before the patient, so as to enlist in the task his intelligent co-operation.
Directions for the guidance of cases of this kind must include every detail of the patient's life. The question of residence is of importance to begin with. A cool and dry climate is better than a wet and warm one, and where other means fail change of climate is sometimes the only cure. A sea-voyage, a residence in a mountain-region, will oftentimes promptly and effectually cure an obstinate diarrhoea. House-drainage and ventilation should be examined into and improved. The occupation may have developed the disease; in overwork may lie the origin and the cause of its continuance. Rest from work is therefore in some instances the one thing needed. In all cases the energies and the brain should not be overtaxed. The bath to keep the skin active can be combined with friction. The hot bath, as hot as can be borne, is the best. It is a stimulant, not a depressant, as is the tepid bath, and it is safer than the cold bath.
The cold sitz bath or the application of cold compresses diminishes abdominal plethora, and is wisely advised in strong persons who are not depressed or chilled by external cold. Sea-bathing is another hydro-therapeutic measure which is of unquestioned advantage in all forms of intestinal catarrh.
Permanent baths have been found very serviceable in many chronic diseases, and there are many reasons for advising them in obstinate diarrhoeas. There can be no better means for bringing to bear a strong and continued influence upon the intestinal mucous membrane. The patient should be kept in the warm bath for one, two, or three weeks, according to his strength and the effect upon the disease. Systematic hot bathing under the direction of a physician at Richfield, Sharon, the Hot Springs of Virginia or Arkansas, is an invaluable aid.
Rest in the recumbent position for cases where the symptoms indicate marked tissue-alteration is very often the most important part of the treatment. Rest and diet are alone necessary to cure many cases, and without these combined means relief is often impossible. The rest should be absolute, the patient using a bed-pan and lying down all the time. The contraindications for this method are a slight diarrhoea which yields to other treatment, and loss of strength and appetite from the deprivation of air and exercise.
If rest is not advisable, or does no good after a fair trial of two to four weeks, outdoor life in fair weather by driving or walking slowly can be suggested. A long drive will bring back a diarrhoea which has taken many weeks to relieve.
The rules for diet must be clearly given and strictly enforced. An exclusive milk diet should have a trial in every case. Skimmed milk can be taken in larger quantities and with less repulsion, and is therefore to be preferred. The exclusive milk diet can be varied with buttermilk, koumiss, or wine-whey; and fruit-juices, as orange-juice, lime-juice, or tamarind-water, please the patient without doing harm. In the case of adults as well as children the milk is made more digestible by diluting it with barley- or rice-water or by adding transformed farinaceous food to milk in the form of Mellin's food and other foods of this class.
Animal broths, as chicken-soup and beef-tea, are well digested if properly made and given in small quantities. Raw meat scraped, beef or mutton rare and thoroughly masticated, the breast of poultry, game, broiled fish, raw oysters, raw or very slightly boiled eggs, or sweetbread, are foods from which selection can be made to add variety to the dietary. Saccharine, starchy, and fatty foods are to be given as little as possible. Vegetables may be added to the list as the condition improves. Rice and fine hominy (grits) are to be thought of first, as being easily digested and nourishing. Good wine in moderation is not hurtful; the red wines diluted with water are the best, but good port, tokay, and whiskey well diluted find application in particular cases.
Whatever food be given, it should be taken in the quantities and at hours prescribed by the physician, who by careful inspection of the stools judges of the necessity of changes in his regulations and of the success of his treatment.
The further treatment of chronic diarrhoea has for its object by the aid of drugs to change the anatomical state of the mucous membrane. Manifestly, the choice depends upon the state of this tissue. In the earlier stages the increased vascularity and hypersecretion call for mild astringents or for medicines which are believed empirically to oppose these conditions. When drugs can be dispensed with, it is better to do so; they should always be made subordinate to the careful regimen already described.
Bismuth in large doses (ten to thirty grains) is a safe and efficacious remedy in this stage. Nitrate of silver in pill form (one-sixth to one-fourth of a grain) has the endorsement of Wm. Pepper and many other practitioners. It should be continued for two or three weeks at least, but it may be given in small doses during several months, with intermissions, without danger of silver staining.48
48 A case is recorded of silver staining of the skin after four weeks' administration (Woodward, op. cit., p. 780).
A routine administration of any drug or class of drugs is reprehensible, and from the numerous remedies which are advocated in chronic diarrhoea selection can be made for trial in the course of intractable cases. The list would include sulphate of copper (one-fourth to one-half a grain), the liquid preparations of iron (liquor ferri nitratis, tinct. ferri chloridi), dilute nitric and sulphuric acids, gallic acid and other vegetable astringents, oxide or sulphate of zinc, alum, precipitated phosphate of calcium, salicin, corrosive sublimate (1/100 gr. every hour), the Indian bael-fruit, etc. No remedy should be abandoned until it has been continuously given for one or more weeks.
The Rockbridge (Va.) alum water is markedly astringent, is not unpleasant, and may be used as a substitute for water with advantage. In fact, there is no better way of introducing in quantity a mild astringent into the intestine than by the drinking of this water.
Cold-water rectal irrigation has a sedative and astringent influence, and when properly used is of great advantage to both children and adults.49 The patient should be placed in the proper position, and the water made to enter the rectum as high up as possible. The number of stools lessens almost immediately after this treatment, peristalsis being inhibited thereby.
49 A long rectal rubber tube, such as advised by Surgeon-General Wales, U.S.N., serves this purpose well.
To the water used in irrigation astringents may be added in small doses. Sulphate of zinc, sugar of lead, or alum may be given in this way in the strength of one grain to four or six ounces of water. This method of treatment promises more and is more rational than the internal administration of drugs.
Opium and its preparations should be avoided except to control frequent or watery discharges or to relieve pain, but it is not often that this is called for if wiser measures are first employed. Any of the remedies spoken of may be given in the form of suppositories with greater advantage often than by the mouth.
In that more severe class of cases called follicular ulceration, in which the follicles are known to be ulcerated from a prolongation of the illness, the obstinacy of the diarrhoea, the character of the discharges, and the effect upon the general health, other measures are to be adopted. The diet should be most strictly regulated and the digestive power of the patient carefully studied. Cod-liver oil is added with advantage to other foods if there is a lack of nutrition. Aids to gastric digestion are called for.
The intestinal lesion is to be reached through the stomach or the rectum. Nitrate of silver in small doses is more especially applicable, and is to be preferred to all other drugs in this stage. It is to be given in small doses and for several weeks.
Turpentine and copaiba have something in their favor in ulceration. Ergot has been suggested, and where there is much hemorrhage from the bowel may be prescribed.
Irrigations with solutions of nitrate of silver seem to be a direct and certain remedy in cases where ulceration has existed for a long time. Two and a half to three pints of distilled water, holding in solution five grains of nitrate of silver, should be thrown up the rectum as high as possible with a rubber tube; the effort should be made to secure immediate exit to the fluid. This procedure is to be repeated after the bowels are moved—once every day or every other day if the rectum becomes irritable.50
50 See case reported by the writer to the Medical Society of the District of Columbia, and published in the Maryland Medical Journal, March 15, 1883, p. 562.