Part 114

Hypernutrition, swift life of the mucous membrane, the result of continued excess of blood, entails the increase of the cell-elements. Lymphoid cells accumulate in the submucous layer, especially where these cells are normally most numerous. There is a saturation of the membrane with an excess of plasma. Cells also appear in increasing numbers in the interfibrillary spaces of the mucous membrane, which increase its bulk, and the follicles of Lieberkühn appear as if pushed apart. Lymph-corpuscles accumulate in the meshes of the closed follicles, which are distended and project above the surface as described. Multiplication of the cells within the follicle (follicular suppuration) causes over-stretching and the wall bursts, forming the first stage of the follicular ulcer. The appearance upon the epithelial surface of an increased number of loosened cells, which are sometimes epithelial in character and at other times resembling pus-cells (epithelial and purulent catarrh), is believed to be due to a rapid manufacture and exfoliation of epithelial elements, and to constitute one of the essential features of catarrh. Desquamation of the epithelium in catarrh of the bowel, even in that of Asiatic cholera, has been called in question by Woodward, who thinks that the stripping off of epithelium is cadaveric.

SYMPTOMS.--Owing to the difference in the intensity and extent of {678} the catarrhal process there is every possible variation in the symptoms of intestinal inflammation. No one symptomatic picture will properly represent all cases, and with a view to greater convenience and exactitude of illustration a division may be made into mild and severer forms.

Under the head of mild forms can be included all cases of intestinal catarrh which by their short duration and benignant character point to a mild degree of inflammation. They correspond to the following anatomical states: hyperæmia of the mucous membrane of parts of the small or large intestine, or of parts of both simultaneously; slight or moderate swelling of the membrane from serous saturation; transudation of serum into the canal; increase of lymphoid cells in the mucous and submucous tissues; and increased manufacture of epithelial cells, but without any marked tumefaction or ulceration of the closed follicles. The termination is by resolution, which is reached in a few days usually, and the membrane is rapidly and entirely restored to the normal state. Between the normal condition of the mucous membrane, with its recurring periods of physiological hyperæmia, and the hyperæmia with exaggerated secretion and peristalsis which leads to diarrhoea, there is no well-defined border-line. Diarrhoea may be regarded as the most certain sign of the catarrhal process. Whenever the frequency and fluidity of the stools are such as to be regarded as pathological, some stage or other of catarrhal inflammation may be assumed to exist.

In a large number of mild forms the onset is sudden. After a meal of indigestible food or an unusual excess pain will be felt in the abdomen, recurring in paroxysms, which start in the neighborhood of the umbilicus and radiate throughout the abdomen. The pain is accompanied by borborygmi, and is succeeded sooner or later by a desire to go to stool. The first one or two movements, which follow each other in quick succession, are more or less consistent or moulded, but in a short time diarrhoea is established by frequent discharges of watery fluid, containing perhaps some undigested fragments of food, which may have been the exciting cause of the illness by mechanical irritation. Each stool is preceded by colics, griping pains in the abdomen, which are relieved by the evacuation. An attack beginning in this way and from such causes may cease in a few hours, and be unattended by any general symptoms if proper precautions are taken. A slight dryness and coating of the tongue, with loss of appetite and occasional griping pains or a tendency to looseness of the stools, may continue for a day or two. Indiscretions in diet or other imprudences, as fatigue, may prolong the mildest attack during one or more weeks, but the character of the illness is here due not to the nature of the disease, but to the addition of fresh causes which delay the natural progress toward recovery.

Severer forms either begin suddenly, as in the milder forms just described, or are preceded for a time by symptoms of gastric or intestinal indigestion. The patient may have complained of distress after eating, flatulence, colicky pains, distension of the abdomen and tenderness on pressure, loss of appetite, with a general feeling of ill-health--symptoms which point to the existence of a condition of the mucous membrane of the gastro-intestinal canal favorable to the action of an exciting cause.

A feeling of chilliness ushers in the attack. This is accompanied by fever, which at first, and sometimes throughout, is of a marked remittent type. {679} The griping pains, colics, which at first are infrequent and dull, now recur at short intervals and become sharper. They are sometimes attended with vomiting of food or of a greenish fluid. The intensity of suffering may be so great as to cause pallor of the countenance, a feeling of faintness, and coldness of the surface with sweating. The paroxysm usually precedes a movement. The more severe pains extend to the lower extremities and the scrotum.

Movement of gas in the intestines produces rumbling, gurgling, or splashing sounds, called borborygmi. They are paroxysmal, lasting a few moments, or are coincident with pain, and frequently are the immediate precursors of an evacuation. The cause for their production is the quick propulsion of the fluids by strong peristaltic action from one part of the bowel to the other or the rapid movement of gas within the bowel. Relief is obtained both from the pain and from the sense of distension by expulsion of flatus.

Tympanites is closely connected with the symptoms just described. An excess of gases within the bowel is not primarily a result of the inflammation of the mucous membrane, but is an early phenomenon due to the decomposition of indigestible food in its transit through the intestine. Later, the gases are developed very readily by the decomposition of even the most digestible articles of food, the mucus, which is the product of the catarrh, acting as a ferment.

The distension of the intestinal canal produces an intumescence of the abdomen which is commonly uniform, but may be greater in some portions of the tract than in others. Thus the transverse and descending colon are more projecting and more distinctly outlined than other portions of the canal.

Sensibility of the abdomen to pressure exists along the line of the colon or over a considerable area. But no defined limitation of the affected part can usually be made by the location of pain to the touch. If there is any local tenderness, it is over the descending colon. In one form of enteritis--typhlitis--the localization of the inflammation in the cæcum produces subjective pain and pain on pressure in a restricted region--a peculiarity which results no doubt from the early intensity of the inflammation and the implication of the connective tissue behind the bowel. But this is not true of inflammation of any other part of the intestinal canal.

A sensation of soreness on movement, as in turning in bed, standing, or walking, is not uncommon, even when the attack is of no great gravity. The patient on standing bends forward to relieve tension, and he may feel nervous when the bed is shaken.

Diarrhoea is the most important symptom, as it is directly related to catarrh. The number of evacuations varies from one or two to twenty or more in the day. In cases of medium intensity there are from six to ten in twenty-four hours, the interval between the movements being two to three hours during the day and somewhat longer at night. The matters passed in quantity range from two ounces to a pint; the average is about four fluidounces. This, however, is subject to great variations, depending upon the intensity of the disease; the more choleriform the attack the greater the amount of fluid passed. The weight of the evacuations varies from five ounces to forty pounds in twenty-four hours; this increase does not depend upon the greater quantity of water only, but the solid constituents are in greater amount.

{680} The normal brown color, which is due to hydrobilirubin, changes as the movements become thinner to yellowish-brown or pale yellow from dilution of the fecal matter with water. An excess of serum or mucus renders them colorless. A greenish-brown, greenish-yellow, or green hue is due to the presence of bile. The rapid descent of the contents of the bowel delays or prevents the reabsorption of bile, or the fluid is expelled before the usual transformations in color take place. The bile-pigment is also absent in duodenal catarrh from closure of the opening of the ductus choledochus.

The coloration of the stools further depends upon the character of the food and drink and upon the drugs given. From an exclusive milk diet the discharges are pale or contain undigested whitish lumps of casein. The preparations of bismuth and iron give a black color and the sulphate of copper a dark-green hue. A green or greenish-brown tint is observed after the use of calomel, and while the experiments of the Edinburgh committee demonstrated that no increase of bile follows its administration in dogs, yet the opinion is still general that the green stools contain an excess of bile.

Blood appears in three forms in the stools: as a coffee-ground or black powder from hemorrhage in the stomach or upper bowel; as a reddish fluid with small coagula in flakes, which come from intense congestion or ulceration of the intestine; or an abundant hemorrhage may result from deep ulceration in the duodenum or elsewhere.

The characteristic odor of the feces is altered in several ways. As the movements become less solid they acquire a nauseous or sour smell, due essentially to the volatile products formed in connection with the decomposition of fatty matters. When very thin and containing little or no feculent matter the discharges lose odor, as in cholera, or they become excessively offensive--cadaveric--in intense and fatal inflammation and in ulceration of the bowels. After exposure to the air the stools of diarrhoea undergo decomposition and develop offensive smells more rapidly than in health. The absence of bile, whether there is diarrhoea or not, gives rise to a peculiar and unpleasant odor, showing that this secretion is to some extent an antiseptic. The escape of fetid gas from the anus is rarely an accompaniment of a decomposed state of the rectal contents. In children the stools are more variable in quantity, color, and odor than in adults, and are more readily affected by the ingesta.

In the diarrhoea of old persons the discharges are thin, yellow, offensive, and often frothy.

The disorder of the digestive apparatus is attended with other symptoms. The tongue is normal in some cases; in others red at the point and edges with a central whitish coat, or the surface is red, polished, and dry. Marked change in the appearance of the tongue is due to a complicating gastric catarrh. There is thirst, with loss of appetite, and a tendency to {681} nausea and vomiting in children and feeble persons. The breath has a peculiarly offensive odor (spoken of as fecal) in some instances.

Fever is not always present. In cases of moderate severity it occurs in the beginning of the illness, but declines rapidly under treatment by rest and diet. The course of fever does not conform to any type even in severe cases, although it so nearly resembles that of typhoid fever in its first week as to lead to mistakes in diagnosis. The height of the fever and its duration are measures of the extent of the lesions and their gravity. Sudden outbursts of fever point to some complication. In catarrh of the bowel due to cold the fever is higher than when indigestion is the cause. In very feeble persons, in children, and in any case from neglect and improper feeding the body-heat may be very high.

The urine is diminished and high-colored. Very little disturbance of the nervous system is seen except in young and old patients; some headache and restlessness are all that may be observed. Moderate delirium at night accompanies very acute attacks. In children convulsions are not unusual in the onset and at the end of the attack. In the aged exhaustion from the illness soon lapses into stupor or coma.

Paraplegia and contraction of the muscles of the extremities are referred by some observers to gastro-intestinal inflammation.

In uncomplicated mild cases of intestinal catarrh there is a movement toward recovery after a few days' illness. The stools become less frequent, smaller, and more consistent. In a week to ten days the tongue cleans, the thirst ceases, the appetite returns, the tympanites and pain diminish. The fever declines, and ceases before the diarrhoea is completely arrested. There are always more or less emaciation and loss of strength from the fever and arrest of nutrition. The liability to relapse is great, and the patient by indiscretions reproduces the same symptoms, thus prolonging the attack for several weeks. Acute intestinal catarrh may pass into the chronic form by a disappearance of fever and amelioration of all the abdominal symptoms. The patient begins to take solid food, gains strength and flesh, but complete recovery does not come. The diarrhoea recurs at variable intervals as the result of indulgences in a mixed diet, over-exercise, or exposure to cold, and in time we have some degree of chronic catarrh permanently established.

Very mild cases may be prolonged by the neglect of the patient to consider his painless diarrhoea of sufficient moment to need attention.

In inflammation of the more intense kind the picture is somewhat different. The prodromes are longer and the general symptoms more severe. Restlessness, a sense of prostration, delirium, and high fever mark the early stages and continue for a longer time. The patient loses flesh and strength quickly. The features express anxiety and illness, the skin is hot and dry, and the thirst great. Vomiting is repeated. Borborygmi, the tension of the abdomen, pain, and sensibility to pressure are all intensified. The stools are at first yellow and thin, but change much from day to day. They may be green or very thin and dark or grayish, and are sometimes very offensive in odor. Blood and mucus may be seen in them, being slimy or grumous and bloody. When the patient is very weak the discharges are involuntary; the tongue is coated white, with bright red tip and edges, and is often dry.

{682} The severer forms last from three to six weeks. After a tedious period of alternate improvement and relapse the illness becomes chronic or the patient dies from asthenia, perforation and peritonitis, or some other complication.

In the most intense varieties which find examples among Europeans and Americans in intertropical countries, or result from acute mineral poisoning and from rapidly-progressing cases of acute ulceration of the intestinal wall, especially in children, there is a sharper and more violent invasion. The strength is reduced in a very short time, and there is rapid emaciation; the features assume an anxious expression; the complexion is leaden or livid; the skin is cold and clammy; the pulse is small, weak, and rapid; the breath comes quick and short, and is frequently complicated with hiccough. In the early stages vomiting occurs, due to a concurrent gastritis; in cases of poisoning vomiting is incessant.

The pain in the abdomen is intense, and less paroxysmal than in other forms. The abdomen is tympanitic and excessively tender to the touch, and the knees are drawn up to relieve the tension of the abdominal muscles. Thin, black, or reddish stools are passed every few moments. As the attack progresses the urine is suppressed, the voice becomes whispering, and collapse is developed. This is marked by cold extremities, dyspnoea, feeble and finally imperceptible pulse. Death may end the scene in a few hours or the patient may rally and recover slowly.

Choleriform diarrhoea occurs chiefly in children during hot weather.