Part 115

VARIETIES DUE TO SEAT.--The symptoms and progress of acute catarrh of the intestines present numerous differences depending upon the seat of the inflammation. The symptomatology already given is that of the most common form (ileo-colitis), in which the lower part of the ileum and a considerable portion of the colon are simultaneously involved. Many cases no doubt occur in which the disease is limited and in which early recovery is the rule. The pathological anatomy of cases of generalized catarrh is better known, as they form the bulk of the fatal cases.

I. Acute Duodenitis.--The most common form of duodenitis is that in which the inflammation spreads by continuity of tissue from the stomach to the duodenum, as in acute gastric catarrh after a debauch. The prominence of the gastric symptoms disguises the intestinal lesion, unless the catarrh, as is frequently the case, extends into and obstructs the common bile-duct and its branches, and suddenly develops icterus with clayey stools and altered urine. Besides icterus, a careful isolation of symptoms will show that some cannot be attributed to the stomach: there is a dull pain seated in the right hypochondrium, extending to the right shoulder or shoulder-blade, which is increased by pressure upon the region of the duodenum. As the gastric symptoms improve there is no change in the icterus, which continues for some days or weeks longer. The connection between burns of the integument and ulcer of the duodenum is well known. Symptoms of perforation, with death, may be the first sign of this lesion, but vomiting of blood, icterus, purging of blood, indigestion, and cardialgia occur from duodenal ulcers.

The typical acute duodenitis described by authors as an independent {683} affection is of rare occurrence. An epidemic of duodenitis has been reported where many persons were simultaneously attacked, all the cases having had the same traits--headache, pain in the line of the duodenum at the left edge of the right hypochondrium, pain in the first and second lumbar vertebræ, constipation, jaundice, slow pulse, and mental depression. Gangrenous inflammation of the duodenum has been once seen, and produced a chill, a severe sense of weight and pain in the epigastrium, retching and eructations of gas, tenderness on pressure, frequent pulse, and high temperature. There was obstinate constipation, with dyspnoea, death ensuing in a few days. At the autopsy gangrenous inflammation of the duodenum was found, which ended abruptly twelve inches from the pylorus. There was a large gall-stone in the gall-bladder.

A fatal case of duodenitis is recorded in which the following symptoms were observed: sudden and severe pain in the right hypochondrium, increased by pressure; rigors, vomiting and purging of a green flocculent fluid, and later of blood; jaundice, fever, delirium, collapse, and death. The pylorus and two-thirds of the duodenal mucous membrane were much inflamed and the orifice of the bile-duct closed.

II. Acute Ileitis, Acute Jejunitis.--When the ileum, with or without the jejunum, is the seat of catarrh, diarrhoea may not be present, provided the inflammation is slight and there is no increase of colon peristalsis. The symptoms then are borborygmi, pain and fulness about and below the umbilicus or between it and the right ileum, especially after eating, and the general symptoms arising from indigestion and malnutrition. Fever is slight or absent; there are malaise and loss of strength. The feces give important indications. They contain unaltered bile and fragments of muscular fibre and starch-granules in excess of the quantity found in health. An increased quantity of mucus, diffused evenly in a fluid evacuation, or globules of mucus stained with bile, or bile-stained epithelium, denote inflammation confined to the small intestine. A larger amount of indican in the urine than is normally present is a sign of the same lesion.

Intense inflammation of the small intestine may exist without diarrhoea or other symptoms betokening the real nature of the attack. Flint mentions having met with three such instances, and Goodhart records thirteen cases of enteritis with marked lesions in which no diagnosis had been made before death. Rilliet and Barthez report twenty-four autopsies in children with intestinal lesions in which no symptoms had been observed.

III. Acute Colitis.--Fifty years ago colitis was synonymous with enteritis, and not with dysentery, as at a more recent date. The older {684} signification expressed the fact that inflammation in the colon is essential to diarrhoea. Later the term was used synonymously with dysentery.

The colon is a conducting tube; the contents are composed of matters unabsorbed in the small intestines. At first the mass entering the colon is fluid, but by the gradual absorption of its watery part it approaches solidity. The discharge from the rectum of a fluid shows that the propulsion through the large intestine is so rapid that the process of drying does not take place, or that from inflammation of the colon there is an excess of fluid transudation from the intestinal wall. The superficial position of the colon, its great size and length, expose it to the action of external cold, to blows, etc.

In catarrh limited to the colon there are essentially the same symptoms as in ileo-colitis, inasmuch as the inflammation of the colon gives to that form its characteristic features--borborygmi, diarrhoea, and tympanites. When the disease in the colon preponderates or exists alone, the pain and tenderness are more superficial and confined to the line of the large intestine. The distended colon projects and the abdominal swelling is not so uniform. If the attack is subacute or mild, the stools contain normal feces mixed with a great deal of mucus; when the inflammation is in the sigmoid flexure, pure mucus is passed. Blood mixed with mucus and tenesmus accompany inflammation low down. Blood may, however, come from intense inflammation of the ascending and transverse colon without disease of the lower bowel.

IV. Proctitis.--The rectum may be the seat of simple catarrh, which differs in its symptoms from catarrh of other portions of the canal. By many this form is called simple, non-infective dysentery. But as it is a form of intestinal catarrh, it is right that it should be considered in connection with colitis. The first indication of its onset is a frequent desire to go to stool, with an unsatisfied feeling after each effort. Normal fecal matter is first expelled in solid form, coated with mucus which may be streaked with blood. Soon, however, the discharges consist of jelly-like mucus, alone or mixed with blood. A small quantity of this is passed with tenesmus at short intervals. The patient complains of a burning feeling in the rectum and a constant and irresistible desire to strain. The same spasmodic contraction may involve the bladder.

This affection rarely assumes a serious form. It usually ends in recovery spontaneously or under treatment by the cessation of the mucus and blood and the discharge of normal fecal matter.

DIAGNOSIS.--A combination of the symptoms described as belonging to inflammation of the small and large intestine gives the most common {685} form of intestinal catarrh, ileo-colitis. This union is diagnosed by the following symptoms: fever; general distension of the abdomen; paroxysmal pains starting from the umbilicus, but having a general distribution; noisy movements of gas; diarrhoea, the stools being large, thin, stained more or less with bile, containing more or less mucus intimately mixed with fluid matter and with particles of partially-digested or unaltered food. It is possible in many cases to recognize the part of the intestinal canal which is the seat of disease from differences in symptoms which have already been described. But great care in observation is needed, combined with a minute inspection and microscopical examination of the stools, to arrive at accurate and well-founded conclusions.

Acute follicular ulceration may be thought to have begun if after a week or more of illness thin and sometimes putrescent stools are passed containing small blood-coagula, with mucus and pus. This opinion would be confirmed by an increase in abdominal tenderness and the persistence of the diarrhoea or tendency to relapse notwithstanding careful treatment and diet. The transition of the disease into the chronic form would give additional support to this view of the nature of the lesion.

Some or all of the symptoms of acute intestinal catarrh are, however, found in other diseases. It is well, therefore, to devote some attention to differential diagnosis, giving a résumé of the salient points of distinction.

Typhoid fever in many of its features resembles intestinal catarrh, and in many cases is confounded with it. Until within quite recent times the symptoms of typhoid fever were grouped under the names gastro-enteritis and follicular enteritis. In the first week of the illness there is reasonable ground for delay in making a positive diagnosis. Etiological data are here of great help. The occurrence of the symptoms in children under two years and in adults beyond fifty years points strongly to intestinal catarrh. Spring and early summer are the seasons for diarrhoea; typhoid belongs to late summer and to autumn. A sudden onset after errors in diet or exposure to cold, with the early development of pain in the bowels, rumbling of gas, diarrhoea, would be easily recognized as a local disorder. In typhoid fever there is a less sudden onset, with prodromal debility, anæmia, indigestion, and nocturnal fever. To these symptoms the diarrhoea, which is attended with little or no pain, plays a very subordinate part. In many cases of mild typhoid the development is sudden, with rigors. A week's study of the temperature, if no rose-spots appear, will be needed before the diagnosis can be made. There is not much difficulty in making the distinction when the attack has reached its second week. At this period in catarrh of the bowel the high fever, with regular morning remissions and evening exacerbations, is not constant, as in typhoid fever; there is tenderness on pressure over the abdomen and gurgling, but no great meteorism; sibilant râles are not heard in the chest; there are no rose-spots; rarely cerebral symptoms except insomnia; and delirium is uncommon. The spleen is not enlarged. The prostration is proportioned to the diarrhoea, and is by no means as {686} great as at the same period in enteric fever. The colicky pains preceding and accompanying the stools are a more marked feature of intestinal catarrh; they are absent in enteric fever or have a feeble intensity.

In children between the ages of two and seven years there are certain peculiarities which augment the difficulties of diagnosis. Intestinal catarrh in them is accompanied by an abundant, frequently painless diarrhoea, by tympanites, cerebral disturbances, a dry and coated tongue, with sordes on the lips and gums, and by a rapidly-developed anæmia, emaciation, and exhaustion. Typhoid fever in children of this age is generally benignant; vomiting is more common than in adults; high grades of meteorism are infrequent; tenderness of the cæcal region is determined with greater difficulty; and severe nervous phenomena and fatal intestinal complications rarely occur. In other words, in young children intestinal catarrh by its severity and enteric fever by its benignity more nearly approach each other than in adults; in many instances the diagnosis must be undecided until late in the attack.

Typhoid fever can of course be known if rose-spots, a splenic tumor, or the characteristic delirium are manifested, or if the fever-curve conforms to the type; but in children all these symptoms may be negative; even the fever has great variability. If fever is continued beyond ten days, and is accompanied by progressive anæmia and emaciation and debility, the attack is enteric fever if all local causes of fever can be excluded. There is no minimum limit to the temperature in typhoid fever, and no matter how low the maxima of the fastigium may be, typhoid fever cannot be excluded.

The large watery stools and the absence of tenesmus mark the difference between diarrhoea and dysentery. Blood may be present in colitis, owing to a high grade of inflammation and to ulceration. Simple catarrh of the rectum, proctitis, is not readily distinguished from infective dysentery. Small mucous and bloody stools may be catarrhal. In the present state of our knowledge dysentery would be known by marked tenesmus, by the grave general symptoms, the reddish fluid stools with flocculi, and by its occurrence in epidemic form.

Enteralgia presents the following features which distinguish it from intestinal catarrh: The tongue in enteralgia is clean or coated white, but with no red tip and edges; the appetite is capricious, but not lost; the bowels are constipated; the pain bears no relation to the ingestion of food or drink, as in enteritis. Fever is accidental, and there are other nervous phenomena. In lead colic there is no fever, tympanites, nor diarrhoea. In rheumatism of the abdominal walls the pain is superficial and sharp, not griping, and is increased by movements of the trunk. The digestive system is in no way disordered. From peritonitis intestinal catarrh is distinguished by a less degree of illness and by its usually favorable result, by diarrhoea, a greater freedom in movement, and by a less degree of suffering on palpating the abdomen. Tympanites, constipation, great tenderness on pressure over the abdomen, and a small, quick pulse, point to peritonitis.

{687} PROGNOSIS.--A simple intestinal catarrh of the form first described involves no danger, and if treated by rest and diet soon recovers. The more severe form, beginning as a primary disease, when rationally treated ends in recovery in most instances.

Unfavorable predisposing causes are--a hot climate (India, the West Indies, and intertropical climates in general); very hot weather of the summer and autumn months; a very early or very advanced age; the contaminated atmosphere of prisons, camps, etc.; all bad hygienic influences; and previous or coexisting illness. When diarrhoea occurs as a complication of the acute infectious diseases it has a special gravity. In typhoid fever, scarlatina, measles, acute tuberculosis, etc. it adds another element of illness and danger. During the progress of chronic general diseases (malaria, scurvy, tuberculosis) it becomes an obstinate and sometimes a fatal complication. Among the exciting causes mineral poisons induce the most dangerous form of intestinal catarrh. Unfavorable symptoms occurring during the course of acute diarrhoea are the early development of high temperature, cerebral disturbance, great sensibility to pressure over the abdomen, thin and bloody or highly offensive stools, involuntary discharges, and very rapid emaciation and loss of strength.

TREATMENT.--There have been many fluctuations of opinion as to the relative value of modes of treatment in this disease. Various therapeutic measures have been suggested which, after enjoying favor for a time, have been abandoned, and revived after long periods of disfavor. Venesection was alternately recommended and forbidden. Emetics and evacuants, mercurials, diuretics, diaphoretics, have been in turn warmly supported and vigorously opposed. Opium, belladonna, the various astringents, and cinchona-bark have run through many changes of favor. Individual drugs give curious evidence of inconstancy. Oxide of zinc, suggested by James Adair in 1785 and by Hendy in 1784, after a hundred years of weak approval is commended highly by Penrose (1863), Brakenridge, and Mackey (1873), and by more recent writers. Acetate of lead, which dates back to Paracelsus, had varying fortunes of repute and disrepute. In the end of the seventeenth century it had a name for curing diarrhoea, but in the following century it was spoken of by Boerhaave as a deceitful and destructive poison, and Cullen in 1789 said that hardly any one then thought of using lead internally. In 1799 it had warm advocates in this country; among them, Thomas Ewall of Washington, who wrote in 1808. Since then it has come into very general use and favor, which it still holds.

In view of the many changes of faith in systems of treatment and in drugs, we have no right to assume that we have as yet reached the perfection of treatment. In fact, experience brings the conviction that our systems are quite imperfect and that drugs fail in our hands when they are most needed.

The prophylactic treatment is of importance, especially in children, delicate persons, and in those suffering from disease or predisposed by idiosyncrasy to intestinal catarrh. Directions must be given by the physician as to the food for children appropriate to their age and digestive capacity. Summer heat and city life being so fatal to them, they should {688} be sent to the cool climate of the seashore or mountains during the first and second years of life. In warm weather laxatives should not be given to children, except with precautions against their acting too freely; the same rule applies to the aged. Too great care in diet in older children predisposes to indigestion and diarrhoea. Variety in food is of service, therefore. It is not well to give children food prepared so as to do away with the necessity for mastication and for active gastric movements. The stomach gains strength by exercise. All reasonable care should be used not to take food in excess of the individual's power of digestion. Unripe fruit, stale vegetables or fruits, cheese, pork, shellfish which are not absolutely fresh, are among the aliments which may produce diarrhoea, and are to be avoided. Many people have to be told what food is unsuited to them, and certain articles of food in individual cases invariably excite diarrhoea. Alcohol is often to be blamed for diarrhoeas which are attributed to indigestible food, and frequent recurrences of intestinal catarrh can only be prevented by abandoning stimulants altogether. The bad effects of sudden changes in temperature are warded off by wearing flannel next to the body. This is an important rule for adults as for children. Even in summer thin flannel or gauze gives protection. Well-ventilated rooms, good house-drainage, personal cleanliness, with all other hygienic aids, are means of prevention. Persistent disinfection of sources of air- and water-contamination should be practised, especially in hot weather. In the country the open privies and wells need frequent clearing out. Cases of fatal diarrhoea are met with in elevated regions where the continued low temperature renders it improbable that heat could have anything to do with their causation. Water should not be used which could in any way be tainted with soakage from privies, barnyards, or other places where animal decomposition is going on. Avoiding the use of cathartics in the onset of acute illness, the nature of which is not known, is a useful prophylactic measure. A fatal diarrhoea may result from injudicious purging in such cases. Care in the use of laxatives should be observed in the chronic wasting diseases--tuberculosis, rachitis, cancer, etc.

The selection of a plan of treatment for intestinal catarrh will depend upon the nature and cause of the symptoms. The diagnosis of the case is incomplete and the treatment irrational until the indications furnished by etiology have been obtained.

If cold has been the exciting cause, the patient should be confined to bed. In the beginning a full dose of pilocarpin, hypodermically, or of the fluid extract of jaborandi by the mouth, may cause a powerful diversion from the bowel to the skin. A hot-water or vapor bath has the same object in view. Hot fomentations or mustard poultices can be next applied to the abdomen. This should be succeeded by a febrifuge {689} mixture containing the tincture of aconite-root, to which an opiate (the deodorized tincture of opium or morphia) is to be added if there is much pain or diarrhoea. A hypodermic injection of morphia given on the first day of the attack immediately after a hot bath will give a quiet night and diminish the intensity of the illness. The subsequent treatment is that common to all the acute forms.

If summer heat has been the cause in adults or children, artificial cooling of the temperature of the room by the evaporation of ice-water or by one of the refrigerating machines yet to be perfected meet the indication. If there is much body-heat (thermic fever), cold sponging, the application of cold to the head, or the giving of pounded ice to satisfy the intense thirst, are all advisable. Such cases are benefited by a change of climate when the acute symptoms subside. The form of diarrhoea due to malaria is to be treated by quinia and change of air to a more healthful climate. Iron, with quinia or arsenic, is needed in obstinate cases.

Intestinal catarrh which proceeds from the presence of undigested food or hard fecal lumps in the bowel is benefited by early removal of the irritating cause. It is not often that substances of this kind are retained when the stools are large and frequent. The peristalsis is here as active as it need be, and no good, but only harm, can come from over-stimulating the contractile muscles. In those instances where there is a distinct history of the taking of indigestible food, especially fruit with seeds or skins, and where the efforts at stool are frequent, ineffectual, and accompanied by colic and borborygmi, or where scybalæ are found floating in the fluid passed, a large enema of warm water given slowly will excite the bowel to successful expulsive efforts. If this does not give a certain amount of prompt relief, a moderate dose of castor oil, calomel, Rochelle or Epsom salts ought to be prescribed, and repeated after some hours until a free fluid or semi-fluid stool results; one or two doses will usually suffice. If the inflammation is localized in the cæcum (typhlitis), as indicated by local pain, tenderness on pressure in the right iliac or right lumbar regions, constipation, flexing of the right thigh on the trunk, and vomiting, a purgative should not be given, nor should prolonged efforts be made to empty the bowel by injection through long rectal tubes. If there is doubt as to whether typhlitis or undigested food and fecal impaction is the cause of the local pain, it is better to err on the safe side, and not to give a purgative unless the case is seen in the onset before the more pronounced symptoms appear; then calomel or castor oil may be tried once, but not repeated in case of failure.