Part 119

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 pneumonia and acute pulmonary congestion are occasional {710} 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.

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.

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.

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. 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.

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 {711} 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.

{712} 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.

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 {713} 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.

Duodenal ulcer is with difficulty recognized during life. 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.

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 {714} 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.