A system of practical medicine. By American authors. Vol. 2 (part 5 of 8)

A system of practical medicine. By American authors. Vol. 2 (part 5 of 8)

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.[25]

[Footnote 25: Potain, Le Praticien, Paris, 1879-80, p. 88.]

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.

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[26] 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[27] 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.

[Footnote 26: McGaughey, Philada. Med. Times, Aug. 1, 1872, ii. p. 407; also, T. N. Reynolds, Detroit Clinic, June 7, 1882, p. 181.]

[Footnote 27: Eskridge, Philada. Med. Times, Feb. 15, 1879, ix. p. 239.]

A fatal case of duodenitis is recorded[28] 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.

[Footnote 28: Die Krankheiten des Duodenums, Mayer, quoted by Leube in Ziemssen's Cyclopædia, Am. ed., vol. vii. p. 373.]

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.[29]

[Footnote 29: These conclusions are based upon the results of one thousand examinations of feces made by H. Nothnägel, and reported in Zur Klinik der Darmkrankheiten; Zeitschrift für klin. Medicin, iv., 1882, p. 223.]

Intense inflammation of the small intestine may exist without diarrhoea or other symptoms betokening the real nature of the attack. Flint[30] mentions having met with three such instances, and Goodhart[31] 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.[32]

[Footnote 30: Clinical Medicine, Philada., 1879, p. 280.]

[Footnote 31: Guy's Hospital Gazette, Sept., 1878, p. 98 et seq.]

[Footnote 32: Maladies des Enfants, Paris, 1861, tome i. p. 748.]

III. Acute Colitis.--Fifty years ago colitis was synonymous with enteritis, and not with dysentery, as at a more recent date.[33] The older {684} signification expressed the fact that inflammation in the colon is essential to diarrhoea. Later the term was used synonymously with dysentery.[34]

[Footnote 33: Journal général de Médecine, Paris, 1825, t. xci. p. 18.]

[Footnote 34: Tweedie, System of the Practice of Medicine, 1841.]

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.[35]

[Footnote 35: In a case seen by the writer of colitis terminating fatally from perforation of the transverse colon this point was illustrated. A woman aged fifty was taken with diarrhoea in August, 1873. In November the symptoms became worse: tongue dry and red; abdominal pain; tympanites; frequent stools, ten to seventeen in twenty-four hours; quantity large, of a yellow or brownish-red color with floating flakes. General symptoms grew worse; blood in stools from time to time. November 24, sudden cessation of discharges from the bowels, and the following day sudden collapse and death. Autopsy: Descending colon and sigmoid flexure comparatively healthy. Transverse colon adherent to stomach; deposits of lymph on colon and small intestines; fluid and feces in the peritoneal cavity. The mucous membrane of the ascending and transverse colon in a state of black pulpy disintegration. In the transverse colon the walls were thinned by ulceration and easily torn; gangrenous appearance of mucous coat; perforation of the colon wall below greater curvature of the stomach.]

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.[36] 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.[37]

[Footnote 36: "The intestinal mucous membrane, especially that of the small intestine, scarcely ever produces pus without ulceration" (Virchow's Cellular Pathology, Philada., 1863, p. 492).]

[Footnote 37: For a more detailed account of the symptoms and diagnosis of follicular ulceration see article on CHRONIC INTESTINAL CATARRH.]

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.[38] 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.

[Footnote 38: Consult "Diseases of Children," Henoch, Wood's Library, New York, 1882, p. 300.]

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.[39]

[Footnote 39: Johnston, "On the Diagnosis of Mild Cases of Typhoid Fever," Am. Journ. Med. Sci., Oct., 1875, p. 372; also, "On the Mild Forms of Continued Fever in Washington," Am. Journ. Med. Sci., Oct., 1882, p. 387.]

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),[40] 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.[41] 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.

[Footnote 40: J. J. Woodward, op. cit., p. 776.]

[Footnote 41: Ibid., op. cit., p. 780 et seq.]

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.[42] 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.[43] 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.

[Footnote 42: The yearly occurrence of typhoid fever and diarrhoea at seashore hotels shows that there is great danger in crowding persons together and saturating the soil with the excreta. In the summer of 1882 in a boarding-house in the mountains of Maryland, where the temperature was never above 75°, there were three fatal cases of diarrhoea in children, and several others of diarrhoea and dysentery which recovered.]

[Footnote 43: The drinking-water supplying a country boarding-house visited by the writer passed through iron pipes imbedded in the manure-heap of a barnyard.]

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,[44] 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.

[Footnote 44: Atropia can be given with pilocarpin to diminish its effect on the heart; atropia is the antidote for pilocarpin. (See Schuk, Centralb. f. d. med. Wissen., Bd. 20, 1882, p. 357; also, Frohnmüller, Med.-Chir. Centralb., July 14, 1882.)]

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.

As the diarrhoea of Bright's disease is salutary, no effort should be made to arrest it. Its periodical recurrence prolongs life. In tuberculosis the special character of the diarrhoea must be considered, and every effort must be made to control it. In the eruptive fevers an early diarrhoea, as in scarlet fever, does harm; it delays or prevents the normal development of the eruption. In the later stages it is of service sometimes, as in measles, when it leads to a rapid fall of temperature. The course of action depends upon the nature of the specific disease and upon the time of the appearance of diarrhoea.

There are certain principles, founded on the knowledge derived from pathological study and from the experience of the past in the treatment {690} of intestinal catarrh, which guide us to a treatment which is more or less rational in all cases.

Rest is essential to the cure of the inflamed intestine, but absolute inertia of the bowel is undesirable, even injurious. The retention of fluids, transuded serum, bile, intestinal juices, and partly-altered food is hurtful. Decomposition sets in and gas is developed, which by distending the bowel causes great suffering and increases the inflammation. The movements of the intestine are not entirely under control; the patient must be fed; digestion and assimilation involve the activity of inflamed parts. The stomach can be made to do most of the work, but the sympathy of action is so close between the stomach and intestines that one cannot function without the other being excited into activity.

The first rule of treatment is to put the patient to bed and to keep him in a horizontal position. Even in mild cases time will be saved by resorting to absolute rest at once. If the attack is at all severe, the bed-pan should be used; the effort to rise and the straining at stool exaggerate peristaltic movement, increasing the frequency of the evacuations. Additional rest can be given to the intestines by applying a flannel binder around the trunk, compressing the abdomen; broad strips of adhesive plaster could be used for the same purpose. In cases where the diarrhoea, tympanites, and griping pain are not relieved by other measures this suggestion may be of service.

In order to lessen intestinal hyperæmia and allay suffering, counter-irritants and soothing external applications are employed. Local blood-letting, although in vogue during more than two centuries, has fallen into disuse. Recent authors still continue to advise the application of leeches to the anus in order to deplete the portal circulation,[45] but it is a decided objection to this remedy that the fluid stools irritate the leech-bites and cause much discomfort. Sinapisms or turpentine stupes may be of some service apart from the relief which they give to pain. Blisters might be more generally used than they are when the tenderness on pressure is confined to the colon. In intense inflammation they should always be tried. Hot poultices of flaxseed meal or hot fomentations of any sort applied over the entire abdomen have a soothing and beneficial effect. A flannel compress saturated with alcohol and covered with gutta-percha cloth makes a most agreeable application.

[Footnote 45: Niemeyer, Practice of Medicine, Intestinal Catarrh.]

The directions for diet should be carefully and explicitly given. In the onset of the attack entire deprivation of all food for twenty-four or forty-eight hours is expedient. To relieve thirst, cracked ice, carbonic-acid water, Apollinaris, Seltzer, or Deep Rock water can be ordered; barley- or rice-water is slightly nourishing and relieves thirst, but all liquids should be given in moderation. When it becomes necessary to give food, the stomach must be made to do the work of digestion, and, as far as possible, of absorption also. Such substances are to be chosen as are converted in the stomach into peptones, and which do not require contact with the intestinal juices for their absorption.

The peptones transformed in the stomach from nitrogenous alimentary principles are highly soluble and diffusible. Milk is better suited to the conditions of intestinal catarrh than any other nitrogenous food. It is palatable, relieves the thirst, and can be taken for a long time without {691} aversion. By removing the cream, the fat, which would require intestinal digestion, is partly got rid of. Skimmed milk does not produce a feeling of distaste and what is called biliousness, as does milk unskimmed. In cases where there is gastric catarrh the milk can be made more digestible by adding an equal quantity of barley-water or rice-water. The casein is then more slowly acted on by the gastric juice and more thoroughly digested. Milk should be given in small quantities at short intervals, as in this way the stomach performs the entire work more thoroughly. If a large quantity is given, a portion of it passes into the intestine unaltered. Buttermilk contains less fatty matter than skimmed milk, and is a pleasant substitute for it. Koumiss, if it could be properly prepared, would be an excellent food for diarrhoea. Even the imperfect imitations are retained and digested when other aliments fail. The whey of milk contains lactin, salts, a little casein, and fatty matter. It may be made by adding to milk rennet, sherry or other wine, cream of tartar, tamarind-juice, or alum. Milk-whey is slightly nourishing, and is said to be sudorific; when prepared with wine it is a mild stimulant well suited to the cases of children.

Where it is desired to give as little work to the digestive organs as is possible, milk and other foods can be given already partly digested, as peptonized milk prepared according to the formulæ of Roberts and Fothergill.[46] Eggs are changed quickly in the stomach. Egg albumen is more easily digested by artificial gastric juice than by pancreatic extract (Roberts). A solution of egg albumen boiled in the water-bath is swiftly and entirely transformed by pepsin and hydrochloric acid. Raw eggs have been thought to be the most digestible, but Roberts found that a solution of egg albumen when raw was very slowly acted on by pepsin and acid, but after being cooked it was rapidly and entirely digested. Eggs are best given, therefore, boiled slightly at a slow heat; when an egg is plunged in boiling water the white sets hard, leaving the yelk soft. The albumen of the white and the yelk should be equally cooked throughout.

[Footnote 46: J. M. Fothergill, Indigestion and Biliousness, New York, 1881, p. 63 et seq. See also quote to article on CHRONIC INTESTINAL CATARRH.]

Beef-tea is said by the chemist to possess little nutritive value; practical experience convinces the physician that it supports life. Peptonized beef-tea may be substituted when thought best. Animal broths thickened with rice, barley, or with peptonized gruel, as advised by Fothergill, or with the addition of vermicelli, are valuable aids when the palate is capricious. Raw beef is not as digestible as when the tendinous and aponeurotic structures of the muscular fibre have been softened, disintegrated, and converted into the soluble and easily-digested form of gelatin by cooking.[47] Scraped raw beef, when the pulp is removed from much of the connective tissue, is easily digested by children as well as by adults.

[Footnote 47: Ibid., op. cit., p. 47.]

In most cases of acute intestinal catarrh the patient can be well sustained by a diet consisting of one or other of the aliments described. For the largest number milk alone--that is, skimmed milk or milk diluted with barley-water, rice-water, or Seltzer water--is all that is necessary to support strength during the attack. Although starch after deglutition is {692} acted on in the intestine only, it becomes desirable sometimes to give farinaceous food in some form or other; milk may be undigested and animal broths may become distasteful; the palate craves some change. In this case a blanc mange made after the formula of Meigs and Pepper is as well suited to adults as to children,[48] the proportion of cream and arrowroot being made larger for adults. Sago[49] and tapioca[50] can be tried to tempt the palate. The flour of the Egyptian lentil[51] is made into a gruel also. Most of the patent foods for infants and invalids contain starch in some form or other. Racahout is one of the pleasantest and best of these. Nestle's food contains baked biscuits of wheat flour ground to a powder. Liebig's food is made of wheat flour, malt flour, and a little bicarbonate of potassium. Revalenta Arabica is an attractive name for the flour of Arabian lentil with barley flour. Any of these may be advantageously employed in cases of some duration and in the later stages of convalescence.

[Footnote 48: Meigs and Pepper, Diseases of Children, Philada., 1870, p. 304.]

[Footnote 49: Put half an ounce of sago into an enamelled saucepan with three-quarters of a pint of cold water, and boil gently for an hour and a quarter. Skim when it comes to the boil, and stir frequently. Sweeten with a dessertspoonful of sifted loaf sugar. If wine be ordered, two dessertspoonfuls; and if brandy, one dessertspoonful.]

[Footnote 50: Half an ounce of the best tapioca to a pint and a quarter of new milk. Simmer gently for two hours and a quarter, stirring frequently; sweeten with a dessertspoonful of sifted sugar.]

[Footnote 51: Take three tablespoonfuls of lentil flour, a salt-spoonful of salt, and one pint of water. Mix the flour and salt into a paste with the water and boil ten minutes, stirring (Food for the Invalid, Fothergill and Wood, New York, 1880).]

The diet for convalescence should be controlled by the physician until the patient has been well for at least two weeks. Liquid preparations give place to fine hominy, corn meal or oatmeal porridge, with milk. Then bread or crackers may be given, the intervals between the meals increasing to three or four hours. Raw oysters, sweetbreads, tender rare steak or mutton finely divided and well masticated, rice, and ripe peaches, succeed the simpler diet. Much saccharine, starchy, or fatty food is to be avoided for at least two weeks after entire recovery.

When the indications derived from the study of the cause have been acted on, and the patient has been placed under a rigid discipline of rest and diet, the treatment of symptoms comes next in order.

In mild cases, where the cause has been irritating ingesta, diet may relieve the symptoms in a short time without medicine. If diarrhoea with slight colicky pains and flatulence continue after a few hours, a mixture holding in suspension subnitrate of bismuth, with five drops of the deodorized tincture of opium in each dose, or a pill of lead and opium, will suffice in a short time to give relief. In severer attacks the fever heat may mount to a high point, giving great distress to the patient. If a temperature of 103° to 104° F. is reached--which is not unusual in children--a warm bath is a sedative and antipyretic remedy, or a bath of 95° can be gradually cooled down to 75° or 65° F.--a procedure which will bring down the body-heat two or three degrees. A substitution for the bath is sponging with cool or cold water, to which vinegar or bay rum may be added; or towels wrung out of cold water can be applied to the trunk and extremities (Ringer) with a very happy effect.

Quinia can be used antipyretically in full doses, dissolved in dilute hydrochloric acid. Pills, especially the sugar- or gelatin-coated pills, {693} should not be given, as they irritate the mucous membrane whether they are dissolved or not. In diarrhoea quinia pills often pass unaltered.

Flatulence, eructations of gas, and borborygmi are controlled by strict diet according to the rules given. Bismuth subnitrate or subcarbonate unites with sulphuretted hydrogen and absorbs it. The alkalies, sodium and potassium bicarbonate, sodium hyposulphite, the aromatic spirits of ammonia, either relieve acidity or prevent fermentation and the development of gas. A satisfactory formula for the early stages of intestinal catarrh is one containing bismuth subcarbonate, sodium bicarbonate, aromatic spirits of ammonia in water or cinnamon-water. When the abdominal distension is great enough to be a cause of distress, external cold--dry cold--is the best, applied with a rubber bag filled with cracked ice or ice-water; it causes absorption of gas. Abdominal compression with a bandage may be of some service also. Mineral acids, especially the dilute hydrochloric acid, by affording aid to the digestion prevent acid fermentation.

Diarrhoea is the central symptom and the best standard by which to measure the intensity of the catarrh and its progress. But it is only a symptom, and the mind ought to be directed to the lesion and not to it. Having the cause in view, the object in all cases is to allay the inflammation. This done, the diarrhoea decreases, then ceases. Shall the effort be made to check the discharges, or shall they be allowed to continue? The evacuant plan of treatment has been advocated, on the ground that the purgative, by increasing intestinal secretion, relieves the congestion of the intestinal blood-vessels and leaves the membrane in a better state than before.[52] But inasmuch as a purgative only acts by bringing about an intestinal hyperæmia and catarrh, there is no good reason for, and many reasons against, treatment by evacuation.

[Footnote 52: Woodward, op. cit., pp. 727, 728.]

A preliminary purgative, as has already been stated, is necessary to expel undigested food and scybalæ, but for the purpose of increasing intestinal or biliary secretion and diminishing engorgement of the vessels this method is unsuccessful and unnecessary. When irritating substances have been removed (and this is done usually without the physician's aid by the spontaneous expulsive movements of the bowel) the effort to check the discharge and to give rest is one and the same. Opium is the one invaluable remedy which we cannot do without.[53] As little of it should be given as is necessary to relieve the intensity of the symptoms. The aim should not be to stop the pain and check diarrhoea, but to take the edge off the sharp agony and to lengthen the interval between the stools. Thus gradually the spasms of peristalsis cease, and there is a diminution, and finally cessation, of the fluid accumulation in the bowel. The diarrhoea is relieved entirely in a period ranging from an hour after the giving of the first dose to one week, according to the severity of the attack. Opium is given in pill form, in the deodorized tincture, Dover's powder, or one of the salts of morphia may be preferred. Any of these may be combined with antacid and antifermentative mixtures, relieving the colic, gaseous distension, and diarrhoea. If opium is combined with, {694} or followed by, evacuants, its effects are thwarted, and it might as well not be given at all.

[Footnote 53: The objections urged against opium, that it increases thirst and nervousness, causes a retention of fermenting products, produces opium intoxication, and that it is a routine practice to give it, and does not cure the inflammation, may be valid, but we cannot do without opium, nevertheless.]

It is the custom to combine astringents with opium, but in acute cases of short duration it is a question whether astringents do not do more harm than good. When good does come from the combination, it is the opium which acts promptly and decidedly. The astringent lags behind, and in cases of some duration and severity supplements the work of the active partner. Bismuth is classed under this head, although it is not an astringent. Its action is mechanical; much that is taken is passed from the bowel as the black sulphide, which appears as a black granular powder in the fluid stool. This is no proof that it may not have been of service in its transit.[54] After death, when large doses have been given, it has been found lining the whole intestinal canal.[55] The subnitrate or subcarbonate can be given in powder on an empty stomach in doses of five to twenty grains alone or in combination with opium, or it can be dispensed with alkalies in water. The enormous doses (one hundred and fifty to nine hundred grains daily), as given by Monneret, are useless or hurtful. The value of bismuth is based on empirical grounds only, but it is irrational to load the bowel with an insoluble powder which if retained must cause irritation. As the discoloration of the stools is an objection to bismuth when it is desired to study their character for diagnosis, oxide of zinc may be substituted for it, as the latter is an absorbent of acids and gases.[56] Gubler has insisted upon combining it with bicarbonate of sodium to prevent the formation of the irritating chloride of zinc in the stomach.[57] One of the oldest and most popular remedies tor diarrhoea is lime in the form of the carbonate or lime-water. The officinal mistura cretæ is perhaps more generally used for children than any other remedy. Lime-water is added with advantage to milk when given to adults as well as children. Carrara-water, made by dissolving the bicarbonate of lime with an excess of carbonic acid, is less nauseous than liquor calcis, and may be mixed with an equal part of milk.[58] Chalk and its preparations are less beneficial than bismuth as astringents, but may be used merely for their antacid effect.

[Footnote 54: Headland asserted that bismuth was insoluble, but it has been detected in the liver, in milk, in urine, and in the serum of dropsy by Orfila, Sewald, Bergeret, and Mayençon (Materia Med., Phillips, vol. ii. p. 81).]

[Footnote 55: Levick, Am. Journ. Med. Sci., July, 1858, p. 101.]

[Footnote 56: Bonamy, "Du Traitement des Diarrhées rébelles par l'Oxyde de Zinc," Bull. gén. de Thér., t. xcii., 1877, p. 251; also, J. Jacquier, De l'Emploi de l'Oxyde de Zinc dans la Diarrhée, Paris, Thèsis, 1878, No. 118.]

[Footnote 57: Gubler, Principles of Therapeutics, Philada., 1881, p. 25.]

[Footnote 58: Phillips, Materia Medica, vol. ii. p. 105.]

The sugar of lead is a valuable astringent, because unirritating and sedative to the mucous membrane. With opium in pill form, in doses of one to three grains, it checks diarrhoea if the inflammation has not lasted long and is not extensive. If there are cases where the bile is passed in quantity, it is especially called for, as it is the only astringent which diminishes the flow of bile.

The mineral acids--dilute hydrochloric, nitric, and sulphuric acids--are given with some success. The first aids gastric digestion, and in small doses with pepsin can be directed after food irrespective of other treatment. The great repute which it has enjoyed in the diarrhoea of typhoid is no doubt due to the improved digestion and assimilation {695} which follow its use. The acid principle is what is lacking in the gastric juice in fever and debility.[59] In all cases of intestinal catarrh rapidity of gastric digestion should be sought for. Nitric acid is of doubtful utility. Without an opiate in combination there is little reason to hope for any result from its use; all the suggested formulæ contain opiates.[60] Dilute sulphuric acid is thought to be more astringent than the others. If it has any efficacy, it is due to the local astringent or alterative effect by contact with the inflamed surface. Much testimony is to be found in its support in cases tending to become chronic and where astringents combined with opiates have failed after some days' trial. It should be administered in doses of five to twenty drops in the form of mixture with mucilage or some aromatic, as lavender and cardamom. An opiate should not be combined with it if it is desired to test it fairly. It would be called for when the stools are pale, abundant, watery, and alkaline.

[Footnote 59: Manassein, Virchow's Archiv, lv., 1872, p. 451.]

[Footnote 60: The favor in which nitric acid is held is due to the advocacy of nitrous acid by Hope ("Observations on the Powerful Effects of a Mixture containing Nitrous Acid and Opium in curing Dysentery, Cholera, and Diarrhoea," Edin. Med. and Surg. Journ., vol. xxvi., 1826, p. 35). Nitrous acid, the same as the fuming nitric acid of the shops, is a reddish-yellow fluid highly charged with nitrogen trioxide. Hope said that ordinary nitric acid did not produce the same effects, and yet nitric acid is now given with the belief that it is of service.]

Calomel is of ancient repute as a remedy in the early stages of diarrhoea. According to recent views, it acts as a sedative to the gastro-intestinal mucous membrane and checks fermentation. It should be given in small doses (one-twelfth to one-eighth of a grain to children, one-fourth to one-half of a grain to adults); it should not be continued for more than two or three days. In combination with Dover's powder it acts well, but it is doubtful which of the two remedies should receive the greater praise for the resulting improvement. A very small dose of the bichloride of mercury has been found beneficial by Ringer for clayey, pasty stools or straining stools containing slime and blood. His formula is--Hydrarg. bichloridi gr. j; Aquæ fluidounce x; a teaspoonful frequently during the day. The gray powder is not as much thought of now as formerly; it is not so good for the early stages of diarrhoea as calomel, but may be tried as an alterative when the stools are green and offensive.

In the vegetable materia medica there are many and ancient remedies. Tannin represents a large class, and there is nothing more than fancy in preferring to it kino, catechu, hæmatoxylon, or blackberry-root. Tannin is precipitated in the stomach as an inert tannate; gallic acid is to be preferred for this reason, and also for its pleasant taste and less irritating effect on the mucous membrane. It is well borne by children, even in large doses, when given with water and syrup. It is to be hoped that the unsightly and unsavory combinations of the astringent tinctures with chalk mixture will be soon given up. They are given chiefly to children, who are repelled by the sight, and still more by the taste, of such compounds. The syrup of krameria is the least objectionable, and catechu and krameria are made into troches which are sometimes available.

Ipecacuanha is said by Bartholow to be extremely serviceable in the diarrhoea of teething children with greenish stools containing mucus or blood. He prescribes it with bismuth and pepsin.

{696} Recently some favor has been paid to coto-bark and its active principle, cotoin. The latter is advised to be given in the following formula:

Rx. Cotoinæ, gr. j; Aquæ distillat. fluidounce iv; Alcohol, gtt. x; Syrupi, fluidounce j.

A tablespoonful every hour. Five to eight drops of the fluid extract of coto are given. It is said to have a speedy and certain effect in acute diarrhoea.[61]

[Footnote 61: Coto-bark was imported into Europe from Bolivia in 1873, and was called quinquina coto. Wittstein of Munich and Julius Jobst of Stuttgart made the first analyses (Neues Repertorium für Pharmacie, xxiv. and xxv.). Von Gietl (idem, xxv.) first concluded from experiments that it was of use in diarrhoea. Cotoin and paracotoin were separated by Jobst. It has been found successful in the treatment of diarrhoea in Germany and of cholera in Japan (Baelz, Centralb. f. d. med. Wissen., 1878, xvi. p. 482). Cotoin sometimes disturbs the digestion to a marked degree. Paracotoin may be used hypodermically.]

Salicin,[62] ergot, guarana, have all been spoken of by enthusiasts as possessing valuable properties in diarrhoea.

[Footnote 62: Lawson, "Diarrhoea and its Treatment at the London Hospitals," Med. Times and Gaz., vol. ii., 1868, p. 122; Bishop, "Salicin in Diarrhoea and Dysentery," Southern Med. Rec., vol. iv., 1874, p. 585; "Comparative Value of Opium and Salicin in Diarrhoea and Dysentery," Detroit Review of Med. and Pharm., vol. x., 1875, p. 387.]

Alum is not often prescribed. Sulphate of copper is fitted for cases in danger of passing into the chronic stage. Sulphate of zinc might be more generally ordered than is the case. The sulphate of iron and the fluid preparations of iron--tincture of the chloride, solution of the pernitrite, and persulphate--are astringents, and could be tried if other remedies fail. The effect of nitrate of silver is to constrict vessels, to coagulate and disinfect excretions, and to form an adherent protecting membrane (Phillips). It occupies the next place to lead, and is suited to a subacute stage when acute symptoms have subsided. It is warmly recommended by William Pepper and others.[63] The oxide of silver has been preferred by some writers.[64] For the protracted diarrhoea of children, in whom follicular ulcers form so rapidly, the nitrate of silver is of special value. To adults it is administered in a pill freshly made in doses of one-eighth to one grain. A solution in distilled water with syrup answers well for children, the dose varying from one-twentieth to one-fourth of a grain.

[Footnote 63: J. Maggregor, "On the Internal Use of Nitrate of Silver in Inflammation of the Intestines," Lancet, 1841, vol. ii. p. 937.]

[Footnote 64: Lane, Med.-Chir. Rev., July, 1840, p. 289 et seq.; Eyre, The Stomach and its Difficulties, London, 1852.]

The theory of the germ origin of diarrhoea has naturally brought into notice antiseptic remedies. Carbolic acid,[65] creasote,[66] naphtha,[67] sulpho-carbolate of calcium,[68] salicylic acid,[69] and chlorine-water have each been advocated. Practice does not support their claim to be considered remedies for intestinal inflammation.

[Footnote 65: Habershon, Lancet, London, 1868, vol. i. p. 7; C. G. Rothe, Berliner klin. Wochenschrift, 1871, p. 527.]

[Footnote 66: Southern Med. and Surg. Journ., vol. ii., 1846, p. 583; ibid., vol. iii., 1847, p. 147; London Med. Gaz., vol. ix., 1849, p. 254; ibid., vol. xii., 1851, p. 235.]

[Footnote 67: Gaz. des Hôpitaux, 1849, p. 46.]

[Footnote 68: Tr. Obstet. Soc. Lond., vol. xii., 1870, p. 12.]

[Footnote 69: W. Wagner, Kolbe's Journ. für prakt. Chemie, Bd. xi., 1875, S. 60.]

{697} Treatment by the rectum may be employed when medicines are rejected by the stomach or when it is desired to bring the drugs into more direct contact with the inflamed colon. Opiates, astringents, and alteratives are employed in this way. Laudanum in two to four ounces of warm water or in warm milk or starch-water can be thrown into the rectum, the fluid being allowed to remain. The injections are to be given often enough to relieve pain and lessen the number of discharges. With the laudanum, or without it, the mineral astringents can be used by enema. Acetate of lead or sulphate of zinc is to be preferred. The objection that but a small portion of the inflamed surface is reached by the fluid is a valid one, and therefore those cases are most benefited where the catarrh is in the lower colon and rectum. Ringer[70] says that it is not at all necessary for the fluid to reach that part of the intestine which is the seat of the catarrh; the impression made on one part is communicated to the other by sympathy. It was the practice with O'Beirne,[71] Hare,[72] and others to inject fluid by a long flexible tube passed beyond the sigmoid flexure. This method is advocated and employed in Europe by Mosler, Winterinz, and Monti. Quite recently Dulles has drawn attention to irrigation of the large intestine as a means of treating inflammation of the colon, according to the plan of Alois Monti of Vienna.[73] Henoch has tried with partial success in children the throwing into the rectum of a large quantity of water holding in solution acetate of lead, alum, or tannin. His method contemplates medication above the sigmoid flexure; a part of the fluid escapes, while the rest remains five or ten minutes in the bowel.[74] Monti says as much as two pints can be injected into the bowel of a nursing child--for older children twice this quantity.

[Footnote 70: Therapeutics, New York, 1882, p. 99.]

[Footnote 71: New Views of the Process of Defecation, Washington, 1834, p. 85.]

[Footnote 72: E. Hare, "On the Treatment of Tropical Dysentery by means of Enemata of Tepid Water," Edin. Med. and Surg. Journ., vol. lxxii., 1849, p. 40.]

[Footnote 73: Dulles, "Irrigation of the Colon," Philada. Med. News, Aug. 19, 1882, p. 199. The patient is placed on the side, back, or on belly, with the hips elevated. A large flexible catheter if a child, a stomach-tube if an adult, is inserted into the rectum. The tube is connected with a reservoir of water elevated above the patient. The rectum is first distended with water, and the tube is gradually made to follow the course of the bowel until it finds its way into the descending colon. Thus the water may be made to distend the whole of the colon to the cæcum. The fluid remains from a few minutes to half an hour.]

[Footnote 74: Henoch, Diseases of Children, Am. ed., New York, 1882, p. 206.]

Messemer[75] reported three cases (one child and two adults) treated in this way with the most striking success. His object at first was to cleanse the rectum, but warm water did not check the diarrhoea. Cold water was tried, and (probably by reflex influences) diminished rapidly the number of the discharges. And Ewald[76] has imitated Messemer's method with results which are surprisingly good. He injected 200 and 300 cc. of cold water, which was expelled by pressure on the abdomen; 50 cc. were then thrown in and allowed to remain. He has used the treatment in a large number of cases in children. The question as to the ability to force water thrown into the rectum through the sigmoid flexure and distend the colon has been settled by the experiment of Mosler in a case where there was a cæcal fistula. Water injected into the {698} rectum traversed the colon and escaped through the fistula in two minutes.[77]

[Footnote 75: J. B. Messemer, "Cold-Water Enemata as a Therapeutic Agent in Chronic Diarrhoea," American Journal of the Med. Sci., vol. lxxvi., 1878, p. 133.]

[Footnote 76: Lectures on Digestion, New York, 1881, p. 149.]

[Footnote 77: Berlin. klin. Woch., No. 45, 1873, p. 533. Woodward, in discussing the claims of Battey of Georgia to priority in the discovery of the permeability of the entire alimentary canal by enema (see paper by Battey in Virginia Med. Monthly, vol. v., 1878, p. 551), quotes from A. Guaynerius, who lived in the fifteenth century, from J. M. de Gradibus (1502), Sennertus (1626), and from others among the older writers to show that it was well known that suppositories and enemata introduced into the rectum are sometimes thrown up by the mouth. He mentions experiments by Alfred Hall (1845), G. Simon (1873), and F. Köster (1874) which demonstrated that large quantities of water may be forced from the rectum into the stomach. (See Woodward, op. cit., foot-note, p. 836.)]

When ulcers are thought to be present, the remedies of particular value are nitrate of silver, bismuth or turpentine, and the mineral acids, given in conjunction with a rigid system of diet.

In hemorrhagic diarrhoea ice externally or ice-water injections, opium, acetate of lead in large doses (ten to fifteen grains), gallic or tannic acid, and ergot are the appropriate remedies.

Some modifications of treatment are required for the choleraic form (in children, cholera infantum); the danger here is imminent from the drain of water and collapse. For the vomiting of the early stages, pounded ice eaten freely, potassium or sodium bromide in ice-water, and counter-irritants over the abdomen, with cold sponging or cold baths and ice to the head if there is much body-heat. Brandy, whiskey, or coffee in full doses is called for early. Iced coffee can be given to children. Spirit of camphor in five-drop doses every ten minutes aids in averting collapse. Small doses of calomel every hour or two may benefit nausea and vomiting. Arsenic is said to do well for vomiting and profuse watery diarrhoea. For adults, morphia hypodermically is perhaps the best remedy for the vomiting and purging; even for children, minute doses given in this way are best for alarming illness. Hypodermic injections of ether have also been suggested.

For the relief of duodenitis means are used to relieve the digestion of the want of the biliary and pancreatic secretions. Nitrogenous food is to be taken, but no fats or starch. Counter-irritation over the epigastrium and right hypochondrium by a blister or iodine is of direct service. If icterus accompany duodenitis and catarrh of the bile-ducts, all treatment must be directed to the duodenum. For ileo-colitis and colitis the rules already given apply.

{699}

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.

[Footnote 1: La Diarrhée chez les Viellards, Paris, Thèsis, 1865, No. 112. See also works of Durand-Fardel and Charcot and Loomis.]

[Footnote 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 {700} lithic-acid diathesis, pyæmia, septicæmia, scurvy,[4] diabetes, leucocythæmia, Addison's disease, and syphilis[5] 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.

[Footnote 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.]

[Footnote 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).]

[Footnote 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]

[Footnote 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 {701} 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.

[Footnote 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 appearance[10] of the mucous membrane. Dark streaks or wavy lines of pigment are also seen.[11]

[Footnote 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.]

[Footnote 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.]

[Footnote 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.]

[Footnote 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 {702} 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.

[Footnote 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 ulcers[14] are found by the side of others which are growing. Healed follicular ulcers are known by a puckered, stellated appearance[15] of the mucous membrane, which is pigmented and of a slate-gray or marbled-brown color[16] if the process has been long completed. Larger dense cicatrices, pigmented also, mark the site of more extensive ulcerations.

[Footnote 13: Illustration, Kupfertafeln zu DR. LESSER über die Entzündung und Verschwärung du Schleimhaut des Verdauungskanales, Berlin, 1830, Bei Enslin, Tab. ii. fig. 4.]

[Footnote 14: Illustration, J. Hope, Illustrations of Morbid Anatomy, figs. 168, 169.]

[Footnote 15: Illustration, Med. and Surg. Hist. of the War, tom. cit., p. 528.]

[Footnote 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 {703} 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]

[Footnote 17: G. Coulon, Bull. de la Soc. Anat. de Paris, 1879, p. 690.]

[Footnote 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.)]

[Footnote 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]

[Footnote 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.

{704} 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. Woodward[25] 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.

[Footnote 21: J. J. Woodward, op. cit., pp. 570, 571.]

[Footnote 22: A. Laboulbène, Anat. path., Paris, 1879, p. 186.]

[Footnote 23: "Einige Formen von Darmgeschwüren; iii., die Dysenterische Darmverschwärung," Med. Jahrb. des k. k. öst. Staates, Bd. xi., 1832, S. 274.]

[Footnote 24: "Der dysenterische Prozess auf dem Dickdarme und der ihm gleiche am Uterus, vom anatomischen Gesichtspuncte, beleuchtet," ibid., Bd. xxix., 1839, S. 88.]

[Footnote 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. Luschka[26] 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.

[Footnote 26: Virchow's Archiv, vol. xx. p. 133.]

[Footnote 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, 3_a_, 3_c_; 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 {705} 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]

[Footnote 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]

[Footnote 29: T. Grainger Stewart, "On Hemorrhage from Waxy or Amyloid Degeneration," Br. and Foreign Med.-Chir. Rev., vol. xli. p. 201.]

[Footnote 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 liver[31] 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.

[Footnote 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 {706} do form in the heart during life is shown by the sudden occurrence of cerebral embolism with aphasia.[32]

[Footnote 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 {707} 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 {708} 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.

[Footnote 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]

[Footnote 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]

[Footnote 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]

[Footnote 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 {709} 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]

[Footnote 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 duration[38]--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.

[Footnote 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.

[Footnote 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 pneumonia[40] 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.

[Footnote 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]

[Footnote 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]

[Footnote 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]

[Footnote 43: Woodward, op. cit., p. 504.]

[Footnote 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 {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.[45]

[Footnote 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 {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.[46]

[Footnote 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.

[Footnote 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 {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.

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 {715} 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 {716} 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. {717} 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]

[Footnote 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.

[Footnote 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 {718} 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]

[Footnote 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.]

{719}

CHOLERA MORBUS.

BY W. W. JOHNSTON, M.D.

SYNONYMS.--Cholera nostras, Sporadic cholera, European or English cholera, Spasmodic cholera, Cholera biliosa, Passio cholerica, Cholerhagia, Trousse-galant, Die Gallenruhr, Brechruhr.

DEFINITION.--An affection of the gastro-intestinal mucous membrane characterized by violent abdominal pain, nausea, and sudden, violent, and incessant vomiting, and by purging of a watery fluid containing little albumen and bile; attended with spasms of the muscles of the abdomen and extremities, a pinched and sunken countenance, pallor, cyanosis, and coldness of the surface of the body; a feeble and rapid pulse, oppressed respiration, and great restlessness; dryness of the tongue, great thirst, and diminished or suppressed urinary secretion and a state approaching collapse, which may rarely prove fatal, but is, as a rule, followed by reaction.

HISTORY.--The term cholera has been in use since the time of Hippocrates, but he confounded with it every disease which seemed to him to come from acridity or corruption of humors, as colics and meteorism with constipation.[1] He well described cholera morbus in saying that "it is a disease which appears in summer, due to imprudence in eating, at the same time as intermittent fever."[2] If Celsus be correct in deriving the name from [Greek: cholê] "bile," and [Greek: reô] "I flow," it is more applicable to the disease now under consideration than to the Asiatic disease, as it is the bile which is absent in the colorless rice-water discharges of Asiatic cholera. Trallian and Ruysch, however, ascribe it to [Greek: cholêra] the rain-gutter of a house.

[Footnote 1: Append. au Traité du reg. les Maladies aigues, 19, ii. p. 495, ed. Littré.]

[Footnote 2: Epidémies, lib. v., ed. Littré, 71, p. 247.]

In the Old Testament mention is made of a disease resembling cholera morbus.[3] Its true pathogeny was known to Galen, and it was accurately described by Celsus,[4] and Aretæus[5] mentions the nature of the discharges and its frequency among young people and children.

[Footnote 3: Hist. Méd. des Maladies epidémiques, Paris, 1825.]

[Footnote 4: Lib. iv. cap. 2.]

[Footnote 5: Lib. ii. cap. 5.]

The first mention of epidemics was in the sixteenth century. Various epidemics in 1695, 1717, and 1718 in Germany were probably cholera morbus. Forestus[6] reports seven observations from 1559 to 1565 of attacks due to indigestible food or drastic medicines. F. Hoffman,[7] {720} J. Frank,[8] and L. Rivière speak of the benignity of the disease as contrasting it with its apparently dangerous symptoms.

[Footnote 6: Opera Omnia, Rothomagi, 1633, "De stomachi affectibus," lib. xxviii.]

[Footnote 7: Medicina rationalis systemica, t. iv. pt. 3, 1734.]

[Footnote 8: Praxeos medicæ universæ præcepta, Leipzig, 1826, p. 43.]

Sydenham's[9] description of the epidemics in England in 1669-72 is the earliest account of the disease in modern literature, and it was he who gave it the name cholera morbus.

[Footnote 9: Sydenham Soc. edition, vol. i. p. 163.]

NATURE.--There prevails at the present time a great diversity of opinion in regard to its nature; the want of uniformity in the appearances presented by post-mortem examinations may in some measure account for this. The present state of our knowledge, derived both from pathological anatomy and a study of the symptoms, will not warrant a positive opinion in regard to it.

Niemeyer,[10] in common with most German and some French authors, considers cholera morbus to be a variety of gastro-intestinal catarrh. Leube[11] thinks it a variety of gastric catarrh with simultaneous inflammation of the intestines and running a peculiar course. It is certainly not identical with the specific Asiatic disease, although in some cases the symptoms and morbid anatomy are exactly similar, and any differentiation is impossible. By some it is believed that cholera morbus is due to surviving germs implanted by previous epidemics of Asiatic cholera.

[Footnote 10: Pract. Med., 1879, vol. i. p. 480.]

[Footnote 11: Ziemssen's Cyclopædia, New York, 1876, vol. vii. p. 146.]

The slight changes found in some fatal cases would lead to the belief that the effect of the exciting cause is something more than a mechanical irritation of the gastro-intestinal mucous membrane.

The sudden onset, rapid development of symptoms, and dangerous collapse justify the theory that there must be some previous change in the individual or some peculiar result of food-decomposition. The nervous system may be so enfeebled by prolonged heat that an irritant quickly destroys its equilibrium and brings about vaso-motor paralysis of the intestinal vessels and abundant serum transudation. Or the irritation may be specific, depending upon the development of poison germs in food which has been subjected to heat influences. There is a close relationship between cholera morbus and cholera infantum in their etiology, symptoms, and pathology.

ETIOLOGY.--Predisposing Causes.--The disease is more common in the tropics, but is not confined to any climate. In temperate latitudes it is more likely to occur in July and August, when the variation of temperature between day and night is great, although the other months of summer and autumn are not entirely exempt. It is said to be more frequent and fatal in Southern Europe than in the northern and temperate climates. In periods immediately preceding and following epidemics of Asiatic cholera many persons are attacked, although there is great liability to errors in diagnosis at these times.

It occurs more frequently in youth and adolescence than in advanced life, and males seem to be more liable to attacks than females, but difference in occupation may assist in this predisposition. Persons endowed with an extreme sensibility of the nervous system and who are subject to frequent attacks of intestinal catarrh are much more liable to the disease. The exhaustion of the nervous system by heat, which is the {721} probable explanation of the phenomena of cholera infantum, has no doubt much to do with the development of cholera morbus. Mental anxiety or overwork in summer increases this nerve-exhaustion and renders the termini of nerves and the centres very susceptible to peculiar irritation.

Exciting Causes.--It is probable that the cause of most attacks is a septic material generated in the fermentation and decomposition of food. This poison acts as an irritant upon the gastric and intestinal nerves and gives rise to excessive peristaltic movements and vomiting. Hence the quality of the food is an element of more importance in the causation than the mere quantity ingested; and herein may reside the chief difference between cholera morbus and Asiatic cholera, the latter being due to a specific, imported, or acclimated poison which invariably produces the same specific form in those exposed to its action.[12] Unripe fruits, partially cooked or decaying meats and vegetables, shellfish and fish some time from the water, may produce the disease in those predisposed to it. The intemperate use of ice-water and other cold drinks after a full meal or when the body is exhausted by heat and fatigue, exposure to showers at the close of a hot day, or passing from a heated room into damp cellars and outbuildings, are frequent exciting causes.

[Footnote 12: "Bias the pugilist, naturally a great eater, had a sudden choleraic attack after having eaten of succulent food" (Hippocrates, lib. v. p. 247, ed. Littré).]

At times there exists a certain condition of inactivity of the digestive organs when the gastric juice is not secreted in sufficient quantity, and perfectly sound food may undergo fermentation and set up an attack.

The offensive exhalation from a filthy alley which had been recently cleaned was the exciting cause of a fatal epidemic in a London school,[13] and Levier recounts an epidemic caused by the drinking-water during the winter in Berne.[14]

[Footnote 13: Lond. Med. and Surg. Gaz., 1829, iv. p. 375.]

[Footnote 14: Schweiz. Zeitschr. f. Heilk., iii., 1864, p. 140.]

Nervous disturbance from other diseases may act as a cause. Leube reports a case of intermittent fever which was followed by an annual attack of cholera morbus preceded by febrile symptoms.[15]

[Footnote 15: Leube, Ziemssen, 1876, vol. vii. p. 148.]

Malaria, sewer-gas, and sudden and powerful mental emotions are credited with the causation of some attacks.

PATHOLOGICAL ANATOMY.--In a few cases an examination of the body has revealed no phenomena sufficient to account for the symptoms, even when they have been the most severe during life. In these cases either the inflammation has not passed the first stage of development and the resulting hyperæmia has disappeared after death, or the irritation of the gastro-intestinal nerves has been sufficiently intense to cause death before the alimentary tract has undergone any consequent structural change.

Usually, however, there are evidences of a general gastro-intestinal catarrh: the mucous membrane is congested throughout and denuded of epithelium. The solitary glands are enlarged and Peyer's patches swollen and prominent. The blood is thickened and dark in color, and the serous membranes dry, sticky, and covered with desquamated epithelium. Indeed, the appearances may be identical with those observed in true Asiatic {722} cholera. The kidneys are congested, sometimes enlarged, and the tubules devoid of epithelium. In protracted cases the general muscular system shows a beginning of granular degeneration.

In no case, however, can a positive diagnosis between Asiatic cholera and cholera morbus be made from post-mortem appearances.

SYMPTOMS.--The attack is usually sudden in its onset, but in some cases is preceded by nausea, thirst, loss of appetite, and slight general distress for some hours, or it may come on in the course of some gastro-intestinal disturbance. Frequently it is developed during sleep, particularly after midnight, the patient being aroused by a feeling of pressure at the pit of the stomach, which is followed by nausea and violent and incessant vomiting with intense pain, the contents of the stomach being ejected with great force.

The matters first vomited consist mainly of the food last eaten, little altered or mixed with gastric mucus and tinged with bile. In a certain proportion of cases the amount of bile is increased, although it is difficult to judge of the relative proportion by the color and taste of the vomited liquid. The general belief that the liver is implicated and the bile secreted in morbid quantity rests upon conjecture alone, and has no solid basis. After a time only yellow, brown, or greenish mucus, with more or less bile, is ejected, and in protracted cases hiccough is most distressing.

Following the vomiting or at the same time with it purging comes on, and it is usually preceded by borborygmi. In rare cases there is no vomiting, but only intense pain in the bowels and copious alvine discharges from the beginning to the end of the attack. The stools in the beginning are normal in color, but soon become pulpy or semi-fluid. As they increase in quantity they become watery, consisting of blood-serum with mucus, cast-off epithelium and pus-cells, and are nearly odorless, and sometimes resemble very closely the discharges of Asiatic cholera, but almost invariably retain the yellow or green color of the bile. Colorless rice-water discharges are observed in undoubted cases of cholera morbus outside of any epidemic influence. The discharges are acrid and irritating, and the neighboring parts become red and excoriated.

At the same time there is intense burning or tearing pain in the abdomen, generally centring at the umbilicus, great thirst and painful contractions of the muscles of the abdomen and extremities, particularly in the calves of the legs, and of the flexors of the thighs, forearms, fingers, and toes. In the beginning there may be tympanites, but this soon disappears, and the abdomen becomes retracted and the muscles drawn up into knots. The cramps usually come on after each act of vomiting and purging, but they may appear spontaneously. Abdominal tenderness is either wanting or slight. As the transudation continues the thirst becomes intense, the tongue cold, dry, and coated, and the tissues shrivelled from loss of water. The skin is cold, clammy, or covered with a viscid sweat, and the surface of the body is cyanosed, violet, or in the extremities it may have a marbled appearance. The nose is pointed, the eyes dark and sunken, and there is a general appearance of collapse.

The mind may be clear throughout, but in protracted cases there is great nervous prostration. The patient becomes dull and lethargic, passing into stupor after great restlessness and jactitation. The voice is faint {723} or whispering, the breath cold, and the respiration sighing. The pulse in the beginning may be depressed, but soon becomes rapid and often imperceptible, and there is great præcordial anxiety.

As the blood becomes thickened the urine is highly colored, small in quantity, and it may be suppressed. An examination shows traces of albumen, casts and desquamated epithelium, and a decrease in the amount of urea and salts. In the last stages there may be a slight rise in temperature, but it has no definite course and it is usually absent. In collapse the temperature of the surface of the body sinks below normal, but the temperature of the interior may rise as high as 101° or 102° F., as shown by the thermometer in the rectum or vagina.[16]

[Footnote 16: London Hosp. Reports, 1856, vol. iii. p. 457.]

PROGRESS AND TERMINATION.--But, fortunately, the course of the disease tends toward recovery in the large majority of cases. The discharges gradually decrease in quantity, the intervals are longer, the appearance becomes more natural, and a profuse perspiration is followed by a refreshing sleep. The surface becomes warmer, the pulse slower and more full, and the skin regains its normal color.

If the case has been a severe one or if it occurs in a person much enfeebled by disease, it pursues a different course. The discharges become almost uninterrupted, and at last are passed involuntarily. The cramps are almost continuous or are convulsive, the pulse grows rapidly weaker and is finally lost, coma succeeds stupor, and death follows in collapse.

The duration of the disease varies from a few hours to two or three days; death has occurred within twelve hours.

Recovery is generally complete after a few hours; and this rapid return to the normal condition shows that there have been no textural change of organs. Sometimes great emaciation, irritability of the stomach, and slight diarrhoea persist for a few days, or symptoms of a general gastro-enteritis may supervene.

DIAGNOSIS.--In making the diagnosis of cholera morbus it is necessary to carefully differentiate it from epidemic cholera and the effects produced by irritant poisons, such as the metallic salts, poisonous fungi, etc.

Occurring during an epidemic of Asiatic cholera, it is not possible to make a diagnosis, as the symptoms of cholera morbus and of mild cases of the Asiatic disease are identical. From severe cases it is to be distinguished by the absence of antecedent diarrhoea, by the presence of bile in the vomited matters, and by the color and fecal odor of the stools. The nausea and abdominal pain are more marked, while the dyspnoea, cyanosis, and shrunken condition of the skin are less marked. The mortality of cholera morbus is slight, whilst about one-half of those attacked with epidemic cholera die.

In irritant poisoning the vomiting follows quickly after the ingestion of a meal or poisonous matter; it continues for some time before purging begins, and is out of all proportion to the diarrhoea. The vomited matters contain blood and mucus and are never serous in character. Corrosive poisons may cause redness, charring, or ulceration of the mouth and throat and a burning sensation in the stomach. The pain over the stomach is more constant and severe, particularly in the intervals of {724} vomiting, and there may be abdominal tenderness and bloody discharges. The expression is more anxious and the pulse rapid and weak.

Elaterium and tartar emetic will bring on vomiting and purging which resemble the symptoms of cholera morbus. Choleriform attacks due to uræmia simulate cholera morbus. The distinction is to be made by the previous history--pain and purging being relatively less prominent in uræmia--by the presence of albumen and casts in the urine, and by the early tendency to coma.

Acute peritonitis, attended by copious vomiting and purging, has been mistaken for cholera morbus, and the true nature of the affection only revealed by the autopsy.

PROGNOSIS.--As a rule, cholera morbus occurring in persons otherwise healthy ends favorably in a few hours. Cases of secondary fever, with gastro-intestinal catarrh, may prolong the attack from a few days to two weeks. Should treatment have no effect in lessening the vomiting and purging, and should the evidences of heart-failure become apparent, a fatal result may be feared. Death has occurred within twelve hours, and the mortality is 3 per cent. of uncomplicated cases.[17]

[Footnote 17: Bartholow, Pract. Med., New York, 1880, p. 58.]

Cases occurring in the course of other diseases possess a special gravity.

TREATMENT.--During the summer months, and particularly in August and September, when the hot days are succeeded by cool nights, iced drinks should be used in moderate quantities; the diet should be light, nutritious, and easy of digestion. Unripe fruits and articles of food liable to fermentative changes should not be indulged in.

Exposure to the night air, particularly after a full meal, should be especially avoided, and the clothing ought to be so arranged that additions may be made as night approaches. Slight attacks of indigestion should not be neglected, and any irregularity of the bowels must receive immediate attention.

The period when the physician is called upon to prescribe for an attack of cholera morbus is usually when the stomach has been emptied of food and the patient is vomiting incessantly, purging, and writhing in pain. If vomiting has not occurred and violent epigastric pain is the only symptom, the stomach should be emptied by an emetic of hot water and mustard repeated until the overcharged organ is completely emptied. Partially-digested food in a state of acid fermentation will thus be got rid of, and the sufferings may be immediately but not wholly relieved.

If spontaneous vomiting has expelled the food, and the matters vomited are green and watery, while pain and frequent stools with muscular cramps, heart feebleness, and threatening collapse are the symptoms presented, the remedy par excellence is a hypodermic injection of sulphate of morphia (gr. 1/8 to 1/3) with sulphate of atropia (gr. 1/120 to 1/100). If one dose is not followed by decided mitigation of suffering, the injection is to be repeated in a half hour or an hour, not giving above one grain of morphia in divided doses. At the same time, and while waiting for the full effect of the narcotic, efforts can be directed to giving ease to the muscular spasms and pain by brisk friction with stimulating lotions or by mustard poultices to the abdomen and extremities. The morphia will be the best and quickest stimulant which can be used; it will therefore be useless in most cases to administer brandy, camphor, chloroform, {725} or other remedies of that sort. Waiting and giving nothing by the mouth is the wiser course. In twenty minutes to half an hour the most perfect bien être succeeds to the previous agony and exhaustion. In some cases the vomiting, purging, and cramps cease more gradually, and six hours will pass before the patient is at ease. The intense thirst is best treated by the giving of cracked ice sparingly at first, more freely later.

Nothing substitutes morphia hypodermically with success, but in some instances or when the stomach is not very irritable it may be necessary to give medicine by the mouth. In this case chloroform (xv to xxx drops), chlorodyne (x to xx drops), or spirits of camphor (v to x drops) every quarter or half hour in ice-water may be directed. Chloroform and camphor can be combined with the deodorized tincture of opium in ten- to twenty-drop doses. Time is wasted in expecting relief from remedies which are inevitably rejected as soon as taken; it is only when the stomach is very tolerant that it is judicious to begin with them.

The weakness of the heart's action must be combated by brandy or whiskey, given by the mouth with pounded ice or administered hypodermically. A considerable quantity of brandy or diluted alcohol may be introduced by repeated injections beneath the skin. Iced champagne may be tried with good effect. H. C. Wood quotes Hall[18] as recommending hypodermic injections of chloral in the cold stage of cholera. Five to eight grains in twenty minims of distilled water can be thus given, and repeated at intervals of fifteen to twenty minutes until some effect is perceived.

[Footnote 18: Lancet, May 2, 1874.]

If vomiting persists after the other symptoms--pain and muscular spasms--are relieved, it is due to the intense gastric hyperæmia; giving nothing which is not necessary is the wiser plan. Carbolic acid, hydrocyanic acid, bismuth, bromide of sodium, or small doses of calomel are remedies which meet the indication. Food should be withheld as long as possible; then iced barley-water, followed by milk and lime-water in very small quantities at short intervals, will test the power of the stomach to retain and digest food.

{726}

INTESTINAL AFFECTIONS OF CHILDREN IN HOT WEATHER.

BY J. LEWIS SMITH, M.D.

Entero-Colitis.

The summer affections of the intestines in children are chiefly of a diarrhoeal character. Diarrhoeal attacks, as is well known, are much more frequent and severe in the summer months than in other portions of the year. Moreover, the diarrhoea of the summer season occurs chiefly among children under the age of two and a half years, and is much more common and fatal in the cities than in the country. In the large cities this malady has heretofore been the annually-recurring scourge of infancy, but of late years its prevalence has been in some degree diminished and its severity controlled by the establishment of health boards and the enforcement of sanitary regulations. Still, it remains an important disease in all our cities, and one that largely increases the aggregate mortality. The truth of this statement is shown by the statistics of deaths taken at random from the mortuary records of any large city. Thus, in New York City during 1882 the deaths from diarrhoea reported to the Health Board, tabulated in months, were as follows:

Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. Under five 34 32 50 50 72 231 1533 817 362 195 68 35 years. Over five 14 15 14 20 15 19 131 149 84 55 31 24 years.

Therefore, in 1882--and the statistics of other years correspond in this particular--it is seen that nine times as many deaths of children under the age of five years occurred from diarrhoea during the five months from June 1st to October 31st as in the remaining seven months of the year. It is also seen, in corroboration of the statement that diarrhoea due to hot weather is chiefly a disease of infancy and early childhood, that during these same five months, which embrace the summer season, the number of deaths from diarrhoea under the age of five years was seven and a half times greater than the number over that age. These statistics agree with the general experience of physicians in city practice. The summer diarrhoea would indeed be comparatively unimportant were its death-rate as low in the first five years of life as subsequently.

The following statistics show how great a destruction of life this malady causes even under the surveillance of an energetic health board; and before this board was established it was much greater, as I had abundant opportunities to observe. The last annual report of the New York Board of Health was made in 1875, since which time weekly bulletins have been {727} issued. The deaths from diarrhoea at all ages in the three last years in which annual reports were issued were as follows:

1873. 1874. 1875. January 94 43 46 February 84 34 52 March 97 40 58 April 114 47 45 May 95 61 89 June 220 144 157 July 1514 1205 1387 August 967 1007 1012 September 424 587 608 October 213 255 185 November 87 105 57 December 53 56 50

Thus, in these three years the aggregate deaths from diarrhoea during the months from June to October inclusive, in which months the summer diarrhoea prevails, were 9885, while in the remaining seven months the number was only 1407. How large a proportion of these deaths in the warm season occurred in children we may infer from remarks made by the Health Board in regard to another year. In their annual report for 1870 the board state: "The mortality from the diarrhoeal affections amounted to 2789, or 33 per cent. of the total deaths; and of these deaths 95 per cent. occurred in children less than five years old, 92 per cent. in children less than two years old, and 67 per cent. in those less than a year old." Every year the reports of the Health Board furnish similar statistics, but enough have been given to show how great a sacrifice of life the summer complaint produces annually in this city.

What we observe in New York in reference to this disease is true also, to a greater or less extent, in other cities of this country and Europe, so far as we have reports. Not in every city is there the same proportionate mortality from this cause as in New York, but the frequency of the summer diarrhoea and the mortality which attends it render it an important disease in, I believe, most cities of both continents. In country towns, whether in villages or farm-houses, this disease is comparatively unimportant, inasmuch as few cases occur in them, and the few that do occur are of mild type, and consequently much less fatal than in the cities.

The comparative immunity of the rural districts has an important relation, as we will see, to the hygienic management of these cases.

ETIOLOGY.--In the causation of this disease two distinct factors are recognized--the one atmospheric, the other dietetic.

The prevalence and severity of the summer diarrhoea correspond closely with the degree of atmospheric heat, as may be inferred from the foregoing statistics. In New York this disease begins in the month of May--earlier in some years than in others--in a few scattered cases, commonly of a mild type. Cases become more and more numerous and severe as the weather grows warmer until July and August, when the diarrhoea attains its maximum prevalence and severity. In these two months it is by far the most frequent and fatal of all the diseases in cities. In the middle of September new patients begin to be less common, and in the latter part of this month and subsequently new cases do not occur, unless under unusual circumstances which favor the development of this malady. In New York a considerable number of deaths {728} of infants occur from the diarrhoea in October. October is not a hot month in our latitude--its average temperature is lower than that of May--and yet the mortality from this disease is considerably larger in the former than in the latter month. This fact, which seems to show that the prevalence of the summer diarrhoea does not correspond with the degree of atmospheric heat, is readily explained. The mortality in October, and indeed in the latter part of September, is not that of new cases, but is mainly of infants, as I have observed every year, who contract the disease in July or August or earlier, and linger in a state of emaciation and increasing weakness till they finally succumb, some even in cool weather.

The fact is therefore undisputed, and is universally admitted, that the summer season, stated in a general way, is the cause of this annually-recurring diarrhoeal epidemic, but it is not so easy to determine what are the exact causative conditions or agents which the summer weather brings into activity. That atmospheric heat does not in itself cause the diarrhoea is evident from the fact that in the rural districts there is the same intensity of heat as in the cities, and yet the summer complaint does not occur. The cause must be looked for in that state of the atmosphere engendered by heat where unsanitary conditions exist, as in large cities. Moreover, observations show that the noxious effluvia with which the air becomes polluted under such circumstances constitute or contain the morbific agent. Thus, in one of the institutions of this city a few years since, on May 10, which happened to be an unusually warm day for this month, an offensive odor was noticed in the wards, which was traced to a large manure-heap that was being upturned in an adjacent garden. On this day four young children were severely attacked by diarrhoea, and one died. Many other examples might be cited showing how the foul air of the city during the hot months, when animal and vegetable decomposition is most active, causes diarrhoea. Several years since, while serving as sanitary inspector for the Citizens' Association in one of the city districts, my attention was particularly called to one of the streets, in which a house-to-house visitation disclosed the fact that nearly every infant between two avenues had the diarrhoea, and usually in a severe form, not a few dying. This street was compactly built with wooden tenement-houses on each side, and contained a dense population, mainly foreign, poor, ignorant, and filthy in their habits. It had no sewer, and the refuse of the kitchens and bed-chambers was thrown into the street, where it accumulated in heaps. Water trickled down over the sidewalks from the houses into the gutters or was thrown out as slops, so that it kept up a constant moisture of the refuse matter which covered the street, and promoted the decay of the animal and vegetable substances which it contained. The air in the domicils and street under such conditions of impurity was necessarily foul in the extreme, and stifling during the hot days and nights of July and August; and it was evidently the important factor in producing the numerous and severe diarrhoeal cases which were in these domicils.

In another locality, occupied by tripe-dealers and a low class of butchers who carried on fat- and bone-boiling at night, the air was so foul after dark that the peculiar impurity which tainted it could be distinctly noticed in the mouth for a considerable time after a night visit. In the street where {729} these nuisances existed and in adjacent streets the summer diarrhoea was very prevalent and destructive to human life. Murchison states that twenty out of twenty-five boys were affected with purging and vomiting from inhaling the effluvia from the contents of an old drain near their school-room. Physicians are familiar with a similar fact showing this purgative effect of impure air--that the atmosphere of a dissecting-room often causes diarrhoea in those otherwise healthy.

The exact nature of the deleterious agent or agents in foul air which cause the diarrhoea, whether they be gases or organisms, has not been fully determined; but at a recent meeting of the Berliner Med. Gesellschaft, A. Baginsky made a report on the bacilli of cholera infantum, which he states he has found both in the dejections and in the intestinal mucous membrane in the bodies of those who have perished with this disease. In the stools, along with numerous other organisms, Baginsky states that he found masses of zoögloea, and the same organisms he detected on the surface of the small intestines, and could trace their wanderings as far as the submucous tissue.[1] But it is evidently very difficult to determine whether such organisms sustain a causative relation to diarrhoea or spring into existence in consequence of the foul secretions and decomposing fecal matters which are present.

[Footnote 1: Allegem. Wien. Mediz. Zeitung, Nov. 6, 1883.]

The impurities in the air of a large city are very numerous. Among those of a gaseous nature are sulphurous acid, sulphuric acid, sulphuretted hydrogen; various gases of the carbon group, as carbonic acid, carburetted hydrogen, and carbonic oxide; gases of the nitrogen group, as the acetate, sulphide, and carbonate of ammonium, nitrous and nitric acids; and at times compounds of phosphorus and chlorine (Parkes). A theory deserving consideration is that certain gaseous impurities found in the air form purgative combinations. D. F. Lincoln, in his interesting paper on the atmosphere in the Cyclopædia of Medicine, writes in regard to sulphuretted hydrogen: "When in the air, freely exposed to the contact of oxygen, it becomes sulphuric acid. Sulphide of ammonium in the same circumstances becomes a sulphate, which, encountering common salt (chloride of sodium), produces sulphate of sodium and chloride of ammonium. The sulphates form a characteristic ingredient of the air in manufacturing districts." The sulphates, we know, are for the most part purgatives, but whether they or other chemical agents exist in the respired air in sufficient quantity to disturb the action of the intestines, even where atmospheric impurities are most abundant, is problematical and uncertain.

Again, the solid impurities in the air of a large city are very numerous, as any one may observe by viewing a sunbeam in a darkened room, which is made visible by the numerous particles floating in it. These particles consist largely of organic matter, which sometimes has been carried a long distance by the wind. The remarkable statement has been made that in the air of Berlin organic forms have been found of African production. Ehrenberg discovered fragments of insects of various kinds--rhizopods, tardigrades, polygastrica, etc.--which, existing in considerable quantity and inhaled in hot weather, when decomposition and fermentation are most active, may be deleterious to the system. Monads, bacteria, vibriones, amorphous dust containing spores which {730} retain their vitality for months, are among the substances found in the air of cities. The well-known hazy appearance of the atmosphere resting over a large city like New York when viewed from a distance is due to the gaseous and solid impurities with which the air is so abundantly supplied--impurities which assume importance in pathological studies, since minute organisms are now believed to cause so many diseases the etiology of which has heretofore been obscure. With our present knowledge we must be content with the general statement that impure air is one of the two important factors which cause summer diarrhoea, without being able to state positively which of the elements in the air are most instrumental in causing this result. But the theory is plausible that minute organisms rather than chemical products are the chief cause. Henoch of Berlin, writing upon this subject, calls attention to the disease known as intestinal mycosis, its prominent symptom being a severe diarrhoea produced by eating diseased meat containing a fungus. He believes that "a portion of the fungus not destroyed by the gastric juice settles upon different parts of the intestine, and there produces its effects;" and he adds, "At present, however, we can regard the mykotic theory of cholera infantum only as a very probable hypothesis. There is no doubt that high atmospheric temperature increases the tendency to fermentation dyspepsias which is present in imperfectly-nourished children at all seasons, and causes them to appear not only epidemically, but also in an extremely acute form which is not frequent under ordinary circumstances. This would lead to the conclusion that, in addition to the heat, infectious germs are present, which, being developed in great masses by the former, enter the stomach with the food." The fungus theory of the causative relation of atmospheric heat to the diarrhoea of the summer season as thus explained by Henoch commands the readier assent since it comports with the well-known facts relating to the etiology of the summer complaint. This disease, as we have seen, is most prevalent and fatal under precisely those conditions of dense population, filthy domicils and streets, and atmospheric heat which are favorable for the development of low organisms.

In those portions of our cities which are occupied by the poor, more than anywhere else, those conditions prevail which render the atmosphere deleterious. One accustomed to the pure air of the country would scarcely believe how stifling and poisonous the atmosphere becomes during the hot summer days and close summer nights in and around the domicils in the poor quarters of the city. Among the causes of this foul air may be mentioned too dense a population, the occupancy of small rooms by large families, rigid economy and ceaseless endeavor to make ends meet, so that in the absorbing interest sanitary requirements are sadly neglected. Adults of such families, and children of both sexes as soon as they are old enough, engage in laborious and often filthy occupations. Many of them seldom bathe, and they often wear for days the same undergarments, foul with perspiration and dirt. The intemperate, vicious, and indolent, who always abound in the quarters of the city poor, are notoriously filthy in their habits and add to the insalubrity by their presence. Children old enough to be in the streets and adults away at their occupations escape to a great extent the evil effects of impure air, but the infantile population always suffer severely.

Every physician who has witnessed the summer diarrhoea of infants is {731} aware of the fact that the mode of feeding has much to do with its occurrence. A large proportion of those who each summer fall victims to it would doubtless escape if the feeding were exactly proper. In New York City facts like the following are of common occurrence in the practice of all physicians: Infants under the age of eight months, if bottle-fed, nearly always contract diarrhoea, and usually of an obstinate character, during the summer months. The younger the infant, the less able is it to digest any other food than breast-milk, and the more liable is it therefore to suffer from diarrhoea if bottle-fed. In the institutions nearly every bottle-fed infant under the age of four or even six months dies in the hot months with symptoms of indigestion and intestinal catarrh, while the wet-nursed of the same ages remain well. Sudden weaning, the sudden substitution of cow's milk or any artificially-prepared food in place of breast-milk in hot weather, almost always produces diarrhoea, often of a severe and fatal nature. Feeding an infant in the hot months with indigestible and improper food, as fruits with seeds or the ordinary table-food prepared in such a way that it overtaxes the digestive function of the infant, causes diarrhoea, and not infrequently that severe form of it which will be described under the term cholera infantum. Many obstinate cases of the summer complaint begin to improve under change of diet, as by the substitution of one kind of milk for another or the return of the infant to the breast after it has been temporarily withdrawn from it. It is a common remark in the families of the city poor that the second summer is the period of greatest danger to infants. This increased liability of infants to contract diarrhoea in the second summer is due to the fact that most infants in their second year are table-fed, while in the first year they are wet-nursed. Such facts, with which all physicians are familiar, show how important the diet is as a factor in causing the summer complaint.

Occasionally, from continued ill-health, the milk of the mother or wet-nurse does not agree with the nursling. Examined with the microscope, it is found to contain colostrum. Under such circumstances if a healthy wet-nurse be employed the diarrhoea ceases. It is very important that any woman furnishing breast-milk to an infant should lead a quiet and regular life, with regular meals and sleep. In the Louisville Med. Journal, Aug. 19, 1882, R. B. Gilbert relates striking cases in which venereal excesses on the part of wet-nurses were immediately followed by fatal diarrhoea in the infants which they suckled.

One not a resident would scarcely be able to appreciate the difficulty which is experienced in a large city in obtaining proper diet for young children, especially those of such an age that they require milk as the basis of their food. Milk from cows stabled in the city or having a limited pasturage near the city, and fed upon a mixture of hay with garden and distillery products, the latter often largely predominating, is unsuitable. It is deficient in nutritive properties, prone to fermentation, and from microscopical and chemical examinations which have been made it appears that it often contains deleterious ingredients. If milk be obtained from distant farms where pasturage is fresh and abundant--and in New York City this is the usual source of the supply--considerable time elapses before it is served to customers, so that, particularly in the hot months of July and August, it frequently has begun to undergo {732} lactic-acid fermentation when the infants receive it. That dispensed to families in the morning is the milking of the previous morning and evening. The common result of the use of this milk in midsummer by infants under the age of ten months is more or less diarrhoea.

The ill-success of feeding with cow's milk has led to the preparation of various kinds of food which the shops contain, but no dietetic preparation has yet appeared which agrees so well with the digestive function of the infant as breast-milk, and is at the same time sufficiently nutritive.

In New York City improper diet, unaided by the conditions which hot weather produces, is a common cause of diarrhoea in young infants, for we meet with this diarrhoea in infants who are bottle-fed at all seasons; but when the atmospheric conditions of hot weather and the use of food unsuitable for the age of the infant are both present and operative, this diarrhoea so increases in frequency and severity that it is proper to designate it the summer epidemic of the cities. Several years since, before the New York Foundling Asylum was established, the foundlings of New York, more than a thousand annually, were taken to the almshouse on Blackwell's Island and consigned to the care of the pauper-women, who were mostly old, infirm, and filthy in their habits and apparel. Their beds, in which the foundlings were also placed alongside of them, were seldom clean, not properly aired and washed, and under the beds were various garments and utensils which these pauper-women had brought with them as their sole property from their miserable abodes in the city. With such surroundings, the air which these infants breathed day and night manifestly contained poisonous emanations; while their diet was equally improper, for it was prepared by these women from such milk and farinaceous food as were furnished the almshouse. When assigned to duty in the almshouse, this service being at that time a branch of Charity Hospital, I was informed that all the foundlings died before the age of two months; one only was pointed out as a curiosity which had been an exception to the rule. The disease of which they perished was diarrhoea, and this malady in the summer months was especially severe and rapidly fatal. The unpleasant experiences in this institution furnished additional evidence, were any wanting, that foul air and improper diet are the two important factors in causing the summer diarrhoea of infants. Since that beneficial charity, the New York Foundling Asylum, in East Sixty-eighth street, came into existence, providing pure air and, for a considerable proportion of the foundlings, breast-milk, many of these waifs have been rescued from death.

I have already stated that this disease occurs, with an occasional exception, under the age of two and a half years. The following table embraces all the cases that came to one of the city dispensaries during my service between the months of May and October, inclusive:

Age. Cases. 5 months or under 58 5 months to 12 months 212 12 months to 18 months 174 18 months to 24 months 93 24 months to 36 months 36 --- Total 573

After the third year the liability to the summer complaint so rapidly {733} diminishes that comparatively few are affected by it. It is seen from the above statistics that by far the largest number of cases occur during the period of first dentition; hence the prevalent opinion among families that dentition causes the diarrhoea. It is the common belief among the poor of New York that diarrhoea occurring during dentition is conservative, and should not be checked. They believe that an infant cutting its teeth suffers less, and may be saved from serious illness, if it have frequent stools. Every summer I see infants reduced to a state of imminent danger through the continuance of diarrhoea during several weeks, nothing having been done to check it in consequence of this absurd belief. The progressive loss of flesh and strength and wasting of the features do not excite alarm, under the blinding influence of this theory, till the diarrhoea has continued so long and become so severe that it is with difficulty controlled, and the patient is in a state of real danger when the physician is first summoned. The following statistics, which comprise cases occurring during my service in one of the city dispensaries, show the preponderance of cases during the age when dental evolution is occurring:

Cases. No teeth and no marked turgescence of gums 47 Cutting incisors 106 " anterior molars 41 " canines 40 " last molars 20 All the teeth cut 28 --- Total 282

It so happens that the period of dental evolution corresponds with that of the most rapid development and the greatest functional activity of the gastric and intestinal follicles, and the predisposition which exists to diarrhoeal maladies at this age must be attributed to this cause rather than to dentition.

SYMPTOMS.--The summer diarrhoea of infants commonly begins gradually with languor, fretfulness, and slight febrile movement. The diarrhoea at first usually attracts little attention from its mildness. The stools, while they are thinner than natural, vary in appearance, being yellow, brown, or green. Infants with milk diet are apt to pass green and acid stools containing particles of undigested casein. The tongue in the commencement of the attack is moist and covered with a slight fur. At a more advanced stage it may be moist, but is often dry, and in dangerous forms of the malady, accompanied by prostration, the buccal surface is red and the gums more or less swollen and sometimes ulcerated. Vomiting is common. It may commence simultaneously with the diarrhoea, especially when food that is unusually indigestible and irritating to the stomach has been given, but more frequently this symptom does not appear until the diarrhoea has continued a few days. I preserved memoranda of the date when vomiting began in the cases treated in two consecutive summers, and found that ordinarily it was toward the close of the first week. When it is an early and prominent symptom it appears to be due to the presence in the stomach of imperfectly digested or fermented and acid food, which, when ejected, gives a decidedly acid reaction with appropriate tests. It contains coagulated casein and undigested particles of whatever food has been given. In many patients the progressive loss of flesh and {734} strength is largely due to the indigestion and vomiting by which the food, which is so much required for proper nourishment, is lost.

Emesis occurring at a late stage of the summer complaint is often due to commencing spurious hydrocephalus, which is not an infrequent complication, as we will see, of protracted cases. Perhaps when a late symptom it may sometimes have an uræmic origin, for the urine is usually quite scanty in advanced cases. It seems probable, however, that deleterious effects from non-elimination of urea are to a considerable extent prevented by the diarrhoea.

The fecal evacuations may remain nearly uniform in appearance during the disease, but in many patients they vary in color and consistence at different periods. In the same case they may be brown and offensive at one time, green at another, and again they may contain masses of a putty-like appearance, the partly-digested casein or altered epithelial cells. The stools sometimes consist largely of mucus, with or without occasional streaks of blood, indicating the predominance of inflammation in the colon. This is the mucous diarrhoea of Barrier. The stools are sometimes yellow when passed, but become green on exposure to the air from chemical reaction due to admixture with the urine.

The character of the alvine discharges is interesting. In addition to undigested casein I have found epithelial cells, single or in clusters (sometimes regularly arranged as if detached in mass from the villi), fibres of meat, crystalline formations, mucus, and occasionally blood, as stated above. In one instance I observed an appearance resembling three or four crypts of Lieberkühn united, probably thrown off by ulceration. If the stools are green, colored masses of various sizes, but mostly small, are also seen under the microscope.

The pulse is accelerated according to the severity of the attack. The heat of the surface is at first apt to be increased, though but slightly in ordinary cases; but when the vital powers begin to fail from the continuance of the diarrhoea the warmth of the surface diminishes. In advanced cases approaching a fatal termination the face and extremities are pallid and cool, and the pulse gradually becomes more frequent and feeble. The skin is usually dry, and, as already stated, the urinary secretion diminished. In severe cases attended by frequent alvine discharges the infant does not pass urine oftener than once or twice daily. The imperfect action of the skin and kidneys is noteworthy.

Protracted cases of the summer complaint are apt to be complicated by two cutaneous eruptions--erythema extending over the perineum and frequently as far as the thighs and lower part of the abdomen, due to the acid and irritating character of the stools; and boils upon the forehead and scalp. The latter sometimes extend to the pericranium, and in case of recovery leave permanent cicatrices. This furuncular affection of the scalp has seemed to me useful in consequence of the external irritation which it causes, since it occurs at a time when, on account of the feeble heart's action and languid circulation, passive congestion of the vessels of the brain and meninges is liable to be present.

Patients who are weak and wasted in consequence of protracted diarrhoea, remaining almost constantly in the recumbent position, often have an occasional dry cough which continues till the close of life. It is due to hypostatic congestion in the lungs, usually limited to the posterior and {735} inferior portions of the lobes, extending but a little way into the lungs. It is the result of prolonged recumbency with feeble heart's action and feeble pulmonary circulation. Infants reduced by chronic diseases, lying day after day in their cribs with little movement of their bodies, are very liable to this passive congestion of depending portions of their lungs, toward which the blood gravitates, and into which but little air enters in consequence of their distance and position and the feeble respirations. The hyperæmia which results is of a passive character, a venous congestion, and the affected lobules have a dusky-red color. This congestion, continuing, soon results in pneumonitis of the catarrhal form, subacute and of a low grade, for pulmonary lobules in which the blood remains stagnant soon exhibit augmented cell-proliferation, perhaps from the irritating effects of the elements of the blood now withdrawn from the circulation.

I have made or procured a considerable number of microscopic examinations in these cases of hypostatic pneumonia, and the solidification of the pulmonary lobules has been found to be due to the exaggerated development of the epithelial cells in the alveoli, together with venous congestion. The affected lobules, whether in the stage of hypostatic congestion or the more advanced stage of hypostatic pneumonitis, when examined at the autopsy, were somewhat softer than in health, of dark color, and many of the lobules could be inflated by strong force of the breath; but in protracted cases the alveoli in central parts of the inflamed area resisted insufflation. The lung in hypostatic pneumonia, even when it is inflated, still feels firmer between the fingers than normal lung.

Hypostatic pneumonia is so common in hospitals for infants that some physicians whose observations have been chiefly in such institutions have almost ignored other forms of pulmonary inflammation. Billard, many years ago, wrote: "... The pneumonia of young children is evidently the result of stagnation of blood in their lungs. Under these circumstances the blood may be regarded as a kind of foreign body." Of all the chronic and exhausting diseases of infancy, no one has, according to my observations, been so frequently complicated by hypostatic pneumonia as the disease which we are considering, although it does not usually give rise to any more prominent symptom than an occasional cough. Limited to a small and almost immovable part of the lung, it does not ordinarily accelerate respiration or render it painful, and the cough is also apparently painless.

When progressive loss of flesh and strength has continued several weeks, and the patient is much exhausted, another complication is apt to occur, known as spurious hydrocephalus or the hydrocephaloid disease, the anatomical characters of which will be described in the proper place. The commencement of spurious hydrocephalus is announced by gradually increasing drowsiness, perhaps preceded by a period of unusual fretfulness. Vomiting and rolling the head are occasional early symptoms of this complication. As the drowsiness increases the pupils become less sensitive to light than in their normal state, and are usually contracted. When the drowsiness becomes profound and constant, the pupils remain contracted as in sound sleep or in opium narcotism. The functional activity of the organs is now also diminished, the vomiting ceases, the stools become less frequent, the buccal surface dry, and the urine more {736} scanty, while the pulse is more frequent and feeble. Spurious hydrocephalus either continues till death, or by stimulation the patient may emerge from it. When profound the usual result is death.

Although the summer complaint in its commencement may be promptly arrested by proper hygienic and medicinal treatment, if it continue a few weeks the anatomical changes which occur are such that recovery, if it take place, is necessarily slow and gradual. Improvement is shown by better digestion, fewer stools and of better appearance, less frequent vomiting, a more cheerful countenance, and the absence of symptoms which indicate a complication. Many recover after days of anxious watching and perhaps after many fluctuations.

Death may occur early from a sudden aggravation of symptoms and rapid sinking, or the attack may be so violent from the first that the infant quickly succumbs; but more frequently death takes place after a prolonged sickness. Little by little the patient loses flesh and strength, till a state of marked emaciation is reached. The eyes and cheeks are sunken, the bony projections of the face, trunk, and limbs become prominent, and the skin lies in wrinkles from the wasting. The altered expression of the face makes the patient look older than the actual age. The joints in contrast with the wasted extremities seem enlarged and the fingers and toes elongated. The stools diminish in frequency from diminished peristaltic and vermicular action, and vomiting, if previously present, now ceases. A feeble, quick, and scarcely appreciable pulse, slow respiration, and diminished inflation of the lungs, sightless and contracted pupils, over which the eyelids no longer close, announce the near approach of death. The drowsiness increases and the limbs become cool, while perhaps the head is hot. The infant no longer has the ability to nurse, or if bottle-fed the food placed in the mouth flows back or is swallowed with apparent indifference. So low is its vitality that it lies pallid and almost motionless for hours or even days before death, and death occurs so quietly that the moment of its occurrence is scarcely appreciable.

ANATOMICAL CHARACTERS.--Since the prominent and essential symptoms of the disease which we are considering pertain to the digestive apparatus, it is evident that the lesions which attend and characterize it are to be found in this part of the system. Lesions elsewhere, so far as they are appreciable to us, are secondary and not essential. I have witnessed a large number of autopsies of infants who have perished from the summer complaint, chiefly in institutions, and they have been sufficiently marked and uniform to enable us to designate it an entero-colitis. Several years since I preserved records of the autopsical appearances in the intestinal catarrh of infants, most of the cases being of summer diarrhoea. The number aggregated eighty-two. Since then I have each summer witnessed autopsies in the institutions in cases of this disease, and the lesions observed were the same as in the eighty-two cases.

The question may properly be asked: Can inflammatory hyperæmia of the intestinal mucous membrane be distinguished from simple congestion if there be no ulceration and no appreciable thickening of the intestine? It is possible that occasionally I have recorded as inflammatory what was simply a congestive lesion, but I do not think I have incorporated a {737} sufficient number of such cases to vitiate the statistics. In a large proportion of the cases there was evident thickening of the intestinal mucous membrane or other unequivocal evidence of inflammation. The following is an analysis of the eighty-two cases:

The duodenum and jejunum presented the appearance of inflammatory hyperæmia in 12 cases. The hyperæmia was usually in patches of variable extent or of that form described by the term arborescent. In 51 cases the duodenal and jejunal mucous membrane was pale and without any other appearance characteristic of catarrh or inflammation. In the remaining 19 cases the appearance of the duodenum and jejunum was not recorded, so that it was probably normal. On the other hand, in the ileum inflammatory lesions were present as a rule. In 49 cases I found the surface of the ileum distinctly hyperæmic, and in that portion of it nearest the ileo-cæcal valve, including the valve itself, the inflammation had evidently been the most intense, since in this portion the hyperæmia and thickening of the mucous membrane were most marked. In 16 cases the surface of the ileum appeared nearly or quite normal; in 14 hyperæmia in the small intestines in patches, streaks, or arborescence was recorded, but the records do not state in which division of the intestines they were observed.

Billard, with other observers, has noticed the frequency and intensity of the inflammatory lesions in entero-colitis in the terminal portion of the small intestines, and the thickening in many cases of the ileo-cæcal valve, and he asks whether the vomiting which is so common and often obstinate in this disease may not be sometimes due to obstruction to the passage of fecal matter at the valve in consequence of the hyperæmia and swelling, but has not observed any retained fecal matter above it, such as we find in any part of the colon, or any other appearance which indicated sufficient obstruction to cause symptoms. Still, it seems not improbable that the reason why the inflammatory lesions are more pronounced at and immediately above the valve than in other parts of the small intestine is that the fecal matter, so commonly acid and irritating in this disease, is somewhat delayed in its passage downward at this point.

Small superficial circular or oval ulcers were observed in the ileum in 4 cases, in 2 of which they were found also in the lower part of the jejunum. In 1 case the records state that ulcers were in the jejunum, but do not mention whether they were also in the ileum. In 1 case, in which there was much thickening of the ileum next to the ileo-cæcal valve, many small granulations had sprouted up from the submucous connective tissue, so that the mucous surface appeared as if studded with small warts.

Softening of the mucous membrane was also apparent in certain cases. The firmness of its attachment to the parts underneath varied considerably in different specimens. I was able in cases in which there was considerable softening to detach readily the mucous membrane with the nail or handle of the scalpel within so short a period after death that it was probable that the change of consistence was not cadaveric. In some cases the vessels of the submucous tissue were injected and this tissue infiltrated.

In all the cases except one lesions were present indicating inflammation {738} of the mucous membrane of the colon. In 39 hyperæmia, thickening, and other signs of inflammation extended over nearly or quite the entire colon; in 14 the colitis was confined to the descending portion entirely or almost entirely; in 28 cases the records state that inflammatory lesions were found in the colon, but their exact location is not mentioned. In 18 of the autopsies the mucous membrane of the colon was found ulcerated.

Therefore, according to these statistics--and autopsies which I have witnessed that are not embraced in them disclosed similar lesions--colitis is present, almost without exception, in cases of summer diarrhoea, associated with more or less ileitis. The portion of the colon which presents the most marked inflammatory lesions is that in and immediately above the sigmoid flexure--that portion, therefore, in which any fermenting fecal matter has reached its greatest degree of fermentation, and consequently contains the most irritating elements, and where, next to the caput coli, it is longest delayed in its passage downward.

The solitary glands of both the large and small intestines and Peyer's patches undergo hyperplasia. In cases of short duration, and in parts of the intestine where the inflammatory action has been mild, the solitary glands present a vascular appearance, like the surrounding membrane, and are slightly enlarged. The enlargement is most apparent if the intestine be viewed by transmitted light, when not only are the glands seen to be swollen, but their central dark points are distinct. If a higher grade of intestinal catarrh or a catarrh more protracted have occurred, the volume of these follicles is so increased that they rise above the common level and present a papillary appearance. Peyer's patches are also distinct and punctate. The enlargement of Peyer's patches, like that of the solitary glands, is due to hyperplasia, the elementary cells being largely increased in number.

The small ulcers which, as we have seen from the above statistics, are present in a certain proportion of cases in the mucous membrane of the colon, and more rarely in that of the small intestine when the inflammation has been protracted and of a severe type, appear to occur in the solitary glands and in the mucous membrane surrounding them. While some of these glands in a specimen are simply tumefied, others are slightly ulcerated, and others still nearly or quite destroyed. The ulcers are usually from one to three lines in diameter, circular or oval, with edges slightly raised from infiltration. Rarely, I have seen minute coagula of blood in one or more ulcers, and I have also observed ulcers which have evidently been larger and have partially healed. The ulcers are more frequently found in the descending colon than in other portions of the intestines. When ulcers are present they commonly occur in the descending colon, or if occurring elsewhere they are most abundant in this situation.

According to my observations, these ulcers are found chiefly in infants over the age of six months--during the time, therefore, when there is greatest functional activity and most rapid development of the solitary glands. Peyer's patches, though frequently prominent and distinct, have not been ulcerated in any of the cases observed by me.

The appendix vermiformis participates in the catarrh when it occurs in the caput coli, its mucous membrane being hyperæmic and thickened. In {739} certain rare cases the inflammation is so intense that a thin film of fibrin is exuded in places upon the surface of the colon. It is apt to be overlooked or to be washed away in the examination. The rectum usually presents no inflammatory lesions, or but slight lesions in comparison with those in the colon. It usually remains of the normal pale color, or but slightly vascular even when there is almost general colitis. Hence the infrequency of tenesmus.

As might be expected from the nature of the disease, the secretion of mucus from the intestinal surface is augmented. It is often seen forming a layer upon the intestinal surface, and it appears in the stools mixed with epithelial cells and sometimes with blood and pus.

The mesenteric glands in cases which have run the most protracted course and end fatally are found more or less enlarged from hyperplasia. They are frequently as large as a pea or larger, and of a light color, the color being due not only to the hyperplasia, but in part to the anæmia. Occasionally, when patients have been much reduced from the long continuance of the diarrhoea, and are in a state of marked cachexia at death, we find certain of these glands caseous.

The condition of the stomach is interesting, since indigestion and vomiting are so commonly present. I have records of its appearance in 59 cases, in 42 of which it seemed normal, having the usual pale color and exhibiting only such changes as occur in the cadaver. In the remaining 17 cases the stomach was more or less hyperæmic, and in 3 of them points of ulceration were observed in the mucous membrane.

All physicians familiar with this disease have remarked the frequency of stomatitis. In protracted and grave cases it is a common complication. The buccal surface in these cases is more vascular than natural, and if the vital powers are much reduced superficial ulcerations are not infrequent, oftener upon the gums than elsewhere. The gums are apt to be spongy, more or less swollen, bleeding readily when rubbed or pressed upon. Thrush is a common complication of the summer complaint in infants under the age of three or four months, but is infrequent in older infants. Occurring in those over the age of six or eight months, it has an unfavorable prognostic significance, indicating a form of summer diarrhoea which commonly eventuates in death.

The belief has long been prevalent in the past that the liver is also in fault. The green color of the stools was supposed to be due to vitiated bile. But usually in the post-mortem examinations which I have made I have found that the green coloration of the fecal matter did not appear at the point where the bile enters the intestines, but at some point below the ductus communis choledochus in the jejunum or ileum. The green tinge, at first slight, becomes more and more distinct on tracing it downward in the intestine. It appears to be due to admixture of the intestinal secretions with the fecal matter.

I have notes of the appearance and state of the liver in 32 fatal cases. Nothing could be seen in these examinations which indicated any anatomical change in this organ that could be attributed to the diarrhoeal malady. The size and weight of the liver varied considerably in infants of the same age, but probably there was no greater difference than usually obtains among glandular organs in a state of health. The following was the weight of this organ in 20 cases: {740}

Age. Weight. | Age. Weight. 4 weeks 5 ounces. | 10 months 6¾ ounces. 2 months 3½ " | 13 " 6 " 2 " 3½ " | 14 " 9 " 4 " 5 " | 15 " 6 " 5 " 6½ " | 15 " 7½ " 5 " 9 " | 15 " 9½ " 7 " 4½ " | 16 " 6 " 7 " 6 " | 19 " 4½ " 7 " 6¼ " | 20 " 9¼ " 9 " 8 " | 23 " 15 "

In none of these cases did the size, weight, or appearance of this organ seem to be different from that in health or in other diseases, except in one in which fatty degeneration had occurred, but this was probably due to tuberculosis, which was also present. In most of these cases the liver was examined microscopically, and the only noteworthy appearance observed was the variable amount of oil-globules in the hepatic cells. In some specimens the oil-globules were in excess, in others deficient, and in others still they were more abundant in one part of the organ than in another. Little importance was attached to these differences in the quantity of oily matter.

Hypostatic congestion of the posterior portions of the lungs, ending if it continue in a form of subacute catarrhal pneumonia and giving rise to an occasional painless cough, has been described in the preceding pages. The character of the cough in connection with the wasting might excite suspicions of the presence of tubercles in the lungs; but tubercles are rare in this disease, and when present I should suspect a strong hereditary predisposition. They occurred in only 1 of the 82 cases.

The state of the encephalon in those patients in whom spurious hydrocephalus occurs is interesting. In protracted cases of the diarrhoea the brain wastes like the body and limbs. In the young infant, in whom the cranial bones are still ununited, the occipital and sometimes the frontal bones become depressed and overlapped by the parietal, the depression being of course proportionate to the diminution in size of the encephalon. The cranium becomes quite uneven. In older children, with the cranial bones consolidated, serous effusion occurs according to the degree of waste, thus preserving the size of the encephalon. The effusion is chiefly external to the brain, lying over the convolutions from the base to the vertex. Its quantity varies from one or two drachms to an ounce or more. Along with this serous effusion, and antedating it, passive congestion of the cerebral veins and sinuses is also present. This congestion is the obvious and necessary result of the feebleness of the heart's action and the loss of brain substance.

DIAGNOSIS.--The occurrence and continuance of diarrhoea in the warm months, without any apparent cause except the agencies which hot weather produces, indicate this disease. The exciting cause of the attack may be the use of some indigestible and irritating substance, dietetic or medicinal, as fruits with their seeds or a purgative medicine; but if it continue after the immediate effects of the agent have passed off, it is proper to attribute the diarrhoea to the summer season.

In the adult abdominal tenderness is an important diagnostic symptom of intestinal catarrh, but in the infant this symptom is lacking or is not in general appreciable, so that it does not aid in diagnosis. When the {741} diagnosis of the disease is established, the symptoms do not usually indicate what part of the intestinal surface is chiefly involved, but it may be assumed that it is the lower part of the ileum and the colon. The presence of mucus or of mucus tinged with blood in the stools shows the predominance of colitis.

PROGNOSIS.--Although this disease every summer largely increases the death-rate of young children, most cases can be cured if the proper hygienic and medicinal measures be early applied. It is obvious, from what has been stated in the foregoing pages, that cholera infantum is the form of this malady which involves greatest danger. Except in such cases there is sufficient forewarning of a fatal result, for if death occur it is after a lingering sickness, with fluctuations and gradual loss of flesh and strength. Patients often recover from a state of great prostration and emaciation, provided that no fatal complications arise. The eyes may be sunken, the skin lie in folds from the wasting, the strength may be so exhausted that any other than the recumbent position is impossible, and yet the patient may recover by removal to the country, by change of weather, or by the use of better diet and remedies. Therefore an absolutely unfavorable prognosis should not be made except in cases that are complicated or that border on collapse. The most dangerous symptoms, except those which indicate commencing or actual collapse, arise from the state of the brain. Rolling the head, squinting, feeble action or permanent contraction of the pupils, spasmodic or irregular movements of the limbs, indicate the near approach of death, as do also coldness of face and extremities and inability to swallow. It is obvious also that in making the prognosis in ordinary cases we should consider the age of the patient, the state of the weather, the time in the summer, whether in the beginning or near its close, and the surroundings, especially in reference to the impurity of the air, as well as the patient's condition.

Cholera Infantum, or Choleriform Diarrhoea.

This is the most severe form of the summer complaint. It receives the name which designates it from the violence of its symptoms, which closely resemble those of Asiatic cholera. It is, however, quite distinct from that disease. It is characterized by frequent stools, vomiting, great elevation of temperature, and rapid and great emaciation and loss of strength. It commonly occurs under the age of two years. It sometimes begins abruptly, the previous health having been good; in other cases it is preceded by the ordinary form of summer diarrhoea. The stools have been thinner than natural and somewhat more frequent, but not such as to excite alarm, when suddenly they become more frequent and watery, and the parents are surprised and frightened by the rapid sinking and real danger of the infant.

The first evacuations, unless there have been previous diarrhoea, may contain fecal matter, but subsequently they are so thin that they soak into the diaper like urine, and in some cases they scarcely produce more of a stain than does this secretion. Their odor is peculiar--not fecal, but musty and offensive, and occasionally almost odorless. Commencing simultaneously with the watery evacuations or soon after is another {742} symptom, irritability of the stomach, which increases greatly the prostration and danger. Whatever drinks are swallowed by the infant are rejected immediately or after a few moments, or retching may occur without vomiting. The appetite is lost and the thirst is intense. Cold water is taken with avidity, and if the infant nurse it eagerly seizes the breast in order to relieve the thirst. The tongue is moist at first, and clean or covered with a light fur, pulse accelerated, respiration either natural or somewhat increased in frequency, and the surface warm, but the temperature is speedily reduced in severe cases. The internal temperature or that of the blood is always very high. In ordinary cases of cholera infantum the thermometer introduced into the rectum rises to or above 105°, and I have seen it indicate 107°. Although the infant may be restless at first, it does not appear to have any abdominal pain or tenderness. The restlessness is apparently due to thirst or to that unpleasant sensation which the sick feel when the vital powers are rapidly reduced. The urine is scanty in proportion to the gravity of the attack, as it ordinarily is when the stools are frequent and watery.

The emaciation and loss of strength are more rapid than in any other disease which I can recall to mind, unless in Asiatic cholera. In a few hours the parents scarcely recognize in the changed and melancholy aspect of the infant any resemblance to the features which it exhibited a day or two before. The eyes are sunken, the eyelids and lips are permanently open from the feeble contractile power of the muscles which close them, while the loss of the fluids from the tissues and the emaciation are such that the bony angles become more prominent and the skin in places lies in folds.

As the disease approaches a fatal termination, which often occurs in two or three days, the infant remains quiet, not disturbed even by the flies which alight upon its face. The limbs and face become cool, the eyes bleared, pupils contracted, and the urine scanty or suppressed. In some instances, when the patient is near death, the respiration becomes accelerated, either from the effect of the disease upon the respiratory centres or from pulmonary congestion resulting from the feeble circulation. As the vital powers fail the pulse becomes progressively more feeble, the surface has a clammy coldness, the contracted pupils no longer respond to light, and the stupor deepens, from which it is impossible to arouse the infant.

In the most favorable cases cholera infantum is checked before the occurrence of these grave symptoms, and often in cases which are ultimately fatal there is not such a speedy termination of the malady as is indicated in the above description. The choleriform diarrhoea abates and the case becomes one of ordinary summer complaint.

ANATOMICAL CHARACTERS.--Rilliet and Barthez, who of foreign writers treat of cholera infantum at greatest length, describe it under the name of gastro-intestinal choleriform catarrh. "The perusal," they remark, "of anatomico-pathological descriptions, and especially the study of the facts, show that the gastro-intestinal tube in subjects who succumb to this disease may be in four different states: (a) either the stomach is softened without any lesion of the digestive tube; (b) or the stomach is softened at the same time that the mucous membrane of the intestine, and especially its follicular apparatus, is diseased; (c) or the stomach is healthy, {743} while the follicular apparatus or the mucous membrane is diseased; (d) or, finally, the gastro-intestinal tube is not the seat of any lesion appreciable to our senses in the present state of our knowledge, or it presents lesions so insignificant that they are not sufficient to explain the gravity of the symptoms.

"So far, the disease resembles all the catarrhs, but what is special is the abundance of serous secretion and the disturbance of the great sympathetic nerve.

"The serous secretion, which appears to be produced by a perspiration (analogous to that of the respiratory passages and of the skin) rather than by a follicular secretion, shows, perhaps, that the elimination of substances is effected by other organs than the follicles; perhaps, also, we ought to see a proof that the materials to eliminate are not the same as in simple catarrh. Upon all these points we are constrained to remain in doubt. We content ourselves with pointing out the fact."[2]

[Footnote 2: Maladies des Enfants.]

On the 1st of August, 1861, I made the autopsy of an infant sixteen months old who died of cholera infantum with a sickness of less than one day. The examination was made thirty hours after death. Nothing unusual was observed in the brain, unless perhaps a little more than the ordinary injection of vessels at the vertex. No marked anatomical change was observed in the stomach and intestines, except enlargement of the patches of Peyer as well as of the solitary and mesenteric glands. Mucous membrane pale. In this and the following cases there was apparently slight softening of the intestinal mucous membrane, but whether it was pathological or cadaveric was uncertain, as the weather was very warm. The liver seemed healthy. Examined by the microscope, it was found to contain about the normal number of oil-globules.

The second case was that of an infant seven months old, wet-nursed, who died July 26, 1862, after a sickness also of about one day. He was previously emaciated, but without any marked ailment. The post-mortem examination was made on the 28th. The brain was somewhat softer than natural, but otherwise healthy. There was no abnormal vascularity of the membranes of the brain, and no serous effusion within the cranium. The mucous membrane of the intestines had nearly the normal color throughout, but it seemed somewhat thickened and softened; the solitary glands of the colon were prominent. The patches of Peyer were not distinct.

In the New York Protestant Episcopal Orphan Asylum an infant twenty months old, previously healthy, was seized with cholera infantum on the 25th of June, 1864. The alvine evacuations, as is usual with this disease, were frequent and watery, and attended by obstinate vomiting. Death occurred in slight spasms in thirty-six hours. The exciting cause was probably the use of a few currants which were eaten in a cake the day before, some of which fruit was contained in the first evacuations. The brain was not examined. The only pathological changes which were observed in the stomach and intestines were slightly vascular patches in the small intestines and an unusual prominence of the solitary glands in the colon. The glands resembled small beads imbedded in the mucous membrane. The lungs in the above cases were healthy, excepting hypostatic congestion.

{744} Since the date of these autopsies I have made others in cases which terminated fatally after a brief duration, and have uniformly found similar lesions--namely, the gastro-intestinal surface either without vascularity or scantily vascular in streaks or patches, sometimes presenting a whitish or soggy appearance and somewhat softened, while the solitary glands were enlarged so as to be prominent upon the surface. In cases which continue longer evident inflammatory lesions soon appear which are identical with those which have already been described in our remarks on the ordinary form of the summer diarrhoea.

During my term of service in the New York Foundling Asylum in the summer of 1884, an infant died after a brief illness with all the symptoms of cholera infantum, and the intestines were sent to William H. Welch, now of Johns Hopkins Hospital, for microscopic examination. His report was as follows: "I found undoubted evidence of acute inflammation. There was an increased number of small, round cells (leucocytes) in the mucous and submucous coats. This accumulation of new cells was most abundant in and around the solitary follicles, which were greatly swollen. Clumps of lymphoid cells were found extending even a little into the muscular coat. The epithelial lining of the intestine was not demonstrable, but this is usually the case with post-mortem specimens of human intestine, and justifies no inferences as to pathological changes. The glands of Lieberkühn were rich in the so-called goblet-cells, and some of the glands were distended with mucus and desquamated epithelium, so as to present sometimes the appearance of little cysts. This was observed especially in the neighborhood of the solitary follicles. The blood-vessels, especially the veins of the submucous coat, were abnormally distended with blood. I searched for micro-organisms, and found them in abundance upon the free surface of the intestine in the mucous accumulations there, and also in the mouths of the glands of Lieberkühn. Both rod-shaped and small round bacteria were found. I attach no especial importance to finding bacteria upon the surface of the intestine. The general result of the examination is to confirm the view that cholera infantum is characterized by an acute intestinal inflammation."

NATURE.--Cholera infantum appears from its symptoms and lesions to be the most severe form of intestinal catarrh to which infants are liable. The alvine discharges, to which the rapid prostration is largely due, probably consist in part of intestinal secretions and in part of serum which has transuded from the capillaries of the intestines. That the intestinal mucous membrane sometimes presents a pale appearance at the autopsy of an infant who, previously well, has died of cholera infantum after a sickness of twenty-four or forty-eight hours, is perhaps due to the great amount of liquid secretion and transudation in which the inflamed surface is bathed. Moreover, it is, I believe, a recognized fact that the hyperæmia of an acutely-inflamed surface when of short duration frequently disappears in the cadaver, as that of scarlet fever and erysipelas. The early hyperplasia of the solitary and mesenteric glands, and the hyperæmia and thickening of the surface of the ileum and colon in those who have survived a few days, indicate the inflammatory character of the malady.

The opinion has been expressed by certain observers that cholera {745} infantum is identical with thermic fever or sunstroke. There is indeed a resemblance to thermic fever as regards certain important symptoms. In cholera infantum the temperature is from 105° to 108°; in sunstroke it is also very high, often running above 108°. Great heat of head, contracted pupils, thin fecal evacuations, embarrassed respiration, scanty urine, and cerebral symptoms are common toward the close of cholera infantum, and they are the prominent symptoms in sunstroke. Nevertheless, I cannot accept the theory which regards these maladies as identical, and which removes cholera infantum from the list of intestinal diseases. In cholera infantum the gastro-intestinal symptoms always take the precedence, and are, except in advanced cases, always more prominent than other symptoms. It does not commence as by a stroke like coup de soleil, but it comes on more gradually, though rapidly, and it often supervenes upon a diarrhoea or some error of diet. In the commencement of cholera infantum the infant is not apt to be drowsy, and it is often wide awake and restless from the thirst. Contrast this with the alarming stupor of sunstroke. Sunstroke only occurs during the hours of excessive heat, but cholera infantum may occur at any hour or in any day during the hot weather, provided that there be sufficient dietetic cause. Again, intestinal inflammation is not common in sunstroke, while it is the common or, as I believe, the essential lesion of cholera infantum. These facts show, in my opinion, that the two maladies are essentially and entirely distinct. Nevertheless, cases of apparent sunstroke sometimes occur in the infant, and if the bowels are at the same time relaxed the disease is apt to be regarded as cholera infantum, and if fatal is usually reported as such to the health authorities. Cases of this kind I have occasionally observed or they have been reported to me, although they are not common.

With the exception of the organs of digestion no uniform lesions are observed in any of the viscera in cholera infantum, except such as are due to change in the quantity and fluidity of the blood and its circulation. Writers describe an anæmic appearance of the thoracic and abdominal viscera, and occasionally passive congestion of the cerebral vessels. The cerebral symptoms often present toward the close of life in unfavorable cases of cholera infantum are often due to spurious hydrocephalus, which we have described above; but as the urinary secretion is scanty or suppressed, cerebral symptoms may in certain cases be due to uræmia.

DIAGNOSIS.--This form of the summer diarrhoea is diagnosticated by the symptoms, and especially by the frequency and character of the stools. The stools have already been described as frequent, often passed with considerable force, deficient in fecal matter, and thin, so as to soak into the diaper almost like urine. The vomiting, thirst, rapid sinking, and emaciation serve to distinguish cholera infantum from other diarrhoeal maladies.

When Asiatic cholera is prevalent the differential diagnosis between the two is difficult if not impossible.

PROGNOSIS.--Cholera infantum is one of those diseases in regard to which physicians often injure their reputation by not giving sufficient notice of the danger, or even by expressing a favorable opinion when the case soon after ends fatally. A favorable prognosis should seldom be expressed without qualification. If the urgent symptoms be relieved, {746} still the disease may continue as an ordinary intestinal inflammation, which in hot weather is formidable and often fatal. If the stools become more consistent and less frequent without the occurrence of cerebral symptoms, while the limbs are warm and the pulse good, we may confidently express the opinion that there is no present danger.

The duration of true cholera infantum is short. It either ends fatally, or it begins soon to abate and ceases, or it continues, and is not to be distinguished in its subsequent course from an attack of summer diarrhoea beginning in the ordinary manner.

TREATMENT.--Preventive Measures.--Obviously, efficient preventive measures consist in the removal of infants so far as practicable from the operation of the causes which produce the disease. Weaning just before or in the hot weather should, if possible, be avoided, and removal to the country should be recommended, especially for those who are deprived of the breast-milk during the age when such nutriment is required. If for any reason it is necessary to employ artificial feeding for infants under the age of ten months, that food should obviously be used which most closely resembles human milk in digestibility and in nutritive properties. Care should be taken to prevent fermentation in the food before its use, since much harm is done by the employment of milk or other food in which fermentative changes have occurred and which occur quickly in dietetic mixtures in the hot months.

It is also very important that the infant receive its food in proper quantity and at proper intervals, for if the mother or nurse in her anxiety to have it thrive feed it too often or in too large quantity, the surplus food which it cannot digest if not vomited undergoes fermentation, and consequently becomes irritating to the gastro-intestinal surface. The physician should be able to give advice not only in reference to the frequency of feeding, but also in regard to the quantity of food which the infant requires at each feeding. Correct knowledge and advice in this matter aid in the prevention and cure of the dyspeptic and diarrhoeal maladies of infancy.

Chadbourne of this city and myself made some observations in order to ascertain how much food well-nourished infants receive daily. We selected infants that had an abundance of breast-milk, and weighed them before and after each nursing, so as to determine how much each infant took during twenty-four hours. The avoirdupois ounce contains 437.5 grains, and we ascertained by careful weight and measurement, employing the metric system for its greater accuracy, that one fluidounce of human milk, with a specific gravity of 1.031, weighed 451.9 grains. With these data it was easy to determine the quantity of milk in fluidounces from its weight. Our first observations related to 12 infants under the age of five weeks, 8 of which nursed twelve times, and the remaining 4 eight, nine, nine, and eleven times respectively, in the twenty-four hours. The quantity of milk received by them in twenty-four hours varied considerably in the different cases, but the average was 12.41 fluidounces. Therefore if a baby in the first five weeks nurse every two hours, it receives only a little more than one fluidounce at each nursing.

The next observations were made upon 15 infants between the ages of five weeks and ten months: 8 of the 15 were under the age of six {747} months, and the remaining 7 were between the ages of six months and ten months. The weighing showed that the younger took nearly the same quantity per day, on the average, as the older infants in this group. The average quantity received by each was twenty-four and six-tenths fluidounces. Hence if the nursings were eight in the twenty-four hours, three ounces were taken at each nursing; if the nursings were twelve, the quantity each time was two ounces.

Biedert of Germany has also made similar observations in order to determine the amount of nutriment required by infants. The results of his weight-studies, as he designates them, were published in the Jahrbuch für Kinderheilkunde, xix. B., 3 H. His weighing showed that infants during their first month, if fed on cow's milk, required from 160 to 200 grammes of milk daily, and in the third month 300 grammes. These quantities in fluid measure are 5.44 to 6.83 ounces, the quantity required each day in the first month, and 10.22 ounces, the quantity required daily the second month. Therefore, both my weights and Biedert's show that infants under the age of two months assimilate a smaller quantity of milk than is usually supposed. For infants older than two months he estimates the quantity of milk required by infants by their weight. He believes that the greater the weight the greater is the amount of food which the infant needs. The method pursued by Chadbourne and myself is more simple, and it seems to indicate with sufficient exactness the amount of food required.

Some infants, like adults, need more food than others, so that there can be no exact schedule of the quantity which they require at each feeding; but while in the first and second months they do not need more than from one to one and a half fluidounces at each feeding, whether of breast-milk, or of cow's milk prepared so as to resemble as closely as possible human milk, infants as they grow older and their stomachs enlarge can take food in larger quantity, and therefore require less frequent feeding. Under the age of two months the stomach is so small that it cannot receive much more than one or one and a half fluidounces without undue distension. At the age of six months it can probably receive and digest without discomfort three ounces, and in the last half of the first year even four ounces. Infants nourished at the breast should be allowed to nurse every two hours in the daytime, whatever the age, after the second month, but less frequently at night, for frequent nursing promotes the secretion of milk, and the milk is of better quality than when it is long retained in the breast. If by the fifth or sixth month mothers or wet-nurses find, as is frequently the case, that they do not have sufficient milk, other food should be given in addition, perhaps after each second nursing or every fourth hour. The kind of food which it is best to employ to supplement the nursing will be mentioned under the head of curative measures. By knowledge on the part of the mother and nurse of the dietetic needs of the infant, and by consequent judicious alimentation, and by measures also to procure the utmost purity of the air, there can be no doubt that the summer diarrhoea may to a great extent be prevented.

Curative Treatment.--The indications for treatment are--1st, to provide the best possible food; 2d, to procure pure air; 3d, to aid the digestive function of the infant; 4th, to employ such medicinal agents as can be safely given to check the diarrhoea and cure the intestinal catarrh.

{748} The infant with this disease is thirsty, and is therefore apt to take more nutriment in the liquid form than it requires for its sustenance. If nursing, it craves the breast, or if weaned, craves the bottle, at short intervals to relieve the thirst. No more nutriment should be allowed than is required for nutrition, for the reason stated above, and the thirst may best be relieved by a little cold water, gum-water, or barley-water, to which a few drops of brandy or whiskey are added.

Since one of the two important factors in producing the summer diarrhoea is the use of improper food, it is obviously very important for the successful treatment of this disease that the food should be of the right kind, properly prepared, and given in proper quantity. I need not repeat that for infants under the age of one year no food is so suitable as breast-milk, and one affected with the diarrhoea and remaining in the city should, if possible, at least if under the age of ten months, be provided with breast-milk. It can be more satisfactorily treated and the chances of its recovery are much greater if it be nourished with human milk than by any other kind of diet. If, however, the mother's milk fail or become unsuitable from ill-health or pregnancy, and on account of family circumstances a wet-nurse cannot be procured, the important and difficult duty devolves upon the physician of deciding how the infant should be fed. In order to solve this problem it will be well to recall to mind the part performed in the digestive function by the different secretions which digest food:

1st. The saliva is alkaline in health. It converts starch into glucose or grape-sugar. It has no effect upon fat or the protein group. It is the secretion of the parotid, submaxillary, and sublingual glands, which in infants under the age of three months are very small, almost rudimentary. The two parotid glands at the age of one month weigh only thirty-four grains. The power to convert starch into sugar possessed by saliva is due to a ferment which it contains called ptyalin.

2d. The gastric juice is a thin, nearly transparent, and colorless fluid, acid from the presence of a little hydrochloric acid. It produces no change in starch, grape-sugar, or the fats, except that it dissolves the covering of the fat-cells. Its function is to convert the proteids into peptone, which is effected by its active principle, termed pepsin.

3d. The bile is alkaline and neutralizes the acid product of gastric digestion. It has no effect on the proteids. It forms soaps with the fatty acids and has a slight emulsifying action on fat. The soaps are said to promote the emulsion of fat. Their emulsifying power is believed to be increased by admixture with the pancreatic secretion. Moreover, the absorption of oil is facilitated by the presence of bile upon the surface through which it passes.

4th. The pancreatic juice appears to have the function of digesting whatever alimentary substance has escaped digestion by the saliva, gastric juice, and bile. It is a clear, viscid liquid of alkaline reaction. It rapidly changes starch into glucose. It converts proteids into peptones and emulsifies fats. While the gastric juice requires an acid medium for the performance of its digestive function, the pancreatic juice requires one that is alkaline. This important fact should be borne in mind, that such a mistake as presenting pepsin with chalk mixture, or the extractum pancreatis with dilute muriatic acid, may be avoided.

{749} 5th. The intestinal secretions are mainly from the crypts of Lieberkühn, and their action in the digestive process is probably comparatively unimportant, but in some animals they have been found to digest starch. It will be observed that of all these secretions that which digests the largest number of nutritive principles is the pancreatic. It digests all those which are essential to the maintenance of life except fat, and it aids the bile in emulsifying fat.

One of the most important conferences in pædiatrics ever held convened at Salzburg in 1881 for the purpose of considering the diet of infants. Among those who participated in the discussion were men known throughout the world as authorities in children's diseases, such as Demme, Biedert, Gerhardt, Henoch, Steffen, Thomas, and Soltmann. None of the physicians present dissented from the following proposition of the chairman: That "all the advances made in physiology in respect to the digestive organs of children only go to prove that the mother's milk is the only true material which is quantitatively and qualitatively suited to the development of the child, which preserves the physiological functions of the organs of digestion, and under favorable circumstances of growth unfolds the whole organism in its completeness." All agreed that when the breast-milk fails animal milk is the best substitute. Henoch, who was one of the conference, expresses the same opinion in his well-known treatise on diseases of children, as follows: "Cow's milk is the best substitute for mother's milk during the entire period of infancy. I consider the administration of other substances advisable only when good cow's milk cannot be obtained or when it gives rise to constant vomiting and diarrhoea."

The many infants' foods contained in the shops were considered by the conference, and, in the words of the chairman, "Now and evermore it is unanimously agreed that these preparations can in no way be substituted for mother's milk, and as exclusive food during the first year are to be entirely and completely rejected." But, unfortunately, we soon learn by experience that animal milk, although it is the best of the substitutes for human milk, is, especially as dispensed in the cities, faulty. It is digested with difficulty by young infants, and is apt to cause in them diarrhoea and intestinal catarrh. Therefore in the hot months its use is very apt to act as one of the dietetic causes of the summer diarrhoea in infants exclusively fed upon it, unless it be specially prepared so as to more closely resemble human milk. The frequent unsatisfactory results of its use have led to the preparation of the many proprietary substitutes for human milk which the shops contain, and which have been so summarily discarded by the German conference.

Woman's milk in health is always alkaline. It has a specific gravity of 1.0317; cow's milk has a specific gravity of 1.029. That of cows stabled and fed upon other fodder than hay or grass is usually decidedly acid. That from cows in the country with good pasturage is said to be alkaline, but in two dairies in Central New York a hundred miles apart, in midsummer, with an abundant pasturage, two competent persons whom I requested to make the examinations found the milk slightly acid immediately after the milking in all the cows.

The following results of a large number of analyses of woman's and cow's milk, made by König and quoted by Leeds, and of several of the {750} best known and most used preparations designed by their inventors to be substitutes for human milk, show how far these substitutes resemble the natural aliment in their chemical characters:

-------------+-----------------------+-----------------------+ | Woman's Milk. | Cow's Milk. | +-------+-------+-------+-------+-------+-------+ | | Mini- | Maxi- | | Mini- | Maxi- | | Mean. | mum. | mum. | Mean. | mum. | mum. | ---------------------+-------+-------+-------+-------+-------+ Water | 87.09 | 83.69 | 90.90 | 87.41 | 80.32 | 91.50 | Total solids | 12.91 | 9.10 | 16.31 | 12.59 | 8.50 | 19.68 | Fat | 3.90 | 1.71 | 7.60 | 3.66 | 1.15 | 7.09 | Milk-sugar | 6.04 | 4.11 | 7.80 | 4.92 | 3.20 | 5.67 | Casein | 0.63 | 0.18 | 1.90 | 3.01 | 1.17 | 7.40 | Albumen | 1.31 | 0.39 | 2.35 | 0.75 | 0.21 | 5.04 | Albuminoids | 1.94 | 0.57 | 4.25 | 3.76 | 1.38 | 12.44 | Ash | 0.49 | 0.14 | ... | 0.70 | 0.50 | 0.87 | -------------+-------+-------+-------+-------+-------+-------+

The following analyses of the foods for infants found in the shops, and which are in common use, were made by Leeds of Stevens's Institute:

Farinaceous Foods. ----------------+-------+-------+-------+-------+--------+-------+ | 1. | 2. | 3. | 4. | 5. | 6. | | | Hubb- |Imper- | | |Robin- | |Blair's| ell's | ial |Ridge's|"A.B.C."| son's | | Wheat | Wheat |Granum.| Food. | Cereal |Patent | | Food. | Food. | | | Milk. |Barley.| ----------------+-------+-------+-------+-------+--------+-------+ Water | 9.85 | 7.78 | 5.49 | 9.23 | 9.33 | 10.10 | Fat | 1.56 | 0.41 | 1.01 | 0.63 | 1.01 | 0.97 | Grape-sugar | 1.75 | 7.56 | Trace.| 2.40 | 4.60 | 3.08 | Cane-sugar | 1.71 | 4.87 | Trace.| 2.20 | 15.40 | 0.90 | Starch | 64.80 | 67.60 | 78.93 | 77.96 | 58.42 | 77.76 | Soluble | | | | | | | carbohydrates | 13.69 | 14.29 | 3.56 | 5.19 | 20.00 | 4.11 | Albuminoids | 7.16 | 10.13 | 10.51 | 9.24 | 11.08 | 5.13 | Gum, cellulose, | |Undet- | | | | | etc. | 2.94 |erm'd. | 0.50 | ... | 1.16 | 1.93 | Ash | 1.06 | 1.00 | 1.16 | 0.60 | ... | 1.93 | ----------------+-------+-------+-------+-------+--------+-------+

Liebig's Foods. ----------------+------+------+-------+-------+------+------+------+ | | | | Keas- |Savory| | | | Mel- | Haw- | Hor- |bey and| and | Baby | Baby | |lin's.|ley's.|lick's.| Matti-|Moor- | Sup | Sup | | | | | son's.| e's. |No. 1.|No. 2.| ----------------+------+------+-------+-------+------+------+------| Water | 5.00| 6.60| 3.39 | 27.95 | 8.34| 5.54| 11.48| Fat | 0.15| 0.61| 0.08 | None. | 0.40| 1.28| 0.62| Grape-sugar | 44.69| 40.57| 34.99 | 36.75 | 20.41| 2.20| 2.44| Cane-sugar | 3.51| 3.44| 12.45 | 7.58 | 9.08| 11.70| 2.48| Starch | None.| 10.97| None. | None. | 36.36| 61.99| 51.95| Soluble | | | | | | | | carbohydrates | 85.44| 76.54| 87.20 | 71.50 | 44.83| 14.35| 22.79| Albuminoids | 5.95| 5.38| 6.71 | None. | 9.63| 9.75| 7.92| Gum, cellulose, | | | | | | | | etc. | ... | ... | ... | ... | 0.44| 7.09| 5.24| | | | | | |Undet-| | Ash | 1.89| 1.50| 1.28 | 0.93 | 0.89|erm'd.| 1.59| ----------------+------+------+-------+-------+------+------+------+

{751} Milk Foods. ----------------+-----------+-----------+-----------+-----------+ | | Anglo- | | American- | | Nestle's. | Swiss. | Gerber's. | Swiss. | ----------------+-----------+-----------+-----------+-----------+ Water | 4.72 | 6.54 | 6.78 | 5.68 | Fat | 1.91 | 2.72 | 2.21 | 6.81 | Grape-sugar and | | | | | milk-sugar | 6.92 | 23.29 | 6.06 | 5.78 | Cane-sugar | 32.93 | 21.40 | 30.50 | 36.43 | Starch | 40.10 | 34.55 | 38.48 | 30.85 | Soluble | | | | | carbohydrates | 44.88 | 46.43 | 44.76 | 45.35 | Albuminoids | 8.23 | 10.26 | 9.56 | 10.54 | Ash | 1.59 | 1.20 | 1.21 | 1.21 | ----------------+-----------+-----------+-----------+-----------+

It is seen by examination of the analyses of the above foods that all except such as consist largely or wholly of cow's milk differ widely from human milk in their composition, and although some of them--as the Liebig preparations, in which starch is converted into glucose by the action of the diastase of malt--may aid in the nutrition and be useful as adjuncts to milk, physicians of experience and close observation will, I think, agree with the German conference that when breast-milk fails or is insufficient our main reliance for the successful nutrition of the infant must be on animal milk. Nestle's Food, which consists of wheat flour, the yelk of egg, condensed milk, and sugar, and which has been so largely used in this country and in Europe, is probably beneficial mainly from the large amount of Swiss condensed milk which it contains.

Although the preference is to be given to animal milk over any other kind of food as a substitute for human milk, yet even when obtained fresh and from the best dairies and properly diluted it is very apt to disagree with infants under the age of one year, producing indigestion and diarrhoea. The close resemblance in chemical character of cow's, ass's, and goat's milk to human milk would lead us to expect that either would be a good substitute for the latter. The fact that the milk of these animals is apt to cause indigestion and intestinal catarrh, especially in the hot months, when the digestive function of the infant is enfeebled from the heat, must be due to the quality rather than quantity of its constituents. The difference in quality of the casein of human and animal milk is well known, since that of human milk coagulates in the stomach in flakes, and that of animal milk in firm and large masses. The German conference saw at once the importance of the problem which confronted them--i.e. how to modify cow's milk so that it bears the closest possible resemblance to human milk. They even discussed the difference of the milk of different breeds of cows, and the proper feeding and care of cows, but the most important suggestion made--and one which has already produced good results in this country and in Europe, and promises to be instrumental in saving the lives of many infants who by the old method of feeding would inevitably perish--was made by Pfeiffer of Wiesbaden. I allude to the peptonizing of milk. The pancreatic secretion digests milk that is rendered alkaline at a temperature between 100° and 150° F. Milk thus treated becomes in from twenty minutes to one hour thinner, resembling human milk in appearance, and if the peptonizing be continued beyond a certain point, and is more complete, its taste is decidedly {752} bitter. The process should be watched and the peptonizing suspended as soon as the bitterness becomes appreciable, for, although more advanced peptonizing so changes the milk that it is more easily digested by the infant than when the peptonizing is partial, yet the bitterness which is imparted to it renders it very disagreeable as a dietetic preparation. Milk thus prepared closely resembles human milk in appearance, and its casein is so digested that it is either not precipitated by acids or is precipitated, like that of human milk, in flakes. By this process a digested or an easily-digested casein is produced, instead of the casein of ordinary cow's milk, which produces large and firm masses in the stomach--masses that the digestive ferments penetrate with such difficulty that they cause indigestion, and occur in the stools in coagula of greater or less size. Pfeiffer pointed out that when peptonized milk is employed "the feces showed absolutely no trace of the white cheesiness." Milk thus prepared quickly spoils, and it is necessary to peptonize it in small quantity and often during the twenty-four hours.

In New York City during the last year peptonized milk has been employed largely as recommended by Pfeiffer, and with such results as to encourage its further use. It is now used in the New York Infant Asylum and New York Foundling Asylum. Five grains of extractum pancreatis (Fairchild & Co.'s) and ten grains of sodium bicarbonate are added to one gill of warm water. This is mixed with one pint of warm milk, and the mixture, in some convenient vessel, is placed in water kept at a temperature of 100° F. for one hour, when it is placed upon ice to prevent further digestion. It should be tasted frequently during the peptonizing process, and if the least bitterness be observed the process should be suspended before the expiration of the hour. With some specimens of milk, especially at a temperature of 115° to 120°, a half hour or even less is sufficient. This artificial digestion is arrested either by boiling the peptonized milk, which destroys the ferment, or by reducing its temperature to near the freezing-point, which renders it latent and inactive, but does not destroy it. I need not add that placing the peptonized milk on ice is preferable to boiling it, since we wish the ferment to continue to act in the stomach of the infant. In the present state of our knowledge of infant feeding, therefore, we can recommend no better substitute for human milk than peptonized cow's milk.

Leeds recommended the following formula for peptonizing milk in his very instructive remarks made before the New York County Medical Association, July 16, 1884. In order that no mistake might be made, I wrote to him for his formula, which he kindly sent me. The following is an extract from his letter: "The formula which I ventured to suggest for the preparation of humanized cow's milk was as follows: 1 gill of cow's milk, fresh and unskimmed; 1 gill of water; 2 tablespoonfuls of rich cream; 200 grains of milk-sugar; 1½ grains of extractum pancreatis; 4 grains of sodium bicarbonate. Put this in a nursing-bottle; place the bottle in water made so warm that the whole hand cannot be held in it without pain longer than one minute. Keep the milk at this temperature for exactly twenty minutes. The milk should be prepared just before using."

The object is of course to provide from cow's milk a food which will be the nearest possible approximation to healthy human milk; and this {753} appears to be achieved by the peptonizing process. Certainly, what physicians have long been desiring--namely, some mode of preparing cow's milk so that its casein will coagulate in flakes like that of human milk--has been obtained by peptonizing.

It is a common error to expect too much of a new remedy which has a real value, and we must not expect that all patients not in an utterly hopeless state will begin to improve as soon as peptonized milk is prepared for them, or that it is a full and exact substitute for human milk, so that wet-nurses may be dispensed with. Healthy human milk is the best of all food for infants under the age of twelve months, and should always be preferred when it can be obtained, but we claim that peptonized milk is a most useful addition to the dietetic preparations for infants, probably surpassing in value the best of those in the shops. We employ it in the belief that it affords important aid in curing the dyspeptic and diarrhoeal maladies of infancy. Who first formulated and recommended the process of peptonizing milk I am not able to state, but I am informed that Roberts of Great Britain called attention to it as a means of improving milk at a time antedating the German conference.

Milk from healthy, properly-fed cows may be prepared without peptonizing, so as to agree with many infants except in the warmest weather, but is obviously less easily digested than peptonized milk. It should be diluted as follows with water boiled so as to free it from germs: In the first week after birth one-fourth milk with the addition of a little sugar. The milk should be gradually increased, so that it is one-third by the end of the fourth week, one-half by the end of the third month, and two-thirds to three-fourths by the end of the sixth month. After the sixth month it is still proper to add one-fourth water, but pure milk may be given. Water increases the urination.

Before peptonizing--which, as we have seen, digests the casein to a great extent, and changes that which is not digested so that it coagulates in flakes in the stomach like breast-milk--was resorted to, it was customary to use a thin barley- or oat-water in place of the water used for diluting the milk. One heaped teaspoonful of barley flour to two tablespoonfuls of water make a gruel of proper consistence. A little farinaceous substance added to the milk by mechanically separating the particles of casein tends to prevent their coagulation in large and firm masses. This was the theory which explained the beneficial action of the admixture. If for any reason peptonized milk be not employed, milk prepared in the way I have mentioned, by admixture with a farinaceous substance, is probably the next best substitute for human milk.

It is very important to determine when and how farinaceous foods shall be given in this disease. It is well known that infants under the age of three months digest starch with difficulty and only in small quantity, since the salivary and pancreatic glands which secrete the ferments which digest starch are almost rudimentary at that age. The artificial digestion of starch is, however, easily accomplished. Among the last labors of the renowned chemist Baron Liebig was the preparation of a food for infants in which the starch is digested and transformed into grape-sugar, and thus infants at any age who are fed with it are relieved of the burden of digesting it. The baron led the way which has been so successfully followed since in the artificial digestion of foods. A considerable part of the starch {754} in wheat flour is converted into grape-sugar by the prolonged action of heat. I frequently recommend that from three to five pounds of wheat flour be packed dry in a firm muslin bag, so as to form a ball, and be placed in water sufficient to cover it constantly and the bag kept over the fire three or four days. During the nights the fire may go out for a few hours. At the expiration of this time the external part, which is wet, being peeled off, the remainder resembles a lump of yellowish chalk. The flour grated from it gives a decided reaction of sugar by Fehling's test. Starch is also quickly transformed into glucose by the action of the diastase of malt, which indeed Liebig employed. If to a gruel of barley flour, oatmeal, or other farinaceous substance, when hot, a little of a good preparation of extract of malt, such as that prepared by Trommer & Co. at Fremont, Ohio, which acts promptly, or by Reed & Carnrick, be added, it becomes thinner. It is claimed that the starch is thus quickly converted into glucose; which seems doubtful. It is, however, so modified that it is apparently more readily digested and assimilated. Farinaceous substances thus prepared may be employed with peptonized or other milk. Infants frequently do better with this admixture than when either the milk or gruel is used separately.

Of the foods contained in the shops which have been most prescribed, and which have apparently been useful in certain cases, I may mention those which have been prepared according to Liebig's formula, of which there are several, the analyses of which I have given, and Nestle's farina. In the use of those foods which contain no milk, as Ridge's food, Imperial granum, etc., it is recommended that milk be added, while for such as contain condensed milk, as Nestle's and the Anglo-Swiss food, only water should be employed. The Anglo-Swiss food contains about 60 per cent. condensed milk and about 20 per cent. each of oatmeal and Russian wheat flour. It gives an acid reaction, unlike Nestle's, which is alkaline. When Biedert's cream conserve was announced great expectations were awakened from the fact that the inventor is an authority in pædiatrics, but, unfortunately, they have not been realized in this country. Much of Biedert's conserve when it reaches us is spoiled, and the directions for its use are too complicated for ordinary family use, since a different mixture is required for each month of the infant's age. I have employed this food, but, with Henoch, "could not convince myself that it is more efficacious than cow's milk." I am informed that the sale of it in this country has ceased.

Condensed milk is largely used in the feeding of infants. The milk is condensed in vacuo to one-third or one-fifth its volume, heated to 100° C. (212° F.) to kill any fungus which it contains, and 38 to 40 per cent. of cane-sugar is added to preserve it. In the first month one part of milk should be added to sixteen of water, and the proportion of water should be gradually reduced as the infant becomes older. The large amount of sugar which condensed milk, preserved in cans, contains renders it unsuitable in the dietetic rôle of the summer diarrhoea of infants. The sugar is apt to produce acid fermentation and diarrhoea in hot weather. Borden's condensed milk, freshly prepared, as dispensed from the wagons, contains, I am informed by the agent, no cane-sugar or other foreign substance, and on this account is to be preferred to that in the cans. It is cow's milk of good quality, from which 75 to 79 per cent. of the water {755} has been removed under vacuum. The sole advantage which it possesses--and it is an important one--is that it resists fermentation longer than the ordinary milk.

To select the best food for the infant from this considerable number of dietetic preparations is one of the most important duties of the physician. If called to an infant unfortunately deprived of wholesome breast-milk, and suffering in consequence from indigestion and diarrhoea, what diet shall we recommend? My recommendation would be as follows: Use cow's milk of the best possible quality and peptonized in the manner stated above, and peptonized in small quantity at a time, such as a pint, or, better, half a pint. This may be the sole food till the age of five or six months. Unfortunately, in the cities the milk that is delivered in the morning is the milking of the preceding evening, mixed with that of the preceding morning, brought often many miles from the farms where it is produced. Milk twelve and twenty-four hours old, notwithstanding the use of ice around the milk-cans, is apt to undergo some fermentative change before it reaches the nursery. This prevents the preparation of the best quality of peptonized milk, so that in some instances during the heated term I have found that the peptonized milk did not agree as well as the condensed milks, like Borden's or Nestle's food. Not a few infants suffering from diarrhoeal maladies seem to do better if some farinaceous food properly prepared be added to the peptonized milk than when the milk is used alone. It is better, I think, that the starch, or a considerable part of the starch, be converted into glucose before the admixture. This can be done if a few pounds of wheat flour be pressed dry in a bag, so as to form a ball, and boiled three or four days, as I have elsewhere recommended. The flour grated from the mass gives a decided sugar reaction to Fehling's test. For infants under the age of six months one tablespoonful of the flour thus prepared should be mixed with twelve tablespoonfuls of water and boiled. When it has been removed from the fire and become tepid, a small quantity of a good extract of malt, as Trommer's or Reed & Carnrick's, may advantageously be added to the gruel to increase the transformation of starch and render it more digestible. To avoid the time and trouble of preparing the food in this manner, one of the foods contained in the shops, in which the starch has been transformed into glucose by the employment of Baron Liebig's formula, may be used, as Mellin's or Horlick's, instead of the wheat flour prepared by long boiling. The older the child, the thicker should be the gruel.

Beef-, mutton-, or chicken-tea should not be employed, at least as it is ordinarily made, since it is too laxative. Occasionally, for the older infants, we may allow the expressed juice of beef, raw scraped beef, or beef-tea prepared by adding half a pound of lean beef, finely minced, to one pint of cold water, and after allowing it to stand for half an hour warming it to a temperature not exceeding 110° for another half hour. By this process the albumen is preserved. Salt should be added to it, and I am in the habit of adding to it also about seven drops of dilute muriatic acid to facilitate its digestion. It is chiefly for infants over the age of ten months that the meat-juices are proper. A concentrated nutriment, prepared, it is stated, from beef, mutton, and fruits, has lately been introduced in the shops under the name Murdoch's Liquid Food. Young {756} infants with dyspeptic and diarrhoeal symptoms can take it, and it appears to be readily assimilated, as the quantity given at each feeding is small. It has its advocates, and it appears to be of some service in cases of weak and irritable stomach.

But since one of the two important factors in producing the summer diarrhoea of infants is foul air, it is obvious that measures should be employed to render the atmosphere in which the infant lives as free as possible from noxious effluvia. Cleanliness of the person, of the bedding, and of the house in which the patient resides, the prompt removal of all refuse animal or vegetable matter, whether within or around the premises, and allowing the infant to remain a considerable part of the day in shaded localities where the air is pure, as in the parks or suburbs of the city, are important measures. In New York great benefit has resulted from the floating hospital which every second day during the heated term carries a thousand sick children from the stifling air of the tenement-houses down the bay and out to the fresh air of the ocean.

But it is difficult to obtain an atmosphere that is entirely pure in a large city with its many sources of insalubrity; and all physicians of experience agree in the propriety of sending infants affected with the summer diarrhoea to localities in the country which are free from malaria and sparsely inhabited, in order that they may obtain the benefits of a purer air. Many are the instances each summer in New York City of infants removed to the country with intestinal inflammation, with features haggard and shrunken, with limbs shrivelled and the skin lying in folds, too weak to raise, or at least hold, their heads from the pillow, vomiting nearly all the nutriment taken, stools frequent and thin, resulting in great part from molecular disintegration of the tissues--presenting, indeed, an appearance seldom observed in any other disease except in the last stages of phthisis--and returning in late autumn with the cheerfulness, vigor, and rotundity of health. The localities usually preferred by the physicians of this city are the elevated portions of New Jersey and Northern Pennsylvania, the Highlands of the Hudson, the central and northern parts of New York State, and Northern New England. Taken to a salubrious locality and properly fed, the infant soon begins to improve if the disease be still recent, unless it be exceptionally severe. If the disease have continued several weeks at the time of the removal, little benefit may be observed from the country residence until two or more weeks have elapsed.

An infant weakened and wasted by the summer diarrhoea, removed to a cool locality in the country, should be warmly dressed and kept indoor when the heavy night dew is falling. Patients sometimes become worse from injudicious exposure of this kind, the intestinal catarrh from which they are suffering being aggravated by taking cold, and perhaps rendered dysenteric.

Sometimes parents, not noticing the immediate improvement which they have been led to expect, return to the city without giving the country fair trial, and the life of the infant is then, as a rule, sacrificed. Returned to the foul air of the city while the weather is still warm, it sinks rapidly from an aggravation of the malady. Occasionally, the change from one rural locality to another, like the change from one wet-nurse to another, has a salutary effect. The infant, although it {757} has recovered, should not be brought back while the weather is still warm. One attack of the disease does not diminish, but increases, the liability to a second seizure.

Medicinal Treatment.--The summer diarrhoea of infants requires, to some extent, different treatment in its early and later stages. We have seen that acids, especially the lactic and butyric, the results of faulty digestion, are produced abundantly, causing acid stools. In a few days the inflammatory irritation of the mucous follicles causes such an exaggerated secretion of mucus which is alkaline that the acid is nearly or quite neutralized. In the commencement of the attack these acid and irritating products should be as quickly as possible neutralized, while we endeavor to prevent their production by improving the diet and assisting the digestion. In the second stage, when the fecal matter is less acid and irritating from the large admixture of mucus, medicines are required to improve digestion and check the diarrhoea, while the indication for antacids is less urgent. Therefore it is convenient to consider separately the treatment which is proper in the commencement or first stage, and that which is required in the subsequent course of the disease.

First stage, or during the first three or four days, perhaps the first week.--Occasionally, it is proper to commence the treatment by the employment of some gentle purgative, especially when the disease begins abruptly after the use of indigestible and irritating food. A single dose of castor oil or syrup of rhubarb, or the two mixed, will remove the irritating substance, and afterward opiates or the remedies designed to control the disease can be more successfully employed. Ordinarily, such preliminary treatment is not required. Diarrhoea has generally continued a few days when the physician is summoned, and no irritating substance remains save the acid which is so abundantly generated in the intestines in this disease, and which we have the means of removing without purgation.

The same general plan of medicinal treatment is appropriate for the summer diarrhoea of infants as for diarrhoea from other causes; but the acid fermentation commonly present indicates the need of antacids, which should be employed in most of the mixtures used in the first stage as long as the stools have a decidedly acid reaction.

Those who accept the theory that this disease is produced by micro-organisms which lodge on the gastro-intestinal surface and produce diarrhoea by their irritating effect are naturally led to employ antiseptic remedies. Guaita administered for this purpose sodium benzoate. One drachm or a drachm and a half dissolved in three ounces of water were administered in twenty-four hours with, it is stated, good results.[3] I have no experience in the use of antiseptic remedies.

[Footnote 3: N.Y. Med. Rec., May 31, 1884.]

If by the appearance of the stools or the substance ejected from the stomach, or by the usual test of litmus-paper, the presence of an acid in an irritating quantity be ascertained or suspected, lime-water or a little sodium bicarbonate may be added to the food. The creta præparata of the Pharmacopoeia administered every two hours, or, which is more convenient, the mistura cretæ, is a useful antacid for such a case. The chalk should be finely triturated. By the alkalies alone, aided by the judicious use of stimulants, the disease is sometimes arrested, but, unless {758} circumstances are favorable and the case be mild, other remedies are required.

Opium has long been used, and it retains its place as one of the important remedies in this disease. For the treatment of a young infant paregoric is a convenient opiate preparation. For the age of one to two months the dose is from three to five drops; for the age of six months, twelve drops, repeated every three hours or at longer intervals according to the state of the patient. After the age of six months the stronger preparations of opium are more commonly used. The tinctura opii deodorata or Squibb's liquor opii compositus may be given in doses of one drop at the age of one year. Dover's powder in doses of three-fourths of a grain, or the pulvis cretæ comp. cum opio in three-grain doses every third hour, may be given to an infant of one year.

Opium is, however, in general best given in mixtures which will be mentioned hereafter. It quiets the action of the intestines and diminishes the number of the evacuations. It is contraindicated or should be used with caution if cerebral symptoms are present. Sometimes in the commencement of the disease, when it begins abruptly from some error in diet, with high temperature, drowsiness, twitching of the limbs--symptoms which threaten eclampsia--opiates should be given cautiously before free evacuations occur from the bowels and the offending substance is expelled. Under such circumstances a few doses of the bromide of potassium are preferable. In the advanced stage of the disease also, when symptoms of spurious hydrocephalus occur, opium should be withheld or cautiously administered, since it might tend to increase the fatal stupor in which severe cases are apt to terminate.

The vegetable astringents, although they have been largely employed in the treatment of this as well as other forms of infantile diarrhoea, are, I think, much less frequently prescribed than formerly. I have entirely discarded them, since they are apt to be vomited and have not proved efficient in my practice. As a substitute for them the subnitrate of bismuth has come into use, and in much larger doses than were formerly employed. While it aids in checking the diarrhoea, it is an efficient antiemetic and antiseptic. It should be prescribed in ten or twelve grains for an infant of twelve months; larger doses produce no ill effect, for its action is almost entirely local and soothing to the inflamed surface with which it comes in contact. It undergoes a chemical change in the stomach and intestines, becoming black, being converted into the bismuth sulphide, and it causes dark stools. Rarely it gives rise in the infant to the well-known garlicky odor, like that occasionally observed in adult patients, and which Squibb thinks may be due to tellurium accidentally associated with the bismuth in its natural state. For those cases in which the symptoms are chiefly due to colitis, and the stools contain blood with a large proportion of mucus, it has been customary to prescribe laudanum or some other form of opium with castor oil. I prefer, however, the bismuth and opium for such cases as are more decidedly dysenteric, as well as for cases of the usual form of intestinal catarrh. In ordering bismuth in these large doses it is important that a pure article be dispensed.

The following are convenient and useful formulæ for a child of one year: {759}

Rx. Tinct. opii deodorat. minim xvj; Bismuth. subnitrat. drachm ij; Syrupi, fluidrachm ij; Misturæ cretæ, fluidrachm xiv. Misce.

Shake thoroughly and give one teaspoonful every two to four hours.

Rx. Tinct. opii deodorat. minim xvj; Bismuth. subnitrat. drachm ij; Syrupi, fluidounce ss; Aq. cinnamomi, fluidounce iss. Misce.

Shake bottle; give one teaspoonful every two to four hours.

Rx. Bismuth. subnitrat. drachm ij; Pulv. cret. comp. c. opio, drachm ss. Misce.

Divid in Chart No. X. Dose, one powder every three hours.

Rx. Bismuth. subnitrat. drachm ij; Pulv. ipecac. comp. gr. ix. Misce.

Divid in Chart No. XII. Dose, one powder every three hours.

Cholera infantum requires similar treatment to that which is proper for the ordinary form of the summer diarrhoea, but there is no disease, unless it is pseudo-membranous croup, in which early and appropriate treatment is more urgently required, since the tendency is to rapid sinking and death. As early as possible, therefore, proper instructions should be given in regard to the feeding, and for an infant between the ages of eight and twelve months either one of the above prescriptions should be given or the following:

Rx. Tinct. opii deodorat. minim xvj; Spts. ammon. aromat. fluidrachm j; Bismuth. subnitrat. drachm ij; Syrupi, fluidounce ss; Misturæ cretæ, fluidounce iss. Misce.

Shake bottle. Give one teaspoonful every two or three hours.

An infant of six months can take one-half the dose, and one of three or four months one-third or one-fourth the dose, of either of the above mixtures.

If cerebral symptoms appear, as rolling the head, drowsiness, etc., I usually write the prescription without the opiate; and with this omission it may be given more frequently if the case require it, while the opiate prescribed alone or with bromide of potassium is given guardedly and at longer intervals. Although every day during the summer months I have written the above prescriptions, it has been several years since any case has occurred in my practice which led me to regret the use of the opiate; but it must not be forgotten that there is danger in the summer complaint, and especially in cholera infantum, of the sudden supervention of stupor, amounting even to coma, and ending fatally. A few instances have come to my knowledge in which, when death occurred in this way, the friends believed that the melancholy result was hastened by the medicine. But injury to the patient in this respect can only occur, in my opinion, through carelessness in not giving proper attention to his condition. It is chiefly in advanced cases, when the vital powers are beginning to fail, when the innervation is deficient, and the cerebral circulation sluggish, that the use of opiates may involve danger. Explicit and positive directions should {760} be given to omit the opiate or give it less frequently whenever the evacuations are checked wholly or partially and signs of stupor appear.

Second Stage.--The summer complaint in a large proportion of cases begins in such a gradual way that the treatment which we are about to recommend is proper in many instances at the first visit of the physician, who is frequently not summoned till the attack has continued one or two weeks. The alkaline treatment recommended above for the diarrhoea in its commencement does not aid digestion sufficiently to justify its continuance as the main remedy after the first few days. In a large number of instances, however, one of the above alkaline mixtures may be given with advantage midway between the nursings or feedings, while those remedies, presently to be mentioned, which facilitate digestion and assimilation are given at the time of the reception of food.

Some physicians of large experience, as Henoch of Berlin, recommend small doses of calomel, as the twelfth or twentieth of a grain, three or four times daily for infants with faulty digestion and diarrhoea. To me, this seems an uncertain remedy, without sufficient indications for its use, and I have therefore no experience with it. The following are formulæ which I employ in my own practice, and which have been employed with apparent good results in the institutions of New York:

Rx. Acid. muriat. dilut. minim xvj; Pepsinæ saccharat. (Hawley's or other good pepsin), drachm j; Bismuth. subnitrat. drachm ij; Syrupi, fluidrachm ij; Aquæ, fluidrachm xiv. M.

Shake bottle; give one teaspoonful before each feeding or nursing to an infant of one year; half a teaspoonful to one of six months.

Rx. Tinct. opii deodorat. minim xvj; Acid. muriat. dilut. minim xvj; Pepsinæ saccharat. drachm j; Bismuth. subnitrat. drachm ij; Syrupi, fluidrachm ij; Aquæ, fluidrachm xiv. Misce.

Shake bottle; give one teaspoonful every three hours to a child of one year; half a teaspoonful to one of six months.

Rx. Pepsinæ saccharat. drachm j-ij; Bismuth. subnitrat. drachm ij. Misce.

Divid in Chart No. XII. One powder every three hours to a child of one year; half a powder to one of six months.

I have also obtained apparent benefit from lactopeptin, given as a substitute for one of the above mixtures before each feeding or nursing. In several instances which I recall to mind I have ordered as much as could be placed on a ten-cent piece to be given every second or third hour, while midway between the feedings in some instances of considerable diarrhoea one of the mixtures of bismuth and chalk recommended above was employed, and the result has been good.

Enemata.--It will be recollected, from our remarks on the anatomical characters, that inflammatory lesions are commonly present in the entire length of the colon, and that at the sigmoid flexure, where acid and irritating fecal matter is probably longest delayed in its passage downward, the colitis is usually most severe. Aware of this fact, I was {761} led to prescribe at my first visit a large clyster of warm water, given with the fountain or Davidson's rubber syringe, especially in cases in which the stools showed mucus or mucus tinged with blood. This, given with the lower part of the body raised a little above the level of the shoulders, washes out the large intestine and has a soothing effect upon its surface. The benzoate of sodium may be added to the water for its antiseptic effect, as in the following formula:

Rx. Sodii benzoat. drachm j; Aquæ, pint j. Misce.

In occasional cases in which the stomach is very irritable, so that medicines given by the mouth are in great part rejected, our reliance must be largely on rectal medication, and especially on clysters containing an opiate. Laudanum may be given in this manner with marked benefit. It may be given mixed with a little starch-water, and the best instrument for administering it is a small glass or gutta-percha syringe, the nurse retaining the enema for a time by means of a compress. Beck in his Infant Therapeutics advises to give by the clyster twice as much of the opiate as would be required by the mouth. A somewhat larger proportion may, however, be safely employed. The following formula for a clyster has given me more satisfaction than any other medicated enema which I have employed:

Rx. Argent. nitrat. gr. iv; Bismuth. subnitrat. oz. ss; Mucilag. acaciæ, Aquæ, aa fluidounce ij. Misce.

One-quarter to one half of this should be given at a time, with the addition of as much laudanum as is thought proper; and it should be retained by the compress. It is especially useful when from the large amount of mucus or mucus tinged with blood it is probable that the descending colon is chiefly involved.

Alcoholic stimulants are required almost from the commencement of the disease, and they should be employed in all protracted cases. Whiskey or brandy is the best of these stimulants, and it should be given in small doses at intervals of two hours. I usually order three or four drops for an infant of one month, and an additional drop or two drops for each additional month. The stimulant is not only useful in sustaining the vital powers, but it also aids in relieving the irritability of the stomach and in preventing hypostasis in depending portions of the lung and brain, which, as we have seen, is so frequent in advanced cases.

The vomiting which is so common a symptom in many cases greatly increases the prostration, and should be immediately relieved if possible. The following formulæ will be found useful for it:

Rx. Bismuth. subnitrat. drachm ij; Spts. ammon. aromat. fluidrachm ss-fluidrachm j; Syrupi, Aquæ, aa fluidounce j. Misce.

Shake bottle. Dose, one teaspoonful half-hourly or hourly if required, made cold by a piece of ice.

Rx. Acid. carbolic. gtt. ij; Liquor. calcis, fluidounce ij. Misce.

Dose, one teaspoonful, with a teaspoonful of milk (breast-milk if the baby nurse), to be repeated according to the nausea.

{762} Lime-water with an equal quantity of milk often relieves the nausea when it is due to acids in the stomach, but it is rendered more effectual in certain cases by the addition of carbolic acid, which tends to check any fermentative process. Perhaps also some of the recent antiseptic medicines introduced into our Pharmacopoeia, as the benzoate of sodium, may be found useful for the vomiting. A minute dose of tincture of ipecacuanha, as one-eighth of a drop in a teaspoonful of ice-water, frequently repeated, has also been employed with alleged benefit.

Of these various antiemetics, my preference is for the bismuth in large doses, with the aromatic spirits of ammonia, properly diluted, that the ammonia do not irritate the stomach. Nevertheless, in certain patients the nausea is very obstinate, and all these remedies fail. In such cases absolute quiet of the infant on its back, the administration of but little nutriment at a time, mustard over the epigastrium, and the use of an occasional small piece of ice or the use of carbonic acid water with ice in it, may relieve this symptom.

In protracted cases, when the vital powers begin to fail, as indicated by pallor, more or less emaciation, and loss of strength, the following is the best tonic mixture with which I am acquainted. It aids in restraining the diarrhoea, while it increases the appetite and strength. It should not be prescribed until the inflammation has assumed a subacute or chronic character:

Rx. Tinct. calumbæ, fluidrachm iij; Liq. ferri nitratis, minim xxvij; Syrupi, fluidounce iij. Misce.

Dose, one teaspoonful every three or four hours to an infant of one year.

{763}

PSEUDO-MEMBRANOUS ENTERITIS.

BY PHILIP S. WALES, M.D.

SYNONYMS.--Membranous enteritis; Infarctus (Kaempf); Diarrhoea tubularis, Tubular looseness (Good); Follicular colonic dyspepsia, Follicular duodenal dyspepsia (Todd); Pellicular enteritis (Simpson); Pseudo-membranous enteritis (Cruveilhier); Pseudo-membraneuse entérite (Laboulbène); Painful affection of the intestinal canal (Powell); Mucous disease (Whitehead); Hypochondriasis pituitosa (Fracassini); Fibrinous diarrhoea (Grantham); Mucous disease of the colon (Clark); Chronic, catarrhal, or mucous diarrhoea; Colique glaireuse (of the French); Chronic exudative enteritis (Hutchinson); Diarrhoea febrilis (Van Swieten); Paraplexia rheumatica, Chlorosis pituitosis, Diarrhoea pituitosa (Sauvages); Arthritis chlorotica (Musgrave); Colica pituitosa (Sennertus); Scelotyrbe pituitosa (Perywinger); Mucositas intestinalis colloides, Concretiones gelatiniformes intestinales (Laboulbène); Tubular exudation-casts of the intestines (Hutchinson).

DEFINITION.--The disease is a non-febrile affection, consisting in a peculiar, and usually persistent, morbid condition of the intestinal mucous membrane, marked by the periodical formation of viscous, shreddy, or tubular exudates composed chiefly of mucin, on the discharge of which temporary amelioration of the accompanying acute digestive and nervous symptoms occurs.

HISTORY.--Although no distinct and separate accounts of pseudo-membranous enteritis occur in the medical writings of the ancients, nor even in those dating up to the eighteenth century, yet there may occasionally be detected in some of the descriptions of certain pathological conditions grouped under such titles as colic, passage of gall-stones, tenesmus, coeliac and pituitous affections, diarrhoea, dysentery, etc., the peculiar features of the disease under consideration. This confusion ruled up to a comparatively recent time. J. Mason Good,[1] writing in the first quarter of the nineteenth century, groups the disease as a species of diarrhoea--diarrhoea tubularis--and remarks that he had "never hitherto seen this species classified, and not often described, although it occurred frequently in practice."

[Footnote 1: Study of Medicine, 1822.]

Aretæus,[2] in the second century, in discussing the subject of dysentery, speaks of alvine discharges sometimes occurring of a substance of considerable length, in many respects not to be distinguished from a sound piece of intestine, which he regarded as the inner coating of the bowel. {764} This false interpretation of a fact arose from the circumstance that the membranous exudate occasionally assumes a tubular form, bearing the impress of the inner surface of the bowel upon which it is formed, and was perpetuated up to a comparatively recent period by successive authors. This error befell Simpson,[3] Morgagni,[4] Lancisi, and Spindler;[5] the last of whom describes the material discharged as worked up into a "materia alba, longa, compacta."

[Footnote 2: Lib. ii. cap. ix.]

[Footnote 3: Ed. Med. Essays, vol. v. p. 153, 1752.]

[Footnote 4: 31st Epistle.]

[Footnote 5: Actis Nat. Cur., vol. v. p. 483.]

Bauer[6] under the title of "intestinal moles" describes in Haller's Disputations the discharges of this disease as "concreta fibrosa quædam pro parte pinguedine rara abducta, membranacea molarum ex utero muliebri rejectarum formam accurate sistentia."

[Footnote 6: "De Moles Intestinorum," Disputationes ad Morborum, Dresdæ, 1747, p. 463.]

In the same volume Kaempf[7] discourses on this subject under the title of "infarction of the intestinal vessels," and also in a separate treatise[8] published somewhat later. In the latter he groups the disease with others of a far different nature, their only point of convergence being preternatural alvine discharges.

[Footnote 7: De Infarctu Vasorum Ventriculi, Basiliæ, 1751.]

[Footnote 8: Abhandlungen von einer neuer methode der hartnackigsten Krankheiten die ihren Sitz im unterleibe haben, zu heilen, Leipzig, 1784.]

Subsequent authors, as a rule, fell into the same error, and it was not until 1818 that membranous enteritis was discriminated by Powell[9] from that condition in which we recognize the presence of gall-stones. Since then more correct views have prevailed, and the disease has now a recognized place in nosology.

[Footnote 9: Trans. of Col. of Phys. London, vol. vi. p. 106.]

ETIOLOGY.--As in other diseases of obscure nature, so in this, there has been much divergence of opinion as to its cause.

The influence of age is striking, as it is rarely seen in childhood or in persons who have passed the forty-fifth year. Of my own cases, the youngest was forty, and the oldest fifty-four. Rilliet and Barthez[10] state that membranous formations in the intestinal canal of children are very rare; that they always occupy the summits of the folds, rarely the intervals, of the mucous membrane; and that they are detached in layers of greater or less extent. They are not diphtheritic. Heyfelder[11] has described similar exudations under the name of enteritis exudatoria.

[Footnote 10: Traité clinique pratique des Maladies des Enfants, t. i. p. 677, 1853.]

[Footnote 11: Studien in Gabiete der Heilwissenschaft, p. 173.]

Sex exerts as marked an influence as age, as the immense preponderance of cases occurs in females. In an analysis of 100 cases, 4 only occurred in males, 2 of which were children. All of my cases were women; with the exception of two cases occurring in males, the same experience is reported by Powell and by Copeland.

In regard to temperament, it is undoubted that the disease invades nervous and hypochondriacal subjects oftener than others, but all temperaments are liable in the presence of those enervative influences that degrade physical health and impair nerve-power. All of my patients belonged to the nervous type. Whitehead says that those of a phlegmatic temperament, not easily excited into action, or persons deficient in elasticity of fibre, compose all but a very small percentage of the sufferers from this {765} complaint, and he had particularly noticed that a large proportion of the women have light flaxen hair, fair complexions, and white skins.

The determinative causes, whatever they may be, occasion perversion of nutrition and innervation of the gastro-intestinal canal, principally, I believe, by their action upon the ganglionic nerves presiding over those functions originating the peculiar exudatory phenomena of this disease. This condition of the nervous system once established, local irritation of any sort may precipitate an attack, and hence the multitudinous influences that have been assigned as exercising a causative agency, as exposure to wet and cold, coarse, bad food, fecal impaction, and the abuse of cathartic medicines, as alleged by Grantham,[12] who asserts that the use of mercury, conjoined with a too frequent use of aperient agents, is the cause of the disease in every case.

[Footnote 12: Facts and Observations in Med. and Surg., 1849, p. 205.]

Farr considered the irritation of the intestinal canal owing to a parasitic growth of a confervoid type (oscillatoria). This view is supported by no other authority than that of himself and Bennett, as nothing of this sort is recorded as occurring in the discharges of patients of other observers; certainly in mine there was no parasitic development. The presence of it in their cases may then be fairly regarded as accidental, or at least unessential.

Habershon regarded ovarian diseases and painful menstruation in the female, and prostatic diseases in the male, as exciting causes.

SYMPTOMS.--The most characteristic symptoms disclosing the presence of pseudo-membranous enteritis are those arising from derangements of the digestive organs. They are, in the beginning, vague and irregular in occurrence, or so over-veiled by associated disorders of the genito-urinary and nervous systems that their nature and import often escape recognition until, weeks, and even months, of fruitless medication addressed to these secondary phenomena having been expended, the disease assumes such severity and presents such a complex of peculiar symptoms that it no longer eludes identification.

The disease rarely starts as an acute affection; sometimes it is subacute, but in the great majority of cases its course is chronic. Its initiation is marked with symptoms of gastro-intestinal disturbances--irregularity of the bowels, constipation and diarrhoea alternately; and dyspeptic annoyance of one sort or another--capricious appetite, nausea or vomiting, and pyrosis, usually increased by liquid diet. In Dunhill's case there was almost daily vomiting of mucus and pus streaked with blood, and occasionally pure blood. This prominence of gastric derangement supplies an explanation why Todd conferred upon the disease the title of follicular dyspepsia.

There is a sense of discomfort, soreness, or rawness of the abdomen, especially along the line of the colon, and in two of my cases the rectum was tender and raw, which augmented to decided pain in sitting or riding, and the abdominal muscles were tense; a feeling of heat or burning in the bowels often occurs, and almost always more or less lassitude and mental depression. These symptoms aggravate, especially upon indiscretions in diet, exposure to wet, or indeed under any sort of enervative influences, at irregular intervals. Their persistence finally induces grave disorders of nutrition, marked by the blood becoming poor and thin, by sluggish {766} circulation and local congestions in the pelvic and abdominal viscera, and loss of strength and flesh. Yet certain patients seem to retain their flesh for a long time, as I have seen, after suffering several years from the disease. The depression of vital powers is still further manifested in a small, slow, soft pulse and a temperature running below the normal standard. The tongue is usually moist, pale, and flabby, and coated with a pearl-white or yellowish-white coating; sometimes, however, it is raw, red, tender, and fissured, or patchy from exfoliation of the mucous coating. The gums and cheeks are usually pale and bloodless, and often the seat of small roundish painful ulcers, which occasionally invade the palate and throat. Grantham[13] says that ulceration of a phagedænic kind sometimes forms on the tonsils. The complexion usually assumes a muddy or flavescent tint, which during the attack may deepen to a jaundiced hue. At other times it presents a transparent or waxy appearance.

[Footnote 13: Op. cit., p. 204.]

The skin is dry and furfy, sometimes cold and clammy, or, from over-action of the sebaceous glands, greasy. There is a disposition, especially on the chest, neck, and face, to papular eruptions or even phlegmonous or carbuncular inflammation.

The urine is high-colored and loaded with abundant phosphates, which in cooling precipitate as a heavy deposit. The bladder is often irritable, and discharges more or less mucus. According to Grantham,[14] patients occasionally pass urine with evident traces of albumen, and seldom containing a normal quantity of phosphates. On an increase in fever or mental excitement a larger quantity than natural of the lithate of ammonium is found; frequently the mucous membrane of the bladder is found thickened in these cases.

[Footnote 14: Op. cit., p. 204.]

The characteristic symptom, however, of this disease is the periodical formation and discharge of mucous exudates varying in physical appearances and frequency. The discharge may occur daily, with every stool, or at irregular intervals--a week, month, or longer--but usually in from twelve to fifteen days. The recurrence may be precipitated by irregularity in diet, exposure to wet and cold, or by excesses of any sort. The paroxysm is marked by tormina or severe pain, which may resemble that of colic or that of the passage of a biliary calculus, extending down the thighs or to the bladder, in the latter case sometimes causing retention, requiring the use of the catheter. The pain is usually referred to some part of the large intestine. In certain cases the paroxysm is announced by chills radiating from some point in the abdomen or even from other parts of the body.

After the paroxysm has endured two, three, or more days--usually a week--membranous exudates, either with a spontaneous or with an artificial movement of the bowels, are voided; after which there is a gradual assuagement of the local and general symptoms, but the patient experiences a sense of exhaustion or lassitude, and the tenderness of the abdomen and the irregularity of the bowels usually persist.

During the attack there is anorexia, but in the intervals the appetite remains fairly good, and the alvine discharges may assume quite a natural condition.

In the course of the disease there is more or less disturbance in the functions of the nervous system. During the paroxysm, when the {767} sufferings are severe, the cast of symptoms running through the case is of a decidedly hypochondriacal type. At times, with the expulsion of the exudates and succeeding respite from suffering, there often occurs a mental rebound which lifts the patient from the slough of despair to the most hopeful anticipations of future health and happiness. In one of my cases this transition was remarkable. This hysterical type is common enough, and the irritability of the nervous system is still further manifested in the occurrence of irregular contractions of various groups of the voluntary muscles, as shown in hysterical tetanus, general convulsions, or chorea in children, or by paralyses of motion.

Copeland[15] reports a case of a lady in whom this disease was complicated with the severest symptoms of hysteria, occasionally amounting to catalepsy. The paroxysms of pain recurred at intervals between four and six weeks, followed or attended by the discharge of large quantities of false membrane in pieces, and sometimes in perfect tubes. The menstrual flow was painful and irregular, accompanied with shreds of false membrane--not, however, contemporaneous with those of the intestine. The sensory nerves are often deranged, for in some cases there is paræsthesia--anæsthesia or hyperæsthesia--in limited areas of the skin. There is more or less headache, neuralgic pains in this or that nerve, or in several at the same time.

[Footnote 15: Dictionary of Medicine, vol. ii. p. 669.]

The special senses do not escape; they manifest various forms of functional derangement. In one of my cases there were constant buzzing in the ears and perversion of the sense of smell, and in another the vision was thought impaired and the services of an oculist sought.

The uterine functions are always involved in greater or less degree. The menstruation is difficult and painful, and occasionally accompanied with membranous discharges. In one of my cases there was a uterine exudate, though the menopause had occurred several years before. Leucorrhoea and cervical inflammation are common.

PATHOLOGY.--Despite the fact that the disease in question, without being very frequent, is far from rare, little light has been shed upon its pathology. Indeed, even its individuality as an independent and distinct affection has been contested, although it is marked by a complex of symptoms as peculiar and characteristic as those of any other disease in the nosology.

There are those who maintain that the disease consists essentially in an inflammatory condition of the intestinal mucous membrane, either of the ordinary or of some specific type, croupous or diphtheritic. Copeland says the formation of the membranes depends upon a latent and prolonged state of inflammation extending along a very large portion, sometimes the greater part, of the intestinal canal, as is evinced by the quantity thrown off. Valleix[16] dismisses the subject summarily with the delivery of the oracular judgment that the greater number of cases of this disease are dysenteric, and the remainder diphtheritic. Habershon is in full accord with this view, having, as he says, seen these membranous exudates "follow severe disease of the intestines of a dysenteric character, and sometimes associated with a state of chronic congestion of the liver, and often perpetuated by the presence of hemorrhoids, polypoid {768} growths, etc." Wilks and Clark,[17] after a full examination of the enteric exudates submitted to them, concluded that they are true casts of the large intestines produced by chronic inflammatory action of the mucous membrane and subsequent exudation. Conjectures have been ventured as to the exact anatomical structure in which the process occurs. Thus, Todd[18] says that the proximate cause of the disease is dependent upon a morbid condition of the intestinal mucous follicles. Golding-Bird[19] holds similar language. He says: "It is probable that the follicles are the principal seat of the disease, for we know that they sometimes secrete a dense mucus differing little in physical qualities from coagulated albumen or even fibrin." Livedey[20] attributed the process to a morbid secretion into the mucous crypts.

[Footnote 16: Guide du Médecine practicien, vol. iii. p. 10.]

[Footnote 17: Trans. Path. Society, vol. ix. p. 230.]

[Footnote 18: Cyclopædia of Practical Medicine, vol. ii. p. 279.]

[Footnote 19: Guy's Hospital Reports.]

[Footnote 20: L'Union médicale, 1868.]

Among those believing in its croupous nature was Powell, who assumed the character of the inflammation to be specific, and the exudate of the same nature and formed in the same manner as that of ordinary croup. This was the view entertained by Cruveilhier and Trousseau and other French authors. Good was misled in a similar manner, as shown by his statement that the exudation bears a striking resemblance to the fibrous exudation thrown forth from the trachea in croup. He says, however, that it is discharged in longer, firmer, and more compact tubes. Serres,[21] in a dissertation upon pseudo-membranous colitis, confounds the exudate with that of thrush, muguet, and infective dysentery. Laboulbène,[22] a later writer, also remarks that there are found in many treatises and in periodical literature a great number of occurrences of false membranes in the dejecta. Most of these cases are referable to dysentery, to muguet, hydatids, etc., but there remain a certain number which are owing to different inflammatory and non-diphtheritic affections of the digestive tube.

[Footnote 21: Thèse de Paris, No. 39, 1836.]

[Footnote 22: Recherches cliniques et anatomiques sur les Affections pseudo-membraneuse, Paris, 1861.]

Whitehead, in summing up his conclusions respecting the nature of the disease, compares it with dermic inflammation. He says: "The mucous membrane (intestinal), like the skin (and is not the one looked upon as an inversion of the other?), is prone under certain conditions in certain constitutions to develop products unnatural to its functions. It is not natural for the skin to produce eczema, neither is it natural for mucous surfaces to produce mucus in a concrete form; that the proximate cause of the symptoms referable to this disease is the hypersecretion and accumulation of mucus on the free surface of mucous membranes; such accumulations sheathe and prevent the healthy performance of the functions natural to the part, and thus induce immediate and remote results, the effect of such suppressed functions; that this hypersecretion indicates a want of balance between nerve-force and germinal matter, and that the nerve-force is perverted by irritation."

Simpson held similar views, and regarded the disease as a chronic pellicular or eruptive inflammation of the mucous lining of the bowels.[23] Other observers have been inclined to ignore the inflammatory nature of the disease, at least as a primary condition, and have sought the proximate cause in some as yet undefined derangement of the nervous {769} system. Thus, Clark does not regard the membranous exudates as the products of inflammation, properly so called--that is, of capillary blood-stasis which has preceded their formation--as the characteristic of such exudates is that they contain fibrin. He says the abnormal cell-forms present arise in some other way than by free cell-development out of an exuded blastema. Good[24] asserts its dependence upon what he calls a "peculiar irritability of the villous membranes of the large intestines, which in consequence secrete an effusion of coagulating fibrin--fibrin mixed with albumen--instead of secreting mucus, occasionally accompanied with some degree of chronic inflammation."

[Footnote 23: Obstet. Works, Am. ed., p. 279.]

[Footnote 24: Study of Medicine, op. cit.]

Also, DaCosta doubts whether the disease is originally inflammatory at all. "Where inflammation," he says, "occurs, is it not secondary rather than primary, the result rather than the cause?" "Is not the true trouble in the nervous system, in the nerves presiding over secretion and nutrition in the abdominal viscera?"

Bennett and Byford represent the opinions of a very small minority who regard the disease as simply an expression of uterine derangement.

MORBID ANATOMY.--As none of the cases coming under my observation terminated fatally, no opportunity was offered to me of making personal investigation into the anatomical changes occurring in membranous enteritis. Such opportunities have been so rarely met with that, indeed, it may be said that the nature of these changes is wholly unknown.

Simpson alludes to a case of phthisis in which the patient had passed large quantities of "membranous crusts or tubes," and in which the mucous membrane of the colon was covered with an immense number of small spots of a clear white color, or vesicles, which, when punctured, discharged a small quantity of clear fluid; and also refers to the case of Wright, in which the mucous membrane of the colon and of the lower portion of the small intestine was studded everywhere with a thickly-set papular eruption.

My endoscopic examinations revealed, in the living subject, the intestinal mucous membrane of a red, verging into a scarlet color, thickened, and denuded of epithelium in patches of varying extent. This condition does not always invade the ampulla of the rectum, but with the long tube I am in the habit of using it was possible in all my cases to reach a point where it existed. The extent of diseased surface can only be conjectured by an inspection of the exudates and by abdominal palpation.

In most cases the exudate is restricted to the large intestines--colon and rectum--and often to a circumscribed portion of them; but in rare cases its length and quantity would seem to indicate that extensive portions of the surface are covered. One of the most remarkable cases recorded is that of a woman forty years old who had been sick for five years with gastro-intestinal derangement. Suddenly the case became acute, and after much suffering she passed membranous exudates three millimeters in thickness and many centimeters long, weighing in all three kilograms.[25]

[Footnote 25: Recueil de Mémoires de Médecine, de Chirurgie, et de Pharmacie militaires, tome xxxvii. p. 297, 1855.]

Kaempf[26] gives another case, in which the length of the membranes {770} discharged was sevenfold greater than the stature of the patient. In Dunhill's[27] case the patient had suffered from this disease for a long period, and during two years passed many yards of perfect cylindrical shape, many of them several feet in length, and sufficiently coherent to permit of their being handled, held up, etc. In one of my cases a perfect cylinder three-quarters of a yard long was voided.

[Footnote 26: Op. cit., p. 232.]

[Footnote 27: Trans. of Path. Society of London, vol. ix. p. 188.]

Laboulbène[28] describes the gastro-intestinal false membrane as thin, soft, and granular, of a more or less yellow color, slightly adherent to the mucous membrane, and when stripped off forming a yellow pultaceous mass. He says it is first deposited in small, irregular, sparsely-scattered patches, located on the summits of the intestinal folds; afterward these patches increase, and cover the folds entirely and almost the whole calibre of the intestinal canal. The mucous membrane, he remarks, beneath the deposit is greatly inflamed.

[Footnote 28: Op. cit., p. 105.]

Powell believes that at times the deposit extends as high as the duodenum, his opinion being solely based upon the clinical features of the disease. In the first of his cases the membrane was found in perfect tubes, some of them full half a yard in length, and certainly sufficient in quantity, he says, to have lined the whole intestinal canal.

In examining the membranes it is always best to float them from the fecal or other foreign material by passing the discharges in a clean vessel containing water. Their physical characters can then be readily studied. They are best preserved in a 10 per cent. solution of alcohol. The exudate consists usually of a single lamina, but at various points in certain cases several superposed laminæ may be observed, enclosing between them particles of undigested food of various kinds. In most cases the superficial layers are more opaque, drier, less elastic, and friable than the deeper.

The configuration of the exudate varies greatly. The more common variety is that occurring in loose, transparent, jelly-like masses, like the white of an egg or glue, tinged often with various hues of yellow. In three of my cases I noticed also the frequent occurrence of a thin, serous, yellow discharge. In some cases the discharge resembles pieces of macaroni, tallow, or wax; in others it assumes a shreddy or ribbon-like form; and in a still rarer class it is tubular, being an exact reprint of the surfaces from which detached. These tubular pieces are, however, more or less torn and broken into smaller fragments of an inch or two in length when discharged.

Its thickness also varies: sometimes it does not exceed that of the thinnest film, and at others it is a quarter of an inch or more.

Its consistence ranges from that degree of loose aggregation that permits elongation into stringy, breaking masses when fished up from the water in which it floats, to a firmness and tenacity that will enable it to be handled without fear of breakage.

The color differs in different cases. It is usually yellowish-white, but this is often modified by tints dependent upon admixture with extraneous matters from the intestinal canal--biliary coloring, blood from the rupture of the vessels beneath the exudate, or with blood and pus. It exhales a feculent odor.

The surfaces of the membranes are ordinarily smooth and uniform, but sometimes reticulated. Certain observers have described the outer {771} surface of the tubular exudate as uniformly smooth, and the inner as broken and flaky at some points, at others ragged and flocculent, and in many places thrown into shallow folds, lying in some situations across, but chiefly along, the axis of the gut.

The microscopic characters of the exudate are pretty uniform. Wilks and Clark[29] describe the surface of the tubes, examined with a linear magnifying power of forty diameters, as exhibiting the appearance of a gelatinous membraniform matrix traversed by a coarse network of opaque yellow lines, studded at their points of intersection by similarly colored rounded masses. From the larger network proceeds a smaller secondary network, and in the recesses of this were found, at close and regular intervals, well-defined round or oval openings, with elevated margins, resembling in size and appearance the mouths of the follicles of the great gut. With higher powers the exudate was found in many cases to consist of a structureless basement membrane, which in certain points showed a fibrous appearance, owing doubtless to the presence of filaments of mucin. Numerous irregular granular cells, as well as granules from the breaking up of these cells, thickly studded the surface of the membrane. In the specimens of Wilks and Clark the surface, besides being marked by the opaque yellow lines and dots, presented various foreign matters, such as bile-pigment, earthy and fatty granules, portions of husks of seed, gritty tissues of a pear, a peculiar form of elastic tissue, stellate vegetable hairs, and a mucedinous fungus. Clark, in describing the fibres found between the layers of the exudates, says that they exhibited a very distinct and regular transverse striation, approaching in character that found in the ligamentum nuchæ of the giraffe. Quekett and Brooke have met with the same fibres in the feces. The transverse division depends probably upon beginning decay. The division is sometimes so distinct and complete as to lead, according to Beale,[30] to their confounding with confervoid growths. Farre[31] actually describes the formation as of a confervoid character.

[Footnote 29: Op. cit., p. 232.]

[Footnote 30: The Microscope in Medicine, p. 194.]

[Footnote 31: Trans. Microscopical Society.]

Here and there, in my specimens, were observed scattered epithelial cells which were occasionally gathered in patches. Small colored masses of irregular shape, doubtless of fecal origin, were also noticed. The cells imbedded in the matrix, according to the above-quoted observers, consisted of two kinds--one more or less spherical, the other more or less cylindrical. In size the spherical cells varied from 1/2000 to 1/800 of an inch in diameter. The smaller cells had no distinct cell-walls. Some of the larger cells were filled with fat-granules, and represented granular cells; others had a single or double vesicular nucleus; a few were acuminated at two opposite points and somewhat compressed. All the other cells possessed demonstrable cell-walls. The cylindrical cells resembled in their general characters those which normally coat the mucous membrane of the larger gut, but they were much more elongated, compressed, and firmly matted together. Many of the more elongated cells were constricted in the middle, and exhibited a nucleus on each side of the constriction. The more or less spherical cells occupied the attached, and the cylindrical cells the free, surface of the membranous tubes.

The perforations in the matrix were of uniform size and appearance, {772} surrounded by elevated margins formed of closely-grouped cylindrical cells, and led to two kinds of pits--one short and flask-shaped, the other long and uniformly cylindrical. The flask-shaped pits were about one-tenth of an inch in diameter and distinctly hollow. The wall of each pit was made up of one or two layers of subspheroidal cells, held together by an amorphous stroma. A few of these follicles contained a deposit which was opaque in situ, and which when broken up was found to consist of large flattened nuclear cells, analogous to those met with in epithelial growths.

The cylindrical pits were also for the most part hollow, about one-sixteenth of a line in length and one-thirty-first of a line in breadth. These walls, devoid of membrane, were composed of small, more or less spherical cells in various stages of development, imbedded in a gelatinous matrix.

In examining the chemical characters of the specimens obtained in my cases the membranes were thoroughly washed, when they were nearly as colorless as the water in which they floated. They were drained on a sieve, and presented a gelatinous appearance, much like the white of an egg. Their specific gravity was about that of distilled water. When treated with strong alcohol, the membranes shrank and assumed a striated appearance. Chemical tests of tincture of guaiacum, peroxide of hydrogen, and others failed to show the presence of fibrin or albumen. Treated with ether, globules of fatty matter were obtained, which were identified by their microscopical characters and by their reaction with osmic acid. By boiling the liquid in which the membranes had been soaked it became faintly hazy, indicating a trace only of albumen. Faint evidence of the presence of this body was also presented by picric acid and Mehu's test. Treated with a weak solution of caustic potassa and heat, the membrane dissolved, leaving a little haziness. The liquid was then filtered, and exactly neutralized with acetic acid, and plumbic acetate added, when a copious precipitate was formed. Mercuric chloride and potassic ferrocyanide failed to produce this effect. From these and other tests used the conclusion was reached that these membranes were composed essentially of mucin.

Both the microscopical and chemical characters of the exudates of the disease under consideration show that they are widely different in nature from those of other diseases. They are evidently a production of the muciparous glands (follicles of Lieberkühn) of the intestinal canal, and consist essentially of mucin. Perroud[32] concluded from his analysis that they contain a small quantity of albumen, but are principally formed of the same substance as that which enters into the composition of the epidermis. The exudates of other diseases of the alimentary mucous membrane contain albumen and fibrin, as well as molecular or homogeneous filaments. The ordinary croupous exudate, according to Cornil and Ranvier, always contains filaments of fibrin, sometimes mucin and pus-corpuscles mingled with the cellular constituents, which vary in character with the locality of the inflammation. The filaments form a reticulum in the meshes of which are contained the other elements.

[Footnote 32: Journal de Médecine de Lyon, 1864.]

Diphtheritic exudates, as shown by Lehmann,[33] consist of fibrin, a large {773} quantity of fatty matter, and 4 per cent. of earthy phosphates, while its structure is made up of epithelial cells united together, which, becoming infiltrated with an albuminous substance and gradually losing their nuclei and walls, are finally converted into homogeneous branching masses. The cells of these masses are liable to undergo fibrinous degeneration. The inflammation determining the exudate is not confined to the conglomerate glands, but involves all the textural elements of the part affected, and the material of the membrane originates from the capillary disturbance in them.

[Footnote 33: Lehrbuch der Physiolog. Chemie, Leipzig, 1855.]

Andrew Clark[34] states that he has observed in his studies of exuded blastema, the product of diseased action in mucous membranes, three varieties. The first is clear, jelly-like, and imperfectly membranous. The second is yellowish, semi-opaque, flaky, and usually membranous. The third is yellowish-white, dense, opaque, distinctly membranous, tough, and rather firmly adherent to the subjacent surface. The first contains only the merest trace of albumen, and no fibrin; the second contains an abundance of albumen, and no fibrin; the third contains both albumen and fibrin in abundance, the latter in a fibrillated form. They all contain the same cell-forms. Yet it is to be noticed that in the first variety there is no evidence of transudation or exudation; in the second, no evidence of a true exudation; and that in the third, in which the existence of a true inflammatory exudation is undeniable, the only additional structural element present is fibre.

[Footnote 34: Op. cit., p. 133.]

DIAGNOSIS.--The diagnosis of membranous enteritis can never in its advance, and rarely in its early stages, present much difficulty. Its chronic course, irregular exacerbations, lack of febrile excitement, the persistent derangement of the intestinal canal, the mental depression, the gradual impairment of health, the various visceral complications, and, lastly and chiefly, the peculiar character of the alvine discharges,--stamp the disease with an individuality entirely its own.

The mucous discharges of certain forms of chronic diarrhoea and the membranous discharges of infective dysentery are all so different in physical character, and are associated with such a different complex of general symptoms, that they cannot be confounded with those of the diseases in question. The peculiar irritative quickness of the pulse of ordinary enteritis, according to Powell and Good, suffices to differentiate this disease from membranous enteritis. The peculiarities of the physical and chemical properties of these exudates, already fully dwelt upon, not only distinguish them from those of the above diseases, but also from such dejecta as may contain fragments of undigested connective tissue, of hydatids, or of worms. The flakes of mucus discharged from the bowels in protracted constipation, fissura ani, and in the later stages of cirrhosis of the liver are composed of mucus in which are found imbedded epithelial cells from the colon and mucus-corpuscles. The microscope will also reveal the character of the fatty discharges that may be associated with diseases of the pancreas, liver, and duodenum. The mucous flakes of cholera stools are composed of masses of intestinal epithelium mixed with amorphous and granular matter, crystals of different substances, and, according to Davaine, of parasitic forms, particularly the Circomonas hominis.

{774} Membranous casts from the upper part of the digestive track are, in rare cases, passed by the bowels. One of the most curious instances of this sort is reported by Villermé:[35] A woman swallowed a tablespoonful of nitric acid, and seventy days afterward a long membranous exudate, one or two lines thick and of a brown color, was discharged, which corresponded in form with the oesophagus and stomach. The patient died a few days later.

[Footnote 35: Dictionnaire des Sciences médicales, tome xxxii. p. 264.]

PROGNOSIS.--The prognosis of the disease as regards life is not unfavorable, but as regards permanent restoration to health and strength the case is entirely different. Theden[36] and Hoffman[37] have, however, stated that the disease is not an unfrequent cause of sudden death.

[Footnote 36: Remarques et Experiences, tome ii.]

[Footnote 37: Med. Ration., vol. v.]

Abercrombie[38] records a case of death from phthisis complicated with this disease, and Wright another case in which the patient died in an extreme state of marasmus. The acute and subacute forms are more amenable to treatment, and the chances are correspondingly greater of permanent recovery, though in all cases there is a strong tendency to relapse. The chronic forms may almost be enrolled among the opprobria medicorum when once they have made deep inroads upon nutrition and the vital powers, and produced that condition named by Todd the pituitous cachexia (cachexia pituitosa). These cases may, however, be alleviated by judicious treatment, diet, and climatic changes, but repeated relapses may be expected as the rule under slight exciting causes or even without apparent cause. Patients under these circumstances drag out a life of valetudinarianism, but it may be cut short at any time by the supervention of some intercurrent disease, as phthisis, renal degeneration, etc., or, according to Grantham, atrophy of the intestines. Broca[39] records two cases of this disease, one of which lasted ten and the other fifteen years. Three of my cases have endured over six years.

[Footnote 38: Inflamm. Affec. of Mucous Memb. of Intestines, pp. 213, 279.]

[Footnote 39: Bullétin de la Société Anat. de Paris, 1854.]

TREATMENT.--The treatment of membranous enteritis embraces medical and hygienic measures. The medical means have for their object, first, the removal of the membranous exudation when it has once formed; and, second, to correct the conditions upon which its formation depends by improving nutrition and invigorating the nervous system. The severe sufferings of the paroxysms are greatly alleviated and the duration of this stage cut short by freely emptying the bowels. The best means to do this is by the injection of hot water with the long elastic bougie three or four times a day, and to assist this with laxatives. Instead of water, solutions of potassa, soda, and lime-water are preferred by some practitioners. As a rule, the enemata cause considerable discomfort, but in the end are followed by improvement in the condition of the bowels. The best laxative is emulsion of castor oil, but occasionally a mercurial, guarded by the extract of belladonna, will furnish more marked relief. Powell and Copeland say that they have employed with decided advantage a purgative consisting of the compound infusion of gentian and infusion of senna, to which were added ten or twenty minims of liquor potassæ. This was repeated, so that four stools in the twenty-four hours were obtained. Clark preferred to regulate the bowels, when needed, with rhubarb, soda, and {775} ipecac, conjoined or not, as required, with mercury and chalk. Good recommends four grains of Plummer's pill every night, and the bowels kept open by two drachms of sublimed sulphur daily. It should always be borne in mind that all active or irritating purgatives are harmful. The bowels by this treatment will not only be disembarrassed of the membranous exudates, but also of any fecal collection the retention of which would surely cause irritation, as occasionally happens even when there is an apparent diarrhoea. This condition may be easily determined by abdominal palpation. The relief from pain procured by free evacuation of the intestine will be enhanced by the employment of hot fomentations to the abdomen. Despite these means, its severity may, however, demand the administration of narcotics. The best form will be a hypodermic injection of a sixth or a quarter of a grain of morphia; enemata of starch and laudanum are also beneficial. Burrows mentions a case in which he succeeded in allaying nervous irritation by the nightly use of thirty drops of laudanum. The patient noticed that the habitual constipation was increased when the accustomed narcotic was omitted. Bromide of potassium in large doses long continued will also be found useful for the same purpose.

During the intervals of the paroxysms local medication of the bowels and medical and hygienic measures should be had recourse to to prevent the re-formation of the exudates by modifying the vital activities of the intestinal mucous membrane and by restoring the general tone of the constitutional powers. For local treatment the nitrate of silver, sulphate of zinc, the sulphate of copper dissolved in glycerin, the tincture of iodine, and carbolic acid cannot be over-prized. From five to ten grains of the metallic salts, fifteen drops of tincture of iodine, ten of the acid, administered through the long rubber tube, are suitable doses to begin with. I am also in the habit of using stronger solutions by mopping it on to the bowel through the endoscopic tube. Kaempf made frequent and large injections of decoctions of various plants--saponaria, taraxacum, etc.--which he imagined possessed dissolvent and resolvent virtues. Cumming[40] speaks highly of the efficacy of electricity.

[Footnote 40: Lond. Med. Gazette, 3d Series, vol. ix.]

For the purpose of improving the general health the preparations of iron are advisable, of which the best are the tincture of the chloride, pernitrate, pyrophosphate, lactate, and potassio-tartrate. Habershon advises infusions of the bitter tonics with hydrocyanic and nitro-muriatic acid. I have found a combination of these acids with henbane and infusion of serpentaria useful. I also employ hot solutions of the latter acid as a local bath over the abdominal region, applied with a large sponge. Clark speaks favorably of the extract of nux vomica and astringent remedies. Simpson praises the oleo-resins under the form of pitch pills and tar, while Clark and others laud copaiba and turpentine. Good advises the copaiba to be given by enema when it cannot be borne by the stomach. Brodie used cubebs in small doses.

The alterative effects of small doses of arsenic, corrosive sublimate, sulphate of copper, etc. may be tried in obstinate cases. Grantham in the early stages of the complaint advises the use of ten grains of iodide of potassium combined with one-quarter of a grain of morphia at bed-time. He {776} also strongly urges the use of cod-liver oil, which, he says, improves the strength and increases the flesh, lessens the spasmodic pains, but does not check the discharges.

Counter-irritation of the abdominal region with tincture of iodine, fly blisters, mustard, etc. has afforded little if any advantage. Dunhill kept a blister open for six months without any good results.

The mineral waters of Pyrmont, Harrogate, and Carlsbad have been found serviceable; the latter, Henoch[41] says, should be preferred before all.

[Footnote 41: Klinik der Unterleub. Krankheiten, p. 668.]

The case will amend more speedily and surely by the adoption of those sanitary measures, as regards clothing, diet, bathing, exercise, and change of climate, which have such important influences upon health. The healthy performance of the functions of the skin is of such paramount necessity in maintaining that of the intestinal canal that the patient should endeavor to avoid any exposure likely to lead to checked perspiration, and should use flannel underwear and stimulate the skin by friction with the hand or the flesh-brush. The diet should be graded to the ability of the stomach to digest and the body to assimilate. Our chief reliance will be upon milk, plain or peptonized, eggs, and beef given in the various forms of acceptable preparations, so as not to impair the tone of the stomach nor clog the appetite by sameness. Such vegetables and fruits as agree with the patient may be allowed. I have tried exclusive diets of milk, farinacea, and meat without marked benefit. All stimulants, tea, and coffee should as a rule be interdicted.

Systematic exercise in the open air and change of climate to a cool, dry, bracing atmosphere will contribute to comfortable existence, if not lead to recovery.

{777}

DYSENTERY.

BY JAMES T. WHITTAKER, M.D.

DEFINITION.--Dysentery is the clinical expression of a disease of the large intestine, of specific and non-specific (catarrhal) origin and form; characterized by hyperæmia, infiltration, and necrosis (ulceration) of its mucous membrane; distinguished by discharges of mucus, blood, pus, and tissue-débris; and attended with griping and expulsive pains (tormina and tenesmus).

ETYMOLOGY.--The name is compounded of the two Greek words [Greek: dys enteron], which, though untranslatable literally into English, have long since received the exact Latin equivalent, difficultas intestinorum. With appropriate alteration the same name is still employed in every civilized language in the common as well as the classical description of the disease. The French synonym, colite, locates the anatomical seat of the disease, while the German Ruhr and the English flux express one of its cardinal symptoms, the frequency (flow) of the evacuations.

HISTORY.--Ancient.--In its clinical history dysentery is one of the oldest known diseases, the name being found in common use before the time of Hippocrates, as in the often-quoted passage from Herodotus (443 B.C.), who relates that it and the plague reduced the army of Xerxes on the desert plains of Thessaly.

Fayrer informs us that in the ancient system of Hindoo medicine of the Ayur Veda, and in the commentaries of Dhanwantari, Charaka, and Sussutra, which carry us back nearly three thousand years, and in later Sanskrit writers, dysentery is described by the name of atisar, under two forms--amapake, or acute, and pakistar, or chronic; these again are subdivided into six varieties, ascribed by those ancient sages to changes in air, bile, phlegm, food, or to perturbations of the emotions and passions.

Hippocrates (430 B.C.) makes frequent reference to the disease, the nature of which he regards as a descent of the humors from the brain. "Men of a phlegmatic temperament are liable to have dysenteries," he says, "and women also, from the humidity of their bodies, the phlegm descending downward from the brain."

"The disease is caused," he says more exactly in another place, "by the overflow of phlegm and bile to the veins of the belly, producing ulceration and erosion of the intestine." In his country, at least, it seemed most to prevail in spring, but it was clearly connected with the heat and moisture of this season in Greece--prime factors everywhere in the genesis of the disease: "For when suffocating heat sets in all of a {778} sudden while the earth is moistened by the vernal showers and by the south wind, the heat is necessarily doubled from the earth, which is thus soaked by the rain and heated by a burning sun, while at the same time men's bellies are not in an orderly state, nor is the brain properly dried." Of the prognosis he observes with great acumen, "Dysenteries when they set in with fever ... or with inflammation of the liver and hypochondrium or of the stomach, ... all these are bad. But such dysenteries as are of a beneficial nature and are attended with blood and scrapings of the bowels cease on the seventh or thirtieth day, or within that period. In such cases even a pregnant woman may recover and not suffer abortion;" whereas, "dysentery if it commence with black bile is mortal." Galen comments upon this statement that such a discharge is as incurable as cancer. The practitioner of our day will interpret this assertion, which was repeated with singular unanimity by all the writers of antiquity, with the belief that the black bile was blood, and that such cases really were cancers. Indeed, Paulus Ægineta distinctly says, "Dysentery arising from black bile is necessarily fatal, as indicating an ulcerated cancer."

Thus, although dysentery is among the oldest of the known maladies, and was recognized then as now by the same symptoms, the disease was by no means closely defined or differentiated in ancient times. As Ackermann long ago pointed out, many other affections were included under the term dysentery, and some of the symptoms of true dysentery, notably the tenesmus, were raised to the dignity of distinct diseases.

The gravity of the so-called lotura carnea, the fleshy stools, was fully appreciated by Hippocrates, as is evidenced by the remark that "if in a person ill of dysentery substances resembling flesh be discharged from the bowels, it is a mortal symptom." Fleshy masses, [Greek: xysmata], scrapings of the guts (originally epidermic exfoliations from the bodies of gladiators, used in pills as a tonic), were frequently alluded to by the older writers, more especially by Aretæus, in description of the discharges of dysentery. Hippocrates was also aware of the fact that dysentery may be a secondary as well as a primary malady. "One may expect," he says in speaking of the victims of gangrene, "that such patients will be attacked with dysentery; for dysentery usually supervenes in cases of mortification and of hemorrhage from wounds." Finally, Hippocrates recognized the effects of emesis in relief of the disease with the remark in one of his aphorisms that a spontaneous vomiting cures dysentery.

Celsus (25 B.C.-45 A.D.), the great encyclopædist, whose works "constitute the greatest literary monument since the days of Hippocrates," compiles all the information obtained up to his time; but it is plain as regards dysentery, though he defines it in terms that might stand in a modern text-book, that he has nothing new to add to the knowledge of the Hippocratic school. He named the disease from one of its most prominent symptoms, tormina (tenesmus he considered a separate affection), speaks of the stools as being mixed with mucus and fleshy masses, and in its treatment especially enjoins rest, "as all motion proves injurious to the ulcer."

Aretæus (50 A.D.), of all the authors of antiquity, wrote the most perfect and at the same time the most picturesque account of the morbid anatomy and symptomatology of this disease. The gross appearance of the ulcers in the intestine and the common character of the discharges he {779} describes with the accuracy of the modern pathologist and the ardor of the true clinician. He speaks of the superficial, the deep-seated, the irritable, and the callous ulcer. There is, he says, "another larger species of ulcers, with thick edges, rough, unequal, callous, as we would call a knot of wood; these are difficult to cure, for they do not readily cicatrize, and the cicatrices are easily dissolved." Their tendency to arrest and renewal and their general and local effects he notices at length. "There may be a postponement of their spreading for a long time," he says, "various changes taking place in the ulcers, some subsiding and others swelling up like waves in the sea. Such is the course of the ulcers; but if nature stand out and the physician co-operate, the spreading may indeed be stopped, and a fatal termination is not apprehended, but the intestines remain hard and callous, and the recovery of such cases is protracted." Vivid descriptions he gives of the stools: "Sometimes they are like chopped tallow, sometimes merely mucus, prurient, small, round, pungent, causing frequent dejections and a desire not without a pleasurable sensation, but with very scanty evacuations." Again, they are "fetid like a mortification;" composed of "food now undigested, as if only masticated by voracious teeth, ... the dejection being discharged with much flatulence and noise; it has the appearance of being larger than its actual amount."

Galen (164 A.D.) attempted to correct the pathology of his contemporaries, who considered all bloody discharges dysenteric. There are four distinct varieties of bloody stools, he claims, only one of which, that due to ulceration of the intestine, deserves to be called dysentery. The bilious stool he derived from melancholy, and the fleshy stool from disease of the liver. But, though Galen regarded the presence of blood as a necessity, he was well aware of the fact that the stools contained ingredients other than blood. It was Galen who first used the word scybala ([Greek: schybala], feces) to express the small, solid masses of excrementitious matter often voided with the stools. In his treatment of the disease he made much use of the various drying earths, the Samian, Lemnian, Armenian, the sources of which he made long journeys to visit in order to become better acquainted with their properties, and which are better substituted in our day by bismuth, chalk, magnesia, and the carbonate of iron. It is the distinguished merit of Galen to have called special attention to the anatomical seat of the disease. Ulceration of the intestine he claimed as the very essence of the disease, and all the physicians of his day, he maintained, regarded as dysenteric only such cases as are attended with ulceration.

Galen was the exponent of the flower of Grecian, we might say of ancient, medicine. With very few exceptions, the later writers, if they do not obscure the original text with their speculations, are content to simply paraphrase the observations of their predecessors, and the subsequent contributions to the ancient history of dysentery may be briefly summed up in a few additional notes.

Coelius Aurelianus (400 A.D.) adopted the humoralistic doctrine of Hippocrates and regarded dysentery as an intestinal rheumatism (catarrh) with ulceration. He seems to have been the first author to recognize the cardinal fact that dysentery, notwithstanding the number of its stools, should be classed with the diseases which constipate the bowels, or, as it {780} was centuries later aptly put by Stoll, "ut hanc morbis adnumeres alvum potius occludentibus," and he blames Erasistratus for using nothing but astringents, whereas many cases of dysentery require laxatives. It is worthy of note that Coelius Aurelianus ascribes the first use of opium in the treatment of dysentery to Diocles of Carystus (300 B.C.), who administered the juice of poppies combined with galls. By the time of Galen opium was so freely used in the treatment of the fluxes as to call for protest against its abuse.

Alexander of Tralles (575 A.D.) is often credited as having been the first to locate the disease in the large intestine. The truth is, he suggested various rules by which the seat of the disease, whether in the small or large intestine, might be definitely determined. But none of these rules--the seat of the pain, for instance, whether above or below the umbilicus, and the interval of time between the pain and discharges, whether long or short--possess the least diagnostic value or add to the attempts in this direction of previous writers--Aretæus, Archigenes, and Galen. Like these, his predecessors, he recognized an hepatic dysentery with discharges of bloody serum, which he attributed with them to atony of the liver, but more boldly than they, and with characteristic independence, he ventured to treat his patients with fresh vegetables and fruits, damsons and grapes.

Paul of Ægina (660 A.D.) locates the disease in the rectum, and gives a graphic account of its symptomatology. He made the mistake of many later practitioners in regarding as a separate disease a symptom, tenesmus, which he describes as an irresistible desire of evacuation, "discharging nothing but some bloody humor, which is the cause of the whole complaint, being an oedematous inflammation of the rectum which creates the impression of feces lodged in the intestine and a desire of evacuation." "Dysentery," he continues, "is an ulceration of the intestines, sometimes arising from the translation of tenesmus, and sometimes being of itself the primary affection; and is attended with evacuations at first bilious and of various colors, then accordingly bloody, and at last ichorous, like that which runs from dead bodies."

In curious contrast to these accurate observations is the absurd suggestion of an obsolete therapy (Galen), that the dried dung of dogs who had eaten bones, when drank in milk which has been curdled by having heated pebbles put into it, is of great service; but as an offset to this freak of fantasy is the renewed advocacy of warm milk, fallen somewhat into disuse since the days of Hippocrates and Galen: "And milk itself moderately boiled is an excellent thing"--a recommendation of the milk diet which now plays such an important rôle in the treatment of so many diseases of the alimentary canal.

Modern.--From this brief survey it is seen that the writers of antiquity left nothing in the symptomatology of dysentery for subsequent authors to describe. All further advance in our knowledge of this, as of all diseases, was now rendered impossible by the extinction of the light of science in the long night of the Middle Ages, whose gloom deepens with succeeding centuries and whose shadows fall close up to our own times.

The modern history of dysentery may be said to begin with Daniel Sennertus, whose first Tractatus de Dysenteria was published at {781} Wittenberg in 1626. Sennert gave the deathblow to tenesmus as a distinct disease, or as even a pathognomonic sign of dysentery, showing that it is often present in purely local troubles, ulcers, fissures, hemorrhoids, etc., or is due to disease of other organs--stone in the bladder, tumors in the womb, etc. He recognized sporadic and epidemic attacks of the disease, and described under the terms fiens and facta forms which coarsely correspond to the catarrhal and diphtheritic varieties of modern pathologists. Improper food, unripe fruits, at least, cannot be the cause of dysentery, because, he shrewdly observes, the epidemic of 1624 began in May, before the fruits were ripe, and ceased in autumn, when they were ripe and in daily use. Moreover, sucklings at the breast suffered with the disease. Nor could moisture alone account for the disease, as this epidemic occurred after an unusually hot and dry spring and early summer. Some other cause must be invoked, and this other cause is perhaps the occult influence of the constellations and planets--an explanation which he afterward admits to be only an asylum of ignorance. In the treatment of the disease the indication should be to heal the abraded or ulcerated intestine; but since this cannot be done unless the cause is first removed, "the abrading, eroding humor should be evacuated and absterged, at the same time its acrimony mitigated and corrected; then the flux should be checked by astringents, and the pain, if vehement, lenified and removed." Purgatives should be repeated until all vicious humors are discharged.

Sydenham colored his descriptions of the epidemic which he witnessed in London in 1669-72 with the artistic touches of the master's hand. "The disease sets in," he says, "with chills and shivers. After these come the heat of the fever, then gripings of the belly, and lastly stools. Occasionally there is no fever; in which case the gripes lead the way, and the purging follows soon after. Great torment of the belly and sinking of the intestines whenever motions are passed are constant; and these motions are frequent as well as distressing, the bowels coming down as they take place. They are always more slimy than stercoraceous, feces being rarely present, and when present causing but little pain. With these slimy motions appear streaks of blood, though not always. Sometimes, indeed, there is no passage of any blood whatever from first to last. Notwithstanding, provided that the motions be frequent, slimy, and attended with griping, the disease is a true bloody flux or dysentery." The efficacy of opium in its treatment causes him to break out in praises of the great God who has vouchsafed us a remedy of so much power. But Sydenham was too good a practitioner not to know that all treatment must be prefaced with laxatives. For "after I had diligently and maturely weighed in my mind," he says, "the various symptoms which occur during this disease, I discovered that it was a fever--a fever, indeed, of a kind of its own--turned inwardly upon the bowels. By means of this fever the hot and acrid humors contained in the mass of the blood, and irritating it accordingly, are deposited in the aforesaid parts through the meseraic arteries." The indications then were plain--viz. "after revulsion by venesection to draw off the acrid humors by purging." It was the frequent and successful practice of Sydenham also to drench the patient with liquids, per os et per rectum--a mode of treatment which both he and the learned Butler, who accompanied the {782} English ambassador to Morocco, where dysentery was always epidemic, hit upon, "neither of us borrowing our practice of the other." Butler declared that the method of deluging the dysentery by liquids was the best. But many attacks are cured almost on the expectant plan alone. This was the case with the excellent and learned Daniel Coxe, Doctor of Physic, in whom "the gripes and bloody motions ceased after the fourth clyster. He was kept to his bed, limited to milk diet; and this was all that was necessary in order to restore him to perfect health."

Zimmermann (1767) did not believe that improper food could be a cause of dysentery, as in the epidemic of 1765 fresh grapes were plentifully supplied to patients and proved an excellent remedy. He also noticed the muscular pains (rheumatism) which had been mentioned by Sydenham before him, and the paralyses first noticed by Fabricius in 1720, as occurring in the course of, or as sequelæ to, the disease. It was only contagious, he thought, in bad cases, when the stools have a cadaveric odor. But his main and most useful contributions were in the field of therapy. He discarded venesection entirely, was among the first to recognize the value of ipecacuanha, and objected strenuously to opium until the cause of the evil was expelled. Hence he was vehemently opposed to all astringents, to the use of which he ascribes the rheumatisms and dropsies which sometimes occur. Wines and spices were likewise put under ban; whey he permitted, but not milk, and water freely, but always warm. Barley-water and cream of tartar were sufficient food and medicine for ordinary cases, while camphor and cinchona best sustain the strength in bad cases.

Pringle (1772) observed the frequent occurrence of dysentery coincidently with malarial fever, and was a firm believer in the contagion of the disease. He claimed that the foul straw upon which the soldiers slept became infectious, but maintained that the chief source of infection were the privies "after they had received the dysenteric excrements of those who first sicken." It is spread in tents and in hospitals, and may be carried by bedding and clothing, as in the plague, small-pox, and measles. Neither food nor drink propagates the disease, he thinks, for, so far as the fruits are concerned, he too had seen it prevail before the fruits were ripe. The first cause of the disease is "a stoppage of the pores, checking the perspiration and turning inward of the humors upon the bowels." Antimony was his specific in its treatment. He was also fond of Dover's powder in its relief, and preferred fomentations to opium, which "only palliates and augments the cause." The best drink for patients with dysentery was lime-water (one-third) and milk.

This period of time is made memorable in the history of dysentery, as of nearly all internal diseases, by the contributions from direct observation upon the dead body by the father of pathological anatomy, John Baptist Morgagni (1779). From the days of Hippocrates down, the seat of the disease had been, as has been shown, pretty accurately determined, and the same acumen which enabled the clinicians to localize the affection had inspired them, as we have seen, to define and describe its nature. But any descriptions from actual post-mortem examinations were not put upon record until the beginning of the sixteenth century, when were published the posthumous contributions of Benivieni (1506-07). In his description of the lesions of the disease he says that "the viscera displayed {783} internal erosion from which sanies was continually discharged." Nearly three centuries elapsed before Morgagni made his anatomical studies--an interval of time void of any contributions from pathological anatomy; and so little attention was paid to this branch of medical science that the descriptions of Morgagni and of his more immediate successors failed to excite any general interest or make any permanent impression. Morgagni himself, while he fully recognized their significance, did not consider the ulcerations of dysentery as absolutely essential to the disease, as many cases, even fatal ones, did not exhibit them at all. They were not liable to be mistaken for the lesions of typhoid fever, the ulceration of Peyer's glands, because, though they may, they only rarely, coexist in the same subject. As to the membranous fragments sometimes evacuated with the discharges of dysentery, Morgagni showed that they are occasionally true fragments or shreds of the intestinal coats, as has been maintained by the older writers, Tulpius and Laucisius, but are far more frequently nothing else than inspissated mucus--conceptions which subsequent studies with the microscope have fully confirmed.

In view of the general disregard of direct observations, it is therefore not surprising to learn that the nature of the intestinal lesions gradually fell into oblivion or at least became underrated in its import. But it is a matter of surprise that Stoll (1780) was able to declare as the result of autopsies made by himself that, although the colon is thickened and inflamed, ulcerations in dysenteries are very rare. This distinguished author did not at all believe in the contagion of the disease, as he had never seen it attack physicians or nurses. It developed, he thought with the older writers, as the result of exposure to cold during a perspiration. He emphatically insisted upon the frequency of rheumatism as complicating the disease, and describes in proof a number of cases of painful swollen joints during and subsequent to the attack. It was his especial merit to have succeeded in dispensing with the acrid bile as a cause of the disease, maintaining that hepatic derangements were only accidental complications, and thus disposed, but only for a time, of bilious dysentery in so far as it was supposed to depend upon defective or abnormal action of the liver.

But Annesley (1828) soon reinstated the liver in the pathology of dysentery, with the exhibition of colored plates displaying abscess of the liver in connection with the disease, as well as illustrating the displacements and constrictions of the colon which sometimes occur in its course.

The fourth decade of our century now brought in the anatomical contributions of Cruveilhier and Rokitansky, to be followed later by those of Virchow, upon which the modern morbid anatomy of the disease is based; while the labors of the Indian physicians and of Copeland, Parkes, and Vaidy put us in possession of the facts pertaining to its general pathology. Fayrer has quite recently published the results of his vast experience with dysentery in India, an important contribution to the practical study of the disease, and Hirsch has treated exhaustively of its medical geography. But the merit of publication of the most complete chapter or work upon dysentery that has ever been written anywhere belongs to, and is the especial pride of, our own country. It constitutes the bulk of the second volume of the Medical and Surgical History of the War of the Rebellion. It is a veritable encyclopædia of knowledge, not {784} only upon the subject of which it treats, but upon all subjects immediately or even remotely collateral to it, and is a lasting monument to the labor and the learning of its author, Joseph J. Woodward, Surgeon of the United States Army.

GENERAL REMARKS.--Dysentery may be a primary or a secondary disease. As a primary disease it occurs in sporadic, endemic (often closely, sometimes curiously, circumscribed), or epidemic form, and is either acute or chronic, according to the nature of its symptoms and lesions. The ancient types of sthenic and asthenic or adynamic, typhoid, bilious, and malarial dysenteries belong rather to history than to modern medicine. The classification of cases in general use at present--viz. the catarrhal and croupous or diphtheritic forms--has reference rather exclusively to the nature of the lesion, and is hence extremely defective. Nor are the divisions (as in cholera) into sporadic and epidemic forms much more satisfactory, in that they indicate simply the range or extent of the disease, and by no means define a separate array of symptoms or lesions; precisely the same symptoms or lesions being encountered in individual cases of either form. None of these divisions clearly indicate differences in etiology, upon which factor alone can any acceptable division of cases be based. Perhaps less objection may be urged against the assumption of catarrhal and specific forms, including under the provisional term catarrhal all the cases which cannot as yet be accounted for by the action of a special or specific cause.

It will become apparent in the study of the etiology of dysentery that while any of the factors invoked may suffice to produce the catarrhal (sporadic) form, none will explain the specific (epidemic) form of the disease; both forms may be alike in their lesion and signs, but they differ widely in their cause. In other words, dysentery is only a clinical, and is in no way an etiological, expression of a disease. In this respect dysentery finds its analogue in a much grosser lesion of the bowels--namely, occlusion, acute or chronic, which, while it presents pretty much the same train of symptoms, may depend upon a great variety of causes, as impaction, strangulation, intussusception, etc. While any of the causes cited may be sufficient to excite the catarrhal form of the disease, the same causes may stand to the specific form only in the relation of predisposing agents. Or, as Maclean has better put it, "It appears that many of the so-called causes of dysentery must be regarded more as acute agents of propagation than of causation."

As a secondary disease dysentery occurs in the course of, or as a sequel to (not infrequently as the terminal affection of), pyæmia and septicæmia (puerperal fever), typhus and typhoid fevers, pneumonia, Bright's disease, variola, scarlatina, abscess of the liver (though the order of sequence is here oftener reversed), scorbutus, marasmus from any cause, tuberculosis, and cancer. It must not be forgotten, however, of these latter affections that each produces its own lesions in the large intestine, which are not to be confounded with those of genuine dysentery.

The view that dysentery shows a periodicity of recurrence at certain distinct intervals or cycles--three, five, or ten years--is entirely without foundation in fact; but there is strong ground for believing that the disease is gradually abating both in frequency and virulence with improvements in sanitation and hygiene. Thus, Heberden shows that the {785} number of deaths set down in the seventeenth century under the titles of bloody flux and gripings of the guts was never less than 1000 annually, and in some years exceeded 4000, whereas during the last century the number gradually dwindled down to 20 (Watson)--a number which is certainly a misprint for 200; and Aitken states that as a cause of death it has been decreasing since 1852. Geissler also remarks[1] that the variation in epidemics is nowhere so well illustrated as in the case of dysentery. A noticeable reduction in the number of cases in England began about 1850, and has continued almost without interruption to the present time, so that now (1880) six to eight times less cases occur than in the forties. The same diminution has been noticed in Bavaria and Sweden. In Sweden the cases treated by physicians in 1857 numbered no less than 37,000, with over 10,000 deaths; whereas now the number is reduced to 400-500 a year, and the mortality has experienced a corresponding reduction from 20-30 to 6-8 per cent.

[Footnote 1: Periodische Schwanderungen der wichtigsten Krankheiten.]

At the same time, it is known of dysentery that it sometimes shows an almost freakish recurrence after long intervals of time, appearing in a place for many decades free from the disease, to establish itself there for years as a regular endemic malady, not to disappear again for a long series of years; in which respect, Hirsch remarks, it much resembles malaria.

Allusion has been already made to the occasional curious circumscription of the disease in definite localities. In fact, dysentery, even when late to assume the proportions of a widespread epidemic, begins, as a rule, and is confined for a time, in individual enclosed regions--prisons, barracks, hospitals, etc.; and in the process of dissemination it is rather characteristic of the disease to leap over or to spare intervening territory and appear in new foci at some distance from its original seat. A direct irradiation or linear transmission of the disease is the exception, and not the rule. The significance of this fact will become evident in the study of the etiology of the disease.

Dysentery is pre-eminently a disease of army life, its victims among soldiers numbering more than all other diseases together. Sir James MacGrigor, Medical Superintendent of the British army, called it the scourge of armies and the most fatal of all their diseases. Aitken says that "it has followed the tracks of all the great armies which have traversed Europe during the continental wars of the past two hundred years." It decimated the French, Prussian, and Austrian armies in 1792. In Cape Colony in 1804 every fourth man among the soldiers was attacked with the disease, and of those attacked every fifth man died. In Napoleon's campaign in Egypt dysentery numbered one-half more victims than the plague; Kinglake says that 5000 men died of dysentery alone in the war of the Crimea; and in our own country during our Civil War from 1861-65 chronic camp dysentery was the cause of more than one-fourth of all the diseases reported, the mortality being at the rate of 12.36 per 1000.

Woodward relates that the dysenteries, acute and chronic, with diarrhoeas, made their appearance in the new regiments at the beginning of the war, and, though mild at first, quickly assumed a formidable character. "Soon no army could move without leaving behind it a host of the victims. They crowded the ambulance-trains, the railroad-cars, the {786} steamboats. In the general hospitals they were often more numerous than the sick from all other diseases, and rivalled the wounded in multitude. They abounded in the convalescent camps, and formed a large proportion of those discharged for disability." Most of the prisoners died of this disease, and great numbers succumbed to it on retirement to their homes after the cessation of the war. It is the story of many a campaign, Eichhorst says, that dysentery kills more men than the enemy's guns.

The fact that it sometimes shows itself in periodic form or with periodic exacerbation, that it is sometimes successfully treated with quinia, and that, as has been noticed from the days of Hippocrates down, it prevails in greatest intensity in malarial regions, has given rise to the view that dysentery is a malarial disease. This view, which was strongly advocated by many of the older writers, Senac, Fournier, Annesley, met with renewed support at the hands of many of the surgeons in our Civil War. But wider observation has shown the fallacy of such a view; for not only may the diseases prevail entirely independently of each other in malarial regions, but there are regions where one does and the other does not exist. Thus Huebner quotes from Rollo concerning St. Lucie (West Indies), a town situated on a mountain in the midst of a swampy country in which both dysentery and malaria abound, while the town itself is almost free from dysentery; and Dutrolan cites Réunion as a place where marsh fevers do not occur, while dysentery is very common. Bérenger-Féraud[2] scouts the idea of any such connection. "Let us mention only St. Pierre de la Martinique," he says, "where there is not a piece of marsh as big as a hand, but where dysentery has made great ravage more than once. We might cite also Mauritius, Gibraltar, Malta, New Caledonia--places exempt, or almost exempt, from malaria, but often visited by dysentery."

[Footnote 2: Traité théorique et clinique de la Dysenterie, etc., Paris, 1883.]

The view that dysentery is a form of typhus or typhoid fever (Eisenmann) or scurvy needs no refutation in the light of existing knowledge regarding the pathogenesis and pathology of these affections. These diseases may often complicate, but can never cause, dysentery.

Dysentery is a disease which spares no age, sex, or social condition, the seeming greater suffering of the poorer classes being due to the filth, food, darkness, dampness--in short, to the bad sanitation--of poverty.

Though the disease is often confined exclusively to soldiers in the midst of a civil population, examples are not wanting of an exclusive selection of civilians or of an indiscriminate attack in every direction. Lastly, dysentery is a disease which may recur repeatedly in the same individual, one attack rather predisposing to than preventing another.

ETIOLOGY.--Dysentery is an omnipresent disease. "Wherever man is," Ayres observed of it nearly a quarter of a century ago, "there will some of its forms appear." But the character of the form, and more especially the extent and severity of the disease, vary in extreme degree with the conditions surrounding the abode of man. No one of these conditions affects the disease so markedly as the climate. It is the testimony of Hirsch, based upon the study of seven hundred epidemics of the disease, that no other disease is so dependent upon the influence of the climate. The home of dysentery is the tropical zone. It prevails in greatest frequency {787} and virulence in the tropics, and in those regions of the tropics where the characteristics of this zone are more pronounced, diminishes in intensity in the temperate regions, and occurs only in sporadic form farther north. At 40° latitude the line may be pretty sharply drawn; beyond it dysentery as an epidemic is almost unknown.[3]

[Footnote 3: Shakespeare (Troilus and Cressida) cites "griping of the guts" among the "rotten diseases of the south."]

India has been from time immemorial the hotbed of this disease. Henderson says it is perhaps more fatal to natives than all other diseases put together, and Hutchinson, Hunter, and Tytler observe that it causes three-fourths of the deaths among the natives of Hindostan. In Egypt the disease is indigenous, and is, according to Frank, post pestem maxime timendus. Greisinger reports that one-half of all the autopsies made by him in Egypt showed dysentery as a primary or secondary affection. It is epidemic here at all times, Roser says, and all fatal cases of acute or chronic disease finally perish with it.

Similar testimony might be adduced from a large part of Africa, much of Asia, the Indian Archipelago, and the West Indies. It rages "murderously" in Peru, causing a mortality in some epidemics of 60 to 80 per cent., and occurs in this country not only in the valleys, but in cities and provinces at the lofty elevation of 8000 to 13,000 feet.

Heat, moisture, vegetable decomposition, and sudden atmospheric change are the distinguishing characteristics of southern climes, and the study of the etiology of a disease incident or indigenous to these conditions calls for an investigation of these various factors.

It is well established of dysentery that it occurs for the most part in the hottest season of the year. Of 546 epidemics tabulated by Hirsch, 404 prevailed in summer and fall, 113 in fall and winter, 16 in spring and summer, and only 13 in winter. Fourteen-fifteenths of the whole number of epidemics occurred in the months of June to September. And it is corroborative of these conclusions that of 1500 deaths from dysentery in the cities of Boston, New York, Philadelphia, and Baltimore from 1816 to 1827, 1100 occurred in the months of July, August, and September. In fact, the Census Reports (1860-70) of our country show the maximum mortality in August and September, and the minimum in January and February.

The prevalence of unusual heat may also call out an epidemic in places where the disease usually shows itself only in endemic or sporadic form. Thus, the severe epidemic of 1540 in England was preceded by a heat so intense as to dry up the wells and small streams, in consequence of which many cattle died of thirst; and the epidemics of 1583 in Germany, of 1758 in France, and of 1847 in our own country, were characterized in the same way. Interesting in this connection is the statement of Frick concerning the epidemic in Baltimore in 1849, who found the cases to increase and decrease almost in proportion to the elevation and depression of temperature. The epidemic of Weimar in 1868, where 12,000 people fell ill with the disease, illustrated the rule when it ceased suddenly on the approach of cool weather at the end of August.

But that heat alone is not sufficient to account for the genesis of the disease is apparent from the occasional occurrence of it in the tropics in the colder seasons of the year; in the colder climates, Russia, Sweden, {788} and Canada; and in temperate regions during exceptionally cool seasons, as in Plymouth in 1769, London in 1808, Massachusetts in 1817. Moreover, the temperate zone is often characterized by seasons of unusual heat, during the prevalence of which dysentery may be almost unknown. Thus, during the summer of 1881, in Cincinnati, the thermometer scarcely fell below 95° F. for weeks at a time, and was often nearly 100° during the entire night, but the records at the Health Office show that while cases of heatstroke were alarmingly frequent, dysentery was unusually rare during the entire season.

That moisture cannot act more, at most, than as an occasional predisposing cause of dysentery is sufficiently clear from the statement of Hirsch, that of 119 epidemics, 62 commenced or were preceded by wet and 57 by dry weather. In truth, dryness long continued and excessive heat have already been invoked as remote causes of the disease. But moisture, as contributing to, or being a necessary element of, vegetable decomposition, the third characteristic of tropical regions, is entitled to further consideration. Annesley observed that among troops stationed in the vicinity of rivers, canals, and places abounding with emanations from the decay of animal and vegetable matters dysentery became extremely prevalent and assumed a more or less malignant nature; and Baly, who studied the disease in its famous outbreak in the Milbank Penitentiary, remarks that "it is greatest at those seasons and in those states of the atmosphere which most favor decomposition of organic matter in the soil."

In Africa it has been noticed that dysentery appears with the rainy season, to disappear only at its close; and the same observation has been made of Bengal, while in Lower Egypt the disease follows the inundations of the Nile. Burkhardt says of 10,000 cases that one-half occur in wet hot seasons, two-fifths in dry hot seasons, and but one-tenth in cold seasons. Moreover, the removal of camping-grounds to dry localities has often arrested the disease or checked its further dissemination. Thus, Mursinna states that the removal of the army of Prince Henry of Hesse from Nîmes, where the disease raged fearfully, to Leitmeritz was attended by its immediate cessation, notwithstanding the fact that the soldiers ate large quantities of fruit. A statement of Dillenius, quoted by Heubner, is in this connection exceedingly instructive: "Dillenius had to march with a dysentery hospital of more than 500 patients from July 26 to August 3, 1812, and it required four whole days to accomplish an ordinary nine or ten hours' march. The patients, extremely exhausted, were finally put into a sheep-shed. Here, in the fresh air and lying on hay, they all improved very quickly. By advice of the physician they ate for medicine the fresh whortleberries which they themselves had picked." Werneck attributes the exemption of the city of Halle since the end of the last century to the draining and drying of the neighboring marshes.

On the other hand, numerous observations go to prove that dysentery is likewise prevalent in dry sandy soils where the factors so necessary to the production of malaria are entirely unknown. Thus, Hirsch quotes from Harthill to the effect that dysentery never occurred among the English troops in Afghanistan until they entered upon its thoroughly dry and sandy plains; and from Lidell, who declared that the disease prevailed most in Panama in March, the dry season at this place. Again, a striking confirmation of exemption from dysentery in a marshy region {789} is offered in the Antilles at Grande-Terre, "a wet, marshy plain severely visited by malaria, but used by patients attacked with chronic dysentery at Basse-Terre as the safest place of refuge and recovery."

The rôle of moisture and vegetable decomposition may be, then, summed up in the words of Annesley, that "all situations which furnish exhalations from the decay of animal or vegetable productions under the operation of a moist and hot state of the atmosphere will always occasion dysentery in the predisposed subject--circumstances which, with other causes [italics ours], combine to generate the disease."

Atmospheric vicissitudes, checking of perspiration, catching cold, are synonyms in the present popular as in the ancient professional conception of the genesis of dysentery. "Of the remote causes of dysentery," Johnson says, "I need say little; they are the same in all parts of the world--atmospheric vicissitudes." And in making this statement the author expresses the almost universal testimony of the Indian physicians. "Sudden change of temperature," observes Kaputschinsky of the Trans-Caucasus, where dysentery is rife, "is in this region no rarity. The sultry heat of noon often alternates with a cutting cold wind, and vice versâ. In the same place is now a warm, now a cold, now a glowing hot breeze, and such changes most predispose to dysentery." And McMullin says of the Barbadoes that "it is a curious fact that this disease is most prevalent where from the immediate contiguity of mountains sudden vicissitudes of temperature are experienced." Didelot says also of South France, "It is not the fruits, as people still believe to-day, which act as causes of dysentery, but the sudden variations of the air." Ruthay remarks of the dysentery of China that the most common cause is a chill caught by sleeping in a draught uncovered or in the open air. Metzler attributes the exemption of Stuttgart (since 1811) from any great epidemic to the fact that the city lies in a valley open only to the east, which permits no contrast of hot days and cold nights; and Seeger, in speaking of the epidemic which occurred in Ludwigsberg in 1872 (a city of twelve thousand population, where no epidemic of any kind had appeared since 1834, and where 870 were suddenly attacked with dysentery) that it first broke out in Kaffeeburg in two streets exposed to the wind, and thence spread to different parts of the city. Exposure of the body, especially the abdomen, during sleep or when perspiring, the sudden laying aside of flannel body-clothes, are proceedings, Fayrer says, pregnant with danger in dysenteric regions. A lamentable dysentery appeared, according to Trotter, on board H.M.S. Berwick Oct., 1780, "in consequence of the hurricane on the fifth of the month, by which the clothes and bedding of the seamen, and indeed all parts of the ship, were soaked in water, and many of the men slept for nights together on the wet decks overcome with fatigue and debilitated from want of food." Fayrer also quotes from Moseley the observation that "it often happens that hundreds of men in a camp have been seized with the dysentery almost at the same time after one shower of rain or from lying one night in the wet and cold."

As illustrating the conjoined operation of all these various causes, together with filth and foul effluvia, more especially exposure to cold, the story of dysentery was never better told than by Sir James MacGrigor, who, in speaking of the Peninsular campaign, remarks that "the army during June as well as July was traversing Castile, where it was {790} exposed to the direct influence of a burning sun darting its rays through a sky without a single cloud, the troops marching and fighting during the day, and bivouacking during the night on arid, unsheltered plains. They felt at times every vicissitude of heat and cold. In the rapid advance they could not be regularly supplied with food or had not time to cook it, and not unfrequently indulged in bad wine and unripe fruit." ... The thousands of sick (chiefly from diarrhoea, dysentery, and remittent fever) were hurried off to Ciudad Rodrigo, the nearest hospital-station to the frontier of Portugal, a town "composed chiefly of ruins with very narrow streets," ... and from having been "so much the object of contest, and alternately the site of the hospitals of all the contending armies, nearly twenty thousand bodies were calculated to have been put into the earth either in the town or under its walls in the course of a few months." ... "It may easily be conceived," the author adds, "in what state cases of dysentery must have arrived after having sustained a journey in extent from four to twenty days, conveyed chiefly in bullock-carts or on the backs of mules, sometimes under incessant rain for several days together."

It is really quite superfluous to cite further opinions or examples in illustration of a fact which is so universally conceded as to be exaggerated in its general significance. Taking cold is the common idea of the cause of dysentery, and is always a satisfactory explanation in a case of obscure origin in this or any disease, even though the patient may be able to recall no possible exposure. The physician himself contents himself only too easily with resort to this refuge, and with further appeal to the locus minoris resistentiæ, as the explanation of the seat of the disease, which he hopes to cure with the aid of the vis medicatrix naturæ. But taking cold is only a popular paraphrase for contracting a disease, and will bear no scientific analysis of its meaning. Mere reduction of temperature will certainly not produce a disease whose habitat is the hottest zone, nor will a sudden chill of the surface be accepted as a sufficient cause so long as men daily remain exempt after a sudden plunge into cold water. Some other factor must be invoked to account for the outbreak of specific (epidemic) dysentery.

The influence of the nervous system, the mechanical and chemical or specific action of the ingesta and dejecta, remain to be especially considered in the etiology of the disease.

The influence of the nervous system is more directly seen in the production of diarrhoeas than dysenteries, but that sustained disturbances of the emotions play an important part in the production of dysentery is shown by the greater frequency of the disease among prisoners of war. In the Franco-Prussian war the French prisoners suffered more than the Germans, and the records of prison-life in our own war, at Andersonville, Libby, and Salisbury, furnish ghastly chapters in the history of this disease. Many other factors contribute to the development of the disease under such circumstances--in fact, all the cruelties of man's inhumanity to man--but the influence of the nervous system is too plain to be mistaken. The communication between the cervical ganglia and the sympathetic nerve-fibres which preside over the cerebral circulation and regulate intestinal peristalsis has been invoked (Glax) in explanation of the direct action of the brain upon the intestinal canal. Curious in this {791} connection is the claim of Savignac, who considered dysentery a disease of the nervous system because in two cases he found spots of softening in the spinal cord.

The noxious action of irritating articles of diet has been recognized in the production of dysentery from the earliest times. Aretæus mentions acrid foods, and Aëtius crudities, as directly causing the disease; and unripe fruits have been especially stigmatized from the days of Galen down. Decomposing, fermenting food and drink cause diarrhoea much more frequently than dysentery, but if the irritation be severe or prolonged, or be superimposed upon a catarrhal state, a diarrhoea, it is claimed, may pass over into dysentery. Impurities in drinking-water were charged with causing dysentery by Hippocrates himself, with whom Avicenna fully coincided; and the view that epidemics of the disease are caused in this way has been abundantly advocated ever since. So far as running water is concerned, the researches of Pettenkofer have shown that all impurities are speedily destroyed, for even at the distance of a few rods from the reception of sewage the water is perfectly safe. Nor does standing water lack the means of purification, provided it be sufficiently exposed to the air. The observations of Roth and Lex have shown that the water of the wells of fifteen churchyards in Berlin contained nitrates in less quantity than the average wells in the city; and Fleck made a similar statement with regard to the wells of Dresden. But no one in our day would rely upon a mere chemical analysis in the detection of the organic poisons or particles of disease. It is the physiological test which remains the most conclusive, and the evidence in favor of the production of dysentery by the ingestion of drinking-water poisoned by the reception of excrementitious matter, especially the dejecta of disease, is as positive as in the case of typhoid fever. Thus, De Renzy found that the number of cases of dysentery "immediately decreased at Sibsagor (India) so soon as better drinking-water was obtained from wells deeply sunk and lined with earthenware glazed pipes;" and Payne found that the cases of dysentery (as well as diarrhoea and lumbrici) almost disappeared from the asylum at Calcutta as soon as the habit of drinking water from the latrines was stopped. In face of such facts, which might be infinitely multiplied, one would hesitate to subscribe to the statement of Fergusson that "true dysentery is the offspring of heat and moisture, of moist cold in any shape after excessive heat; but nothing that a man could put into him would ever give him a true dysentery."

The relation of the action of the dejecta must be studied from the double standpoint of the development and the dissemination of the disease, as originating the catarrhal form by mechanical or chemical irritation of the intestinal mucosa, and as spreading the specific form by direct or indirect infection.

By the time the contents of the alimentary canal have reached the colon they have become, through absorption of their fluids, more or less inspissated, and hence as hard, globular masses fill the sacculi of the large intestine. Mechanical irritations by crude, indigestible residue of any kind of food, more especially of vegetable food, or chemical irritations, as by fermenting food, accumulate in this region, fret the mucous membrane into a state of inflammation, even ulceration, and produce the anatomical picture and the clinical signs of dysentery. If there be a superadded or {792} pre-existent catarrhal condition of the mucosa or a defective peristalsis of the muscular coat, which is sluggish enough at best, the development of a pathological state is much facilitated. And there is no doubt that the dysentery of the tropics is increased by the bulky, indigestible, feces-producing character of the food.

The anatomical construction of the colon may also favor these processes by its mere abnormal length or size or by duplicatures in its course. The protracted constipation of the insane, in whom the transverse colon is often found elongated or displaced--to assume the well-known M-form, for instance--may partially account for the frequency of dysentery in these cases (Virchow), though the neglect which comes of preoccupation of the mind, with the general inhibition of peristalsis, is a more frequent cause of the constipation.

Wernich (1879) sums up the action of the feces, independently of a specific cause, in attributing the dysentery of the tropics, aside from the great changes of temperature, to (1) bad aborts, the dejecta being deposited in all parts of the towns or into an opening made in the floor of the hut, with which is associated total lack of personal cleanliness; (2) to the diet, which causes a large amount of feces; and (3) to the relaxation of the intestine in general, permitting accumulations of infecting matter.

Upon the question of the propagation of the disease by the dejecta rest in great measure the all-important problems of a specific virus and of the contagiousness of the disease.

It is the almost universal opinion of those who have had the opportunity of widest observation that epidemic dysentery arises from, or is due to, a specific cause, a miasm, a malaria (in its wide etymologic sense, bad air), which emanates from the soil. The simultaneous sudden attack of great numbers under the most diverse surroundings admits of explanation in no other way. But the precise nature of the morbific agent is still unknown. The similarity of epidemic dysentery to malaria would indicate the existence of a low form of vegetable life, a schizomycete, as the direct cause of the disease. But the proof of the presence of a specific parasite or germ is still lacking, and though its speedy disclosure by means of the solid-culture soils may be confidently predicted, it cannot, in the light of existing knowledge, be declared as yet.

Especial difficulty is encountered in the study of micro-organisms in diseases of the alimentary canal because of the myriad variety in enormous numbers found in healthy stools. Decomposition and fermentation both begin in the large intestine, so that the feces swarm with the bacteria and torulæ productive of these processes. Woodward declares that his own observations have satisfied him that "a large part of the substance of the normal human feces is made up of these low forms in numbers which must be estimated by hundreds of millions in the feces of each day," bacteria, micrococci, and torulæ being found "floating in countless multitudes along with fragments of partly-digested muscular fibres and other débris from the food;" but while the torulæ are increased, the other micro-organisms, bacteria, etc., do not appear to be more numerous in the stools of dysentery than in healthy feces.

The doctrine that dysentery depends upon parasites is very old in medicine, and included animal as well as vegetable growths. Langius (1659) declared that swarms of worms could be found in dysenteric stools, and {793} Nyander (1760) went so far as to call dysentery a scabies intestinorum interna; which extravagant conception would have speedily met with merited oblivion had not his preceptor, the great Linnæus, incorporated the Acarus dysenteriæ into his Systema Naturæ. Sydenham about this time (1670) expressed a much clearer conviction of the cause of the disease when he spoke of "particles mixed with the atmosphere which war against health and which determine epidemic constitutions."

Baly (1849) first proclaimed the idea of a vegetable fungus, similar to that described by Brittan and Swayne in cholera, as the parasite of the disease; and Salisbury (1865) described algoid cells and species of confervæ as occurring abundantly in all well-marked cases. Klebs (1867) found spore-heaps and rod-like bacteria in the stools of dysentery as in cholera, but maintained that those of dysentery were larger and thinner than those of cholera. Hallier (1869) maintained that although there was no morphological difference in the micro-organisms of the stools of dysentery, typhoid fever, and cholera, he was able by culture-experiments to develop the micrococcus of dysentery into a special fungus, which he called Leïosporium dysentericum. Busch (1868) demonstrated nests and colonies of micrococci, as well as mycelium, in the villi and among the glands of the mucous and submucous tissues in the cases of dysentery from Mexico which he examined, but Heubner (1870) was able to disclose them in equal numbers in preserved preparations or fresh contents of healthy intestines. Dyer[4] (1870) believes that the parasites constituting the mildew or sweat which forms a viscous pellicle upon fruit is the agent which directly produces and propagates the disease. Mere immaturity of fruit gives rise only to diarrhoea. This parasite occurs in some years more than others, which accounts for the irregularity of occurrence of the disease. He avers that it is only necessary to clean fruit, more especially plums, to prevent the disease. This suggestion merits place only as a curiosity in the history of the mycology of dysentery.

[Footnote 4: Journal f. Kinderkrankheiten, No. 317.]

More important are the results of the experiments of Rajewski (1875), who found the lymph-spaces filled with bacteria, and who was able to produce a diphtheritic exudation upon the surface and in the substance of the mucous membrane of the colon by the injection of fluids impregnated with bacteria into the bowels or blood of rabbits; but this result was only obtained when the mucous membrane had been previously irritated or brought into a catarrhal state by the introduction of dilute solutions of ammonia. It remains for subsequent investigation to confirm these highly significant conclusions, which, when properly interpreted, may explain the action of the predisposing and exciting causes of the disease. Rajewski's bacteria, it is needless to state, were simply the bacteria of common putrefaction. Lastly, Prior (1883) describes a micrococcus as the special micro-organism of dysentery, and Koch (1883), in prosecuting his studies of cholera in Egypt, remarks incidentally upon a special bacillus which he encountered in the intestinal canal in dysentery, though he is as yet by no means prepared to ascribe to it pathogenetic properties.

The question of contagion hinges upon the specificness of the disease, and cannot be definitely determined until this problem is finally solved. The old writers believed in the contagion of dysentery. Helidæus {794} declared that he "had often seen it communicated by the use of clyster-pipes previously used in the treatment of those suffering with the disease, and not properly cleaned;" and Horstius and Hildanus speak of the communicability of the disease from the latrines contaminated by dysenteric excreta. Van Swieten maintained that washerwomen contract it, and that physicians and nurses might be affected. Degner saw the disease spread from street to street in Nimeguen, while every one who came in contact with the disease became affected. Pringle observed it spread from tent to tent in the same way; and Tissot went so far as to declare, "Sil ya une maladie veritablement contagieuse c'est celle ci." Ziemssen believed that the disease is only contagious when the element of crowd-poisoning is superadded; and Heubner states that trustworthy army surgeons in the Franco-Prussian War frequently saw infection occur when many severe cases were heaped together in a small space. Under these circumstances thorough disinfection of the privies checked the spread of the disease. But it was the universal testimony of these surgeons, as also of our own surgeons of the Civil War, that the disease was never transported to the civil population by any of the tens of thousands of cases on their return to their homes.

By most modern writers dysentery is given a place, in respect to contagion, between the exanthematous maladies, typhus and scarlatina, which are without doubt contagious, and the purely miasmatic diseases, malarial and yellow fevers, which are without doubt not contagious. Dysentery is ranked with typhoid fever, which is contagious, not by contact with the body, but with the discharges. It is not a question in dysentery of epithelial drift or pulmonary exhalations, but of ingestion or reception of the dejecta of the disease. By this observation it is intended to convey the impression that dysentery, like typhoid fever, is mostly spread in this way, but the reverse may be true; it may be spread, like yellow fever and malaria, by poisons in the air. But dysentery, as has been repeatedly remarked, is only a clinical expression of a disease which may be caused in many ways; and among these causes, least potent perhaps, but present nevertheless, is contagion. For, not to mention the epidemics which were undoubtedly spread in this way, as among the Allies at Valmy in 1792, among the French in Poland in 1807, and in the hospital at Metz in 1870, dysentery has been directly communicated by the use of clysters, bed-pans, and privies in a most unmistakable way.

According to Eichhorst, the poison of dysentery is endowed with extraordinary persistence of duration or tenacity of life in the stools; for "observations are recorded where dysenteric stools have been emptied into privies, and individuals employed to clean them out after the lapse of ten years have been infected with the disease. These observations go to prove, of this as of other similar affections (typhoid fever), that the virus or microbe of the disease finds its most favorable nidus in vaults, cesspools, sewers, etc. When the poison is exposed to the air it is much more speedily destroyed, but is in the mean time of course a possible conveyer of the disease." Fayrer quotes from an anonymous writer, "whose views are as remarkable for their force as for their originality," the rather extravagant assertion that "if human excrement be not exposed to the air there can be no dysentery."

{795} Knoewenagel has recently[5] opened up a new series of reflections in his suggestion of a possible direct infection of the large intestine per rectum, where the disease usually begins and is mostly best expressed. He calls attention to the fact that people who suffer with constipation indulge in longer sessions at stools and induce in straining efforts a degree of relaxation of the rectal mucosa. The mucous membrane at its orifice may become at the same time abraded by hardened fecal masses, to leave open surfaces or crevices upon which germs may lodge. Moreover, aspiration follows the efforts at expulsion, and the air with its particles is drawn directly into the rectum, thus affording all the conditions for immediate or direct infection.

[Footnote 5: Schmidt's Jahrbucher, Sept. 25, 1882.]

At any rate, it must be admitted that the evidence in favor of contagion is in some cases too strong to be ignored. A single instance may suffice for illustration: Flügel reports that the towns of Nordhaben and Reichenbach, containing together twenty-two hundred inhabitants, were visited by dysentery in 1873, when nearly four hundred people were attacked. The visit of a relative carried the disease from Reichenbach to the daughter of an innkeeper at Tauchnitz, and from this house the disease spread over the whole place, so that in a short time more than one hundred people fell ill. Four to six, sometimes as many as eleven, members of one family were successively or simultaneously affected. The use of the same bed was the surest means of contagion.

The duration of the poison was proven in an exquisite case, which is, however, not entirely free from objection: Two children of an officer were severely affected in September and October, 1872. In January, 1873, the house was vacated and occupied by a successor in office, whereupon in April, six months after dysentery had disappeared from the place, the wife and child of the second officer were affected with the disease.

To sum up the etiology of dysentery in a few words, it may be said that few chapters in medicine are so thoroughly unsatisfactory, as the prospect of reconciling the accumulated discordant facts is very discouraging. Because of the singular uniformity in the symptoms and lesions the temptation is strong to look for a common cause, and to ascribe all cases to this cause, explaining differences by degree rather than by kind. Such a view would find solid support in the assumption of a specific germ, and would ally dysentery with typhoid fever, a disease which has likewise, in all cases, uniform symptoms and lesions, and which prevails in both sporadic and epidemic form. The advocates of this view would fix the poison of the disease in the air and alimentary canal (but not in the blood), and explain the existence of individual cases, as well as the prevalence of epidemics, by meteorological conditions as affecting the growth or dissemination of specific germs. Nor would the adoption of this view exclude the possibility of producing the catarrhal (sporadic) cases by many kinds of noxious germs, including those of common putrefaction. Hot air and wet air are notorious bearers and breeders of germs, and the law of gravity keeps them near the surface of the earth--conditions which coincide with the prevalence of the disease in the tropics and among individuals (soldiers) who sleep upon the ground. If the contagion of the disease be admitted, the existence of a {796} contagium animatum is implied at once, for no chemical poison has the power of propagation.

But the germ of dysentery has not been found as yet, and until it has been found, cultivated in suitable soil, and inoculated to produce the disease, the evidence of its existence remains merely presumptive.

So that at the present time dysentery must be regarded as a malady which stands in closer relation to, or finds a better analogue in, cholera than typhoid fever; for cholera is a disease which has the same geography, has likewise nearly uniform symptoms and lesions, so far as it leaves any, and certainly has two distinct forms of origin--one clearly specific, cholera Asiatica, and the other catarrhal, cholera morbus.

PATHOLOGY.--Dysentery is a local malady, but, like every local malady if sufficiently severe, it may show constitutional effects. It is usually gradually ushered in from a lighter form of gastro-intestinal catarrh. After a stage of incubation which lasts from a few hours to a few days symptoms of dyspepsia and diarrhoea set in or increase, attended with anorexia, heartburn, nausea, eructation or borborygmi, pain in the abdomen, and copious fluid discharges. Hereupon ensue the pains and the discharges characteristic of the disease. Violent griping and colicky pains (tormina) traverse the abdomen, with sickening sensations of depression. The desire of evacuation of the bowels (tenesmus) becomes intense and more or less constant, and the discharge itself is attended with little or no relief. At the same time the region of the rectum, intensely inflamed, is the seat of intolerable burning pain, which becomes excruciating with the introduction of a speculum or the finger.

The discharges may be copious, dark-brown, thin, and highly offensive (bilious dysentery), may contain occasional hard round fecal casts of intestinal sacculi (scybalæ), or may become more and more scant, until with the most violent efforts only the minutest quantity is extruded of mucus, generally streaked or tinged with blood (rose mucus) like the rusty sputum of pneumonia. Later, all effort at emptying the alimentary canal may be futile (dysenteria sicca), or the mucus may be pure or commingled with pus to remain perfectly colorless (dysenteria alba), or with blood in larger quantity (dysenteria rubra). In other cases, or at other periods in the same case, the discharges consist of fleshy masses composed of inspissated mucus or pus, blood, and tissue-débris (lotura carnea). Sometimes, though rarely, the discharges consist of pure blood, but oftener of a copious turbid fluid, which on standing separates into a clear upper layer of serum and a sediment of disintegrated lotura carnea. Or, lastly, the sediment is composed of small round vitreous masses, evidently swollen by maceration to look like sago-grains, which have been erroneously supposed to represent the liberated contents of the intestinal follicles.

The general condition of the patient suffers correspondingly. There may be fever or there may be none throughout the whole course of the disease, but the pain and discharges quickly exhaust the strength of the patient, and in severe or long-continued cases lead to emaciation and profound prostration.

The skin is hot and dry; the tongue is heavily coated; the face wears an anxious expression. The abdomen is tumid with gases, or in more advanced cases sunken, discolored, and tender, especially in the course {797} of the colon, whose thickened walls may often be felt beneath the emaciated surface. The anus is spasmodically constricted, or in the worst cases paralyzed, patulous, and livid or blue. Prolapse of the rectum is common in children, and excoriation of the perineum by the acrid discharges is not infrequent.

Finally, a typhoid state may set in or a pyæmia occur, when the discharges may become involuntary or unconscious, and brain symptoms--insomnia, stupor, delirium, and coma--supervene; or the patient may linger long enough to perish by simple exhaustion or marasmus.

Under favorable hygiene the great majority of cases of catarrhal dysentery recover without special treatment in the course of from three to ten days, but specific dysentery has no definite duration and but little tendency to spontaneous cure. The worst cases are often quickly controlled by appropriate interference, and the most surprising results may be sometimes obtained in cases of even years' duration. On the other hand, a certain percentage of cases is characterized by a defiance to every kind of treatment, including the last resort, a change of climate.

An acute case of catarrhal dysentery generally subsides without lesions, and the natural duration of the attack may be much abbreviated by proper treatment. Specific or epidemic dysentery lasts from two to four weeks, or, becoming chronic, continues for years or for life, with exacerbations and remissions.

Various complications are liable to occur in the course of the disease. Three deserve especial mention--viz. affection of the joints (rheumatism), paralysis, and abscess of the liver. Perforation and peritonitis, always possibilities, and deformities of the colon, thickenings, and constrictions, are not infrequently left.

MORBID ANATOMY.--The lesions of dysentery are the ordinary signs of inflammation of a mucous membrane and its subjacent structures. They do not differ in any essential way from those of any mucous surface in a state of inflammation, the minor variations being due to differences in the anatomy and physiology of the part affected. Thus, a description of the pathological process in inflammation of the pharynx, bronchi, or uterus would answer upon the post-mortem table for the same process in the large intestine, and the finer microscopic lesions could be differentiated in any case only by the histology of the part affected.

A slight lesion of any mucous membrane constitutes what is known as a catarrhal process; a more grave affection, a diphtheritic process; a more chronic inflammation, a hypertrophic or hyperplastic process. Hence an easy distinction between sporadic and epidemic cases might be based upon the character of the lesion found. But, as has been stated already, it is impossible to draw a line between catarrhal and specific cases, the same lesions being found in either form. The difference, so far as the morbid anatomy is concerned, is wholly in degree or stage, and not at all in kind, the specific (epidemic) form presenting the graver lesion as a rule. So most cases of sporadic dysentery show only catarrhal lesions, while most cases of epidemic dysentery show diphtheritic lesions.

Catarrhal dysentery shows as its first obvious alteration a hyperæmia of the mucous surface. It is limited exclusively to the large intestine in the vast majority of cases, and only in rare exceptions affects the small intestine, though cases have been mentioned as curiosities in which the {798} process has reached the stomach in its upmost prolongation. The hyperæmia is most marked, as a rule, in the lowest parts of the large intestine, the rectum and descending colon, but there is, as Virchow has pointed out, a peculiar predisposition to affection at the seat of all the flexures, the iliac, hepatic, splenic, sigmoid, where the additional element of fecal arrest or impaction is superadded to the cause of the disease.

The catarrhal process occurs first in detached spots or streaks upon the projecting folds or duplicatures of the mucous membrane; which spots coalesce to form extensive surfaces. Examined by transmitted light, these surfaces show a distinct arborescence of the vessels. Or the disease may commence in the follicles in distinct areas of the large intestine, and may remain confined to these structures to constitute the variety known as follicular dysentery.

The hyperæmia of inflammation is attended with dilatation and paresis of the vessel-walls and retardation of the circulation. The whole process may be arrested at this stage, so that there escapes from the vessels, at most, only serum to develop the oedema which, with the defective nutrition from arrest of the circulation, gives rise to the softening of the epithelial cells. These cells may be thus lifted from their bed to constitute the process of desquamation, the fundamental anatomical characteristic of acute dysentery, by which process the submucous connective tissue is laid bare and the so-called catarrhal ulcer results. Or the epithelium, but partially detached, may remain upon the surface, "either raised in the shape of small vesicles which contain clear serum, or it forms a grayish-white layer resembling the mealy scurf of the epidermis--an appearance which probably induced Linnæus to term dysentery scabies intestinorum interna" (Rokitansky).

Kelsch maintains that the inflammatory process in dysentery commences in the delicate connective tissue between the follicles, the network of small spindle-shaped cells with multiple nuclei becoming speedily penetrated by a number of very small, newly-formed vessels. Where the epithelium is desquamated the surface is covered with granulations as after a wound. The disposition of the follicles is soon deranged, for, instead of standing in rows like gun-barrels, they are pushed asunder and uplifted, so as to remain at different heights. Their interior becomes blocked with mucus or their orifices occluded, so that retention-cysts are formed to give rise to the appearance of the bead necklace. Soon the walls of neighboring follicles coalesce, dissolve away, and communication is established between them. The interior of these communicating tubes or canals is filled with vitreous mucus; the walls are stripped of their lining cells, but their "blind extremities contain still adherent colossal epithelial cells." Moreover, the follicles break into each other under the proliferative budding process, so that the end of a distorted tube may be found in the interior of another. Where follicles are destroyed the mucous membrane above them or in their vicinity collapses--a condition observed and described by Colin as effrondement. The mucosa in these regions may appear perfectly uninjured, but by "blowing upon it with a tube it is lifted up like an ampulla to show an opening in its centre," though more frequently the mucous membrane collapses or sinks in at the region of destruction. The inner surface of the mucosa is rendered additionally uneven by the elevations or protuberances caused by the {799} proliferations in the submucous connective tissue. The older writers (Pringle, Hewson) regarded these projections as tumors of the mucosa, and Rokitansky, who describes their true nature, speaks of them as warty, tubercular (nodular) swellings or fungoid excrescences--constituting a condition, he says, which Gély has termed hypertrophie mamelonné. The alternate elevations and depressions thus produced have been likened to the representations of bird's-eye views of mountain-chains.

As a rule, occasional red blood-corpuscles are also permitted to escape through the vessel walls in the process of diapedesis to give to the surface mucus its characteristic tinge, and punctate submucous hemorrhage is very frequently seen.

The pressure of the swollen, softened mucosa upon the sensitive nerves, and the irritation of the acrid intestinal contents, are often invoked to account for the constant desire of defecation (tenesmus) which constitutes such an essential symptom of the disease; but both the tenesmus and the colicky pains (tormina) precede the anatomical changes, and are much more rationally explained by the direct action upon the nerves of the cause of the disease, or by the derangement of innervation effected through changes in the circulation.

An acute case of catarrhal dysentery may exhibit no further lesions, and in the lightest cases even these may have entirely disappeared post-mortem, so that no change at all may be observed at the autopsy.

In a more severe or protracted case the other alterations which constitute the more complete cycle of the inflammatory process follow the stage of hyperæmia. The arrest of circulation becomes more or less complete, and the white corpuscles emigrate from the vessels to form the pus-cells. Fibrin, or the elements which compose it, also escapes to infiltrate the mucous membrane and remain upon its surface. The pseudo-membranous or diphtheritic process is now developed, and may vary in intensity from a mere frosting of the surface to dense infiltration of the entire thickness. The false membrane, as well as the mucous membrane, next suffers necrosis to form more or less extensive sloughs. These sloughs are grayish-white when fresh, dark-brown when stained by the intestinal contents, or greenish or black when undergoing gangrene. They may cover patches of the mucosa or the whole mucosa from the ileo-cæcal valve to the rectum. They soon become soft and pultaceous, hang in flaps or festoons in the interior of the intestinal tube, or, detached, are voided in fragments or shreds. One such fragment nine inches long is recorded in Woodward's exhaustive description of the pathology of this disease. Examined under the microscope, they are seen to consist of coagulated fibrin, red and white blood-corpuscles, epithelial cells and débris, necrotic pieces of mucosa, and myriads of micrococci and other micro-organisms.

The fall of the sloughs leaves the dysenteric ulcer. Its edges are irregular and ragged, its base uneven like a crater, and its surface is more or less covered with pultaceous débris. The submucous connective tissue may form its base, or, this structure having been also destroyed, the muscularis may be exposed, or in more extensive necrobiosis the peritoneum itself may be laid bare. Occasionally this last barrier is broken down, and perforation occurs. Or an acute peritonitis may be developed, in dysentery as in typhoid fever, by simple extension of the inflammatory {800} process without perforation. Perforation is very rare in cases of follicular ulceration, and is by no means frequent in the diphtheritic process, but it is the most frequent cause of peritonitis in chronic dysentery. It may occur in any part of the colon, but does occur most frequently in the cæcum. The resulting peritonitis is fatal as a rule, but the danger is obviated sometimes, as in typhoid fever, by agglutination of the gut to a contiguous structure or viscus. Perforation usually occurs late in the disease, but it may occur very early. Thus Nägele reports from the Franco-Prussian War a case in which perforation took place on the fourth day, the diagnosis having been confirmed by an autopsy. In rare cases a perityphlitis may ensue, with its natural consequences, or periproctitis may be developed with perineal abscess, or, finally, fistulæ may form to burrow about and discharge themselves anywhere in or upon the surface of the abdomen, the lumbar region, or the thigh. Bamberger describes cases of perityphlitis attending dysentery, in some of which resorption occurred, while in others pus was discharged upon the surface of the abdomen; and the writer of this article once saw, in consultation with T. A. Reamy, a case of fistula which extended from the descending colon to the vagina. Through the opening made to discharge the pus from a fluctuating abscess pointing in the vaginal vault an india-rubber tube could be passed for six to eight inches. The patient finally died from marasmus.

Chronic dysentery is distinguished by the alterations which occur in inflammation developing more gradually and extending over a longer period of time. Under the irritative changes resulting from an altered circulation the connective tissue undergoes marked hyperplasia, so that the wall of the intestine becomes at times enormously thickened, and its calibre is often correspondingly diminished. Cornil observes that acute or subacute dysentery is characterized by infiltration of the submucous connective tissue, followed by destruction, while in chronic dysentery the predominant lesion is essentially a proliferation and thickening of the connective tissue of the large intestine. The muscular tissue also undergoes hypertrophy, and the peritoneum becomes thickened and opaque. Sometimes the peritoneum is covered with patches of false membrane, or agglutination occurs with other portions of the intestine to give rise to contortions or occlusions.

Ulceration shows itself in chronic dysentery in every grade and stage of the process, from the first denudations to old cicatrizations. In bad cases the whole course of the colon from the ileo-cæcal valve to the rectum may constitute one vast tract of suppuration. Blood-vessels may be opened by the necrotic process, and copious, even fatal, hemorrhage may ensue. When pure blood is discharged, the hemorrhage usually occurs in this way per rhexem, but the quantities of blood evacuated with other elements usually escape per diapedesem.

The cicatrization which results puckers the edges of the ulcers, and may in cases of extensive or circular ulceration lead to more or less stenosis of the intestinal tube. According to Rindfleisch, the scars of dysenteric ulcers are very prone to contract, so that "the liability of a subsequent stricture is directly proportionate to the extent of the previous ulceration." The danger in these cases may be immediate from entire, or more remote from partial, occlusion. Thus, Bamberger records a case of {801} typhlitis due to impaction of feces above a stenosis gradually developed from a dysenteric ulcer.

Although dysentery is a disease of the large intestine, its lesions are not exclusively limited to this structure. It is always a purely local disease at first, and, strictly speaking, continues so throughout its course, yet it produces in severe or chronic cases widespread and general effects. Rapid emaciation sets in, and anæmia is soon pronounced in all the internal organs. The mesenteric glands show signs of irritation or of absorption of specific products in hyperæmic pigmentation and hyperplasia. The kidneys in acute cases exhibit venous stasis, and in chronic cases may undergo parenchymatous change. The joints are peculiarly liable to suffer in certain cases, and the nervous system may exhibit lesions--points to be described in the symptomatology of the disease. Should pyæmia occur, it superimposes its own particular lesions in the serous membranes and internal organs. All of these affections are to be regarded, however, rather as complications than essential effects.

But the liver is found affected so frequently in dysentery as to constitute more than a mere coincidence. Schneider has recently (1873) reported of the results of his observations on 1400 cases of tropical dysentery that in the 395 post-mortem examinations the liver was found normal in but 10 cases. The abnormalities were as follows: hyperæmia of various grades, 160; fatty degeneration, 62; abscess, 57; nutmeg liver, 47; perihepatitis, 25; granular atrophy, 19; syphilitic atrophy, 8; cicatrices, 6; excavation with helminth, 1. Bérenger-Féraud (1883) reports of 411 fatal cases of dysentery observed at Senegal that the liver appeared sound to the naked eye 98 times (23 per cent.) and diseased "undeniably" 313 times (77 per cent.). Of the 313 cases of hepatic affection there were found--hypertrophy, softening, or hyperæmia, 123 times (39 per cent.); abscess, 143 times (46 per cent.); simple discoloration, 29 times (9 per cent.); atrophy or cirrhosis, 18 times (6 per cent.). Annesley found abscess of the liver 21 times in 29 cases of dysentery; Hospel, 13 times in 25 cases; and Budd found ulceration of the large intestine 10 times in 17 cases of hepatic abscess. Gluck had the opportunity of making 28 post-mortem examinations in 151 cases of dysentery in Bucharest, finding abscess of the liver 16 times. All these authors adopt the explanation first offered by Budd of direct transfer of diseased products through the mesenteric and portal veins.

But more extensive observation has developed the fact that the frequency of abscess of the liver in connection with dysentery is a peculiarity of tropical climates. In the temperate and colder regions of the North this complication is not by any means so frequent. Frerichs declares that of 16 observations collected by Louis and Andral, "ulcers were present in only 3, and in 2 of these cases the ulcers were tubercular; of his own 8 cases, there was intestinal affection in none." Gluck believes that the liver is more prone to show suppuration when already predisposed to it by a preceding amyloid or cirrhotic change of malarial origin. Eichhorst calls attention to the well-known fact that abscess of the liver is especially a disease of the tropics independently of dysentery, and the frequency of its occurrence here may be a mere coincidence. But it must be remembered that opportunity for post-mortem examination, upon the {802} results of which these statistics are based, does not occur in the great majority of cases of dysentery, and abscess of the liver is very often overlooked. Thus, Schneider cites cases where persons with abscess of the liver of the size of the head were considered simulants up to twenty-four hours before death. Since the diagnosis of hepatic abscess has been made so easy by aspiration, cases begin to multiply; and it is doubtless the experience of most practitioners, in the temperate zone at least, that the decided majority of cases of hepatic abscess acknowledge an existing or previous attack of dysentery. Certainly, few authors would now venture to subscribe to the view of Annesley, that the abscess of the liver was the primary malady and was the cause of the dysentery.

SYMPTOMATOLOGY.--Dysentery, as stated, begins, as a rule, with the general signs of a gastro-intestinal catarrh. So frequent is this mode of inception, and so few are the exceptions, that it is impossible to resist the conclusion that the disease is caused by the introduction of a noxious element into the alimentary canal. The irritation thus induced begins at the stomach, and is rapidly propagated throughout the whole tract of the intestine. In the course of a few days the cause of the disease becomes strictly localized to the large intestine, whose greater capacity and more sluggish movement fit it for the easier reception and longer retention of noxious matter.

But specific dysentery and the more intense forms of catarrhal dysentery occasionally exhibit distinctive symptoms from the start, and in rarer cases the disease is suddenly announced with such tempestuous signs as to excite the suspicion of poisoning. Thus, a case (one of five lighter cases) is reported from the Rudolfstiftung in Vienna (1878) where the disease closely simulated Asiatic cholera, and where it rapidly ran a fatal course, in spite of laudanum, soda-water, ice pills, mustard plasters, injections of amyl nitrite, camphor, and ether, and faradization of the phrenic nerve to stimulate the failing respiration. Finger reports similar cases from the hospital at Prague.

Ordinarily, the peculiar pains of dysentery first proclaim the character of the disease. The severe grinding, twisting pains, tormina, are more or less localized in the course of the colon, and hence surround or traverse the entire abdomen, the pains at the epigastrium being due to spasmodic contractions of the transverse colon. The patient in vain adopts various postures in relief or sits with his hands firmly compressing the abdominal walls. The tormina are more or less intermittent or remittent, and are usually experienced in greatest severity toward evening. During their acme the face wears the aspect of the intense suffering, which is expressed in outcries and groans. At the same time there is upon pressure over the whole abdomen more or less tenderness, which soon comes to be especially localized at the cæcum or sigmoid flexure.

The tenesmus (cupiditas egerendi) is a more distressing, and certainly more distinctive, sign of dysentery. It is the feeling of heavy weight or oppression, of the presence of a foreign body in the rectum, which demands instant relief. At the same time intense heat is felt in the rectum, which the patient likens sometimes to the passage of a red-hot iron. The desire of evacuation becomes as frequent as urgent. In well-marked cases the patient sits at stool half an hour or an hour at a time, straining until faint {803} and exhausted, leaving the commode with reluctance, only immediately or very soon to use it again.

Great depression is felt at the stomach at the same time, with nausea, occasionally with vomiting; and strangury, with the discharge of only a few drops of scalding urine or blood from the bladder, adds additional suffering to the disease. Retraction of the testicle and prolapsus ani, especially in children, are prone to occur in severe cases.

But neither the pain nor the prostration is so characteristic of dysentery as the stools, which, though of very varied nature, are nevertheless distinctive. After the discharge of the intestinal contents the first evacuations consist of mucus in the form of glairy, stringy matter, like the white of an egg, expressed as the result of the violent efforts at straining. The mucus may be pure or tinged with blood, but it is usually very scant in quantity, and stands in this regard in marked contrast with the violence of the efforts to secure its extrusion. It is the frequency of its discharge which constitutes an especial distress. Twenty to forty, even two hundred, times in the twenty-four hours the patient must go to stool. In the worst cases the patient sits at stool or lies upon the bed-pan the most of the day.

The mucus is sooner or later mingled with pus or stained with blood. The presence of pus by no means necessarily implies the existence of ulceration, as the apparently pure mucus always shows occasional white blood-corpuscles under the microscope, and even extensive suppurations occur without apparent solutions of continuity.

The presence of blood is equally characteristic of dysenteric stools. Usually it is intimately commingled with the mucus or pus or forms the chief element of the copious so-called bilious discharge. The evacuation of pure blood indicates erosion of vessels low in the colon, often in the rectum itself, though enormous quantities of blood are sometimes voided from unbroken surfaces. Thus Lécard reports the case of a soldier who "while sitting restless at stool lost one and a half quarts of blood." The patient died on the fifth day of the disease, and at the autopsy there was found "apoplectiform congestion from the ileo-cæcal valve to the anus, but no ulcers anywhere, nor any broken vessels."

Besides the mucus, pus, and blood, the dysenteric stools contain the sloughs which have been torn off by violent peristalsis in cases of the diphtheritic form. Usually they are separated in shreds and fragments, but occasionally large sheets, even casts of a section of the colon, are voided en masse. These were the cases considered by the older authors to be detachments of the mucous membrane itself. As already observed, these fragments consist for the most part of inspissated mucus, pus, blood, and tissue-débris; but there is no doubt that in some cases partially necrosed mucosa also enters into their construction. One enormous tubular cast fourteen inches long, preserved in our Army Medical Museum, was found to be "composed of pseudo-membranous lymph in which no traces of the structure of the mucous membrane could be detected" (Woodward).

There still remains to be mentioned the boiled-sago or frogs'-spawn matter whose origin has given rise to such a curious mistake. Not infrequently these vitreous-looking bodies compose the bulk of the sediment in the stools of dysentery, and even some of our modern authors, {804} unacquainted with the more searching investigations of Virchow, have regarded them as expressed contents of intestinal follicles. Virchow found that under the application of iodine they always assumed a blue color, whereupon he ironically remarks that the sago-like mucus is really mucus-like sago. They are simply granules of starch ingested as food, to remain partially or wholly undigested.

The scybalæ, the composite matter known as the lotura carnea, and the micro-organisms found in the stools have already received mention elsewhere.

Although the stools of dysentery are scant, as a rule, they are so frequent as to discharge during the entire twenty-four hours a very large quantity of albuminous matter. Oesterlen has made the curious calculation to show that the mean daily loss of albuminates in dysentery of moderate intensity is from 50 to 60 grammes during the first fourteen days, and on an average about 20 grammes during the next eight days. The total loss experienced in an attack of three weeks' duration thus amounts to about 1000 grammes--in rough figures, two pounds avoirdupois. The rapidity with which emaciation, hydrops, and marasmus occur in severe cases is thus easily accounted for. Nägele speaks of cases where patients were reduced to skeletons in eight to fourteen days, so that the convalescence extended over six weeks to eight months.

The alteration in the character of the secretion in dysentery is not confined to the mucous membrane of the large intestine. On the contrary, all the digestive juices are changed, in some cases entirely checked. In the graver cases the saliva takes on an acid reaction and loses its glycogenic properties; the gastric juice in the same cases becomes alkaline and loses its peptonizing properties; while the secretion of the bile is wholly arrested. Uffelmann, who had the rare opportunity of studying the secretion of bile in a case of biliary fistula, relates that during an attack of dysentery the bile ceased entirely to flow, and only began to show itself again, at first greenish, then greenish-brown, finally brown, during the process of resolution on the ninth day of the disease. The anorexia, nausea, and vomiting which so often mark the access or attend the course of dysentery find thus easy explanation.

Should the disease continue, the general strength of the patient becomes so profoundly reduced as to resemble the status typhosus. The tongue, which has been hitherto thickly coated, now becomes black, shows fissures, and bleeds, while the gums are covered with sordes. The pulse becomes feeble, thready, or barely perceptible. The skin is dry and harsh or scaly. The abdomen is tumid or collapsed, the anus paralyzed, and the discharges continuously ooze out to excoriate the perineum. While the brain is usually clear throughout the disease, insomnia, stupor, or coma develop in the gravest cases from absorption of disease-products (Senator), or death suddenly ensues from heart-clot or from thrombus of the venous sinuses of the dura mater (Busey).

Pyæmia announces itself with a series of chills, followed by irregular temperature, by the speedy occurrence of multiple abscesses in distant organs, venous thromboses, affections of the serous membranes, pleuritis, pericarditis, and embolic pneumonia. Gangrene of the intestine, which may occur as early as the third day of the disease (Nägele), is evidenced by the signs of general collapse.

{805} COMPLICATIONS AND SEQUELÆ.--The lighter cases of dysentery, as well as most of the grave cases, run their entire course without complication, and often without sequelæ. But a certain percentage of cases is attended with complications on the part of the joints (rheumatism), of the nervous system (paralysis), and on the part of the liver and the kidneys.

Arthritis, when it occurs, shows itself, as a rule, in the second week of the disease (Eichhorst), or after the disease has run its course, during the period of convalescence (Huelte). That it is not a mere coincidence is evidenced by the fact that it is present in a large number of cases in certain epidemics, while it is not present independently of dysentery. Thus, Braun of Stannenheim saw in the two epidemics of 1833-34 more than forty cases of rheumatism, and Huelte reports ten cases observed by himself in the epidemic at Montargis in 1854. Certain epidemics are distinguished by the rarity of this complication, while most are marked by its absence altogether. In the epidemic at Rahden (1872), 400 cases among 3800 inhabitants, Rapmund saw inflammation of the joints set in only six times; and the entire absence or extreme rarity of it in later epidemics have led most physicians to deny any connection between the diseases, or to regard the joint affection as incident to a complicating scorbutus or neuralgia. All authors who admit it describe the knee-joint as being the most frequent seat of the affection, but acknowledge that it is mostly polyarticular; while there is much difference of opinion whether it ever presents the general signs of true rheumatism--pyrexia, diaphoresis, or its complications on the part of the heart. Huelte maintains that it does not, and that it is allied to gonorrhoeal rheumatism in this respect, while Eichhorst states that it may not only show all these signs, but may be followed in exceptional cases by suppuration and ankylosis. It usually lasts four to six weeks, but neither its occurrence nor its severity stands in any relation to the intensity of the attack of dysentery. It is probably to be regarded as a manifestation of a light pyæmia or septicæmia, as it is a frequent manifestation of this condition in or after scarlatina, puerperal fever, and the septic fevers of surgery.

Paralysis has been observed to occur after dysentery ever since the days of Galen, and, disregarding the observations of ancient and of the older periods of modern times, we find occasional records of cases in our own days. Leyden,[6] in reporting a case of paresis and rheumatic pains following an attack of dysentery, says that although post-dysenteric paralysis is now rarely mentioned, it was frequent in the older reports, and claims it as an admitted fact that it occurs not at all infrequently now. Joseph Frank quotes some observations of this kind, and refers especially to the dissertation of Fabricius.[7] These paralyses, Fabricius observes, have been seen after the premature suppression of malignant epidemics of dysentery by opiates and astringents. Observations were afterward recorded by Graves in which paralysis occurred after colics and inflammation of the intestines; and English veterinary surgeons mention the fact that paralytic weakness of the posterior extremities of horses and cattle follow attacks of intestinal inflammation. The paralysis, when it occurs, is usually confined to the lower extremities, but may extend to {806} and involve the upper extremities, by preference in the form of paralysis transversa (opposite arm and leg). Brown-Séquard attributes it to reflex contraction of the blood-vessels; Jaccoud, to exhaustion of the nerve-centres; and Röser, to the contact of the inflamed transverse colon with the solar plexus. Remak first suggested the idea of an ascending neuritis--a view which would seem to be corroborated by the paralysis observed after the experiments, by Lewisson, of crushing the uterus, kidneys, bladder, or loop of intestine, and which finds additional support, as Leyden remarks, in the length of time which lapses before it appears. Landouzy[8] says that Finger found diffuse myelitis in a patient affected with paralysis supervening upon cancer of the intestine, and that Delioux and Savignac saw spots of softening in the cervical and lumbar region of the cord in the case of a man affected with post-dysenteric paralysis. Weir Mitchell suggests the possibility of other factors--long marches, malaria, bad diet, and injuries to the spine--in the genesis of the cases, mostly paraplegias, observed by him; and Woodward calls attention to lead-poisoning (as by treatment) in explanation of a certain number of cases.

[Footnote 6: "On Reflex Paralysis," Volkmann's Sammlungen.]

[Footnote 7: Paralysis seu hemiplegia transversa resolutionem brachii unius et pedis alterius exhibet, Helmstedt, 1750.]

[Footnote 8: Des Paralysies dans les Maladies aigues.]

Abscess of the liver gives rise to few distinctive symptoms, and is mostly recognized or suspected, in the absence of positive signs, by the persistence or obstinacy of the dysentery. The ease and impunity with which aspiration may be performed in its recognition justifies the use of it in every doubtful case.

Regarding complications on the part of the kidneys, Zimmerman recognizes four classes of cases: (1) mild cases, showing no albumen and no casts; (2) severe, long-continued cases, with putrid stools, status nervosus, and collapse, showing albumen; (3) cases commencing with nervous symptoms, paralysis, scanty urine, showing kidneys filled with exudation-cells and detritus; and (4) cases of speedy renal complication and death. To these may be added the cases of protracted chronic dysentery with long-continued suppuration, entailing the possibility, of really rare actual occurrence, of amyloid degeneration and chronic parenchymatous change (Bartels).

Dysentery may be further complicated by parotitis; by venous thrombosis (phlegmasia dolens); by diphtheritic deposits on other mucous surfaces, which Virchow declares to be exceedingly rare; and by hydrops, which is oftener a concomitant of the period of convalescence.

Besides the deformities of the colon, which may ensue as a consequence of ulceration or peritonitis, a long attack of dysentery is apt to leave a hyperæsthetic or non-resistant state of the mucous surface, so that every imprudence in exposure or in diet begets an intestinal catarrh or a relapse of the disease.

DIAGNOSIS.--When dysentery presents itself with its whole train of symptoms the recognition of the disease is very easy. The tormina and tenesmus, the peculiar discharges, the rapid reduction of strength, leave no doubt as to the nature of the affection. The prevalence of an epidemic of the disease will often establish the character of a case even when all the signs are not present or when anomalies occur. Embarrassment in diagnosis only attends the recognition of catarrhal or isolated cases, and in these cases there may be a doubt as between dysentery and {807} diarrhoea--if such a symptom can be called a disease--or typhoid fever, cholera, or some purely local affection of the rectum, cancer, hemorrhoids, etc. In children difficulty of diagnosis may arise as between dysentery and intussusception.

Dysentery is differentiated from that lighter form of intestinal catarrh whose main symptom is diarrhoea by the presence of tenesmus in dysentery, as well as by its mucous, muco-purulent, diphtheritic, and bloody discharges. Dysentery lasts longer than diarrhoea as a rule, and does not yield so readily to treatment.

Typhoid fever shows from the start brain symptoms, which are absent from dysentery; has a typical temperature-curve, whereas there may be no fever in dysentery, or, if any, of irregular remittent type; is often prefaced by epistaxis and attended with bronchitis, both of which are absent in dysentery; and exhibits ochre-colored pea-soup stools, altogether different from those of dysentery.

Cholera morbus distinguishes itself from dysentery by its sudden onset, its profuse vomiting and discharges, its violent cramps, and the speedy collapse.

Cancer of the rectum can be usually felt, and hemorrhoids can be always seen, so that no difficulty should be experienced in the recognition of these cases.

Intussusception occurs mostly in children, and has, in common with dysentery, vomiting, mucous or bloody stools, colic, tenesmus, nervous unrest, and prostration, so that a differential diagnosis may be impossible for a few days. The more strict localization of an intussusception, which may sometimes be felt as a sausage-like mass, most frequently in the right ileum and hypochondrium, the greater frequency and persistency of the vomiting and pain, the presence visibly or palpably of the invaginated gut at the anus or rectum, soon enable the careful examiner to recognize the case.

PROGNOSIS.--The prognosis of dysentery varies between extremes. Some cases are so mild as to merit the remark of Sydenham concerning certain cases of scarlet fever: "Vix nomen morbi merebantur." They terminate of themselves under favorable hygiene without especial treatment. On the other hand, no known disease has a more frightful mortality than dysentery in some of its epidemics, especially in army-life. It was this class of cases which Trousseau had in mind when he called dysentery the most murderous of all diseases. Sixty to eighty may be the appalling percentage of death in these cases.

Under favorable surroundings the average mortality of dysentery amounts to 5-10 per cent., but is much influenced by the age and the general condition of the patient, as well as by the complications which occur in its course. Thus, Sydenham said of it over two hundred years ago, "It is not infrequently fatal to adults, and still more so to old men, but is nevertheless exceedingly harmless to infants, who will bear it for months together without suffering, provided only Nature be left to herself." But dysentery is by no means always harmless to infants, for in some epidemics this period of life has been visited with the greatest severity. Thus, Pfeilstücker reports of Würtemberg (1873-74) that the greatest mortality, 39 per cent., occurred at the age of one to seven years, and the least, 4 per cent., at the age of thirty-one to fifty years; {808} and Oesterlen says of England that dysentery causes 20 per cent. of deaths from all causes in the first year of life.

Nor does the prevalence of a greater number of cases necessarily imply a heavier mortality. For Bianchi reports of Rome that cases of dysentery constituted but 2.28 per cent. of all the admissions into the Ospedale di San Spirito in 1873, while in 1874 the percentage increased to 3.68; yet the mortality of 1873 was 17.02 per cent., while that of 1874 was but 9.09 per cent.

Complications on the part of the nervous system, the status typhosus, pyæmia, and great prostration, necessarily render the prognosis grave, yet even these cases are not necessarily fatal. Thus, Jules Aron reports from the epidemic at Joigny (1876) a case of recovery after complete paralysis of the sphincter ani. The recognition and discharge of an hepatic abscess relieves the patient from the dangers of this complication. Peritonitis alarmingly aggravates the prognosis, and perforation is almost of necessity fatal.

PROPHYLAXIS.--The improved sanitation of modern times has already diminished the frequency and mitigated the severity of epidemics of dysentery; and this fact, which is only an accidental observation as it were, gives the clue to the means of its further prevention.

The selection of proper sites for camping-grounds, barracks, and hospitals, the prevention of overcrowding in tenement-houses, ships, and jails, the regulation of sewage, the care for the food and drink, the observation of the strictest cleanliness by authoritative control,--all these are general measures which suggest themselves in the prophylaxis of this or any disease.

In the management of individual cases the first precaution is to prevent the dissemination of the disease. Whether it be really contagious or not, every case should be managed, as Bamberger suggests, as though it were contagious; and this protection of others secures for the individual patient the most favorable hygiene.

The bedding must be frequently changed; the windows kept open to secure free ventilation, which, in the light of existing knowledge, is the only true disinfectant; and all the furniture of the sick-room, especially including the receptacles for the discharges, must be kept perfectly clean. For this purpose the best purifier is very hot water. The temperature of the sick-chamber, if it be subject to regulation, should never be allowed to sink below or rise above 65-70° F.

The drinking-water should be secured, during an epidemic, from the purest possible source, and if good drinking-water cannot be had, what there is should be thoroughly boiled.

The discharges should properly be mixed with sawdust or some combustible substance and burned, or if this be impracticable should be buried in the soil a few feet below the surface, and not emptied into water-closets or privy-vaults used by others.

Such articles of food should be abjured as have a tendency to produce intestinal catarrh. So unripe fruits, vegetables which readily undergo fermentation--in short, all indigestible substances--should stand under ban. But no prohibition should be put upon ripe fruits or simple nutritious food of any kind.

Lastly, individuals should protect themselves from catching cold. The {809} researches of Pasteur have disclosed the fact that certain germs of disease will grow and multiply in the body of an animal whose temperature is reduced, when they would not increase without it.

TREATMENT.--The first requisite in the treatment of an individual case is perfect rest. Patients with even the lighter forms of catarrhal dysentery should observe the recumbent posture, and cases of more serious illness should be put to bed. Rest in bed, an exclusive diet of milk--which should always have been boiled--and the time of a few days is sufficient treatment for the mildest cases. Where there is objection to milk, meat-soups, with or without farinaceous matters, rice, barley, etc., may take its place.

A case which is somewhat more severe will require perhaps a light saline laxative--a Seidlitz powder, a dose of Rochelle salts or Epsom salts in broken doses--or a tablespoonful of castor oil or five to ten grains of calomel, to effect a cure. For the relief of the pain of the lighter cases nothing is equal to tincture of opium, of which five to ten drops every three or four hours in a tablespoonful of camphor-water acidulated with a few drops of nitric acid will generally suffice; or Dover's powder in broken doses, one to three grains, with five to fifteen grains of bismuth or soda, or both, is a good substitute for a change.

The successful treatment of dysentery in any form depends upon a recognition of the fact that the disease is local as to its seat, and is probably specific as to its cause. The anodynes relieve the effects, but the laxatives remove the cause. Consequently, the most rational treatment of the severer cases is the irrigation of the large intestine and the thorough flushing out of its contents. The use of clysters in the treatment of dysentery dates from the most ancient times, with the object, however, rather of medicating than washing out the bowel. O'Beirne (1834) and Hare (1849) were the authors of the irrigation treatment, which they executed by means of a long tube introduced into and beyond the sigmoid flexure. Since Hegar has recently shown how the whole tract of the large intestine can be thoroughly inundated and flushed with a common funnel and rectal tube, the practice has continually gained ground, until it is now admitted as the most valuable method of treatment. H. C. Wood of Philadelphia, and later Stephen Mackenzie of London, have reported a number of cases in which irrigation of the bowel with large injections medicated with nitrate of silver, drachm j-pint j, was attended with the most surprising results--sometimes but a single injection effecting a cure; and the writer of this article has reported one case almost in articulo mortis where complete cure followed the irrigation of the bowel--on three occasions with three pints of water containing three drachms of common alum. This case was all the more instructive from the fact that a relapse had occurred after very striking but only temporary relief had been obtained with the nitrate of silver, the alum having been substituted simply on the ground of expense.

Salicylic acid has also been extensively employed in this way with the best effects, but carbolic acid has been discarded since the reports of several cases of poisoning have been published. Should it become a question of the necessity of a parasiticide, the bichloride of mercury in extremely dilute solution, 1 to 1000, would be the agent par excellence; but it is probable that the simple flushing of the bowel is the chief {810} curative agent. The use of alum is not attended with the dangers which have ensued from the absorption of carbolic acid, and which might ensue from the bichloride of mercury. The water used in the injections should always be cold. Ice-water injections alone give at times the greatest relief. Wenzel uses injections of ice-water in all recent and acute cases, whether slight or severe--in bad cases every two hours. He seldom finds it necessary to use opium. The object is to introduce as much water as possible without producing too much pain. The large intestine of an adult holds, on an average, six imperial pints, but in the author's experience not more than three or four pints can be safely introduced. The patient should lie upon the back or the left side with the hips elevated and the head low, while the injection is slowly introduced from a funnel, fountain, or a bulb syringe whose nozzle is thoroughly anointed with vaseline. In the absence of a thoroughly competent assistant the operation should be performed by the physician himself, for the proper use of an irrigating enema is a practice which requires both judgment and skill. When pain is experienced, the further influx of the fluid should cease for a few minutes, when it may be resumed again and again until the largest possible quantity is introduced. It is impossible to over-estimate the value of this treatment in cleansing, disinfecting, and constringing the foul and flabby surface of the whole seat of the disease. As was said by Hare, "It changes a huge internal into an external abscess, and enables us to cleanse the bowel of its putrid contents."

Of all the remedies which have been recommended in the relief of dysentery besides the irrigation method, but one, ipecacuanha, deserves the name of a specific. This remedy was first introduced into practice in 1648 by the botanist Piso, who was led to adopt it from the popular praise he had heard of it while travelling in Brazil. He considered it the most exquisite gift of nature, and administered it in infusion according to the Brazilian (subsequently known as the French) method. Légros made three successive voyages to South America to import supplies of the drug to France, but neither he nor the French merchant Grènier, who had brought over more than one hundred and fifty pounds of it, could secure its general use. Thereupon, Grènier acquainted Adrian Helvetius, a Dutch physician practising in Paris at the time, with the wonderful virtues of the Radix dysenterica, who, having experimented with it first upon patients of the lower classes, was later successful in curing the Dauphin of France. The further use of it, by permission of the king, at the Hôtel Dieu, enabled him to secure a monopoly of its sale and secured for him a grant of a thousand pounds. Grènier hereupon put in his claim for a division of the profits, and upon the refusal of Helvetius instituted suit to obtain his rights. Justly indignant at the loss of his suit, he revealed the secret, and ipecacuanha became common property at once. Extravagant ideas were now entertained of its value, but in the extreme reaction which followed every virtue of it was disavowed, so that the drug came to be almost forgotten. From this temporary oblivion the remedy was rescued by an English army surgeon, E. Scott Docker, in 1858, who administered it, in combination with laudanum, in his regiment, on the island of Mauritius, in all cases and stages of the disease with such success that out of fifty cases he lost but one. Although such indiscriminate use and such almost unvaried success has not attended, and from the nature {811} of different cases could not attend, its universal employment, there is no doubt of the inestimable value of the service rendered in the restoration of the remedy in the treatment of dysentery. Yet over twenty years elapsed before its author received from his country, at the urgent solicitation of the Director-General, in recognition of this service, a grant of four hundred pounds.

Remarkable testimony as to its efficiency soon began to appear. Ewart[9] recommends ipecacuanha in every form and type of acute dysentery, as well as in the acute attacks supervening upon chronic cases. Its advantages are simplicity, safety, comparative certainty, promptitude of action, decrease of chronic cases and of complications, especially abscess of the liver, and great reduction of mortality. "It produces all the benefits that have been ascribed to bloodletting, without robbing the system of one drop of blood; all the advantages of mercurial and other purgatives, without their irritating action; all the good results of antimony and other sudorifics, without their uncertainty; all the benefits ascribed to opium, without irritating, if not aggravating or masking, the disease." To the objections urged against it he replies that the nausea is only temporary and evanescent--that vomiting is exceptional and of but short duration; moreover, it permits nourishment and assimilation and produces sleep. If uncontrollable sickness and vomiting occur, they are probably due to abscess of the liver, malaria, some other cachexia, Bright's disease, strumous mesenteric glands, hypertrophy of the spleen, peritonitis, or extensive sloughing.

[Footnote 9: Indian Annals Med. Science, April, 1863.]

Cunningham prefaces the treatment by a sinapism to the epigastrium and half a drachm of the tincture of opium. Then from one to one and a half drachms of ipecacuanha are administered in powder. It causes considerable nausea, and vomiting occurs in one to two hours. During the nausea copious perspiration breaks out, the pulse becomes fuller, softer, and less frequent, the tenesmus and abdominal pains cease, and the patient has no more stools for twelve to twenty-four hours. The next evacuation is easy, fluid, but free from blood or mucus. Sometimes the dose of ipecacuanha may require to be repeated.

Malun reports the results of treatment of 436 cases occurring in twenty-one months. There were only 6 deaths, and in only 1 of these could the remedy be fairly said to have failed. Under all other plans of treatment the mortality has varied from 12 to 22.3 per cent.

Mr. Docker says that the mortality of dysentery in the British army during the ten years that followed the adoption of the ipecacuanha treatment fell from 11 to 5 per cent.

The remedy is best administered in large doses, 20 to 40 grains, and should be repeated every four to twelve hours until permanent good effects are secured. A dose of 15 to 30 drops of tincture of opium, or morphia, one-fourth grain hypodermically, will best protect the patient from too great exhaustion. The beneficial results are mostly obtained in the acute cases, though surprising results sometimes follow in cases of very long standing. Thus, Gayton records a case of severe chronic dysentery of eighteen months' duration which was entirely cured by ipecacuanha, and probably most physicians of large practice can recall cases where the continual relapses of the dysenteric habit have been completely broken up by {812} one course of active treatment. Should the remedy fail to be of service in the course of forty-eight hours, it should be discontinued.

Batiator, the bark of the root of the Ailanthus glandulosa; mudar, the bark of the root of the Calotropis gigantea; and bael-fruit, more especially in chronic cases,--have been proposed by Roberts, Duval, Chuckerbutty, and others as substitutes for ipecacuanha, but are not likely to soon supplant it.

Materia medica is rich in drugs whose virtues have been vaunted in dysentery, and cases occur where the judicious physician will make his selection according to the indications in a given case. Turpentine internally, as well as externally in the form of a stupe (Copland), has had advocates from ancient times; astringents, tannic acid or the substances which contain it, kino, catechu, krameria; the acetate of lead, nitrate of silver, etc.; antiseptics, carbolic acid, salicylic acid, boracic acid; anodynes, opium and its preparations; and quinia,--are among the agents most frequently employed.

Bonjean (1870) had occasion to laud the efficacy of ergotin in checking hemorrhage and controlling the discharges in a report which substantiates the claim of Rilliet and Lombard in the epidemic at Geneva in 1853. Massolez had the same good results in the war of the Crimea, as had also Andrea in the Spanish hospitals of Ceuta and Tetuan.

Clysters of nitrate of silver, 4 grains to 5 ounces of water (Duchs), or with a few drops of tincture of opium (Berger); of ipecacuanha (Begbie and Duckworth); of laudanum and starch (Sydenham, Abercrombie); of the various astringents,--may be tried in obstinate, more especially chronic, cases.

Local inspection of the rectum by means of the speculum may possibly reveal an ulcer, which is the chief or sole cause of the tenesmus and bloody discharge. Maury reports such a case in which the ulcer was deep enough to hide a small sponge. In such cases topical treatment may effect a cure.

Dilatation may suffice to overcome a stricture in the rectum, the result of cicatricial contraction, or colotomy may be necessary in cases more refractory or situated higher in the bowel. Post[10] reported a successful colotomy, with the formation of an artificial anus in the left lumbar region, in such a case.

[Footnote 10: New York Med. Record, 1879, xvi. 24, p. 260.]

The food should be fluid, but nutritious, and milk best fulfils both these requisites. Where milk cannot be tolerated it may be substituted by soups, beef-tea, mutton-broths, chicken-soup, etc. But it should be known of these substitutes that they contain little or no nutritious matter on account of the insolubility of the albuminoids, and are really only stimulants. Soft-boiled egg, thin custards, sweetbreads, scraped or chopped raw beef--albumen thus in substance--constitute the best food. But during the intensity of an attack the patient should almost altogether abstain from food, both from lack of inclination for it and from lack of ability to digest it. During convalescence the food should be on the basis of animal diet, though ripe fruits and fresh succulent vegetables should not be altogether withheld.

In all cases of pronounced prostration stimulants are to be freely used, and of all stimulants alcohol is the best, as it has also nutritive and {813} antiseptic properties. Alcohol is thus triply indicated in the treatment of dysentery, but the choice of the form and strength will be a matter of judgment in the individual case.

Where life is imperilled by hemorrhage or anæmia from any cause, a forlorn hope is offered in transfusion, which in the hands of C. Schmidt (1874) has proved successful in two cases.

Abscess of the liver is best treated by aspiration or hepatotomy; rheumatism, by the salicylates; and paralysis, by the constant current of electricity.

Obstinate cases of chronic or continually recurring dysentery are thoroughly cured only by a sea-voyage, a sojourn at the seashore, a mountain-excursion, or a permanent change of climate.

{814}

TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS.

BY JAMES T. WHITTAKER, M.D.

HISTORY.--Typhlitis ([Greek: typhlos], blind), inflammation of or about the head of the colon, more especially the vermiform process, is a disease of modern recognition. Individual cases had been reported as curiosities where foreign bodies or fecal accumulations had excited inflammation in this part of the intestine, but it is undoubtedly to Dupuytren[1] that the credit is due of having first individualized this disease as a separate affection. About the same time (1827) Longer Villermay published his communications in the Archives gén., t. v. 246, on the diseases of the vermiform process, to be followed in the same year by Mêlier[2] and Hussar and Dance with observations on inflammation of the connective tissue in the region of the cæcum. These affections, which had been hitherto described as inflammatory tumors in the right iliac region, now received from Puchelt[3] the distinct name perityphlitis.

[Footnote 1: Leçons oral de Cliniq. chirurg., t. iii. art. xii.]

[Footnote 2: Arch, gén., Sept., 1827.]

[Footnote 3: Heidelberg klin. Annal., i. 571 and viii. 524.]

Perhaps the most remarkable events in the history of these affections since this time are the contributions of Stokes and Petrequin (1837) on the value of opium in the treatment of perforation of the vermiform appendix, of Albers,[4] who first distinguished the special form of typhlitis stercoralis, and of Oppolzer (1858-64), who set apart, perhaps as an unnecessary refinement in differential diagnosis, a paratyphlitis, an inflammation of the post-cæcal connective tissue. Matterstock[5] (1880) deserves especial mention for having given such prominence to anomalies of the vermiform appendix in the etiology of the affection; and Kraussold[6] (1881) has connected his name with the therapy of the disease by the boldness with which he expresses his convictions regarding the necessity of early evacuation, by incision, of inflammatory products, as first practised by Willard Parker in 1843.

[Footnote 4: Beobacht. aus dem Gebiete der Pathologie, ii. 1.]

[Footnote 5: Handbuch d. Kinderkrank., Bd. iv. p. 893.]

[Footnote 6: Volkmann's Sammlung., No. 191.]

GENERAL REMARKS.--Typhlitis, strictly speaking, is limited to affections of the cæcum and its appendix vermiformis; perityphlitis is mostly due to extension of the inflammation to the peritoneal envelope of these organs; while paratyphlitis signifies an involvement of the extra-peritoneal and post-cæcal connective tissues. Both perityphlitis and paratyphlitis are therefore secondary processes, though they may, in exceptional cases, arise from affections of organs other than the cæcum, as from {815} perinephritis, psoitis, vertebral caries, or as an expression of metastatic processes in pyæmia, septicæmia (puerperal fever), typhoid fever, etc.

ETIOLOGY.--Typhlitis and its allied affections or complications show especial predilection for the male sex and the period of adolescence. Nearly three-fourths (733) of the whole number (1030) of cases of perityphlitis collected from the literature by Matterstock were males, and this proportion holds good in infancy and early youth as well as in adolescence. The greatest number of cases, 33 per cent., occurred at the ages of 21-30; next, 30 per cent., at 11-20; while the ratio gradually decreases toward both extremes of life. So the opinion is expressed with singular unanimity by all authors that these diseases pre-eminently affect the bloom of life.

The observation that typhlitis has so often been found to arise from disease of the vermiform process has led to a closer study of its anatomical relations, and developed the fact that this organ is subject to great variation in size, shape, and situation.

Normally, the appendix vermiformis arises from the posterior interior aspect of the cæcum as a tube of the diameter of a goosequill and a length of three to six inches, with a general direction upward and inward behind the cæcum. It is commonly provided with a small mesentery, which retains it in its place. Its cavity communicates with the cavity of the cæcum by a small orifice which is at times guarded by a valvular fold of mucous membrane, while its free closed end terminates abruptly in a blunt point. It is commonly found filled with mucus throughout its entire length. The existence of this superfluous structure, which is found only in man and certain of the higher apes, has given rise to much speculation among the anatomists and physiologists, especially of the teleological school, as to its possible use. It is now, however, the generally acknowledged opinion that the appendix vermiformis is a relic or rudiment of a subsidiary stomach in lower forms of life. The head of the large intestine, which forms almost an additional stomach in the Gramnivora, and is three times the length of the whole body in the marsupial koala, is very much reduced in the Carnivora, whose food contains but little indigestible matter, and is greatly reduced in the Omnivora, as in man. The vermiform appendix is the shrivelled remnant of the great cæcal receptaculum of the lower animals. In the orang it is still a long convoluted tube, but in man it is reduced, as stated, to the size of a quill three or four inches in length, and is often entirely absent.

Kraussold, who complains that the vermiform process has hitherto received only step-motherly treatment at the hands of anatomists and clinicians, undertook a series of investigations which went to show how often and what extreme anomalies do occur. In some cases the appendix was disposed in an exactly opposite to the normal direction, its blind end being turned upward along the ascending colon. In one case it was found wound about the ileum; in another, spirally turned at its end and lightly adherent to a hernial sac. Sometimes it was abnormally long or short, open or closed with a valve, cylindrical, saccular, or bulbed, fixed or free, curved or bent upon itself at a sharp angle, provided with a short mesentery, and sometimes, as stated, it was entirely absent.

But by far the most interesting point connected with this organ was the frequency with which it was found the seat of ulceration or stricture {816} from cicatrization somewhere in its course, the result of dysentery, typhoid fever, syphilis, and more especially of tuberculosis. Clinicians who have been struck with the frequency with which typhlitis has occurred in tuberculous subjects find in this discovery a satisfactory explanation of this very remarkable coincidence.

Normally, the vermiform appendix is found filled, as stated, with a tough vitreous mucus, but not infrequently masses of feces, foreign bodies, intestinal worms, etc. find their way into it, where they may remain innocuous or may excite a dangerous inflammation. This fact, in connection with the general uselessness or superfluousness of this structure, has led pathologists to characterize the vermiform process with the significant appellation of a death-trap.

Two anatomical factors deserve especial emphasis in explanation of the frequent origin of disease in the vermiform appendix. One is the existence of the valvular fold of mucous membrane, already mentioned, at or near the orifice of the tube in the cæcum, the clinical importance of which was first pointed out by Gerlach. This fold is most marked between the ages of three and twelve, and when pronounced narrows the orifice to one-half or one-third of the whole calibre of the tube. As a rule, this fold, and the consequent diminution in the size of the orifice, are but little marked in the first years of life and in old age, which accounts for the relative infrequency of typhlitis at these periods of life.

The second mechanical factor is the deformity caused by the abnormal anatomical position of the organ, either as a congenital defect or as a pathological change. Matterstock quotes from Züngel, who observed in 59 cases in the Hamburg hospital whole or partial obliteration 30 times, catarrh and old fecal concretions 43 times, abnormal adhesions 12 times, and tubercular ulceration (without perforation) 11 times. Toft claims as the result of 300 personal investigations that every third person between the ages of twenty and seventy showed the traces of present or past inflammation, and that actual ulceration existed in 5 per cent. of all bodies examined. Kraussold declares that this percentage is rather too low than too high, and adds that among his patients--who were, it should be stated, mostly phthisical--it was remarkable how extraordinarily often the whole vermiform appendix was the seat of an encroaching ulcer. In a number of cases cicatrices or cicatricial alterations were found where typhoid fever or dysentery had existed in the previous history.

Attention should at least be called to a last anatomical factor in explanation of the frequency of ulceration and inflammation of this structure, in that its walls are so sparsely endowed with muscular tissue as to render it unable to empty itself of the virus or germs of disease which enter it from the comparatively stagnant reservoir, the cæcum.

Constipation is usually invoked as a cardinal factor in the genesis of typhlitis (typhlitis stercoralis). Speck calls attention to the frequency of the disease in East Siberia, where the food, mostly vegetable, contains a large amount of indigestible residue. But that this condition cannot sufficiently account for the disease in most cases is proved by the fact that constipation is more frequent in advanced life and among females, in whom typhlitis with its associate lesions is more infrequent. For the same reason a sedentary mode of life loses force as an argument in its production. Perhaps the most efficient cause of the condition is a local {817} paresis of the muscular tissue of the cæcum produced by the irritation of intestinal catarrh, of disease virus, of a fecal concretion or a foreign body--an irritation which may induce first a spasmodic action, and subsequently, as a result, a partial paralysis or a paresis. The same condition may be brought about more directly by the presence of a centre of irritation--viz. by reflex inhibition of innervation. Accumulation and impaction of feces must then necessarily ensue, and it is highly probable that this accumulation occurs in this way as a result more frequently than as a cause of the condition. For the symptoms of a simple accumulation of feces (coprostasis) are never so severe, at least at the start, as to mark the onset of a genuine typhlitis. Nor is there anything in healthy feces to induce the signs of a severe blood-poisoning which so commonly announces the advent or course of typhlitis.

Room is here open for the surmise that most cases of typhlitis pur et simple are due to the presence in the cæcum of the germs or virus of disease taken with the food or drink, and traversing innocuously the whole length of the alimentary tract, to finally bring up in this most stagnant part of the intestinal canal.

The rôle of pure mechanical causes cannot be ignored or underrated in perityphlitis, understanding by this division processes which commence in the vermiform appendix. For it is the rule to discover in the vermiform appendix in these cases either fecal concretions or foreign bodies. Haeckel and Buhl found concretions of meconium in a new-born child, and fecal concretions, intestinal stones, are far more frequently encountered than foreign bodies. In 146 accurately observed adult cases recorded by Matterstock, fecal concretions were met with 63 times, foreign bodies 9 times, while in the other cases nothing could be discovered; and in 49 cases among children, fecal concretions were discovered 27 times, foreign bodies 3 times, and nothing abnormal in the remaining cases. Not infrequently a small foreign body acts as a centre of crystallization for feces which become superimposed in successive layers. Hairs, as of the beard, sometimes officiate in this way. Among other foreign bodies met with in fatal cases of perforation, independently of feces, may be mentioned round-worms (Faber), cherry-stones (Paterson), needles (Payne), fish-bones (Züngel), gall-stones (Hallete), a mass of ascarides (Klebs), buttons (Gerhardt), etc., etc. As already intimated, supposed foreign bodies are often found on examination to be nothing else than intestinal concretions. As to cherry-stones, which are so often accused of producing typhlitis, Biermer and Bossard found it difficult or impossible to force them into the vermiform process.

MORBID ANATOMY.--The lesions revealed upon the post-mortem table show for the most part the ordinary picture of perforative peritonitis, which is by far the most frequent cause of death. The peritoneum in the vicinity of the perforation is found hyperæmic, swollen, necrosed, covered with flakes of soft fibrin, or partially agglutinated to contiguous structures. The wall of the bowel is very much thickened by catarrhal swelling of its mucosa, proliferation of its submucous tissue in more chronic cases, oedema of all its coats, or suppurative processes. Not infrequently the mucous tissue is the seat of extensive ulceration which may involve other structures of the gut or form an abscess, even as large as a man's head, in its immediate vicinity. The abscess may remain strictly localized or {818} may wander to discharge itself into the ileum, cæcum, duodenum, and diaphragm (Bamberger) with resultant empyema (Duddenhausen), colon (Prudhomme), bladder (Bossard), in which case the fecal concretion became the nucleus for a vesical stone; acetabulum (Aubry), inferior vena cava (Demaux), or peritoneal cavity, the most frequent eventuality. Duddenhausen saw in one case a pylephlebitis result, Von Buhl a pylephlebitis and metastatic liver abscess, which condition, Matterstock says, is noted 11 times in 146 autopsies; and older writers speak of discharges into the pleural sac, into the lungs, pericardium, uterus, vagina, etc. A curious case was observed by Eichhorst in Frerichs' clinic, where pus found escape through the umbilicus. So cases of burrowing sinuses with abscesses at distant seats, as in the groin or lumbar region, fistulæ with continuous discharge, and other curiosities, may be found among the records by the curious.

In cases of more acute course the lesions are often found centred about the vermiform appendix. The most various contortions, adhesions, or erosions are observed in this structure. Occasionally a constriction occludes the course of the tube, while the distal end is dilated into a condition of hydrops. It may be found perforated in one or in several places. The cicatrices or agglutinations of old attacks may be encountered; it may be cut in two or three pieces (Matterstock), or have been entirely absorbed. Kraussold records a case of this kind in a colleague who died of typhlitis. Upon the post-mortem table no trace of the vermiform appendix could be encountered except a dimple on the mucous surface of the cæcum, indicating the site of its former orifice.

SYMPTOMATOLOGY.--Typhlitis announces itself in two ways--suddenly and insidiously. In adults the disease begins as a rule with violent signs; in children there is often a prodromatous stage which may last for days or for months before a positive diagnosis can be established. There are in these cases anorexia and vomiting, constipation and diarrhoea, colicky pains, mostly concentrated about the ileo-cæcal region. There are at this time a disinclination to stand or walk, a stooped posture or gait, occasionally a light icterus, a feeling of formication or paresis in the right leg, and lastly an increased resistance or a palpable tumor in the right ileum.

In the adult the disease is wont to begin with more tempestuous signs. Not infrequently it is ushered in with a well-marked chill, upon which immediately supervenes a sharp pain at the affected region. A general collapse of strength soon follows, with fever, thirst, a husky voice, a coated tongue, vomiting, singultus, and an expression of anxiety. The impression of serious illness becomes apparent at once. The case early bears the aspect of a grave infectious disease. A constant, dull, boring, gnawing, or lancinating pain in the right iliac region first excites the suspicion of the physician as to the real nature of the disease. In children the pain is sometimes felt first in the epigastrium; in three cases mentioned by Büchner, Herzfelder, and Traube it was first experienced in the left ileum. There may be at this time no tumor, but there is increased resistance to pressure and exquisite tenderness to touch in the neighborhood of the cæcum. The whole abdomen is more or less tender, and often tumid. If there should be also gurgling from displacement of gas, doubt is excited as to the possible existence of typhoid fever.

{819} In the course of a few days the tumor takes shape. A typhlitis stercoralis shows a distension of the whole ascending colon, a sausage-shaped tumor, smooth or nodulated, along the entire right side of the abdomen, with increased resistance also in the transverse colon. More frequently in typhlitis--and, as a rule, in peri- and paratyphlitis--the tumor or tumefaction is more localized about the head of the colon. Frequently the swelling is so great as to be visible as a protrusion or bulging of the affected region. Percussion shows dulness, tanquam femoris, in cases of pure typhlitis, whereas in peri-, and more especially in paratyphlitis, there is tympanites on light and dulness only on deep percussion. Palpation or palpatory auscultation occasionally, though very rarely, reveals a peritoneal friction sound (Gerhardt).

The third cardinal symptom of the disease is the disturbance of digestion, which, as stated, often precedes or attends the first manifestation of the pain and the tumor. Anorexia, nausea, and vomiting--which is in the last stage of the disease often substituted by singultus--present themselves as occasional or constant signs of the disease. Constipation remains as a rule throughout the whole course of the disease with an obstinacy which sometimes excites apprehension of an intestinal occlusion; or the constipation may alternate with diarrhoea or dysenteric phenomena, more especially in the earlier stages. The tongue is, as a rule, heavily coated, or in typhoid states is dry, glazed, or fissured, and sordes covers the teeth and gums.

Fever is not a necessary factor in typhlitis, but when present distinguishes itself by its irregular range. The pulse is usually accelerated, full, and hard; the skin is dry and harsh; the urine is scanty and high-colored, and contains "almost without exception unusually large quantities of indican" (Eichhorst).

Perforation, when it occurs, is usually recognized at once by the signs of more or less immediate collapse, which quickly results in death.

The abdomen becomes suddenly distended, meteoric over its entire surface, the normal hepatic dulness giving place to a tympanitic resonance.

Not infrequently perforation occurs as the result of an accident, as after a push or blow upon the abdomen (Volz), heavy lifting (Volperling), riding in a wagon (Marsh), after dancing (Cless), mere turning of the body in bed (Langdon Downs), after emesis (Urban), purgation (Stokes), enema (Mêlier), etc., etc. That the slightest agitation may suffice at times to break down the last barrier of serous tissue separating the intestinal and peritoneal cavity is shown in the case recorded by With, where fatal perforative peritonitis occurred after a fit of immoderate laughter.

Paratyphlitis distinguishes itself from the other forms of the disease by its more insidious character. There is also in paratyphlitis, as a rule, less disturbance in the alimentary canal. The cæcum in paratyphlitis is mostly empty or is filled with gas, whose presence is recognized by tympanitic resonance on lighter percussion. On the other hand, paratyphlitis is characterized by the greater frequency of pressure signs in the right lower extremity. If the subjacent iliac and psoas muscles be implicated, the thigh is flexed upon the leg in decubitus. Various paræsthesiæ, formication, numbness, pain, and veritable paresis are experienced in the right leg. Dysuria, retraction of the testicle, and priapism may also occur in this form of the disease. Or pressure upon the iliac vein {820} induces thrombosis, with oedema, milk leg. The long-continued process of suppuration in paratyphlitis leads also at times to hectic fever or pyæmia, with slow marasmus.

In all cases relapses are very frequent, as repeated occurrences of the disease constitute the rule. Eichhorst records the case of a court-officer who suffered five attacks of paratyphlitis in the short space of one and a half years.

DIAGNOSIS.--The recognition of the disease is mostly simple. The pain, the tumor, and the disturbances of digestion sufficiently, and for the most part sufficiently early, distinguish the affection.

Simple impaction of feces is differentiated by the history of constipation; by the feel of the hardened feces, which form an elongated, nodulated, sausage-shaped tumor along the entire ascending colon, and later in shifting along the transverse colon; by the comparatively slight tenderness; and by the entire relief which follows thorough irrigation of the bowel.

Cancer may be eliminated by regard of the age of the patient, the slow development and course of the symptoms, and the gradual manifestation of its cachexia.

Invagination is an affection for the most part of early childhood--is marked by the sudden appearance of violent symptoms of disturbance of digestion, vomiting, often stercoraceous, occlusion, diarrhoea, or dysentery, with straining and discharges of blood.

DURATION.--Typhlitis and its complications have no definite duration. A case may terminate fatally in the course of a few days or may extend itself over months, or with its effects over years or for life. The disease is, as a rule, much shorter in childhood than in adult life. According to Matterstock, nearly one-half (44 per cent.) of children succumb to the disease within the first three days. Wood records the case of a girl aged ten who died in nine hours. The average duration of cases of typhlitis without suppuration ranges from fourteen to twenty-one days. The early evacuation of inflammatory products by aspiration or incision may cut the disease short at any time, or exacerbations and remissions may manifest themselves for months or years--a condition especially liable to occur when burrowing sinuses or fistulæ develop, or when passive encapsulated abscesses are aroused into activity by some accident or indiscretion on the part of the patient.

PROGNOSIS.--A case of typhlitis stercoralis has no gravity, and should terminate or be terminated within twenty-four to forty-eight hours after its recognition. Neglected or unrecognized cases, however, are not infrequently fatal from the circumscribed or more especially diffuse peritonitis which may ensue.

Typhlitis independent of fecal impaction is always a grave affection, requiring in every instance a very guarded prognosis.

Every form of typhlitis is more fatal in childhood than in adult life, and any case of the disease may present grave complications or assume a dangerous form at any time. The greater danger of childhood lies in the greater liability to peritonitis. Most subsequent writers confirm this statement, first made by Willard Parker, who also remarked that suppurative processes, abscess formation, is more common in the adult. The mortality of perityphlitis alone in childhood is 70 per cent., in adult life 30 per {821} cent., so that the proportion of recoveries is exactly the reverse of these figures at the different periods of life.

The general adoption of the opium treatment has, however, rendered the prognosis of typhlitis far more favorable--has, in fact, reduced the mortality in adult life from 80 per cent., the appalling figures of the older statistics (Volz), to 30 per cent., the ratio of modern times.

The means of earlier detection and readier relief of accumulated pus have also contributed much to reduce the mortality of typhlitis. In 1872, Bull of New York had to report of 67 cases of perityphlitic abscess collected by him, mostly treated without operation, a mortality of 47½ per cent., while ten years later (1882) Noyes of Providence was able to report of 100 cases treated by operation a mortality of only 15 percent. (Pepper[7]).

[Footnote 7: "Contribution to the Clinical Study of Typhlitis, etc.," Trans. Med. Soc. Penna., 1883.]

The development of fistulæ or wandering abscess, the occurrence of pyæmia and peritonitis, necessarily aggravate the prognosis of a simple case. Perforation is fatal of necessity, yet cases are not wanting where recovery has occurred even after this gravest of all the accidents of the disease. Thus, Patschkrowski reports, from Frerichs' clinic, a case of recovery after perforation, and Pepper mentions the results of an autopsy made upon an old man who died of vesical hemorrhage, in whom he "found that there had, at some unknown previous time, been perforation of the appendix."

PROPHYLAXIS.--The prevention of typhlitis has reference more especially to cases of habitual recurrence of the disease in adults, or to the earliest, prodromatous, stage in childhood. The slightest manifestation of pain in the right iliac region should be looked upon with suspicion in these cases, and absolute rest enjoined at once. Since in childhood perforation has occurred in insidious cases after so slight an irritation as a laxative or an enema, or even after a bath, every provocation of this kind should be avoided. Injunction is to be put upon all solid food in all cases in the inception as well as throughout the course of the affection, that the element of coprostasis be not superadded to the irritation of the disease. Adults subject to frequent recurrences or relapses will thus avoid also the development or aggravation of an intestinal catarrh, which in other cases of trivial import may become dangerous to them. Many cases of typhlitis are doubtless aborted at the start by the observance of absolute rest and abstinence from food or rigid diet at the start.

TREATMENT.--Perhaps no disease requires such careful consideration of its cause or form, inasmuch as the different varieties call for entirely different treatment. A typhlitis stercoralis, for instance, requires an exclusive evacuant treatment, whereas a peri- or paratyphlitis demands a treatment that shall put the bowels at rest.

The safest and most effective method of emptying the cæcum of impacted feces is by irrigation of the bowels by means of the funnel syringe devised by Hegar. The patient is put in the knee, elbow, or chest posture, and warm water--which is the best solvent for hardened feces--is allowed to slowly inundate the whole tract of the colon, after the manner and with the precautions already pointed out in the article on dysentery. Feeble or reduced patients should be supported in this posture until as much water as possible is slowly introduced. As a rule, a single thorough irrigation will suffice, or one or several additional operations may be required {822} to secure the desired effect. At the same time, broken doses, twenty grains, of sulphate of magnesia may be administered every hour or two, not so much for the purpose of exciting additional peristalsis as of turning water into the intestinal canal from above.

The other varieties of the affection call for opium at the start, with the double view of preventing the irregular, spasmodic, or tetanic contraction of the muscular coat and of obviating the danger of peritonitis. Opium is not contraindicated in these cases, even if the element of fecal impaction be superadded, as all clinicians are familiar with the fact that the bowels will move of themselves at times even under its full narcotic effects.

The remedy is best given in fluid form, as in the tincture, that the dose may be graduated in its repetition to secure its full effect without danger. When a quick action is required, morphia hypodermically may be preferred; yet it is to be remembered that opium with all its active principles is of more value in the relief of peritonitis than morphia alone. A careful watch should be kept upon all patients treated with large or frequently-repeated doses of opium, that its toxic effects be avoided. Not infrequently symptoms of poisoning have supervened after a sudden relief of pain, necessitating the use of means to keep the patient awake for a number of hours.

Hot embrocations, or poultices applied over large surfaces of the abdomen, give great comfort to the patient, though the very opposite treatment of an ice-bag, occasionally shifted or suspended, is more agreeable in some cases in the inception of the disease.

So soon as a distinct doughy sensation or a more marked fluctuation indicates the development of pus, steps should be undertaken at once to secure its evacuation. In cases of doubt it is best to make a tentative exploration with the needle of the aspirator, a large-sized needle being preferred on account of the liability of occlusion with tissue-shreds or other débris. It is quite surprising how rapidly a case clears up at times after the evacuation of even only a drachm or two of oedematous fluid. More frequently, however, the aspiration must be repeated until a quantity of pus is secured and the abscess completely discharged.

An abscess of more superficial situation, of larger size, or of continuous formation is best relieved by free incision. As to the time of the operation, the old rule, ubi pus ibi incisio, holds good here as elsewhere. An early evacuation of the products of inflammation prevents the supreme danger of perforative peritonitis or the formation of burrowing sinuses, fistulæ, amyloid degeneration, and marasmus.

Indurated tumors are sometimes made to soften under the long-continued use of cataplasms, and chronic thickenings of the walls of the intestine are relieved by general tonics, mild laxatives, mineral waters, and gentle frictions with iodine or mercurial ointments.

Perforative peritonitis calls for opium in maximum doses as a means of facilitating possible agglutinations or encapsulations, and a forlorn hope is offered in an early laparotomy, which the bolder surgeons are now undertaking in the equally desperate cases of perforation by gall- or kidney-stones, etc.

Under no circumstances should a patient affected with typhlitis leave the bed until the last trace of inflammation has subsided, as in no disease is there greater liability to recurrence or relapse.

{823}

INTESTINAL ULCER.

BY JAMES T. WHITTAKER, M.D.

Intestinal ulcer, Ulcus intestinorum entero-helcosis ([Greek: helchôsis], ulcer), represents a solution of continuity in the wall of the intestine, affecting first, as a rule, its mucous coat. Ulcer of the intestine, like ulcer of the stomach, its occasional congener and not infrequent associate, is the expression of an insult or injury offered to the intestinal coat in its inner exposed surface, or of a necrobiosis the result of a local occlusion in the general blood-supply. Hence, ulcer of the intestine may be a purely local disease, or be the local expression of a general, so-called constitutional, disease. While in many cases the lines differentiating these conditions may not be distinctly drawn, as many so-called constitutional conditions (tuberculosis, typhoid fever, etc.) are discovered to be--at first, at least--local processes, the toxic ulcer (arsenic, mineral acids) may be taken as a type of the local process, acting from within, and the syphilitic ulcer as the type of the general process, acting from without. At the same time, it must be recognized of syphilis that an ulcer may result from the dissolution or breaking down of a gummatous mass anywhere in the course of the intestine, or may be the effect of infection by extension into the rectum of syphilitic processes about the genital organs, or, lastly, of direct introduction of the disease in perverted intercourse (pederasty, coitus heterotopicus).

Ulcer of the intestine is occasionally, though comparatively very rarely, observed also as the result of pressure from within or without. Such an ulcer is properly considered of traumatic or mechanical origin, as it is induced as the direct effect of mechanical irritation or arrest of blood-supply. Thus, dense masses of inspissated feces, foreign bodies, indigestible residue of food, may fret the mucous surface into a condition of hyperæmia, and, later, absolute ulceration. Undue retention, as behind a cicatricial contraction, or an occlusion from whatever cause at places where the intestinal tube normally offers resistance (at the ileo-cæcal valve, sigmoid flexure, etc.), may lead to ulceration in the same way. Schönlein has called attention to the paralytic condition of the intestinal muscularis in age as a predisposing cause of mechanical intestinal ulcer; and Virchow has noticed the same condition among the insane, whose intense preoccupation leads to neglect of evacuation of the bowels. Certain intestinal parasites, more especially ascarides, are admitted as occasional causes of ulceration, and more superficial solutions of continuity in the rectum have been noticed as the result of too frequent or too careless use of enemata.

{824} Curling was the first to call attention to the fact that extensive burns of the skin are sometimes followed by ulceration of the intestines. The ulcerative process is almost exclusively confined to the duodenum. Various attempts have been made to explain the intestinal ulcer consequent upon burning of the skin, but a satisfactory explanation is lacking as yet. Leube suggests an inhibition in the force of the circulation by reason of accumulation of waste products in the blood, while Billroth believes the ulcer to be the result of an embolic process. Whatever the cause, the frequency of its occurrence makes it more than a mere coincidence. According to Meyer, it is observed most frequently in women, and shows its first symptoms in seven to fourteen days after the initial burn.

Aside from toxic and traumatic causes, ulcer of the intestine occurs as the result of dysentery, typhoid fever, and tuberculosis--diseases mentioned in the order of frequency in the production of intestinal ulcer. The ulcers of dysentery in the large intestine, and of typhoid fever in the small intestine, assume such prominence in these affections--having even been erroneously considered at one time as the cause of these maladies--that their study belongs to the history of these diseases. The ulcer of tuberculosis is rather an accident in the course of this affection, and is now recognized as the occasional result of direct infection by the ingestion of tuberculous flesh, or, far more frequently, of the deglutition of tuberculous sputum. As a rule, the tuberculous ulcer shows itself late in the course of pulmonary phthisis, and is the cause of the obstinate and colliquative diarrhoea which speedily exhausts the patient. Yet cases are occasionally met in which numerous or extensive ulcers occur in the intestinal canal early in the history of phthisis, before any serious damage has been inflicted upon the lungs. The tuberculous ulcer affects, and for the most part is confined to, the same structures which form the seat of disease in typhoid fever--viz. the solitary and agminated glands of the ileum. When the bacilli tuberculosis are conveyed to the intestine by means of the lymph- and blood-supply through the mesenteric vessels, the resulting ulcer takes the shape of the vascular arrangement; that is, the long axis of the ulcer is at right angles to the course of the tube. Thus, if sufficiently extensive, the ulcer may be circular or form a girdle or ring entirely around the tube. With the tubercular ulcer or ulcers are usually found tubercular nodules or plaques in the serous coat, which are visible to the naked eye as opacities or milky deposits beneath the peritoneal coat. The glands of the mesentery may be at the same time so much increased in size as to form visible or palpable tumors in the abdomen.

The frequency with which tuberculosis affects the vermiform appendix has already been noticed in detail in the etiology of perityphlitis.

The ulcer of the intestine which is the result of a catarrhal process, so called, belongs to the history of chronic diarrhoea and dysentery.

The true intestinal ulcer, per se, which has its analogue in the stomach as the gastric ulcer, ulcus rotundum, is due to the same cause as in the stomach--viz. to arrest of circulation and erosion by the gastric juice. It is a well-established fact in physiology that gastric digestion is continued--is, indeed, mainly effected--in the small intestine; hence it is not surprising to learn that an arrest of circulation in the small intestine {825} is attended by the same result. The fact that this so-called peptic ulcer is found almost exclusively in the duodenum speaks most emphatically for this origin of the disease. Arrest of the circulation in the intestinal wall may be due to embolus, which, according to the observations of Nothnägel and Parènski, is not infrequently found in the branches of the duodenal artery; to infarction, the condition so commonly encountered in pyæmia and septicæmia; or to thrombotic occlusion, as seen in amyloid degeneration--a disease process which selects by preference the vessels of the alimentary canal, along with those of the kidney and spleen.

The duodenal resembles the gastric ulcer in form as well as origin. It has the same appearance, in its recent stage at least, of having been cut out with a punch, shows no inflammation, induration, or thickening about its borders, and presents the same funnel-shape with terraced walls, its apex below eccentrically situated, as a rule corresponding to the situation of the artery. It is most frequently found in the upper horizontal portion of the duodenum, but is occasionally, though rarely, seen in the descending portion. In the further course of the duodenum the gastric juice becomes gradually neutralized, so that ulcers situated below the orifice of the gall-ducts are very great exceptions. In Krauss' collection of 47 cases but 2 were found in the lower sections of the duodenum. The intestinal like the gastric ulcer is usually found single or alone, but occasionally two, three, or even four ulcers are encountered. According to the tables of Morot, a single ulcer is found in 81.8 per cent. of cases, two in 9.2 per cent., and three and four in 4.5 per cent. each.

Duodenal like gastric ulcers are attended with the liability to hemorrhage and perforation in equal if not greater degree. There is also the same tendency to implication of contiguous structures. Stich records a case of perforation of the aorta; Eichenhorst mentions the formation of abnormal communication with the gall-bladder; and Frerichs, a thrombosis of the vena porta in consequence of duodenal ulcer. Lastly, the process of cicatrization may be followed by the same disasters as occur in pyloric ulcers in consequence of contraction and constriction. Thus, the orifices of the pancreatic or choledochus ducts may be narrowed or completely closed, or the whole lumen of the duodenum obliterated, with consecutive dilatation of the stomach and oesophagus, as in the case narrated by Biermer. A very nice question in differential diagnosis as between pyloric carcinoma and pyloric or duodenal ulcer is sometimes raised in this way. In the vast majority of cases it is safe, even in the absence of a palpable tumor and without regard to the age of the patient, to decide this question in favor of carcinoma. Cases of complete occlusion constitute the rule in carcinoma, and the very great exception in ulcer.

It remains to be said that duodenal is much more rare than gastric ulcer, in the ratio of 1 to 30, and that, unlike gastric ulcer, it chiefly affects males. According to the statistics of Krauss, already cited, the ratio of males to females is 9 to 1, and according to Trier the ratio is 5 to 1. It occurs in greatest frequency between the ages of thirty to forty, diminishing in frequency with advancing age.

SYMPTOMATOLOGY.--Ulcer of the intestines announces itself by symptoms which are, as a rule, much more vague and indefinite than the same process in the stomach. In a certain percentage of cases the symptoms {826} may be entirely latent, and the cause of a sudden death be revealed only on the post-mortem table. In less severe cases the entire symptomatology of intestinal ulcer is grouped under the term dyspepsia, no characteristic phenomena being manifest throughout the course of the disease.

On the other hand, a very small ulcer may give rise to the most dangerous symptoms--hemorrhage and perforative peritonitis, which may be even fatal in the course of a few days or hours.

Among the symptoms that appear with prominence in the course of the disease is pain. Although cases are abundantly on record marked by the entire absence of pain, and although pain is by no means so universally present as in gastric ulcer, it occurs in the great majority of cases of ulcer of the intestine. The pain of intestinal ulcer distinguishes itself from gastric ulcer by being more independent of the character of the food or the time of taking it. For the most part, it occurs in attacks of colic, which are characterized at times by their extreme severity, long duration, and obstinacy to every means of relief. These attacks occur in paroxysms with complete or only incomplete remissions, and are ascribed, as in gastric ulcer, to the erosive action of the gastric juice upon exposed nerve-fibres, the intervals of relief corresponding to the periods of exhaustion of the nerve-centres. At the same time, in exceptional cases, a long-continued localized tenderness to pressure may indicate the seat of the disease.

Palpation may elicit, besides tenderness, points or regions of induration or intumescence. Such a condition is more especially encountered in cases of tuberculous disease, the so-called scrofula of the intestine or the tabes mesenterica of childhood. More localized enlargements are occasionally to be felt in the vicinity of the duodenal or other intestinal ulcer in consequence of circumscribed peritonitis, with its resultant agglutinations and adhesions. In this connection caution must be exercised not to confound masses of impacted feces with tumefactions. The history of constipation or the administration of a light laxative will generally suffice to remove this source of error.

Anorexia is a symptom of intestinal ulcer as a rule. The loss of appetite may amount to a complete aversion to all food or only to the more fatty articles of diet. A curious exception to this rule is not infrequently seen in the unappeasable hunger of children the victims of tuberculous ulceration. The contrast offered in the extreme emaciation of these patients has been made the subject of frequent comment.

With this loss or perversion of appetite and defective digestion of the food, the general condition soon begins to fail. Though cases are occasionally met in which a bien-être has been maintained for years, or a condition of obesity has been retained, these cases form the exception in the history of intestinal ulcer. More or less emaciation gradually develops as a rule, and a reduction of the general strength that is out of all proportion in its degree to the loss of flesh. At the same time the mental condition of the patient suffers a degradation to the level of the sufferer with chronic dyspepsia.

The disturbances of digestion which occur in intestinal ulcer present many varieties in degree and kind. Some patients show none or but few of the signs, while others run the gamut, so to speak, in the semeiology of dyspepsia. Heartburn, eructations, pyrosis, borborygmi, flatulence, gastralgias, pseudo-anginas, nausea, and vomiting, the familiar {827} phenomena of gastric or intestinal catarrh, attend at some time or other in the course of the disease most of the cases of intestinal ulcer.

The condition of the discharges demands notice in detail, more especially as abnormalities in the evacuations belong among the few of the more constant symptoms of the disease.

Diarrhoea is the rule in intestinal ulcer. The discharges consist at first of the undigested food and the digestive juices, which have been hurried along the alimentary canal and prematurely evacuated on account of the increase of peristalsis caused by the irritation in the upper part of its tract. The arrest of the digestive process leads to early decomposition of the ingested matters, and thus imparts to the discharges an exceedingly offensive odor. While, in exceptional cases, constipation may be present, or even obstipation of the bowels, the discharges are usually so abundant as to constitute a diarrhoea, which in some cases is so frequent or profuse as to become colliquative and speedily exhaust the strength of the patient.

An ulceration situated in the colon or rectum would furnish the discharges characteristic of dysentery, already described in detail, while the same process in the ileum would show the evacuations characteristic of typhoid fever or tuberculosis.

The most characteristic ingredient of the true duodenal ulcer is blood. As stated in the article on HEMORRHAGE OF THE BOWELS, ulcer of the intestine constitutes the most frequent source of this accident, which is sometimes so grave as to destroy life in the course of a few days or hours. The blood from an intestinal ulcer may be evacuated both by the mouth and the anus, or may be retained in the alimentary canal and not appear at all. Such cases constitute the condition known and described under the heading of occult or concealed hemorrhage, which is recognized by the rapid general collapse of the patient. When the blood issues from a duodenal ulcer, it is intimately commingled with the contents of the alimentary canal. The discharges in such cases are usually black, tarry, and more or less fluid; whereas blood from the colon or rectum still preserves its fresh red color and is discharged separate from the feces or simply coats its exterior. Occasionally cases are met where the blood coagulates in the interior of the intestinal canal, to form a cast of its lumen or to accumulate in great mass in the sigmoid flexure or rectum. In one case in the experience of the author such an accumulation was the cause of a very severe tenesmus, which was only relieved by the digital evacuation of large masses of inspissated, coagulated blood.

The presence of pus would indicate lesion of the colon, as typically shown in dysentery, as suppuration, at least with any visible products, does not occur in ulcer of the duodenum.

DURATION.--Ulcer of the intestine has no definite duration. As in the case of its prototype, gastric ulcer, it may speedily be covered with cicatricial tissue and never appear again in the course of a long life. But such a course is as unusual as in gastric ulcer. Frequent recurrence constitutes the rule in intestinal ulcer, or a partial recovery with frequent relapses, as in the course of ulcer of the stomach. So ulcer of the intestine is not infrequently a lifetime malady, with exacerbations and remissions dependent largely upon the prudence or imprudence of the patient with regard to diet. It need hardly be stated that ulcer of the intestine {828} may terminate fatally even in the course of a few days from hemorrhage, circumscribed and later diffuse peritonitis, or may drag out a slow length of years, to finally destroy the patient with the general symptoms of inanition, hydrops, and marasmus.

DIAGNOSIS.--From what has been already stated, it is seen that ulcer of the intestine is often entirely overlooked or may be readily confounded with other maladies of the digestive tract. Cases of traumatic or toxic origin are generally readily recognized by the history of the patient, and tuberculosis reveals itself by the youth of the individual, the existence of the disease elsewhere, the gradual emaciation, the premature senescence--in short, the general signs of the phthisical habitus, the meteorism, and perhaps the presence of nodular enlargements of the mesenteric glands.

The most characteristic symptom of the peptic ulcer is, as has been stated, hemorrhage. But hemorrhage is present in only the minority of cases, is, as a rule, occasional and transitory, and is at all times difficult of differentiation as to its source. Blood from a gastric ulcer may also be voided per rectum as well as per os, and the blood from a duodenal ulcer after regurgitation may be wholly discharged by vomiting. The absence of vomiting and the presence--more especially the persistence--of tarry evacuations from the bowels would speak for ulcer of the intestine. Dilatation of the duodenum, a condition of ectasia, closure of the bile-duct with consecutive jaundice, or the presence of fatty stools from occlusion of the pancreatic duct (a sign not now regarded of the same value as in the days of Bright), would also declare in favor of ulcer in the duodenum.

As between intestinal ulcer and catarrh or intestinal ulcer and carcinoma, precisely the same rules would hold as in the case of the stomach. A simple enteralgia would be recognized by its more frequent occurrence among females or individuals of neurotic temperament; by its connection with faults of diet, malaria, or exposure to cold; by the absence of hemorrhage, diarrhoea, or peritonitis.

PROGNOSIS.--Too much caution cannot be exercised in the prognosis of ulcer of the intestine; for even in the cases which run a perfectly mild course the gravest, even fatal, accidents are liable to occur. The danger of perforation in cases of typhoid fever from a single or from one of the few ulcers that may be present imparts one of the chief elements of gravity to this disease; and the same catastrophe may occur at any time in dysentery or tuberculosis. The duodenal ulcer may likewise have a sudden gravity imparted to a mild case by a copious hemorrhage or a peritonitis, and, even though the patient escape all possible complications, to recover with the surface of the ulcer healed so that the loss of substance is filled in with firm cicatricial tissue, the danger of contraction or stenosis still remains. The ulcers of dysentery in the colon and of syphilis in the rectum are especially liable to be followed by deformities of this kind, while the tuberculous ulcer in the ileum not infrequently results in a more or less complete stenosis. The ulcer of typhoid fever in its cicatrization almost never reduces the size of the intestinal canal.

TREATMENT.--The most valuable therapeutic means of relieving the pain and obviating the dangers of ulcer of the intestine consist in the {829} regulation of the diet. The food should be light, easily digestible, and during the acute stage of the disease as nearly fluid in its consistency as may be. Milk would be the staple article of diet in all cases were it not for the fact that in some cases constipation attends its too exclusive use. The various soups, without solids, broths, preparations of starch (sago, arrowroot, tapioca, etc.), may sufficiently nourish the patient until the healing process shall have commenced. Raw beef, chopped up and made into an emulsion, is perhaps the most nutritious and least injurious of any kind of food. Bread, potatoes and other vegetables should be ruled out altogether, because of their liability to produce masses of feces whose inspissation may do mechanical damage to ulcers in process of cicatrization.

Where there is failure in the general strength early resort should be had to alcohol, which may be administered in the form of red wine (in preference to white, because of the tannin it contains), wine-whey, or, in more serious prostration, of sherry wine, milk punch, egg-nog made with good whiskey or brandy.

In the worst cases, where all food irritates, feeding by the mouth may be abandoned altogether for a time, and the strength of the patient sustained by nutritive enemata of beef or pancreatic emulsion.

The diarrhoea should be controlled rather than entirely checked, for fear of the greater evil of constipation. A little bismuth with bicarbonate of sodium or oxide of zinc may suffice for the milder cases, while in the more aggravated cases resort must be had sooner or later to opium.

Constipation is best relieved by careful injections of warm water or by the administration of the lighter laxatives--mineral waters, Seidlitz powders, citrate of magnesia, castor oil, etc.

Vomiting is combated by ice, soda-water, champagne, cherry-laurel water, and in graver cases morphia hypodermically.

Pain may be relieved by applications of hot water, cataplasms, injections of hot water, and, when necessary, by morphia with or without belladonna.

Hemorrhage is checked by ice internally and externally, turpentine, ergot or preferably ergotin by hypodermic injection, and opium.

Peritonitis, more especially perforative peritonitis, calls imperatively for the liberal use of opium.

Patients the victims of intestinal ulcer must maintain a guarded diet for months, often for years, after all signs of the disease have disappeared as the best prophylaxis against recurrence. Constant vigilance is also required to avoid constipation, and the greatest temperance exercised with regard to the use of alcohol. The author has at the present time a patient under treatment who presents all the symptoms of duodenal ulcer, including hemorrhage, with every indulgence in strong drink, and in whom all symptoms disappear under entire abstention. Sometimes a course of mineral waters, a sea-voyage, or other change of life or scene constitutes the best means of avoiding frequent relapse.

It need hardly be said that an ulcer in the rectum, which is readily recognized by its attending tenesmus, calls for local treatment; and it is equally plain that tuberculosis or syphilis requires appropriate internal means of relief.

{830}

HEMORRHAGE OF THE BOWELS.

BY JAMES T. WHITTAKER, M.D.

GENERAL REMARKS.--Hemorrhage of the bowels occurs in both sexes, though more frequently in the male, and at all ages, though more frequently at the middle period of life. In the infant a form of it is sometimes considered as a distinct affection under the head of melæna neonatorum, and in age it sometimes shows itself as a distinct sign of a disease characteristic of age--namely, cancer. According to the tables of Bamberger, it is caused in the order of frequency by dysentery, typhus fever, cancer (of the colon), mechanical injury, poisons and foreign bodies, ulceration (tubercular, follicular), the round ulcer of the duodenum, and aneurism; last and least frequent is the so-called vicarious hemorrhage.

ETIOLOGY.--Hemorrhage from the intestinal canal arises from (1) anomalies in the contents of the bowel; (2) disease of the wall of the bowel; and (3) from general diseases.

(1) The inspissation of the natural contents of the bowel during long-standing or habitual constipation may convert the feces into dense masses which irritate and scratch the mucous membrane, and thus induce hemorrhage directly by simple solution of continuity, or indirectly as the result of extreme hyperæmia. Such hemorrhage is nearly always slight, streaking or coating the surface of the scybalous mass or being extruded from the anus as a small deposit of blood during the last act of defecation; in which latter case it is found mostly associated with hemorrhoids or fissure of the anus--conditions which require separate description. Independent of these conditions, the hemorrhage nearly always has its origin in the lowest regions of the large intestine, where condensation of the feces is naturally greatest.

Foreign bodies in the intestinal canal descended from the stomach may also be the cause of hemorrhage in the same way. Thus, stones of fruits, bones of fish, fragments of oyster-shell, or other substances in no way connected with aliments (false teeth, buttons, pins and needles, etc.), may be swallowed accidentally or purposely (as by children or the insane) to produce intestinal hemorrhage. Drastic cathartics (podophyllin, gamboge, etc.) and poisons (arsenic, mineral acids) occasionally act in the same way. Thus, Tardieu reports[1] the case of a servant to whom was administered by a homoeopath veratrin with coffee, with fatal effect in six days. At the autopsy, made by Amussat and Reymond, the stomach and small {831} intestine were found filled with a dark-brown or black bloody fluid, but there was no trace of perforation, ulceration, or organic disease.

[Footnote 1: Annales d'Hygiène, July, 1854.]

Under this head mention should be made also of certain parasites whose habitat is the intestinal canal, the walls of which they perforate. Two varieties, the Anchylostoma duodenale and the Distoma hepaticum, are frequent causes of hemorrhage, the former from the duodenum and jejunum, the latter from the rectum, in hot climates, more especially in India and Egypt.

(2) Anomalies in the intestinal walls produce hemorrhage as the result of intense hyperæmia (per diapedesin) or of actual loss of substance (per rhexin). Copious, even fatal, hemorrhage has thus ensued from dysenteric and typhoid processes (and even without discoverable cause) where no ulceration or loss of substance could be discovered on autopsy; and this accident is so frequent as the result of ulceration in the diseases mentioned as to constitute a characteristic sign or complication. It must be said, however, that cases of alarming or fatal hemorrhage without apparent cause during life or lesion after death were more frequently reported in the literature of the times preceding our more accurate knowledge of pathology and pathogeny. Few clinicians or pathologists would now be content with reports made without full knowledge of the history of the case or microscopic examination of the intestinal walls. Thus, the report to the Société Médicale d'Emulation, April 2, 1834, by Dubois of a young man who quickly died of intestinal hemorrhage five days after a severe headache, and on the same occasion by Guillemot of several similar cases, would awaken the suspicion of masked typhoid fever; and the case of an old man aged seventy-four who died of intestinal hemorrhage after four days' diarrhoea, reported by Husson,[2] would call for a close examination of the vessels in the intestinal walls. In fact, Bricheteau, who reported a case from the Hôpital Neckar, was able on autopsy to discover a rupture in a small artery of the intestines.

[Footnote 2: Proceedings of the Anatomical Society at Paris, 1835.]

Embolic processes leading to the formation of ulceration (by predilection in the duodenum) are often attended with intestinal hemorrhage, which would be more constantly present were it not for the fact that, as in the stomach, the speedy establishment of collateral circulation prevents the consequences of complete infarction.

Besides dysentery and typhoid fever, tuberculosis and syphilis are occasional causes of ulceration and necrosis of the intestinal walls which may be attended with hemorrhage. Cancer of the intestine most frequently affects the rectum, but wherever situated may show hemorrhage as one of its signs.

The local hyperplasia of the mucous tissue which constitutes a polypus--and which in children, in whom it most frequently occurs, is mostly situated in the rectum--is suspected to exist or is recognized by the frequent discharge of blood from the bowels. A far more grave affection of the intestinal walls, likewise most frequent in childhood, is the peculiar dislocation known as intussusception or invagination. This condition is so commonly attended with distressing evacuations of blood and mucus as to simulate dysentery. The strangulation of the intussuscepted mesentery with its vessels easily accounts for the hemorrhage in such cases.

A more extensive compression is exercised at times by tumors in the {832} abdominal cavity, as by pregnancy, ovarian growths, etc., occlusions in the course of the portal system (cirrhosis hepatis), interference with the general circulation, as in diseases of the heart or lungs, with intestinal hemorrhage as a consequence.

Diseases of the blood-vessels themselves, as amyloid degeneration, aneurism, should not be omitted from the list of factors possibly productive of this result.

(3) The general diseases attended with hemorrhage from the bowel are characterized for the most part by more or less general disintegration or dissolution of the blood, with the manifestation of hemorrhage in various parts of the body--kidneys, uterus, subcutaneous tissue, etc.; the enterorrhagia being an accidental localization, so to speak, of the effusion. The most prolific causes of this disorganization are the micro-organisms which "touch the life of the blood corruptibly;" and hence the various acute infectious diseases may show in the severer forms hemorrhage from the bowels. Under this head may be ranged variola, which boasts even of a hemorrhagic form; typhus, yellow, and malarial fevers; the forms of nephritis marked by uræmia, cholera, icterus gravis, erysipelas, etc. Disintegration of the blood or partial dissolution of its corpuscular elements occurs also in those obscure affections which constitute the group, or are included in the description, of the hemorrhagic diatheses, as hæmophilia, leuchæmia, pernicious anæmia, scurvy; of any of which enterorrhagia may be a distinct or dangerous sign.

Melæna neonatorum is the distinct name given to a hemorrhage from the bowels which occurs a few hours or days after birth, and which is often so profuse as to cause death at once or in a short time. In most cases no anatomical lesions can be discovered after death, save an intense hyperæmia of the intestinal mucosa, so that the etiology of this affection is involved in obscurity. The various causes assigned in its production--ulceration of the stomach or duodenum (Bohn), embolism (Landau), fatty degeneration (Steiner), premature ligature of the umbilical cord (Kiwisch)--answer only for individual cases. Betz reported a case in a family subject to hæmophilia, and Trousseau once saw twins thus affected; but that heredity cannot account for all cases is shown by the fact that it occurs mostly in healthy children from healthy parentage. Klebs is inclined to attribute the affection to the action of micro-organisms, introduced perhaps as the result of puerperal infection, but this cause can be assumed in only a small minority of cases; at least, but a small percentage of cases coincide with puerperal disease on the part of the mother.

The affection is fortunately rare. Eichhorst states that Hecker observed it but once in 500 births, and Gemich but once in 1000 births. According to Rilliet, the hemorrhage is oftener (8/14) intestinal, rarer (4/14) gastric, and rarest (2/14) both. It is almost always abundant and quickly repeated, the blood being mostly pure, in clots or masses and fluid, though it is sometimes commingled with meconium. It usually ceases within twenty-four hours, though it may continue for three, five, or more days. Of 23 cases reported by this author, 12 recovered and 11 died.

MORBID ANATOMY.--Hemorrhage from the bowels, being only a symptom of very many different conditions, is marked by lesions characteristic of the condition in an individual case. These lesions are more appropriately described in connection with the various diseases. Not {833} infrequently in these cases the intestine is distinguished by the absence of any lesion at all; but, from whatever cause, hemorrhage from the bowels, like hemorrhage from any other source, shows a more or less profound anæmia of all the internal organs, and in more chronic and protracted cases leads to fatty degeneration, more especially of the heart.

SYMPTOMATOLOGY.--Hemorrhage from the bowels is usually readily recognized by the discharge of blood, either pure or mixed with the natural contents of the alimentary canal. The actual seat of the hemorrhage may, however, only rarely be recognized by the rectal speculum. The colicky pains, borborygmi, or sensations of fluids in the abdomen which are occasionally experienced may not be relied upon in fixing the seat of the effusion. Should the hemorrhage occur in quantity, or, more especially, should the seat of the effusion be low in the intestinal canal, the blood which escapes is more or less pure. When the hemorrhage is higher, or when the stay of the blood in the bowel is longer, it becomes more or less incorporated with the contents of the bowels or altered by the intestinal juices to present a discharge of mushy or semi-fluid consistence, of dark-brown or black color. So-called tarry stools are thus largely composed of blood.

But serious, even fatal, hemorrhage sometimes occurs without the escape of any blood at all. Such are the so-called cases of concealed, occult, or internal hemorrhage, in which the nature of the malady is only suspected or recognized by the general symptoms attending the profuse loss of blood. Should the hemorrhage be gradual, anæmia slowly supervenes, with hydræmia and subcutaneous dropsy. Traube reports a fatal case of oedema of the glottis from such a cause. Sudden hemorrhage announces itself by pallor and prostration, dyspnoea, vertigo, and syncope. Amaurosis, tinnitus aurium, formication, emesis, and, if the disease be high up in the intestinal canal, hæmatemesis, are the common attendants of serious hemorrhage. In the worst cases of sudden effusion the patient may present the appearance of complete collapse, and the intestinal canal be found on autopsy distended with blood throughout a great part of its course, while no blood whatever has escaped from the rectum. In such cases, or with more gradual loss of blood, the patient experiences a sense of increasing weakness, the skin becomes cold and bedewed with a clammy sweat, the pulse grows feebler, the temperature falls, and death from exhaustion more or less speedily ensues.

DIAGNOSIS.--The presence of blood in any quantity in the stools is readily recognized by its coarser characteristics. Ridiculous errors have been made by mistaking the coloration produced by bismuth, iron, logwood, etc. administered internally, or by coloring matters introduced into the discharges for purposes of deception. The microscope, Zeichmann's test for blood-crystals, and in extremely doubtful or medico-legal cases the spectroscope, furnish easy means of detecting blood in whatever quantity or character.

It is the cause and seat, rather than the existence, of the hemorrhage that mostly cause embarrassment in differential diagnosis. Hemorrhage from the lungs, nose, or stomach is usually readily excluded by the absence of any evidence of disease of these organs, and the presence of the other symptoms of any general disease attended with enterorrhagia makes a diagnosis in most cases easy enough. Alterations in the contents of the {834} bowel, the presence of foreign bodies, are recognized by the history of the case and by careful local examination, while a diagnosis of anomalies in the walls of the bowel is usually reached by exclusion. In no doubtful case should local inspection or digital examination of the anus and rectum be omitted.

TREATMENT.--As in all cases of hemorrhage, the first requisite is absolute rest. The patient should be at once put to bed and kept perfectly quiet. Many a case of hemorrhage in typhoid fever is produced by arising from bed to go to stool. The bed-pan is an absolute necessity in the management of a case of typhoid fever after the second week of the disease. Rest is the chief agent in prophylaxis as well as therapy.

The most effective styptic in enterorrhagia is cold. An ice-bladder should be laid upon or suspended immediately above the abdomen during the whole duration of the flow. The injection of ice-water into the bowel should be practised only in cases where the hemorrhage is believed to come from the colon. Otherwise, the peristalsis it awakens may only aggravate the danger. Should rest and cold fail to quickly check the hemorrhage, resort should be had at once to ergot. This remedy, in the form of ergotin, is most effective when introduced beneath the skin. In cases of less imminent danger the practitioner may be content to give the remedy by the mouth.

Small doses of the simple or camphorated tincture of opium frequently repeated speedily arrest contractions of the bowel, and at the same time feed the brain in threatening syncope. The astringents proper--tannic acid or its preparations, acetate of lead, alum, the perchloride of iron--are seldom necessary or advisable, but may be called for in obstinate or protracted cases.

To turpentine has been ascribed, from time immemorial, specific virtues in relief of hemorrhage of the bowels, and its administration is still a routine system with many older practitioners. It is most effective in large doses--one drachm, with milk or in emulsion, every hour or two until the hemorrhage ceases.

In relief of collapse, alcohol, ether, and musk are imperatively indicated, with the external application of heat; and in the treatment of the anæmia and hydræmia the preparations of iron, including, later, the mineral waters which contain it. In the worst cases of sudden alarming hemorrhage the physician should not fail to practise the transfusion of blood or solutions of salt or soda.

Milk is the best food and drink during the attack, and after it for some days or weeks. Chopped or scraped raw beef may substitute it later, while all farinaceous foods are to be strictly avoided for some time.

{835}

INTESTINAL OBSTRUCTION.

BY HUNTER MCGUIRE, M.D.

When a mechanical impediment to the passage of the contents of the bowel along the intestinal canal exists, the condition is known as intestinal obstruction. The causes of this occurrence are numerous, the symptoms urgent, the diagnosis difficult, the treatment uncertain, and the termination, unless relieved by nature or art, speedily fatal. There is no class of cases to which the practitioner is called more important, or which demands on his part greater skill and judgment.

It is customary to divide the causes of obstruction of the bowels into two great classes--acute and chronic.

In acute cases the attack is sudden, the symptoms violent, and, unless the cause is speedily removed, life ends in a few hours or at most in a few days. In chronic cases the causes act comparatively more slowly, the symptoms are chronic and less urgent, and danger of death less imminent. In this class the cause is not uncommonly spontaneously relieved, and the individual restored to perfect health without the aid of medicine or the surgeon's art. This result may happen in apparently the most desperate cases.

This classification of acute and chronic obstruction is necessary for a proper clinical study of the subject, but it should be remembered that in practice there will be found some cases which partake of many of the symptoms of both acute and chronic obstruction, making it difficult to determine to which division the cases properly belong. It will also be seen that some, at first, well-marked acute cases subside and become chronic in character, and that (old) chronic cases of obstruction sometimes suddenly change their nature and become acute. Again, some of the causes mentioned as giving rise to acute obstruction of the bowel in rare instances produce symptoms of chronic obstruction, and some of the causes referred to as giving rise to symptoms of chronic obstruction in rare instances provoke signs of acute obstruction. These cases are exceptional. As a rule, the following list embraces conditions which produce symptoms of acute obstruction:

1. Congenital malformations.

2. Impaction of foreign bodies, gall-stones, enteroliths, etc.

3. Twisting of the bowel--volvulus.

4. Internal strangulation by loops, bands, false membranes, diverticula, mesenteric pouches, slipping of a portion of bowel into natural or unnatural openings, diaphragmatic hernia, etc.

{836} 5. Invagination.

As a rule, the following causes produce symptoms of chronic intestinal obstruction:

1. Constipation and fecal accumulation.

2. Stricture of the bowel, sometimes cancerous.

3. Compression of the bowel from abdominal tumors.

4. Contraction of the bowel from inflammatory changes, often tuberculous.

A consideration of external hernia is, of course, not included in this paper, but the possibility of the symptoms of intestinal obstruction being due to this cause should never be overlooked.

Congenital Strictures and Malformations.

Cases of congenital strictures and malformations are confined almost wholly to the rectum and anus, and come more properly under the province of the surgeon. Some of the cases, however, belong to the physician, the obstruction being so slight as not to require surgical assistance. With all of them, however, the physician should be familiar, that he may be able to distinguish between congenital malformation giving rise to immediate obstruction and other forms of intestinal occlusion. He should know, too, when to seek the aid of the surgeon. For these reasons, as well as to make the history of the causes of intestinal obstruction as complete as possible, it has been thought proper to include in the list congenital occlusion and malformation of the intestine. They will be treated, however, in the briefest possible way, and the reader is referred to works on surgery for a more detailed account of the pathology, symptoms, and treatment.

When congenital occlusion of the colon occurs, it is almost invariably found in the sigmoid flexure, and is due, as most congenital atresia of the intestine, to foetal peritonitis. Congenital occlusion may be found in any portion of the small bowel, but a frequent site is the lower part of the ileum and the ileo-cæcal opening. The following case[1] gives an example of a form of stricture of the duodenum in infants, with the symptoms and pathological changes. The septum is supposed to be an unnaturally developed valve, or two valvulæ conniventes united: "A child when born presented no unusual symptoms for the first twenty-four hours. Vomiting then came on, and continued with short intermissions until death, which took place some thirty-eight hours after birth. The bowels were never relieved during life. The only disease found was stricture of the duodenum close to the entrance of the gall-duct, so that a probe passed down the latter entered the duodenum immediately below the constriction. There was nothing to indicate in what manner the constriction had occurred. On the gastric side of the latter the duodenum was immensely distended--so much so that at first sight it appeared like the pyloric end of the stomach itself, and only by a more careful examination was the distinction between the stomach and intestine detected by a ridge running around their place of junction."

[Footnote 1: Quoted by Mr. Pollock in Holmes's System of Surgery, from Pathological Transactions, vol. xii. p. 101.]

{837} Cases like this, a number of which are on record, are instructive and of pathological interest; when, however, congenital occlusion exists in the small intestines, no treatment can be suggested. If the sigmoid flexure is the part involved and diagnosis can be made, opening the intestine in the right groin and establishing an artificial anus should be attempted.

In the development of the foetus the anal part of the bowel, beginning below, develops upward, and the intestinal portion, commencing above, grows downward; both portions, advancing, finally unite, making one continuous tube. When, however, there is some interruption in the foetal development of the intestine, and the two portions of bowel fail to unite, we have malformation of the rectum and anus and intestinal obstruction; or the two portions of bowel may have been united and continuity of the intestinal track established, and subsequent intra-uterine inflammation may obliterate the canal. Under these circumstances a ligamentous cord represents the original tube. The cord descends from the cul-de-sac in which the upper part of the bowel ends to the skin about the anus, or is lost in the tissues about the neck of the bladder. In congenital malformations the following conditions may be found: 1st. The anal orifice may be so minute as not to allow the feces to escape; or the aperture may be occluded by a membrane, through which the meconium may be seen; or the anus may be entirely absent. 2d. The rectum may be occluded by a membranous septum, the presence of which is not suspected until symptoms of intestinal obstruction arise, and then it is discovered by introducing the finger or a probe; or the rectum may be entirely absent, the colon terminating in the iliac fossa in a dilated pouch, or ending at the top of the sacrum or stopping at any point between this and the normal anus, the place being determined by the period of arrest of foetal development; or, the anus being absent, the rectum may open into the vagina, bladder, urethra, and other places. These cases belong exclusively to the surgeon.

Impaction of Foreign Bodies.

Intestinal obstruction may arise from the introduction, accidental or otherwise, of foreign bodies into the stomach and bowels. Coins, marbles, bullets, fruit-seeds, etc. are often swallowed by children, sometimes intentionally, and if the object is round and small it rarely gives rise to any serious trouble. The foreign body, however, if small, may drop into the appendix vermiformis or some other diverticulum and end in serious mischief, or if the individual has stricture of the bowel the foreign body may be arrested by it.

Foreign bodies which are pointed or irregular in shape, swallowed by accident or design, may give rise to dangerous and fatal symptoms, but not unfrequently they escape per vias naturales. Thus, pins, needles, pieces of bone, artificial plate and teeth, small pen-knives, and other pointed or irregular-shaped bodies, have passed in this way. Sharp-pointed bodies, as needles, sometimes make their way through the walls of the stomach and present themselves at other and more distant parts of the body. I have removed a needle from the calf of the leg which {838} the patient had a month before accidentally swallowed. Jugglers accidentally, in practising their calling, and insane people, not unfrequently intentionally, introduce into the stomach all sorts of foreign bodies, such as buckles, forks, spoons, knives, pieces of wood, iron, bone, etc. Gross[2] records the case of a juggler who let a bar of lead ten inches long and weighing a pound slip into his stomach. Bell of Iowa removed it by gastrotomy, and the man recovered. Agnew[3] reports a post-mortem of an insane woman in whose intestinal canal he found three spools of cotton, two roller bandages, a number of skeins of thread, and a pair of suspenders.

[Footnote 2: System of Surgery, by S. D. Gross, 6th ed., vol. ii. p. 616.]

[Footnote 3: Agnew's Surgery, vol. i. p. 393.]

The morbid appetite of some people, particularly girls and pregnant women, sometimes induces them to swallow powdered chalk, magnesia, and other substances, and when this practice is continued for a long time the insoluble powder is deposited in the bowel and forms hard masses which more or less completely obstruct the intestines.

Stony concretions or enteroliths are found generally in the cæcum or in the sacculi of the colon, very rarely in the small intestines. They are round or oval, and when two or more are found together they have facets. They consist usually of carbonate of lime or magnesia or sesquioxide of iron. Other concretions are sometimes seen composed of starch or the felted husks of oats, called oat-stones (avenoliths), found particularly among the poorer classes of people in Scotland. Other vegetable remains of husks, fibres, etc. may produce the same thing. Young and middle-aged people more frequently suffer with these concretions than the old. Foreign bodies made up by the gradual accumulation of hair, string, and other substances are not unfrequently found in the stomach and intestines. The mass produced in this way is often very large. Sometimes the foreign body is arrested in the oesophagus. In a post-mortem reported to the writer by Fairfax a large copper coin, accidentally swallowed a few days before, was found lodged in the gullet. Ulceration followed, a neighboring artery was opened, and the patient died from hemorrhage.

Impaction of the bowel by gall-stones escaping from the gall-bladder into the bowel is by no means an unfrequent cause of fatal obstruction. Small gall-stones, after giving rise to intense pain and often grave symptoms during their passage through the bile-ducts, may escape into the duodenum and be discharged through the rectum, as any other small foreign body. If, however, there is constriction or stricture of the bowel at any point, the small gall-stone may lodge there, and if other stones follow and lodge, the collection may soon be great enough to produce obstruction. A very large single stone or a number of stones forming a coherent mass may collect in the gall-bladder, slowly distend the dilatable biliary passages, and escape into the bowel; or--and this is more common--an opening made by ulceration between the distended gall-bladder and the duodenum allows the concretion to escape into the small intestine. These stones or aggregation of stones are sometimes three, four, or five inches in circumference and from one to four inches long. They occur, as a rule, in people over fifty years of age, and more commonly in women. Brinton, in his excellent book on Intestinal Obstruction, makes the average age in these cases fifty-three and a half {839} years, and from the statistics he has gathered it will be seen that their occurrence is four times as often in females as in males. In 41 cases collected by Leichtenstern, 32 were women and 9 men. The site of the impaction is always in the small intestines. In 32 cases observed by Leichtenstern, 17 were found in the lower part of the ileum, 10 occupied the duodenum and jejunum, and 5 the middle part of the ileum.

SYMPTOMS.--Foreign substances introduced into the stomach do not always immediately give rise to serious symptoms. It is wonderful sometimes to see how tolerant the stomach is of their presence. Many instances are recorded of foreign bodies remaining in the stomach for months without producing dangerous symptoms. The mass may be discharged by vomiting, or it may escape through the pyloric opening into the intestine, and ultimately be discharged through the rectum, or, lodging in the bowel, give rise to symptoms of inflammation and obstruction. If, however, the foreign mass remains in the stomach, and is not removed by the surgeon's art or spontaneously discharged by ulceration, as in several rare instances has been the case, it uniformly proves fatal.

Before the foreign body is discharged by ulceration through the walls of the abdomen, adhesive inflammation unites that portion of the alimentary canal, gastric or intestinal, in which the mass is lodged with some part of the abdominal wall. By this union the cavity of the peritoneum is protected, just as we see the peritoneal sac protected by an effusion of lymph in hepatic abscess opening into the small intestine. If the adhesion between the canal and abdominal wall is imperfect, or by an undue amount of inflammation is disunited, the foreign body or inflammatory products which surround it may escape into the peritoneal sac and produce fatal peritonitis. Instead of passing through the abdominal wall, the foreign substance may escape into the bladder or vagina, or from the small intestine into the colon or rectum. Dangerous peritonitis may follow the simple presence of the foreign body in the alimentary canal from the obstruction it produces when no attempt at discharge by ulceration has been made. If the size and shape of the body permit its passage into the small intestine, it makes its way very slowly along this tube, giving rise to occasional attacks of colicky pains and symptoms of partial impermeability of the bowel.

At any moment the foreign body may lodge, become impacted in the canal, and all the grave symptoms of enteritis and general peritonitis present themselves. Symptoms of inflammation may appear, and after a longer or shorter time suddenly disappear, as if the foreign body had glided over some point of obstruction and again begun its descent through the tube. Its course is always irregular, passing quite rapidly over a portion of the intestine, then going more slowly, then lodging for a time at some point where it is obstructed by a fold or the contents of the bowel or by spasmodic contraction of the muscular coat of the intestines. As the calibre of the small intestine gradually diminishes as it approaches the cæcum, the passage of the foreign body becomes more and more difficult as it is propelled onward toward the ileo-cæcal valve. After a time it may reach the cæcum, where, of all places, it is most apt to lodge; but it may continue its course to the rectum, where it gives rise to tenesmus and a constant desire to go to stool. Finally, spontaneously or aided by the finger of the physician or some instrument, it is {840} evacuated per anum. Not unfrequently, the foreign body can be felt through the abdominal walls, and its course traced day after day as it makes its way along the canal.

It is a common practice with uninformed persons to give castor oil or some purgative medicine when a pin, needle, coin, or other foreign substance has accidentally passed from the mouth into the stomach. Such practice is irrational and hurtful. Experience has shown that the larger and more solid the alvine discharges, the more likely the foreign body is to escape by the natural outlet; and the physician should order such a regimen and diet as will probably secure this condition of the contents of the bowel.

Long residence of a foreign mass at any point in the intestinal canal is certain to produce some chronic enteritis and effusion of lymph and subsequent stricture of the bowel, or the presence of the foreign body may produce an ulcer; and when this is healed the resulting cicatrix may end in serious obstruction from the natural tendency of the new material to contract. Signs of constriction of the bowel may not be noticed for some time after the escape of the foreign body.

Obstruction from the presence of intestinal stones and concretions is almost invariably preceded by impaired health, emaciation, or cachectic appearance, signs of partial impermeability of the bowels, and repeated attacks of inflammation, especially in the region of the cæcum. It terminates sometimes by the concretion becoming encysted, by its spontaneous evacuation, or by ulceration and perforation, or sometimes by complete occlusion of the bowel, and death.

As occlusion of the bowel by the presence of gall-stones always occurs in the small intestines, the symptoms are at once of the most urgent and violent character. The signs are those of internal strangulation, and the termination is often rapid in the extreme. Colicky, griping pains are soon succeeded by violent agony; vomiting begins at once, and is constant; at first bile is thrown up, and afterward feculent matter; the pulse is small, wiry, and frequent; the belly is retracted; the features are pinched, the extremities cold, and prostration soon comes on, succeeded by collapse.

Evidences of disorder of the liver, symptoms of inflammation of the peritoneum in that region, or attacks of hepatic colic sometimes precede obstruction of the bowel by gall-stones; unfortunately, however, for the purposes of diagnosis, these premonitory symptoms are not invariably present.

Acute Internal Strangulation, Twisting, etc.

When a portion of bowel within the abdomen is constricted, its circulation interfered with, and the passage of the contents of the bowel interrupted, it gives rise to acute internal strangulation. This condition is very similar to that of external strangulated hernia. The difference is, that one is inside and the other outside of the cavity of the abdomen.

Twisting of the gut upon its mesenteric axis, the passage of the bowel through some natural or unnatural opening, the encircling of one portion of bowel by another or by bands, false membranes, etc., may cause {841} internal strangulation. It may happen at any age, and involves generally the small intestine or the more movable parts of the large bowel--viz. the sigmoid flexure and cæcum.

Twisting, or torsion, is not an unfrequent cause of intestinal obstruction, and may involve almost any portion of the intestinal tube. Its most common site is the sigmoid flexure, and next in point of frequency the cæcum. It sometimes, but rarely, involves the small intestines, and may occur as a simple twisting of one loop of intestines upon another. Several conditions are necessary for its production. First, the mesentery must be elongated. This change in the mesenteric root may have been caused by the dragging of an old and large hernia, or the mesentery may have been lengthened by relaxation of the abdominal walls from childbearing or by the disappearance of fat. However caused, before torsion of the gut takes place the mesentery is elongated, so that the two ends are approximated and something like a pedicle formed. Second, the portion of bowel attached to the lengthened mesentery may become filled with an enormous quantity of fecal matter and paralyzed by the great distension. In this paretic condition it may be displaced by the living, moving parts around it, and become bent and twisted, or the length of bowel belonging to the elongated portion of the mesentery may be the seat of inflammation, and, paralysis following, it becomes without resistance subject to the pressure and movements of the active vital parts surrounding it. A portion of bowel with its accumulated contents having a redundant mesentery and paralyzed by enormous distension or by inflammation, or by both, may readily be twisted more or less completely, and in some cases several times upon itself.

The weight of the bowel and its contents, along with the rapid distension of the intestine above, fixes the gut in this state of torsion and effectually prevents it from untwisting. A semi-rotation of the paretic and distended bowel about the mesenteric axis is sufficient to interfere with the supply and return of blood and provoke enteritis. Indeed, the rotation is rarely sufficiently great to produce complete obstruction, and the symptoms are frequently rather those of inflammation than of internal strangulation. For weeks before the final attack the patient usually has symptoms of intestinal disorder, such as flatulence, constipation, and spells of colic, due no doubt to the changes provoked by the elongated mesentery and bent or curved intestine. When torsion takes place the attack is sudden and the symptoms violent and urgent. Vomiting, meteorism, insuperable constipation, and frequently tenesmus, are soon followed by collapse and speedy death. The patient may die in twenty-four hours; he rarely lives beyond the fourth day. In some cases excessive tenesmus and bloody stools are seen in the early stages of torsion of the bowel. The condition may be mistaken for intussusception, but can usually be distinguished by the premonitory symptoms of twisting and by the more rapid course, the sudden meteorism, and quick collapse of the latter.

Still another way by which displacement of intestine may occasion obstruction to the passage of its contents is when a portion of the intestine has a long and narrow mesentery, and around this mesentery, which is like a pedicle, another portion of the bowel is thrown, encircling and compressing it. The accompanying figure, taken from Ziemssen's Cyclopædia, gives a good idea of this condition (Fig. 23). It represents a {842} loop of the small intestine placed around the mesenteric pedicle of the sigmoid flexure. Leichtenstern calls this "intertwining or knotting of two intestinal loops."

In consequence of inflammation of the peritoneum and effusion of lymph, peritoneal surfaces are joined together, and before the lymph is fully organized these surfaces are separated by the constant movements of the organs and the change in the relationship of the parts, and strings and bands of various shapes and sizes are formed in which a portion of the intestine may become entangled and constricted. Sometimes the bowel accidentally becomes engaged in a loop or noose of false membrane, or becomes bound down under a band of fibrin; or, the peritoneal surfaces of some of the organs having been joined together or to the wall of the abdomen or pelvis, a loop of bowel may escape into a slit or opening and become incarcerated; or a fold of bowel may fall into a fissure in the omentum or mesentery or broad ligament of the uterus or suspensory ligament of the liver, and become constricted; or the appendix vermiformis may be twisted around the intestine in such a way as to cause ligation of the tube, or, by becoming attached to some neighboring part, it may form a loop through which the intestine may pass and become obstructed. In the same way the bowel may be constricted by a diverticulum. (This is well shown in Figs. 23, 24, and 25.) Bands entangling the bowel and causing strangulation may be attached to the fimbriated process of the Fallopian tube or the ovary or uterus. Indeed, it is impossible to describe in a limited space the almost infinite ways in which these bands and strings may engage and incarcerate the intestinal tube (Figs. 24, 25).

{843} [Illustration: FIG. 25. An appearance of the natural relations of the diverticulum to the intestine. a, gastric extremity; b, rectal extremity.]

Internal strangulated hernia may result from the bowel falling into a pouch of the peritoneum and becoming ligated by the orifice of the pouch, or passing into the foramen of Winslow, of which there are three cases of strangulation recorded; or a retro-peritoneal hernia may be formed; or, more common still, a hernia of the intestine through the diaphragm.

In diaphragmatic hernia an opening is more frequently found in the posterior part of this muscle. Two hundred and fifty-two cases of this form of internal hernia have been collected by Leichtenstern, in which the diagnosis was made in only five cases. He found the oesophageal opening, a spot just behind the sternum, and a gap between the lumbar and costal parts of the muscle, the weakest points in the diaphragm.

Diaphragmatic and other forms of internal hernia may exist and not produce symptoms of strangulation either at the time of formation or subsequently, just as we so commonly see in cases of external hernia. When the bowel is constricted, however, and its circulation interfered with, symptoms of internal strangulation come on, and are exactly like the symptoms of external strangulated hernia. The attack is sudden, the symptoms acute and urgent, and the course and termination very rapid. Unless the constriction is relieved death may take place in twenty-four hours; life is rarely protracted beyond three or four days.

The patient has first eructations, soon succeeded by nausea and vomiting. The matter vomited consists of the contents of the stomach, then of gastric fluid, bile, and the contents of the intestines. When the last is ejected the vomiting is called fecal or stercoraceous. The patient complains of a sense of constriction about the abdomen, griping pains about the umbilicus, flatulence, tenesmus, and insuperable constipation. One or two free stools from the large intestine below the site of strangulation may be passed, but this should not deceive the practitioner. As a rule, peritonitis soon follows strangulation. The belly becomes tympanitic and tender, the pulse small and wiry, and the face anxious. When gangrene supervenes the pain subsides, the pulse becomes weak and intermittent, the surface cold and clammy, and the patient soon dies in a state of collapse. Slight delirium may precede death, or the mind remain unimpaired to the end. Very often, when gangrene sets in and pain disappears, the patient has a grateful sense of relief and is hopeful of recovery.

{844} Intussusception, Invagination.

One of the most frequent and important causes of intestinal obstruction is intussusception or invagination of the bowel; by which term is meant the protrusion or slipping of one portion of bowel into a portion immediately adjoining.

This condition is sometimes found after death in persons old or young, but particularly the latter, in whom during life there were no symptoms of intestinal obstruction or intestinal trouble of any kind. The displaced intestine in these subjects is easily reduced, is unattended by any signs of inflammation, and is evidently the result of spasmodic contraction of the transverse muscular fibres of the bowel at one part, with distension and relaxation at another part, by which, just before death, one piece of the bowel is pushed into an adjacent piece. Not unfrequently two or more invaginations are seen in the same subject. Flint[4] counted as many as fifteen in a child who died of typhoid fever. This invagination of the death-struggle almost invariably involves the small intestine, and may be the protrusion of a piece of the bowel above into a piece immediately below, or the reverse, a portion of bowel below being pushed into a portion above. It has been suggested that this slight and temporary intussusception may occur during life and give rise to temporary symptoms of intestinal obstruction, which disappear when reduction of the displacement spontaneously takes place.

[Footnote 4: Practice of Medicine.]

It will be seen by the diagrams that three successive portions of intestine enter into the formation of an intussusception--an entering, returning, and receiving portion. Two mucous surfaces and two serous surfaces are thus brought into apposition. The mesentery attached to the included lengths of bowel--viz. the entering and returning lengths--is necessarily pulled down with the bowel in its descent, and is also embraced by the receiving portion of the intestinal tube. The traction excited by this portion of mesentery, thus wedged in between the middle and inner layers of the bowel, materially alters what would otherwise be the relationship of the parts. Fig. 26 shows simple invagination of the ileum like the finger of a glove, in consequence of the traction exerted. The entering or invaginated portion does not always lie in the axis of the enveloping tube, but is more or less curved, until very often its lower orifice is in contact with the wall of the outer layer. The concavity of this curve looks {845} toward the mesenteric edge of the invaginated portion of bowel, and the convexity toward the opposite side of the receiving portion. The convex side of the middle cylinder is often thrown into transverse folds or convolutions. Intussusception, which gives rise to symptoms characteristic of intestinal obstruction during life, is invariably from above downward. It is doubtful whether there is on record a single well-authenticated case of inflammatory invagination where the lower segment of bowel protruded into the upper.

Reference to the diagrams will show that the lumen of the bowel is diminished, and that more or less intestinal obstruction must follow invagination. This obstruction is increased by the inflammation which necessarily follows this condition. The large and numerous blood-vessels of that portion of the mesentery involved in the invagination are compressed and stretched; arterial supply, and especially venous return, are interfered with; congestion quickly follows, with copious inflammatory exudation; the layers of intestine become swollen, and blood, sometimes in abundance, is poured out from the mucous membrane. Peritonitis, limited sometimes to the invaginated part, more often spreading to the peritoneum covering neighboring structures, soon begins, and the contiguous serous surfaces are agglutinated and the intussusception rendered irreducible. Lymph and other inflammatory products are poured out freely; the coats of the intestine become distended and thicker, and the inner and middle layers of the invagination are separated by the deposit; the invaginated part becomes more and more curved toward the mesenteric border of the outer layer; and occlusion of the bowel, begun by the invagination, is made more or less complete by the changes wrought by inflammation (Fig. 27). That intestinal obstruction is not always complete in intussusception is shown by the fact that fecal matter, often in considerable quantity, is passed through the bent and narrowed tube, the intestine retaining, at least for a time, its contractile power. The changes produced by inflammation are chiefly seen in the inner and middle layers of intestine, the receiving or outer layer of the invagination often escaping any serious damage. These changes vary with the character and duration of the inflammation. Sometimes they are limited to an agglutination of the opposed serous membranes, an effusion of blood and serum from the mucous surfaces, and an enormous distension and swelling of all the invaginated parts; or the inflammation may end in mortification of the middle or both the inner and middle cylinders, the dead part coming away in shreds or in large fragments, or, if the patient lives long enough, the entire invaginated tube being discharged through the anus. If the inflammation involves the invaginated parts unequally, strips and shreds of the bowel are detached by ulceration and sloughing, and may escape in the discharge from the bowels in pieces so small as to be unnoticed; but if the intussuscepted part dies en masse, a circular line of demarcation is formed by ulceration, and the dead segment is detached and drops into the cavity of the bowel below, and escapes through the rectum. It is often so complete that the inner and middle cylinders can be recognized, and the part of the intestinal tube to which the expelled bowel belonged can be determined. In favorable cases the blood-vessels of the healthy bowel above and below the dead segment pour out a circular mass of coagulable lymph, which, becoming organized, closes the breach and {846} completes the intestinal tube. To accomplish this it is necessary that the ends of the two portions of bowel should be accurately coaptated: if they are not, some opening may be left through which the contents of the gut may escape into the peritoneal cavity, producing fatal peritonitis; or the new formation may be imperfectly organized, and burst during some peristaltic movement of the bowel or from the pressure of gas accumulating in the gut; or the supply of lymph may be so redundant as to obstruct the calibre of the bowel, or end in cicatricial contraction, stricture, and obstruction. Aitken[5] records four instances where the curved end of the invaginated portion of bowel by prolonged pressure caused ulceration and perforation of the coats of the enclosing bowel, the invaginated portion passing through the side of the enclosing segment and projecting into the cavity of the peritoneum.

[Footnote 5: Science and Practice of Medicine.]

Gangrene and ulceration, however, do not always follow intussusception. The mesenteric injuries may be sufficient to produce congestion and exudation, and the patient survive the invagination for weeks, and death eventually occur without sloughing or ulceration; or spontaneous reduction of the invagination may take place and recovery of the patient follow. The last termination must be rare, and impossible when firm adhesion between the serous surfaces has taken place; but that it does exceptionally occur is proved by cases where the diagnosis of intussusception was undoubted, the invagination being felt in the rectum or seen prolapsed through the anus. The most common termination, if the patient survives, is mortification of the invaginated part and separation in mass or by shreds or fragments.

Intussusception may occur in any portion of the intestinal canal, but some points are more liable to it than others. 56 per cent. of the cases collected by Brinton were ileo-cæcal; in 32 per cent. the small intestine alone was involved; 28 iliac and 4 jejunal; in 12 per cent. the colon, including its sigmoid flexure, was the part implicated.

When the rectum is involved, it usually forms the outer layer of the invagination, the middle and inner layers being formed by the bowel which has passed from above into it; when prolapse of the rectum itself occurs, the mucous membrane is generally alone involved, but along with this the muscular coat may also descend and a true invagination of the rectum be found.

The most common variety of intussusception is the ileo-cæcal. It is in this form that we find the greatest length of bowel involved. This invagination begins generally at the ileo-cæcal valve, the lips of which at first turn toward, and descend into, the cavity of the cæcum, drawing with them the end of the ileum; in this case the valve forms the lowest point of the invagination. If the invagination continues, the end of the cæcum is next inverted; and if the process still goes on, more and more of the colon is invaginated, until in some rare cases it traverses the whole of the large intestine, appearing just above or even protruding through the anus. In this variety the vermiform appendix lies between the middle and inner layers of the intussusception, and its opening, usually stretched and enlarged by the inverted cæcum and inflammatory effusion, is found close to the ileo-cæcal orifice. In this intussusception the cæcum and colon are large and roomy, and the invaginated portion not so liable, {847} as it is when the small intestine is alone implicated, to strangulation and sloughing; nor is there seen in ileo-cæcal intussusception, unless the portion of bowel involved is very short, the marked curvature of the invaginated portion so commonly found in the small intestine. In the ileo-cæcal form it is twisted or much convoluted rather than bent.

Another variety of ileo-cæcal invagination--very rare, however--is where the ileo-cæcal orifice does not descend into the cavity of the cæcum, but the lower end of the ileum passes through the valve into the large intestine. In this instance the invaginated portion is tightly compressed by the valve, and strangulation is speedy and complete. An invagination may occur in the lower part of the ileum, and the inner and middle layers pass on to the ileo-cæcal valve, and be arrested at that point, and afterward, in consequence of violent peristaltic action, the whole intussusception, inner, middle, and outer layers, be invaginated into the colon. In this way the invagination becomes doubled.

While intussusception may occur in either sex and at all periods of life, it happens nearly twice as often in males as in females, and is most frequently seen in childhood. Leichtenstern[6] found in his statistics of 473 cases that one-half were seen in children under ten years old, and one-fourth of all intussusceptions occurred in children from four to twelve months old. Invagination of the small intestine is found almost exclusively in adults. Brinton from his records gives the mean age of its occurrence 34.6 years. According to the same author, the average age of ileo-cæcal invaginations is 18.57 years, and one-half of all cases of this form of intussusception observed by him were in children under seven years of age. Leichtenstern states that the lower part of the ileum is the most frequent site of invagination in the small intestine, and the descending colon and sigmoid flexure the most common portion involved in intussusception occurring in the large intestine.

[Footnote 6: Op. cit.]

The mechanism of intussusception is probably not always the same. The following is thought to be the most frequent process: A segment of bowel becomes paralyzed by local peritonitis, some injury, diarrhoea, or colic, and while in this state a segment of bowel above is subjected to violent peristaltic action, and is forced into the unresisting portion below. In this case the paretic segment forms the outer or receiving layer of the intussusception. Leichtenstern believes that the paretic portion is turned in and invaginated into the normal bowel below, and that the clinical course of intussusception and post-mortem appearance correspond with this explanation. If such is the case, the paralyzed portion forms the inner layer, and the active bowel below the receiving layer. Another theory, which applies with much force to the most common of all invaginations--viz. the ileo-cæcal--is, that as violent anal tenesmus produces prolapse of the rectum, so prolonged and powerful tenesmus at the ileo-cæcal opening may cause prolapse of the lips of this orifice, and, eventually, invagination of the ileum, or of both this and the cæcum, into the colon. When we remember that the ileo-cæcal valve is furnished with a sphincter muscle, the analogy is complete. The idea so long entertained that intestinal worms may occasion invagination of the bowel has generally been abandoned. A polypoid tumor, by dragging down the portion of bowel to which it is attached, may produce invagination; and {848} Brinton's statistics give 5 per cent. of cases of intussusception from this source. An examination of a larger number of cases would probably show a much smaller percentage due to this cause.

A majority of cases of intussusception, however, take place suddenly, without previous diarrhoea, colic, traumatism, or ill-health of any kind, and probably occur without any tenesmus or paresis of a portion of bowel. It may be that the longitudinal fibres of a segment of gut contract, dilating and shortening a portion of the bowel; while this part is distended a portion immediately above may be lengthened and narrowed by contraction of the circular fibres, and violent peristalsis going on at this moment, aided, possibly, by contraction of the muscular wall of the abdomen, forces the upper and narrow segment into the lower and dilated one.

At first the invagination involves a small portion of the bowel, but, active peristaltic action continuing, it rapidly increases in size. This increase is made at the expense of the sheath or outer layer, which turns in to form the middle layer. The length of the invagination varies from two or three inches to three, four, or five feet.

The symptoms of intussusception generally come on suddenly, and indicate both intestinal obstruction and inflammation. Pain resembling violent colic, and referred to the site of the invagination, is a prominent symptom. The pain is intense, paroxysmal in character, but after a time it becomes continuous. At first pressure gives relief, but in a few hours tenderness, denoting peritonitis, appears, limited to the invagination or spreading gradually over the whole abdomen. Vomiting soon follows, and, with rare exceptions, is persistent. After two or three days occasionally blood and sometimes fecal matter are ejected from the stomach. Diarrhoea, with bloody, mucoid stools, is rarely ever absent, and is characteristic of invagination. The patient has from fifteen to twenty passages a day. If the large intestine is involved, the diarrhoea is accompanied with tenesmus. Above the obstruction gas and ingesta accumulate, and produce abdominal distension, sometimes well marked. Generally the tumor formed by the invagination can be felt through the abdominal wall, and is a symptom of great importance. Meteorism and peritonitis may render the existence of the tumor obscure or altogether prevent its recognition, but in intussusception of the colon and at the ileo-cæcal valve the solid cylindrical mass can usually be found, and frequently, when the small bowel alone is implicated, a very careful and patient examination will enable the observer to detect it. Sometimes it changes its site, size, and shape; occasionally it can be felt in the rectum or is seen protruding through the anus.

The urgency of the symptoms of invagination depends upon the portion of bowel involved and the degree of constriction of the gut and its attached mesentery. When the bowel is tightly constricted the symptoms are acute, and the patient may die in a day or two; when the bowel is not constricted the symptoms are chronic in character, and in the early stages not urgent. The difference here is like that between strangulated and incarcerated hernia.

In acute cases the attack is sudden, obstruction complete, and the symptoms those of internal strangulation of the bowel, often followed by collapse, which may destroy life in a few hours. These cases are {849} chiefly jejunal and iliac invaginations, and the higher up in the small intestine the seat of obstruction the more violent and urgent the symptoms. Constriction, being great, is followed by engorgement and inflammation of the invaginated bowel, and if the patient lives long enough gangrene ensues, by which the obstructing mass is separated and discharged en masse or in fragments through the anus. Not unfrequently life is saved in this way. That gangrene has taken place and separation of the invaginated segments is in progress are often known by the very fetid character of the evacuations and by their admixture with blood and shreds of necrosed bowel. When the sequestrum has been detached entire, it is often passed with difficulty. Frequently it lodges at some point in the bowel, producing temporary obstruction and giving rise to tenesmus and pain as it passes along the large intestine. There is no doubt that the continuity of the intestine above and below the neck of the invagination has been established, and complete cures effected in the way already mentioned. Usually, however, the patient dies from collapse, peritonitis, or perforation of the bowel before the obstructing mass can be removed by gangrene. Children almost invariably die before this can take place, and adults live from the seventh to the fourteenth day, according to the greater or less violence and acuteness of the symptoms. When the slough has been discharged and the continuity of intestine established, recovery is still uncertain, and death very often happens for reasons referred to in speaking of the separation of the sequestrum.

Separation of the invaginated portion and its expulsion, according to Leichtenstern, in the majority of cases takes place from the eleventh to the twenty-first day, but in chronic cases it is often delayed for months. According to Brinton, separation of the sequestrum occurs between the eighth and fifteenth in intussuscepted small intestine, and between the fifteenth and twenty-second days in acute cases of ileo-cæcal and colic invaginations.

In chronic cases of intussusception, which usually embrace the ileo-cæcal and colic varieties, strangulation is not common and the course of the disease is protracted. These cases often last for several months, and the symptoms are not always well defined. At first the pain is paroxysmal, with long intervals of ease. Vomiting succeeds, but is not persistent; discharge of the contents of the bowel below the seat of lesion takes place and afterward fecal matter from above this point, because the permeability of the bowel is not usually lost in chronic cases. Eventually the alvine discharges become bloody, mucoid, and characteristic of intussusception; the severity of the symptoms may gradually increase, the pain becoming greater, more constant, the vomiting more incessant, the discharges from the bowels more frequent, and in one, two, or three months the patient dies from asthenia. Several authentic cases are related where the disease lasted one or two years before terminating fatally. Very often some days before death the pain and tenderness cease, and the operations become free from blood and normal in character.

{850} Constipation.

Constipation is a prominent symptom in all of the conditions which give rise to intestinal obstruction, and habitual constipation or loss of the powers provided for the advance of the contents of the intestines not unfrequently leads to permanent occlusion of the canal. It is impossible to fix any definite rule as a standard of health for the number and quantity of alvine evacuations. Some individuals have a passage from the bowels once every day; others, in the enjoyment of as good general health, suffer from the ordinary inconveniences of constipation if they have less than two or three daily fecal discharges; others, again, apparently equally as well, have a movement from their bowels once in two or three days or once a week, or even once in two weeks. Habershon[7] records the case of a "woman sixty years old who from youth upward had had a passage from the bowels only every six or eight days, and whose health had been perfect." A lady under my own observation, for twenty years never had an alvine discharge oftener than once in two weeks, and three times in her life had passed two months without a movement of her bowels. This lady was the mother of several children, and, although not in perfect health, was able to attend to her ordinary household duties. Such cases are not very uncommon, and occur, as far as I have been able to ascertain, more frequently in women than in men.

[Footnote 7: On Diseases of the Abdomen, quoted by Leichtenstern in Ziemssen's Cyc. P. of Med., vol. vii. p. 588.]

The number of fecal evacuations and the quantity discharged have been shown by Bischoff and Voit to depend, to some extent, upon the character of the food ingested, vegetable diet producing abundant, and animal diet scanty, stools. Doubtless, the quality of the food partly explains the quantity of the alvine evacuation, although, to some extent, this must depend upon the time that the feces remain in the colon, a long residence there taking away a greater part of the watery constituents and making the fecal mass thicker and harder; but the variations in the number of stools in persons living on the same diet can only be explained by the variations in the activity of the peristaltic action in different individuals, or in the same individual at different periods and under different surroundings.

The causes of habitual constipation are of the most varied and diversified character, and it is not always possible in an individual case to point out the original or primary one. Not unfrequently several causes are in operation at the same time to produce sluggishness of the intestinal canal and constipation. Very often it begins with change of scene and habits, by which the daily visit to the water-closet is interfered with, or after confinement to bed with some temporary indisposition. It is more likely to occur in men and women whose habits are sedentary and who are constitutionally lazy and indolent. The feces are allowed to remain in the rectum and colon, and every hour after the ordinary time for going to stool diminishes the watery parts of the fecal mass and makes it harder and more consistent. Many cases of chronic constipation, begun in this way, have ended in dilatation and thickening of the intestine, ulceration of the mucous membrane, and, eventually, perforation of the coats and escape of the contents of the gut into the peritoneal cavity. Rapid {851} excretion of water by the kidneys, lungs, and skin produces constipation by withdrawing a large proportion of the water from the fecal mass, rendering it unnaturally dry and of diminished bulk. In diabetes, constipation arises from this cause unless the patient makes up the loss by drinking an unusually large quantity of water. Constipation in nursing-women is explained by the loss of water in the secretion of milk. The profuse sweating which attends malarial fever, phthisis, and other diseases readily accounts for the constipation which often accompanies these disorders.

Certain articles of food not necessary to mention here produce constipation. They fail to excite peristaltic action; or articles of diet which at first act as a stimulus to the bowels, and even provoke temporary diarrhoea, lose their power if kept up too long--just as certain purgative medicines lose their force if continued for too long a period. Gradually they cease to increase the peristaltic action, and rather add than otherwise to the inactivity of the intestines. Eating the same kind of food day after day is very apt, sooner or later, to result in diminished sensibility of the intestinal canal, a reduction of the peristaltic force, and deficiency in the secretion of the digestive juices, which in itself is a common cause of constipation. Frequent change of diet is generally needed to supply the stimulus necessary for that intestinal motion which relieves the bowels.

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