Volume 2 — DISEASES OF THE DIGESTIVE SYSTEM. (continued 12)

⁴⁴ H. R. Storer, Gynæcological Journ., 1869, vol. i. p. 80.

The history of each individual case, a full knowledge of etiological factors, and a careful physical examination will in most instances lead to a proper diagnosis.

PROGNOSIS.—The result of treatment depends upon the age. Although in infancy constipation is very common, cure is the usual result where a mixed diet begins to be taken in childhood. At from one to fourteen years of age regular movements can usually be secured, unless there is a radical defect in the organization of the child. In young girls at puberty and after, if constipation once is established it is apt to become inveterate, associated as it is with imperfect development and with uterine displacements. In middle life in men the result depends upon the cause and upon attention to the physician's counsel. If intestinal catarrh or atony is the cause, a persistent subordination of the life of the individual to the object in view will generally end in cure. In women who have borne children the hope of relief depends upon the duration of the malady before treatment. It is a dispiriting task to attack a constipation of many years' standing in women with relaxed abdomens, uterine prolapsus or retroversion, and general debility. In old age the causes are generally such as cannot be removed. The bowels can be moved when the occasions demand, but there is very little expectation of establishing a spontaneous habit of regular fecal movements.

At every age and from whatever cause perseverance and hope on the part of the patient and doctor are the chief elements of success. In neglected cases the worst results may happen: dilatation of the colon, ulceration, fecal impaction and obstruction, perforation; or in milder cases chronic indigestion, hypochondria, etc.

TREATMENT.—The physician can render great service by giving to parents advice which will prevent constipation in children. He should insist upon the importance of habits of regularity in defecation. At the period of puberty in young girls this is of even greater moment, and no opportunity should be lost for pointing out the danger of neglect. As a prophylactic measure in adults counsel should be given suited to the occupation. To persons leading sedentary lives the necessity of exercise ought to be made clear. In the trades little can be done, but in the case of literary men and those who read or write for many hours prevention is easier than cure. Daily exercise, walking or riding, frequent bathing with active sponging and friction of the surface, especially over the abdomen, will be of much service. Avoiding constrained positions where pressure is brought to bear upon the abdomen, as in bending forward to write, is quite an important item. Among ignorant people advice of this kind is rarely attended to, but even here the doctrine of regularity should never cease to be preached. Active business-men, especially young men, need emphatic teaching. They cannot plead ignorance for the habitual and persistent neglect of the simplest rules of health of which they are in this country so often guilty. The symptoms of indigestion which are precursors of constipation should receive due attention, and a mode of life and dietary suited to a complete digestion of the food will favor the timely and proper expulsion of waste matter.

Acute constipation in a previously healthy person, lasting for one to three days, does better without interference. No harm attends temporary inaction of the bowel, and if a spontaneous stool takes place at the end of this time it is a sign of a healthful and vigorous condition. After this the normal regularity is restored. The habitual clearing out of the bowel by a purgative pill or dose of mineral water whenever such a state of matters occurs creates the necessity for the interference. The man who never lets himself go over a day without an action is miserable if he misses his purgative and its effects.

In the onset of acute diseases the custom of giving a preliminary purgative is generally unnecessary, often injurious. It disturbs the rest which such cases need; it produces exhaustion in some diseases, as pneumonia, pleurisy, and rheumatism; it irritates the mucous membrane when irritation involves danger, as in intestinal catarrh and typhoid fever.

When it is desirable to empty the bowel in acute constipation a warm-water enema for adults and children is the best means. When a laxative is necessary in case of a failure of the enema, one mild in its operation should be chosen—a compound rhubarb pill, one to five grains of calomel, a teaspoonful of Rochelle salts, or half a bottle to a bottle of the solution of the citrate of magnesia or the tartro-citrate of sodium. For children calomel, in doses of one-third of a grain to one grain, is one of the most certain and least objectionable. One grain of powdered rhubarb can be added to this for a more active effect.

Under such circumstances as a blocking up of the bowel with a mass of partially digested or undigested food, fruit-stones, skins, or other foreign bodies, where the symptoms are violent pain, tympanites, and vomiting, the best method is to give large enemata of warm water through a long rectal tube passed as high up as possible, and to administer calomel in doses of one to three grains, repeated every two to three hours until the bowels are moved. Cold can be applied to the abdomen to diminish tympanites and prevent inflammation. Should the constipation not yield and the pain, vomiting, and tympanites augment, the case will then be considered one of intestinal obstruction, and be treated as such.

When called upon to treat chronic constipation, the physician should remember that it is not the symptom, but its causes, to which he should direct attention. Constipation is so often a symptom, a complication, of other diseased states that its management is a matter of secondary importance. Moreover, its causes are so peculiar to the individual and depend upon so many variable habits of life that each case asks for special study. The cure is only to be found by learning the particular cause—the habit of neglect, hurried eating, the use of aperients, uterine displacement, or any of the many causes enumerated.

The digestion and all that concerns it is of primary importance, and to it attention should be at once directed. The stomach and intestinal digestion should be examined separately, and the relative power to digest different articles of food determined. A diet, then, should be selected, not with a view to correcting the constipation, but as to its suitability to the digestive capacity of the patient. No system of diet can be fixed upon as suited to every case: the aim is to secure normal digestion and absorption and normal peristalsis. Many trials may have to be made before a proper dietary can be chosen. When there is indigestion of fats and malnutrition, with pale offensive stools containing much mucus, an exclusive nitrogenous and easily digestible diet—such as is advised in the article on INTESTINAL INDIGESTION—should be prescribed. In constipation connected with membranous enteritis a similar system of diet is proper. The drugs given should be those which aid intestinal digestion, and reference must be made again to this subject, already treated of. Many cases of constipation can only be cured by this treatment; the routine treatment by purgatives and a diet of vegetables and fruits would aggravate and not relieve. A course of exclusive milk or skim-milk diet, if persevered in for some weeks, will cure cases of constipation of this kind without the use of laxatives. Of course a purgative must sometimes be given if enemata fail, but the least irritating one should be selected.

The mineral waters best suited to constipation depending upon intestinal catarrh are in this country those of the Rockbridge Alum Springs and Capon Springs (Va.), the California Seltzer Springs, and the milder waters of Saratoga. The most suitable from Europe are the waters of Apollinaris, Vichy, Buda, Vals, Ems, Salzbrunn, Selters, Mt. Doré, and Kissengen. The warm baths of Virginia (Warm Springs, Hot Springs) are useful in increasing the activity of the skin and in giving relief to the catarrhal state. A month spent at the Warm Springs, with a daily bath the natural heat of which is 98°, will work a complete transformation in the abdominal circulation. This should be conjoined, of course, with a properly-regulated diet and exercise. Another month spent at the Rockbridge Alum Springs will complete the restoration of the bowel to a normal state. It is much to be regretted that the really valuable mineral springs of Virginia lack so many of the comforts which the invalid requires. In cases where it is more convenient a stay at the Arkansas Hot Springs is to be suggested, and for obstinate cases of intestinal catarrh with sluggish circulation, obesity, and gouty tendencies these springs are to be preferred. A season at some of the mineral baths of Europe, as Aix-la-Chapelle, followed by the strict regimen of the grape cure (as at Bingen, Durkheim, Vevay, Montreux, or Meran), is a rational mode of treatment which offers an almost certain prospect of cure.

If the case is one of atony of the colon due to impaction of the rectum and dilatation of the rectum and colon, without gastric or intestinal indigestion, a quite different regimen is required. The constitution and mode of life are the guides to the general plan to be followed. Sedentary pursuits are to be given up as far as possible. Long vacations and travel must be insisted on, with active exercise by walking and riding; also cold bathing or sponging, with brisk friction of the whole body. Sea-bathing is useful both as an exercise and for the effect upon the sluggish peripheral circulation, but the slothful life at the seashore, with over-indulgence in eating and drinking, is a source of more harm than good. Warm baths, and cold douches to the abdomen, compresses of cold water or of alcohol, the cold douche to the spine while in the hot bath, are all beneficial. Massage for women, children, and feeble persons takes the place of exercise. The kneading of the muscles over the abdomen can be combined advantageously with an effort to accelerate the passage of the contents of the colon by manipulation in the direction of movement.

The interrupted electrical current, used for the purpose of developing the feeble abdominal muscles, is a source of much advantage.⁴⁵ But to be of service it should be persevered in for months, the patient himself making the application under the direction of the physician. In addition, the introduction of one insulated electrode into the rectum, while the other is in contact with the abdominal muscles or along the line of the large intestine, has been advised. The Swedish movement cure may be a useful aid in some cases. The movements exercise the muscles of expulsion. These are deep inspiration, flexion and extension of thighs or trunk, twisting the trunk, pressure on the abdomen and colon, stroking in the direction of fecal movement.

⁴⁵ S. T. Stern, "Die faradische Behandlung der Obstipation und der nervosen Enteropathie," Centralblatt für Newenheil, 5 Jahrg., Mai, 1882, p. 201; also, I. Althaus, "Treatment of Obstinate Constipation by Faradization of the Bowel," Lancet, London, 1867, ii. 606.

In the relaxed condition of the abdomen in women who have borne children or in old persons the wearing of an abdominal support sometimes gives help and comfort.

The best diet for cases of atony of the colon and rectum is one which is easily digested and has a moderate amount of waste, as a full colon will stimulate muscular action. Various articles are suggested with a view to excite peristalsis by irritation of the mucous surface, but as such substances are in themselves insoluble and innutritious, it is unwise to resort to them. The following list includes the foods suitable to such cases: Fresh vegetables, as spinach, raw or stewed tomatoes, lettuce, kale, salsify, peas, asparagus, kohlrabi, and other summer vegetables; in winter canned vegetables, if well prepared, take their place. Among fruits, fresh fruit in general, especially grapes, peaches, and oranges; dried fruit, as figs, raisins in small quantity, stewed prunes, and baked or stewed apples, can be tried.

Too much vegetable matter is harmful, as the bowel is filled with an excess of waste, much of which is undigested food; the quantity must be regulated by the appearance of the stools and by the success of the regimen. If the blockade continues obstinately, the vegetable diet should be reduced. The microscope in many cases can alone decide the amount of undigested vegetable matter. Meats are all advisable in moderation. The least digestible, as ham and veal, are to be avoided. Graham-flour bread, brown bread, or bran bread are better than bread made of the best bolted flour. The first is more digestible, and bran bread⁴⁶ is thought to increase peristalsis, but this is a doubtful effect. Oatmeal well boiled, fine hominy, corn meal, or cracked wheat with milk are pleasant and digestible. A cup of café au lait at breakfast or before breakfast is the best morning drink;⁴⁷ it has a laxative influence. Tea is thought to have the opposite effect. Milk at breakfast answers well for those who take it with relish. An orange on rising in the morning is a pleasant remedy.

⁴⁶ "The Efficacy of Bran Bread in relieving Despondency ... dependent on an Irregular and Constipated State of the Bowels," Journ. Ment. Sci., London, 1858-59, v. 408-411.

⁴⁷ "Treatment by Café au Lait," Gaz. des Médecins prat., 1840, No. 4, p. 13.

Certain drugs are called for to aid these measures in giving tone directly or indirectly to the weakened bowel muscles. Strychnia stands first, but it woefully disappoints one who trusts much in the theoretical arguments for its use. In fact, it may be said of all drugs given for constipation that they stand in a very subordinate rank to the measures already discussed. They should be thought of last, not first, and but little confidence should be put in the vaunted value of new drugs. Strychnia can be combined in anæmia and debility with the dried sulphate or carbonate of iron, and with quinia or arsenic,⁴⁸ or in feeble digestion with dilute hydrochloric acid and pepsin. Belladonna was advised by Trousseau as a stimulant to unstriped muscular fibre, and it can well be given with strychnia; ipecacuanha and atropia are approved of in conjunction.⁴⁹ A pill of ergot, belladonna, and strychnia would answer the indication of a feeble peristalsis. DaCosta has suggested giving one drop of the fluid extract of belladonna with compound tincture of gentian or cinchona three times daily after meals. The sulphate or valerianate of zinc, oxide of zinc, extract of valerian or gentian, capsicum, or black pepper can be tried in pill form with belladonna and strychnia.

⁴⁸ Bartholow thinks arsenic overcomes constipation when due to deficient secretion and dryness of the feces (Mat. Med., New York, 1879, p. 129).

⁴⁹ Legros and Onimus, Journal de l'Anat. et de la Phys., t. vi. pp. 37 et 163. Ringer says one grain of ipecacuanha taken while fasting each morning will relieve constipation from torpor (Therapeutics, New York, 1882, p. 438).

These remedies are slow-acting, and in the mean while the bowels must be moved artificially, methodically, and taught to act at stated hours. For this purpose a small enema of cool or cold water at the same hour every day after breakfast does well. It is irrational to distend the bowel, already weakened by distension, with large enemata of warm water. Recourse should not be had to this until all hopes of effecting a cure are gone, or only as an occasional remedy in impacted accumulations where the mass must be softened before it can be removed. If the enema does not in time empty the colon sufficiently, laxatives will have to be taken with some regularity until the habit is created. A tumblerful of water with or without a teaspoonful of salt, or a tumblerful of any alkaline water charged with carbonic acid, taken on rising in the morning, may prove effective. A tablespoonful of sweet oil at night acts well as a lubricator and softens the feces. If these more simple means fail, it becomes unfortunately necessary to give a purgative drug: any one of this class can be combined with strychnia, belladonna, vegetable tonics, and iron. Those to be preferred are aloes, colocynth,⁵⁰ and podophyllin. The compound podophyllin pill or a pill of one-sixth of a grain of belladonna and podophyllin at night or three times daily, the pill of aloes and myrrh, or the Lady Webster pill, are well-approved forms of administration. A compound rhubarb pill acts well if taken after dinner.

⁵⁰ A few drops of the Prussian tincture of colocynth several times daily is advised by Ringer (Therapeutics, New York, 1882, p. 642).

If one desires to select a purgative which will probably increase the outflow of bile, selection can be made from the following drugs: podophyllin, aloes, rhubarb, colchicum, euonymin, colocynth, calomel, jalap, sodium sulphate, potassium sulphate, cream of tartar; and among the rarer alkaloids iridin, sanguinarin, physostigma, and juglandin. These, according to Rutherford, Vignal, and Dodds, increase the secretion of bile in fasting animals. Ox-gall and pig-gall are laxatives only; they have no effect on the liver, but can be added to other purgatives in pill forms.

Salines largely diluted may be given to strong adults: Epsom or Rochelle salts quite early in the morning, a solution of sulphate of magnesia with dilute sulphuric acid, to which dried sulphate of iron may be added, are quite popular; and of the bitter waters, Hunyadi Jânos, Friedrichshall, or Pullna water serves the purpose. One grain of sulphate of quinia added to a saline will increase its effect. The milder laxative waters are to be preferred to the bitter waters. The Saratoga waters, Congress, Geyser, Hathorn, answer the purpose taken early in the morning, or among the European springs those of Kissengen, Plombières, Marienbad, Homburg, Seltzer, or Leamington in England, are not too active in their effects. In atonic constipation, the form now under consideration, the laxative chalybeate waters are indicated where there is anæmia or debility. These are represented by the Columbian, Pavilion, Eureka, and Excelsior Rock among the Saratoga waters, and by the Bedford Springs water.

It is well to administer a number of drugs in rotation in habitual constipation, as the susceptibility to a particular drug is lost after continued use. Increase of the dose is the usual method to offset this result, but it is irrational to meet exhaustion by over-stimulation. Rest of the part stimulated by using a remedy which brings about the result in a different way is the wiser course. The dose should be gradually reduced, tempting the bowel to act more and more without aid. Among the laxatives which can be borne in mind in alternating treatment the following list includes some which can be used with advantage: the fluid extracts of rhamnus (buckthorn) and cascara sagrada; alum, which is called for in certain forms of atony; sulphur in the form of confection or sulphur with guaiacum⁵¹ (half a drachm of each in powder at night); the wine of colchicum (five drops or more three times daily), advantageously used in gouty or rheumatic persons; the infusion or tincture of euonymus; the tincture of benzoin; senna in fluid extract and in the compound powder of liquorice.

⁵¹ Fuller, Lancet, London, April 23, 1864, p. 459.

Infants and children should be cured of constipation without purgatives if possible. Attention to the diet of the infant, and close inspection of the stools to see the effect of the food given, will guide to a proper system of feeding. Breast-milk is the best remedy; next, a food which most nearly resembles mother's milk—cow's milk properly diluted with barley-water, oatmeal-water, or rice-water—stands first. Condensed milk, given in barley- or oatmeal-water, is a second and excellent substitute in cities. Antacids prevent a too rapid coagulation of the casein and the formation of curdy lumps. Lime-water with milk or bicarbonate of potassium or of sodium may be administered with the food or before it. The quantity of food must be lessened until the child can digest all it takes.

The infant should be taught to empty the bowel at the same hour daily by always placing it at this hour in a position favorable to and suggestive of defecation. Dilating the sphincter at the same time with the soap suppository or the small end of a Davidson's syringe, or just touching the margins of the anus, will excite the necessary reflex movement. If defecation is painful, examine the inner edge of the anus for small cracks or for eczema ani.⁵² Over-stretching the sphincter with the finger in cases of rigid or spasmodic contractions will sometimes produce permanent relief.

⁵² Betz, "Eczematous Proctitis," Memorabilien, iv., Dec. 28, 1859, S. 190.

In children the question of diet is equally important. Most cases of constipation in them originate in intestinal catarrh from improper diet and over-feeding. Strict rules of diet should be rigidly enforced, and each case receive special study in order to determine upon the best dietary. The minutest details of the child's life, its habits and surroundings, are to be controlled so as to secure the best possible influences for health. Feeble development and muscular inertia must be remedied by change of climate and tonics—iron, strychnia, and cod-liver oil. When other methods fail to give early relief, a purgative may be needed. Rhubarb, magnesia, calomel, Friedrichshall or Hunyadi water, given in milk, the compound liquorice powder, the compound anise powder, are better than the more active cathartics.⁵³ Habitual administration of laxatives to children ought to be regarded as a confession that the case is incurable; it is a last resort, for which necessity is the only argument.

⁵³ The compound anise powder, a non-officinal preparation in use in Washington, is a convenient form of administration: heavy calcined magnesia, 360 grs.; rhubarb powdered, 180 grs.; oil of anise, 40 minims; stronger alcohol, one fluidrachm. The bicarbonate or fluid magnesia is also a good preparation. Ringer knows nothing so effectual in bringing back the proper consistence and yellow color to the motions of children as podophyllin. Dissolve one grain of the resin in one drachm of alcohol, and of this give one or two drops on a lump of sugar twice or three times a day (op. cit., p. 458). Bouchut suggests the same solution, with simple syrup as a menstruum.

In old persons tonics should be combined with the laxatives, as strychnia, iron, quinia, gentian with aloes, colocynth, rhubarb, or podophyllin. The rectum should always be examined, as impacted fecal masses will often be found there.

ENTERALGIA (INTESTINAL COLIC).

BY W. W. JOHNSTON, M.D.

SYNONYMS.—Enterodynia, Tormina, Colicodynia, Colalgia, Dolor colicus, Passio colica, Spasmus intestinorum, Ileus spasmodicus, Spasmus ventriculi, Neuralgia mesenterica; Spasm of the bowels, Cholick or Cholick Colic, and Pain in the Belly; Ger., Das Banchgrimmem, Die Kolik; Fr., La colique.

HISTORY.—Colic is described by Hippocrates.¹ He recommended the use of emetics and gave other sound advice regarding the treatment of the affection. Galen² administered sedatives, as opium and henbane, and he advised them to be combined with carminatives. Aretæus³ speaks of the pain of colic extending to the back, limbs, and testicles, and also states that when affecting the sides of the body it may be confounded with pleurisy, hepatitis, or splenitis. Alexander⁴ points out the differential diagnosis of the disease and directs a proper course of treatment. Cupping, friction of the extremities, and dry fomentations were recommended by Celsus;⁵ and internally he advocated a mixture of poppy, anise, pepper, etc. Aëtius⁶ describes the affection. Serapion⁷ and Avicenna⁸ treated of colic more clearly than any previous writers had done, and advised narcotics administered by the mouth and rectum. Atony of the bowels is given as a cause of the disease by Haly Abbas,⁹ and Alsaharavius adds¹⁰ to the etiology a hot intemperament, indurated feces, and poisonous medicines. Rhazes¹¹ directs the administration of emetics when the colic is due to indigestion.

¹ De Affect., xv.

² De Med. Sec., loc. ix.; iv., de loc. Affect., vi. 2.

³ Morb. Acut., ii. 6; Chron., ii. 8.

⁴ Lib. x. 1.

⁵ Medicina, Libri octo, iv. 14.

⁶ Lib. iii. 1, 29.

⁷ iii. 32.

⁸ iii. 16, 4.

⁹ Pract., vii. 28.

¹⁰ Ibid., xvii. 2, 12.

¹¹ Divis. 69.

NATURE AND DEFINITION.—Enteralgia is the name given to intestinal pain which is independent of indigestion and of inflammation or other organic change in the wall of the bowel, and corresponds to gastralgia and other visceral neuralgias. It involves the nerves which pass to the intestine along the line of attachment of the mesentery, and which are derived from the superior mesenteric plexus, with a prolongation from the junction of the right pneumogastric nerve with the coeliac plexus.¹²

¹² The very extensive distribution of terminal nerve-filaments in the intestine is an explanation of the frequency and severity of attacks of intestinal pain. "We may form some estimate of the extent to which the nervous system of the intestines is developed from the fact that about one hundred ganglia belonging to the submucous and over two thousand to the myenteric plexus are to be found in one square inch of the intestine of the rabbit" (Frey, Histology, New York, 1875, p. 493).

The pain of enteralgia is not spasmodic, and is not accompanied by flatulence, borborygmi, or other signs of indigestion and gaseous distension of the bowels.

Colic, on the other hand, applies to intestinal pain accompanied by indigestion, distension of the bowel with gas, or the contact of irritating ingesta. The pain is spasmodic, and is relieved by the passage of gas and other contents from the bowel. The pain is due to the local irritation of the richly-gangliated plexus of nerves seated in the submucous layer and which extends from the pylorus to the anus.

At present enteralgia must be considered from its symptoms and from post-mortem examinations as a pure neurosis of the sympathetic system. Opportunities are rarely offered for studying the post-mortem appearances of the disease, from the fact that when idiopathic it seldom ends fatally. Out of forty-nine autopsies on patients who had suffered from colic due to lead-poisoning, only one was found with any change of the abdominal ganglia of the sympathetic. Ségoud found the ganglia and some of the fibres of the sympathetic hypertrophied and indurated,¹³ and "in recent times Kussmaul and Maier have published an example of sclerosis of the coeliac and superior cervical ganglia."¹⁴

¹³ Ségoud, Essai sur la Névralgie du Grand Sympathique, Paris, 1837.

¹⁴ M. Rosenthal, "Diseases of the Nervous System," Wood's Library, New York, 1879, vol. ii. p. 265.

The pathology of enteralgia due to a vitiated state of the system, a morbid condition of the tissues of the intestines, the presence of irritating ingesta, or to reflexion from other organs, differs in no wise from a neuralgia of other parts arising from constitutional, local, or reflex causes. Pain will likewise manifest itself here in consequence of deleterious substances circulating in the blood, as in Bright's disease, rheumatism, gout, or lead-poisoning. The terminal nerve-fibres of the intestines are irritated in attacks of colic by substances or food within the alimentary canal; gases are generated from the decomposition of the ingesta. The consequent dilatation of the gut produces loss of tone and abolition of the contractile power of the muscular coat. Constipation and pain from pressure exercised on the neighboring nerves will be the result.

Obstinate constipation, and even symptoms resembling ileus, may arise from a portion of the intestine thus distended becoming bent upon itself, the sharp angular flexure interrupting or completely obstructing the passage of the feces.¹⁵

¹⁵ F. H. Hamilton, Med. Gaz., New York, 1880, vii. p. 3.

ETIOLOGY.—Enteralgia may be either idiopathic or symptomatic. The causes can best be considered by dividing them into general and reflex.

Under the head of general causes may be mentioned an inherited neurotic temperament, particularly in individuals of a hypochondriacal tendency. Females are far more apt to suffer from this affection than males, on account of their more impressionable nature and greater liability to nervous diseases in general. Hereditary tendencies, overtaxing the mental powers during the developmental period of youth, and later in life excessive mental labor and anxiety of business affairs, are causes. It may occur in the cachexia developed during the course of many chronic diseases, as diarrhoea, rheumatism, gout, phthisis, cancer, Bright's disease, etc. Various morbid conditions of the blood are followed by enteralgia, as anæmia arising from prolonged lactation, masturbation, or venereal excesses, and the presence of various blood-poisons, as syphilis, malaria, lead, copper, and arsenic. Other causes are living in cold, damp climates, with sudden changes of temperature and chilling of the body. Persons addicted to the use of tobacco or alcohol and to dissipations of various kinds may become predisposed to enteralgia. Idiosyncrasy is a predisposing cause.

Enteralgia is often secondary to ovarian, uterine, or other distant disease. Also, owing to intimate sympathetic relations, pain is often felt in the bowels as a result of disease situated in some of the solid abdominal viscera, as the liver, spleen, and pancreas. In the same way, organic affections of the brain and spinal cord, especially acute myelitis and spinal sclerosis and lesions of the vertebral bones, excite intestinal pain. Emotion may also bring it about. The application of cold to the feet or catching cold in general is followed by pain which is due to reflex influence.

There may be a predisposition to colic from hereditary influence and the neurotic temperament. A feeble digestion is a source of constant risk. Much of the pain occurring in the course of dysentery, catarrh of the bowel, invagination, fecal impaction, and other structural affections is of the nature of colic. The most frequent by far of the local causes is the direct irritation of the terminal nerve-fibrils by substances within the alimentary canal and by over-distension of the bowel with contained gas. Some of these irritants are partly-digested and indigestible articles of food; food taken cold or in excessive quantity; the decomposition of food and consequent distension of the bowel by gas. Acid drinks and alcohol have the same effect. Constipation with scybalæ may produce colic in an otherwise healthy person. A morbid state of the intestinal secretions, either as regards quantity or quality, is said to have a like result, but this is a doubtful cause. Foreign bodies within the canal, as fruit-stones, various concretions, worms, and gall-stones if of large size, may produce pain during their passage through the bowel. Cathartic medicines may be enumerated as among the local causes, and also various poisonous drugs. Lesions of any sort seated in the intestinal wall, as ulcers and neoplasms, induce paroxysmal pains.

SYMPTOMS.—The pain of enteralgia occurs in attacks which come on slowly and continue for a variable time—some hours or days. The pain is situated about the umbilicus, and is relieved by deep pressure, although at the same time there may be hyperæsthesia of the skin. The intensity of suffering ranges from a dull heavy pain to one which is acute and lancinating. Retraction of the abdomen is common, but there may be tympanites. No signs of indigestion may appear, but eructations of tasteless gas, or even borborygmi, may be complained of.

The duration of an attack of enteralgia is variable and depends to a great extent upon the cause. Usually, when the symptoms are severe, the duration is short. It may pass off in less than an hour, or a succession of paroxysms continue to recur, and the attack will be kept up for several days, weeks, or even a month. One seizure predisposes to another, and each is liable to be more severe than its predecessor.

The malady may end gradually or as rapidly as it was ushered in. Attacks are often mitigated, or even terminated, by the occurrence of some other morbid condition—by a profuse sweat, the discharge of lochia, the menses, or some secretion which has been checked. The development of rheumatism or gout may relieve it. Attacks often terminate with vomiting, belching, and more especially with movements of the bowels and discharge of flatus. A free emission of pale, colorless urine is sometimes followed by relief. This occurs in hysterical cases, and the disease is generally accompanied with some uterine disorder and with tenderness along the spine.

The attack of intestinal colic may be developed suddenly and with full intensity, or it may be preceded a short time, usually a few hours, and rarely much longer, by prodromic symptoms. These are nausea, a sensation of weight in the epigastrium, anorexia, eructations, tympanites, rumbling, and slight griping pains. The patient is irritable and restless, his bowels are usually confined, and urination is often rendered painful by the distended bowels pressing upon the bladder.

These symptoms, which are in truth but a part of the attack, being only of a lower grade, increase in severity and the pain becomes more acute and distinctly paroxysmal. It is of a sharp cutting, twisting, or most frequently griping character, and is in the earlier part of the attack usually referred to the umbilicus or to one of the iliac fossæ, and sometimes radiating thence in different directions. Generally it becomes concentrated about the umbilicus. The exacerbations of pain vary in degree of severity, in duration, and in frequency of recurrence, while the intervals may afford complete relief or merely a remission of the acute suffering. The sufferer either lies quietly upon his abdomen or upon one side or the other, with his body bent forward and thighs flexed, or he is restless and writhes in pain, groaning and crying out from the intensity of suffering. He may seek relief by trying a variety of positions and by pressure applied with the hands or some solid object against the abdomen. Anxiety and pain are depicted in his features. His face and extremities are cool and covered with a clammy sweat. The pulse is small, hard, and generally slower than normal. Breathing is sometimes oppressed, as a result of spasmodic contraction of the abdominal and thoracic muscles. Often the muscles of the hands, calves of the legs, and the feet are similarly affected. The tongue is moist and as a rule clean. The bowels are constipated—at times so much so as to amount to obstruction—or, again, diarrhoea and tenesmus may be present.

Other abdominal symptoms are nausea or vomiting, eructation of gas, and borborygmi. Micturition is at times urgent and painful, and the testicles are frequently retracted.

The abdomen is occasionally tender, but pressure generally affords relief. It is distended with gas, especially over the large bowel. Palpation often reveals lumps or knots situated within the abdominal walls and due to spasmodic contraction of its muscles, particularly of the recti. In thin persons the constricted and dilated coils of the intestines can also be distinguished as nodular masses which rapidly alter in shape and position.

The severity of attacks of colic varies from a few slight griping pains felt at intervals to a seizure of such intensity that the patient suffers agony and presents symptoms of an alarming nature. Fortunately, these grave cases are comparatively seldom observed. In them the local and general symptoms are aggravated. Pain is more intense and constant, having less marked intervals of relief, and the patient may pass into collapse, with a small, rapid, and wavering pulse, restricted respiration, shivering and chilliness, and a cool, clammy skin. The abdomen is greatly distended; hiccough comes on, also stercoraceous vomiting, tenesmus, and in the worst cases involuntary stools and suppression of urine. Nervous symptoms have been observed, as dizziness or fainting, and finally delirium and convulsions may end the scene.

VARIETIES.—Attention has been called to a distinct form of enteralgia due to the effects of alcohol.¹⁶ It affects steady drinkers, and is, as a rule, met with only during the hot months. The presence of undigested food within the alimentary canal or exposure to cold may act as exciting causes of the disease. The development is usually gradual. Dull pains, felt at first over the abdomen, become later more continuous and fixed about the epigastrium or umbilicus. Sometimes they are complained of more over the bladder. Bilious vomiting and hiccough are prominent symptoms; the patient is thirsty, and the liquids taken only promote vomiting; and the bowels are constipated. There is restlessness, and sleep is obtained with difficulty. Paralysis at times supervenes, and affects the lower as well as upper extremities. In the worst cases delirium and even convulsions occur. The disease nearly always ends in recovery in from three to ten days. Severe intestinal and gastric pain occurs in opium-eaters, but especially in women who use morphia in excess. The suffering is always greater when the opiate is reduced, but can only be cured by breaking up the bad habit.

¹⁶ Colica bacchanalium, J. H. Claiborne, Med. Monthly, New York, 1855, p. 227.

A variety of colic which occurs epidemically¹⁷ in some of the inter-tropical countries has been studied and described by different observers. It is known by various names, such as colique sèche; colique végétale; rachialgie végétal; colic of Poitou, of Devonshire, of Madrid, of Java, of Surinam; colique nérveuse; endémique des Pays Chauds (Fonssagrives); endemic colic, dry colic, bilious colic, nervous colic; girafy; dandy, etc. Ségoud called it a neurosis of the great sympathetic, and attributed the disease to the effect of cold.¹⁸ The symptoms resemble, in many respects, those of lead colic, and at one time they were erroneously considered identical with it.¹⁹ Thompson and Chisholm,²⁰ after an experience with the disease in the West Indies, assert that such is not the case. Epidemics which occurred in Madrid and several of the Spanish provinces, and many hundred cases witnessed among the French soldiers by other observers, were ascertained not to be due to lead-poisoning.

¹⁷ Colique végétale, or endemic and epidemic colic, did not escape the notice of the older writers. It is mentioned by Aretæus; Paulus Ægineta describes an epidemic of the disease which extended through Italy and a large part of the Roman empire, and he states that attacks were often followed by paralysis. François Citois gives an account of an epidemic which raged at Poitou in 1616. Monson Smith described the disease in 1717. In 1724 it appeared in Devonshire, England, and presented the characteristic symptoms and sequelæ. In more recent times epidemics of the disease have occurred in nearly all the countries of Europe. It prevailed in the northern part of France and in Belgium from 1853 to 1859, inclusive. It has likewise visited the Caribbee Isles, Cayenne, Guadaloupe, Madagascar, India, the West Indies, some of the provinces of Spain, Java, the west coast of Africa, the Antilles, Senegal, New Zealand, Brazil, and various other localities. The disease occurs in all seasons, but is more prevalent in summer and in the commencement of autumn.

¹⁸ Ségoud, Essai sur la Névralgie du Grand Sympathique, Paris, 1837.

¹⁹ The disease frequently appeared on board of French war-vessels, and was regarded by Lefèvre (Recherches sur les Causes de la Colique sèche) as due to lead-poisoning. He asserts that lead is more used in French ships than in those of other nations, and accounts for its being epidemic in tropical countries because a warm climate aids in developing the affection, and because there men drink more freely of water. (See also Dutrouleau, Arch. gén., 1855, "Mal des Européens dans les Pays Chauds.")

²⁰ Quoted by Oppolzer, Wien. med. Woch., Bd. xvi., 1867, p. 724.

The affection is not accompanied with any constant lesion. Pascal²¹ made post-mortem examinations in six cases and found the mucous membrane of the duodenum a little reddened: the gall-bladder contained thick bile, and in a few cases there was congestion of the sympathetic ganglia. The attack is usually marked by certain prodromic symptoms. The patient complains of malaise, loss of appetite, a load in the epigastrium, embarras gastrique, dull pains in the colon, borborygmi, and cramps or tingling in the limbs. For the first few days the bowels generally move several times daily. The stools are difficult, painful, and of a black or dark-green color, offensive odor, and accompanied with the discharge of flatus. As the disease progresses the bowels become constipated and the discharge of gas ceases. After a few days the pain is more severe and radiates to the lumbar region, the testicles, or the thighs. It is seated principally in the epigastrium, in the line of the transverse colon, or it may involve the whole abdomen. Movement aggravates the pain, while pressure often relieves it. The tongue is large, trembling, and coated white or yellow; the breath is fetid, the saliva viscid, and mouth sticky. Anorexia is complete; there are hiccough, nausea, vomiting of undigested food and mucous or bilious matters, and constipation with hard black stools. The patient is restless and sleepless. The abdomen may be distended or retracted, and micturition is often painful and the urine high-colored. The pulse is generally slower than in health, but becomes accelerated when the attack is over. The skin is pale, the conjunctiva often stained with bile, and in the later stages oedema of the lids and emaciation come on. The effect upon the nervous system may manifest itself by amaurosis, deafness, delirium, mania, coma, epileptiform convulsions, or paralysis. The paralysis affects the extensors of the hand, arm, and leg, or it may become general and end in death.

²¹ "Recherches anatomico-pathologique sur la Colique dite de Madrid," Rec. de Mém. de Méd. mil., Paris, 1826, xix. pp. 98-113.

The duration of the disease is from eight to fifteen days, but in some cases it becomes chronic. Relapses frequently occur. At times intermittent or remittent symptoms develop, and occasionally the affection is complicated with enteritis or peritonitis. The prognosis depends very much upon the character of the epidemic, and the most serious cases are those accompanied with either cerebral symptoms or peritonitis.

The paralysis sometimes passes off in a few days, but oftener lasts indefinitely. Emetics, purgatives, and anodynes are recommended in the treatment of the disease, and frequently a change of climate is necessary in order to recover fully from the affection.

DIAGNOSIS.—The diagnosis of enteralgia usually presents some difficulty even when the symptoms are well marked. That the disease is a true neuralgia is apparent from the periodical recurrence of the pain, its sharp and darting character, from the sudden cessation followed by complete relief, and from the absence of symptoms of indigestion. Affections bearing a certain resemblance to enteralgia are to be excluded.

In lumbo-abdominal neuralgia the pain is unilateral and extends around to the back. Tender spots can usually be detected by pressure on the umbilical or hypogastric regions or on the spinous processes of the vertebræ. In dermalgia the soreness is superficial, and light pressure gives more pain than deep compression, while nervous and hysterical symptoms are constantly associated with this form. Gastralgia is more frequent than enteralgia, and the pain is located about the ensiform cartilage. In myalgia of the abdominal parietes pressure causes pain, as do also movements of the body, coughing, sneezing, etc. Rheumatic pains would likely be felt in other muscles. In ileus the pain is more continuous, the tenderness localized; there is constipation of a most obstinate character, and vomiting of stercoraceous matter. The patient has an anxious expression and a rapid, feeble pulse. In renal calculus the pain is situated in the course of the ureter and shoots down to the pubes and thighs. There is frequent desire to urinate, accompanied by a scanty discharge of urine, and a copious flow of urine is followed by cessation of pain. The maximum of pain in hepatic colic is situated in the right hypochondrium, and is often reflected into the shoulder of the same side. Icterus may also be expected. Colic arising from lead-poisoning is usually associated with sufficiently characteristic symptoms to render the diagnosis easy. When syphilitic the pain is apt to be most severe at night.

In catarrh of the bowel the skin is hot and dry, the pulse accelerated, and other indications of a symptomatic fever are presented. The pain is more constant, more localized, and pressure causes it to be increased. Tenderness on pressure is not invariably met with, but the rule holds good that when deep pressure increases the pain inflammation rather than enteralgia is indicated.

If colic is due to indigestible food, a sensation of weight will be complained of at the epigastrium, griping pains occur at short intervals, with flatulence, vomiting, and later diarrhoea. If the attack be wind colic, the abdomen is enlarged by tympanitic distension; borborygmi and belching occur. If it is the result of accumulation of feces, there would be a previous history of constipation, and the lump of feculent matter can be located by palpation and percussion.

PROGNOSIS.—The prognosis of idiopathic enteralgia is favorable, the disease generally terminating after a variable period. Attacks are very apt to recur, and each one will, in all probability, prove more severe than the preceding. In symptomatic enteralgia the prognosis will depend upon the nature of the fundamental disease.

Colic terminates favorably in nearly every case. Death has rarely occurred from complications, as convulsions, and rupture of the bowel has been observed from great distension.

TREATMENT.—If attacks of enteralgia are associated with hysterical symptoms, it would be proper to employ antispasmodic sedatives. The compound spirit of ether is very useful in these cases, especially if they are accompanied with flatulence. Rubbing the spine with stimulating or anodyne liniments frequently promises well. The hypodermic dose of morphia gives relief more quickly than can be got in any other way, but in pure enteralgia with frequently recurring paroxysms care must be taken not to create the demand for the remedy by giving it often. The radical cure of the disease is a more important matter than the treatment of the acute attacks.

If the cause of enteralgia be located in some of the solid viscera or in the nervous system, remedies should be addressed to these parts, and the reflex nervous impressions allayed by the bromides or other nervous sedatives. The valerianate of zinc in doses of one grain three or four times a day is extremely useful in neuralgia from reflex irritation of the female pelvic organs. Constitutional remedies are indicated in the cases due to a morbid condition of the blood—iodide of potassium and mercury if a syphilitic poison or if of a rheumatic or plumbic origin; colchicum if gouty; quinia if malarial; and iron when an anæmic state is presented. H. C. Wood states that alum is used with success; being of service when there is no lead in the primæ viæ, it must act in some other way than as a chemical antidote. Arsenic is very highly recommended in idiopathic enteralgia. Excellent results have been reported from the use of nitrate of silver,²² hydrocyanic acid, belladonna,²³ and iodoform. Change of climate and travel may have to be resorted to in obstinate cases.

²² Nauman, Deutsche Klinik, Bd. iii., 1851, p. 388.

²³ Lancet, vol. i., 1867, p. 81.

The objects of treatment in colic are to relieve suffering and terminate the attack as soon as possible. For this purpose the various anodyne and antispasmodic remedies, as opium, hyoscyamus, chloral, ether, chloroform, Indian hemp, and camphor, may be employed. Carminatives are most useful, alone or combined with anodynes and cathartics. Oleum cajuputi often affords immediate relief. Warm teas of chamomile, ginger, valerian, or peppermint sometimes do good. When the suffering is very acute nothing acts so promptly as a hypodermic injection of morphia, either alone or combined with atropia.

The surface of the body should be kept warm, and hot applications to the abdomen assist in relieving pain. The heat may be conveniently applied by means of poultices, hot salt- or sand-bags, or rubber bottles filled with hot water. Cold,²⁴ used externally, is more grateful in some cases, and is preferable if there be much tympanites. Sinapisms, turpentine stupes, and stimulating and rubefacient liniments answer well in some cases, and should be tried. Anodyne applications to the spine occasionally do good, and cold, applied by means of the spinal ice-bag, is recommended by Ringer.

²⁴ Roux, Journal de Médecine, Paris, 1765, p. 48.

In order to treat the disease successfully and bring the attack to an end, its cause should be ascertained if possible, and remedies directed to its removal. If it be the result of indigestion, the contents of the stomach should be removed by emetics. Drastic or powerful cathartics will only tend to aggravate the disease, and on that account mild laxatives are to be preferred in all cases. Castor oil, calomel, pil. rhei comp., senna, etc. may very properly be prescribed.

In flatulent colic means should be directed to expel the gas. Anodynes—preferably chloroform—and carminatives should be administered by the mouth, and enemata containing turpentine or asafoetida injected into the rectum. In severe cases a clyster with ten or fifteen drops of liquor ammoniæ is said to do good. If distension of the bowel be so great as to threaten rupture, it may with propriety and safety be relieved by puncturing the colon with an exploring-needle or a fine trocar. In cases of flatulent colic where the gas arises from the decomposition of food remedies to check fermentation, such as alkalies, creasote, carbolic acid, or the sulphites, would be indicated. Good sometimes results from pressure and massage of the abdomen. Rubbing with etherized oils and electricity have also been used successfully. If the attack be from fecal impaction, it may be possible to liquefy and remove the mass by using saline cathartics, as sulphate of magnesium, aided by large oily or mucilaginous clysters, which in obstinate cases should be injected through a flexible rubber tube passed up the rectum as far as possible. Injections of an infusion of tobacco are now seldom used for this purpose, on account of the dangerous symptoms which often supervene. If pain or tenderness be present at the seat of impaction, cathartics should be used very cautiously or not at all, and opium given instead. The administration of this drug, by relieving pain and allaying spasmodic action, is often followed by free catharsis.

Persons subject to attacks of colic may diminish the intensity, or even prevent the recurrence, of the disease by employing during the intervals such remedies as would be indicated in their individual cases. Phosphate of sodium has been highly recommended for preventing the recurrence of attacks of colic. R. N. Taylor states²⁵ that his experience with the use of the drug is quite extensive, and he found the treatment uniformly successful. Thirty grains dissolved in a glassful of water may be taken three times a day—preferably before meals—and this quantity should be reduced if it causes any irritation of the stomach. The bowels should be regulated and strict attention given to diet. A milk diet is of course best in obstinate cases. Any article of food known to disagree must be excluded, and tea, coffee, and alcoholic drinks should also be prohibited.

²⁵ Med. Herald, Louisville, 1880-81, ii. p. 348.

ACUTE INTESTINAL CATARRH (DUODENITIS, JEJUNITIS, ILEITIS, COLITIS, PROCTITIS).

BY W. W. JOHNSTON, M.D.

SYNONYMS.—Enteritis, Catarrhal enteritis, Mucous enteritis, Endo-enteritis, Ileo-colitis, Entero-colitis, Diarrhoea. Older synonyms: Chordapsus, Cauma enteritis, Enterophlogia, Enterophlogosis, Colica acuta seu inflammatoria, Ileus inflammatorius, Enteralgia inflammatoria, Febris intestinorum seu Iliaca inflammatoria, Colique inflammatoire.

HISTORY.—It is interesting to start at the fountain-head of the two streams of inquiry—the clinical and the anatomical—and to follow each in its widely-diverging wanderings until they unite to give to the phenomena of intestinal inflammation a just interpretation.

The symptom diarrhoea was fully described by the earliest writers in medicine.¹ The symptomatic differences between diarrhoea, dysentery, and lientery and the different forms of diarrhoea (bilious, watery, etc.) were given in detail by the Greek and Roman physicians. The Arabians had a much more elaborate classification of the fluxes. Avicenna made seven varieties of simple diarrhoea. European writers followed closely in these footsteps. Sennert made twelve and Sauvages twenty-one varieties of diarrhoea, depending upon as many different causes, as undigested food, worms, the bile, etc. Many recent writers have adhered closely to the older authors in their method of treating of diarrhoea, regarding it as a disease and dividing it into varieties based on the causes or on the appearances of the stools. Among them may be mentioned Cullen (1789), Good (1825), Tweedie (1841), G. B. Wood (1852), Trousseau (1865), and Habershon (1879).

¹ J. J. Woodward, Med. and Surg. Hist. of the War, Part 2, Medical Volume, foot-note, p. 273 et seq.

It was only after many years of laborious investigation that the appropriate lesion was affixed to a symptom so well understood and described in its clinical aspects. The first conception of abdominal and intestinal inflammation had no relation to diarrhoea. Under the name [Greek: eileos], Hippocrates described abdominal symptoms of intestinal obstruction and inflammation. For Sennert (1641) inflammation of the intestines meant peritonitis. Bonet (1679), Hoffman (1710), and Boerhaave (1758) included under this head peritonitis, ileus, and all febrile and painful abdominal affections. Sauvages (1763) and Morgagni (1779) gave in detail the symptoms of peritonitis and called the disease intestinal inflammation—enteritis. In 1784, Cullen made an advance in subdividing enteritis into e. phlegmonodoea and e. erythematica—the one involving the entire wall of the intestine and the peritoneum, the other the mucous membrane lining the intestine. John Hunter (1794) first fixed the place of peritonitis as a distinct affection from inflammation of the mucous membrane of the intestines.²

² J. Hunter, A Treatise on the Blood, Inflammation, and Gun-shot Wounds, London, 1794, p. 284.

Up to this time constipation was the chief symptom of enteritis. The meeting of the streams, the affixing the symptom diarrhoea to its appropriate lesion, was brought about hypothetically at first by J. Carmichael Smith in these words: "I think it is probable (for we can have no positive evidence of the fact) that in diarrhoeas from catching cold the villous or interior coat of the stomach is sometimes slightly inflamed."³

³ Paper read Jan. 8, 1788, Med. Communications, London, vol. ii., 1790, p. 168.

On the Continent enteritis soon after this was limited in its meaning by Pinel (1798) to inflammation of the mucous membrane of any part of the intestines. He gave the name catarrhal diarrhoea to the same condition. A still further restriction of its meaning was made by Broussais (1821), who defined enteritis to be an inflammation of the mucous membrane of the small intestine; he gave the name colitis to the same disease in the colon. This distinction was adopted by Rostan (1826), Andral (1836), C. H. Fuchs (1846), G. B. Wood (1852), Wunderlich (1856), Grisolle (1865), Flint (1866), and Aitkin (1868). According to the views of some authors, chiefly English, as Copland (1844), Bristowe (1871), Roberts (1874), Habershon (1879), enteritis includes inflammation of the serous as well as of the mucous coat of the intestines.

Niemeyer (1864), Jaccoud (1869), Leube (1875), Bartholow (1880), and most German and French authors prefer the name intestinal catarrh as applied to inflammation of the mucous coat; inflammation of the serous coat is peritonitis; the word enteritis is abandoned as involving a pathological error.

NATURE AND CLASSIFICATION.—Catarrh of the intestines is an inflammation of the mucous membrane of the intestinal tract. There are various peculiarities of the catarrhal process due to the anatomical structure of the parts involved, the presence of open glands, lymphatic follicles, etc. This disease is to be distinguished from inflammation of the serous coat of the intestine (peritonitis). The two are quite distinct in their etiology, pathological anatomy, and symptomatology, although they have been often confounded under the same name, enteritis.⁴ As so much confusion prevails as to the proper meaning of enteritis, it is best to abandon the word altogether.

⁴ For cases called enteritis in which the lesions of peritonitis were found, see Hamilton, Edin. Med. Journ., vol. ii., 1857, p. 304; also Breed, Chicago Med. Examiner, Oct., 1869, p. 579.

Diarrhoea is still regarded by some authors (J. J. Woodward) as synonymous with intestinal catarrh; by others it is considered separately as a disease distinct from catarrh. Habershon describes the lesions of catarrhal diarrhoea and mucous enteritis almost in the same words.⁵ It is an unscientific method to take one symptom of a pathological state, to erect it into a disease, subdividing it into varieties which are but differences in the intensity of its manifestation, and to assign to it no fixed lesion. Diarrhoea is in reality but a sequence and symptom of hyperæmia or inflammation of the intestinal mucous membrane.

⁵ Such a method of treating the subject involves a repetition, with an inversion, of the same description. Thus, catarrhal diarrhoea has as its lesion mucous enteritis; mucous enteritis has for its symptom (catarrhal) diarrhoea.

ETIOLOGY.—Intestinal inflammation is more prevalent in the Northern, Middle, and Western than in the Southern States. There is no relation between the distribution of malarial and intestinal diseases: in some regions where malarial disease is rife there is very little disease of the intestines. Limited areas in Lower Mississippi, Eastern Kentucky, Eastern North Carolina, etc. have a special predisposition to diseases of this class.⁶

⁶ F. A. Walker, Statistical Atlas, 1874, table v. p. 3; also plates xlii. and xlv.

During the Civil War diarrhoea and dysentery were more frequent and fatal in the central region than in the Atlantic and Pacific regions.

It is difficult to compare the relative liabilibity of the native and foreign-born populations in the United States to intestinal disease. Inasmuch as children, among whom the bulk of such cases occur, bear such a small proportion to the adult foreign population, allowing for differences due to this cause, statistics show that the foreign-born race has a very distinct predisposition to these forms of disease.⁷ The Swedes, Norwegians, and Danes have a marked susceptibility to intestinal diseases; the English and Welsh have the same tendency; but the Irish have a comparative immunity. The colored race is more prone to intestinal than to malarial diseases in the Middle States, but there is the reverse susceptibility in the Northern and Southern States.

⁷ The number of children under ten to 1000 native population is 306; number of children under ten in 1000 foreign population, 47 (F. A. Walker, "Relations of Race and Nationality to Mortality in the United States," Statistical Atlas, 1874, p. 213).

Under ten years more males than females have enteritis, in the proportion represented by the figures 362 and 299. After ten the predisposition of the two sexes is about the same.

The summer is the season when diarrhoea is most prevalent and most fatal. June, July, and August are the months in which the greatest number of cases occur and in which there is the highest mortality. The extraordinary death-rate in these months in cities is of course due to the influence of summer heat on children, and the death-rate from diarrhoea and entero-colitis is chiefly among infants under one year. But among adults the same rule holds. The highest monthly mortality from acute diarrhoea among the U.S. troops (white) between 1861 and 1866 was 147, in July, 1862; the next highest was 114, in August, 1862. June and September were after these the most fatal months. According to the census of 1870, the most fatal month is August.

Elevation of temperature in the summer months is the cause of the prevalence of intestinal catarrh and of its great mortality among infants and children. The number of deaths bears a direct ratio to the degree of heat, the highest death-rate occurring in seasons of unusual high temperature.⁸ The effect of excessive or prolonged heat is to arrest or weaken the digestive processes; undigested masses in the stomach or the intestines act as foreign bodies and produce inflammation.

⁸ Among the numerous publications bearing on this subject, those contained in The Sanitary Care and Treatment of Children and their Diseases (Boston, 1881) are of especial value. S. C. Busey's article contains much valuable matter on the relation of summer heat to illness and mortality among children.

Sudden changes of temperature from cold to heat or from heat to cold develop diarrhoea. If the air is at the same time saturated with moisture, the effect of a change in temperature is greatly intensified. In the first hot days of June there is on the Atlantic coast, especially in cities, a rapid increase in the number of cases of gastro-intestinal disturbance. A larger number of children are taken ill in June than in August. The child in time becomes habituated to heat, and if not attacked early runs less risk of illness in the later months. A sudden or unusual exposure to low temperature, as in lying on damp ground, leads to the same result. The check to perspiration after violent exercise is especially provocative of diarrhoea. In these instances the congestion and consequent inflammation of the mucous membrane are brought about through the effect of heat or cold upon the peripheral nervous system. Cold may act more directly by the driving of suddenly-cooled blood from the surface of the body to the interior. External burns belong to the same category, as they lead to extensive inflammation, sometimes to ulceration, of the duodenal mucous membrane through reflex influence. A case is reported of a boy aged twelve years who after an external superficial burn of the left thigh was taken with profuse diarrhoea which ended fatally in three hours (Ziemssen).

Contamination of the atmosphere with emanations the result of the overcrowding of many human beings together, as in prisons, camps, or asylums, especially where decomposition of organic matter is going on, is of great influence in causing diarrhoea. Persons living in badly-ventilated houses, or in houses improperly drained where the air is vitiated by escaping gas from sewer-pipes, are especially prone to be attacked. But sewer-gas, per se, does not cause diarrhoea any more than it causes diphtheria or scarlatina.⁹ It is a step backward to hang upon this ready explanation all our doubts and our ignorance of the origin of disease. The specific germ of the zymotic diseases may be conveyed in the gases from sewers, but there are other and more direct modes of communication which should receive equal attention.

⁹ Longstaff (Brit. Med. Journ., London, 1880, vol. i. p. 519) believes that summer diarrhoea has a specific poison which is intimately connected with the process of putrefaction, and that the infective material has its source in the public sewers.

Children are much more liable to intestinal inflammation than adults. This is due to the greater susceptibility of the mucous membrane in them to congestion and catarrh from external influences and from direct irritation. In infants fed upon an unsuitable diet—cow's milk or other substitutes for mother's milk—this susceptibility is much increased. The age most liable to attack is under one year, or from the first to the second year, when, in consequence of dentition, weaning, and a change from a diet chiefly or almost wholly liquid to one of solids, there is a great liability to a disturbance of the normal equilibrium. Intestinal catarrh forms almost one-third of the total number of the affections of childhood. According to the census of 1870, 761 out of every 1000 deaths from diarrhoea, dysentery, and enteritis occurred under the tenth year. In old age a similar predisposition exists, and a mild attack will in old persons induce more serious symptoms than in middle life. Epidemics of diarrhoea among the aged in asylums and hospitals are not uncommon.

Temperament and idiosyncrasy are causes of differences in predisposition. Many persons in consequence of taking cold invariably have diarrhoea, while others as invariably have nasal catarrh or bronchitis. Certain articles of food, as oysters and eggs, lead always in some persons to intestinal disturbance. An exaggerated sensibility of the mucous membrane to particular impressions is the cause of this peculiarity.

Previous attacks of intestinal inflammation render the individual liable to recurrences from very slight causes. The suppression of the menses and of hemorrhoidal discharges and the healing of eruptions are said to be followed by serious diarrhoea, but such an occurrence is probably more often a coincidence than a result.

Sedentary life, by enfeebling muscular movement and by inducing indigestion and constipation, brings on diarrhoea. Constipation impairs the muscular tone of the bowel, and hardened fecal accumulations act as irritants which sometimes provoke acute catarrhal processes—diarrhoea and dysentery. Insufficient clothing in children and in adults makes the skin more susceptible to changes of temperature and conduces to intestinal congestion. Smoking in excess and the use of narcotics and stimulants are mentioned as debilitating causes which pave the way for disease in the intestine; the habitual use of the stronger liquors, by keeping up chronic engorgement of the mucous membrane, is undoubtedly a potent cause. Occupations which involve deprivation of fresh air and sunlight, and all trades which enfeeble the individual, make him liable to all digestive disorders. A feeble constitution, debility from disease, from over-fatigue, or from loss of sleep, or any perturbing influence, puts the body in a state favorable to indigestion and diarrhoea.

The eruptive fevers are accompanied more or less by gastro-enteric catarrh. In scarlet fever, measles, and variola there is a state of equilibrium between the skin and the intestinal mucous membrane. When the morbid manifestation does not normally appear upon the skin there is a transference of irritation to the intestine. The administration of purgatives in the early periods of scarlet fever and measles delays, sometimes prevents, the outburst of the eruption on the skin. The intestinal catarrh of the eruptive fevers has sometimes the significance of an exanthem and sometimes of a secondary complication. In measles it is more frequently the former; in scarlatina and variola it comes later as a complication.

Uræmia, malarial infection, chronic suppuration, pyæmia and septicæmia, cancerous and strumous disease of the mesenteric glands, scurvy, tuberculosis, Bright's disease, and chronic wasting diseases in general, are conditions in which diarrhoea appears as a result of the defective nutrition of the vessels of the intestinal wall and their liability to dilatation and hyperæmia, or from the presence in the blood of septic matter.¹⁰

¹⁰ For experiments relating to the production of intestinal catarrh by injections of irritating or putrid matter into the blood consult Traité clinique et expérimentelle des Fièvres dites essentielles, Gaspard et Bouillaud; also, Path. anat., Lebert, tome ii., Texte, Paris, 1861, p. 205.

The ingestion of a larger quantity of food than the stomach and intestines are able to soften, and the taking of food essentially indigestible or improperly prepared by cooking, are causes of the passage of masses of food more or less unaltered along the intestinal tract. Hyperæmia follows the mechanical irritation of the mucous surface. When articles of food are in a partial state of putrefaction, so that the antiseptic properties of the gastric juice cannot be quickly enough brought into play, there is a rapid fermentation in the stomach, with the development of symptoms of gastric and subsequently of intestinal catarrh. Unripe fruit, vegetables composed of hard tissue, as early potatoes, cucumbers, pineapples, and cherries, by their indigestible nature, are frequent causes. Oysters, crabs, fish, and lobsters often occasion acute diarrhoea in consequence of being in an unfit condition for food. Cheese has been known to produce violent illness with symptoms of intense intestinal irritation; these effects are due to some poisonous substance, hitherto undiscovered, developed in the course of putrefaction. New coffee causes diarrhoea; six months is usually the time before coffee grown in Ceylon reaches the European and American markets; by this time it does not have this effect.¹¹

¹¹ J. Stevenson, "Medical Notes from Ceylon," Edin. Med. Journ., Feb., 1862, p. 693.

The irritant and caustic poisons, as mineral acids, caustic alkalies, corrosive sublimate, arsenic, oxalic acid, tartar emetic, and carbolic acid, kindle an intense inflammation of the mucous membrane of the stomach, duodenum, and of the lower portion of the intestinal canal. Softening of the coats of the intestines from corrosion, with perforation, is not an infrequent result.

Drastic purgatives act as irritant poisons in producing acute hyperæmia of the mucous coat with excessive transudation of serum; or, in other words, an acute catarrh. A discharge of vitiated bile or an excess of bile is given by recent¹² as well as by older writers as a provoking cause of diarrhoea. The proper relationship is the reverse of this: an intestinal catarrh the result of irritant action upon the mucous surface entails a more active outflow of bile, just as some cathartics by irritating the duodenum excite the gall-bladder to empty itself.¹³ Impacted fecal masses are direct irritants, exciting inflammation (typhlitis, dysentery); putrefactive changes in long-retained fecal collections have an additional power of irritation. Foreign bodies accidentally or purposely swallowed, intestinal parasites, the pus from an abscess which bursts into the intestine, likewise are excitants of disease. Tubercle nodules, typhoid ulcers, cancer, or other neoplasms in the wall are surrounded by areas of inflammation.

¹² Roberts, Th. and Pract. Medicine, Am. ed., Philada., 1880, p. 160.

¹³ "The propositions which are the foundation of the whole theory that bile can cause diarrhoea, and that its absence leads to costiveness, cannot be looked upon as proved" (J. Wickham Legg, On the Bile, Jaundice, and Bilious Diseases, New York, 1880, p. 661).

Alcohol taken in excess, as in a debauch, leads to acute gastro-intestinal catarrh. The stomach symptoms are the earliest to develop and are the most prominent. Habitual alcoholic indulgence is a more common source of chronic than of acute intestinal catarrh.

The influence of unwholesome drinking-water as a cause of diarrhoea has been carefully examined by Woodward.¹⁴ Turbid or muddy water holding inorganic matters in suspension, he concludes from the evidence, is not a source of disease, and the injurious effects of such waters have been grossly exaggerated. Water containing inorganic substances in solution produce diarrhoea, and are purgative if the dissolved matters have purgative properties. Limestone-water may produce temporary disturbance of the bowels, but is wholesome. Carbonate and sulphate of lime and magnesium in solution are more cathartic, but not as much so as selenitic waters which contain an excess of sulphate of lime. The salts of sodium and potassium in the waters of Colorado, New Mexico, and Utah are still more liable to produce diarrhoea.

¹⁴ Med. and Surg. History of the War, Part 2, Medical Volume, p. 599 et seq.

Water contaminated with organic matters of vegetable origin, which are found in states of decomposition in marshes and stagnant pools, does not, in the opinion of Woodward and Parkes, have very great influence in the production of diarrhoea or dysentery. Impurities from decomposition of animal matters are unhealthful. This is especially true of water impregnated with soakage from privies and sewers; and yet epidemics of diarrhoea cannot as often be clearly traced to this source as can outbreaks of typhoid fever. Parkes says water contaminated with three to ten grains per gallon of putrescent animal matter may be hurtful.

Contusions and injuries of the bowel by sudden pressure or shock to the abdominal wall may lead to intestinal inflammation. The large intestine is more exposed from its size and position to such injuries. Pressure upon the bowel by a tumor, as an enlarged or retroverted uterus, may cause diarrhoea, the source of which may be overlooked. Early-morning diarrhoea from a displaced womb is of frequent occurrence.

Emotional influence, as sudden fright or grief, will produce sudden diarrhoea. Lesions of nerve-centres—corona radiata, optic thalamus, or corpus callosum—induce hyperæmia, softening, and ulceration of the mucous membrane of the small intestine.¹⁵

¹⁵ Rosenthal, "Diseases of the Nervous System," Wood's Library, New York, 1879, vol. ii. p. 266.

Minute organisms (bacteria) are thought by some observers to be the cause of diarrhoea, especially of a zymotic form, which prevails in the summer months. In accordance with this theory, the dejecta from infected persons are the vehicle of the contagious poison which by air- and water-contamination infects others.¹⁶

¹⁶ Wm. Johnston, Lancet, London, 1878, vol. ii. p. 397; also, Brit. Med. Journ., London, 1879, p. 81; also, G. E. Paget, "On the Etiology of Zymotic Diarrhoea," Brit. Med. Journ., Nov. 19, 1881, p. 819.

PATHOLOGICAL ANATOMY.—A description of the morbid anatomy of acute intestinal catarrh includes the changes which are observed (1) in the exterior appearances of the intestines, (2) in their contents, and (3) in the condition of their mucous lining.

1. The external appearances of the intestines depend upon the degree of distension of the tube, the character of the contents, and the presence or absence of inflammation of the serous coat. Great distension of the colon, of the cæcum, and of the small intestines is met with in acute intestinal catarrh of some duration, and is due to relaxation of the muscular coat. The colon usually presents the greatest distension. The calibre of the tube may be lessened by strong contraction of the muscular layer in acute intestinal inflammation of great intensity with early and fatal termination. The color of the exterior varies with the tension of the wall, the color of the contents, and the amount of vascular injection. If the bowel is much distended with gas, the color is pale; the mingling of bile with the feces causes a yellowish or brownish color; if blood is in the tube a dull red hue is given to the walls. If the intestine is congested or inflamed, the vessels are outlined distinctly and can be seen in different layers. The areas of external redness generally correspond to internal hyperæmic patches. The serous membrane shows arborescent congestion at the mesenteric attachment or is inflamed from perforation; the signs of peritonitis are most marked in the neighborhood of the irregularly-shaped, round, oval, or pin-point openings in the gut. The abdominal cavity may contain fecal matter, food, medicines, or worms which have passed through the perforation.

2. The intestinal contents, instead of being homogeneous, of pale-yellow color, and pea-soup-like appearance in the small intestine, brown and more condensed in the lower part of the large intestine, may present various changes. The fluid is usually increased in quantity, and is thinner than normal in the colon: the color is greenish from the bile, very pale from the closure of the bile-duct, red or black from blood. The odor is absent from excess of serum, or very offensive from decomposition due sometimes to the closure of the common bile-duct and the want of bile. Shreds or masses of mucus may float in the liquid. Undissolved pills or drugs, as bismuth, accumulated seeds, skins of fruits or vegetables, parasites, or foreign bodies are seen. Epithelial cells, the débris of digestion, micrococci, and bacteria are visible under the microscope.

3. Inflammation involving the mucous membrane of the whole intestinal canal is rarely or never met with. The nearest approach to generalized catarrh of the bowel is found in eruptive fevers, especially measles. Inflammation extending throughout the whole length of either the small or large intestine alone, and affecting all parts equally, is also rare. The ileum is the part of the small intestine most frequently the seat of disease, but the ileum is rarely affected alone. Inflammation is more frequently limited to the colon than to the small intestine. The most common form of intestinal inflammation is ileo-colitis, where the lower part of the ileum and a part of the colon, sometimes of considerable extent, are inflamed. The duodenum is sometimes the seat of a local inflammation, but this rarely happens except in the case of external burns; duodenitis is most frequently an extension of catarrh from the stomach, but the pathological anatomy of the duodenum presents some peculiarities which will be described hereafter.

(a) Hyperæmia of the intestinal mucous membrane may exist without inflammation. The engorgement of the veins by mechanical retardation in disease of the liver, heart, or lungs does not constitute catarrh, although it is sooner or later followed by catarrhal processes, usually of a chronic nature. Gravitation of blood to the most dependent parts in cases of long illness distends the vessels, and post-mortem hypostasis leads to the passage of serum and coloring matter into the meshes of the mucous and submucous tissue. In fatal cases of acute diarrhoea sometimes no lesion has been observed. The hyperæmic membrane pales after death, as does the skin in scarlatina and erysipelas.¹⁷ The presence or absence of hyperæmia is therefore no positive proof of the previous existence or non-existence of inflammation. To constitute inflammation there must be other changes besides hyperæmia, as oedema, softening, and infiltration with cell-elements.

¹⁷ It is difficult to recognize post-mortem hyperæmia in the mucous membrane of the mouth or throat where intense inflammation has been seen in life.

A degree of vascular turgescence visible to the naked eye is nearly always present in the mucous and submucous tissues which have been the seat of catarrh. It is usually found in the lower part of the ileum, the cæcum, sigmoid flexure, and other parts of the colon. The redness is diffused over a surface of several feet in length or is circumscribed in patches of varying size. When vessels of small size are distended with blood, red branching lines are seen (arborescent or ramiform injection) which have their starting-point in the insertion of the mesentery. When the capillary system is engorged a fine interlacing network can be discovered, which gives to the membrane a more uniform red color. Parallel lines or bands of redness extend in a transverse direction across the axis of the canal corresponding to the folds of mucous membrane in the small and large intestine.

The shades of color depend upon the intensity and duration of the congestion. In acute mild forms the color is light red; in more intense grades the membrane is more vivid or purplish. Brown and slate-colored tints show a passage into the chronic stage. A black hue occurs in gangrenous inflammation. Minute dots (speckled redness) are due to minute extravasations, and ecchymotic irregular patches are sometimes seen.

Bile-staining of the mucous surface is met with; this cannot be removed by washing. In metallic poisoning the redness is more vivid and the mucous membrane is eroded.¹⁸

¹⁸ For colored plates illustrating hyperæmia and inflammation of the intestines see Carswell, Path. Anat., London, 1838, plate ii. figs. 1 and 2. These are beautiful representations of (1) ramiform vascular injection passing into (2) capilliform injection, which becomes (3) uniformly red, or from its intensity (4) ecchymotic or hemorrhagic. See also Annesley, Morbid Anatomy, London, 1828, plates x. (Fig. 2), xiii., xxii., xxiv., and xxv. Many of these are illustrations of peritonitis as a complication of enteritis. See also Kupferlafelnzer, Lesser, Ueber die entzundung und Verschwarung der Schleimhaut des Verdauungskals, Berlin, 1830, tab. iv. fr. 3; also J. Hope, Illustrations of Morbid Anatomy, London, 1834, figs. 116, 118, 124, and 125. These plates are wonderful in their truthfulness and execution.

(b) Acute oedema and increase in the cell-elements in the inflamed parts give rise to swelling and to softening, so that the mucous membrane seems to be easily scraped off. This is not always the case, as no loss of firmness of the reddened tissue is often found. In the small intestine the villi, which in health are not seen, become enlarged, giving a "plush-like" or velvety appearance to the mucous membrane; they are sometimes club-shaped from epithelial accumulations on their free extremities.

(c) When the small intestine is examined the solitary glands, which in the normal state are barely visible, are so enlarged that they appear as rounded prominences. They are described as looking like grains of mustard-seed on a red ground, and are the size of pinheads. When they are distinctly seen it may be concluded that they are enlarged. In children the glands are enlarged when there has been slight or no diarrhoea.

Peyer's patches are also tumefied, and are more distinct from being elevated above the surface, but they have not in intestinal catarrh as great a relative enlargement when compared with the solitary glands as in typhoid fever. The interfollicular substance of the patch may hypertrophy without any increase in the size of the follicles; a reticulated appearance is then given to the gland. The color of the swollen follicles in recent inflammation is translucent from oedema; later they are gray and opaque. These changes are more marked at the lower end of the ileum, because the isolated follicles and Peyer's patches are more numerous there.

(d) Catarrhal ulcers—erosions—are produced by the loss of epithelium or from a process of vesicle-forming and rupture, as in stomatitis. They may enlarge, undermine, and coalesce, thus reaching quite a large size. They may deepen and perforate the wall of the bowel, causing peritonitis, or they may heal, forming cicatrices which in contracting may narrow the canal.

Small follicular ulcers are found on the mucous surface. They result from the breaking down of the exposed wall of the closed follicle from over-distension. The ulcer is either on the apex of the dome of an isolated follicle or is within the area of a Peyer's patch. Sometimes several ulcers may be seen on the surface of the swollen patch.¹⁹ The ulcerative process is sometimes very rapid. In the case of a child aged eight years, with no previous intestinal disease, who died in the Children's Hospital, Washington, in June, 1882, after a two days' illness with watery discharges and rapid prostration, the solitary glands throughout the ileum were many of them enlarged. As many as a dozen small ulcers were seen at the apices of the enlarged follicles.

¹⁹ See photograph facing page 302 of Med. and Surg. History of the War.

In the large intestine the same lesions are found, but in a more advanced stage, especially in the cæcum and descending colon. Enlarged solitary glands of the size of a pinhead or small bird-shot are scattered along the canal.

Follicular ulcers²⁰ are found in the large intestine, occupying the summit of the enlarged follicles and involving a large extent of mucous surface. Pigment-deposits are seen which give rise to the appearances described as occurring in chronic intestinal catarrh.

²⁰ For description of the mode of formation and growth of follicular ulcers see article on CHRONIC INTESTINAL CATARRH.

(e) The mucous surface is covered, especially in the areas of redness, with an adhesive, opaque mucus of neutral or alkaline reaction and of yellow, red, or brown hue, depending upon the relative amount of bile or blood. It is composed of mucus-corpuscles, epithelium-cells of cylindrical and prismatic form, pus-cells, and sometimes blood-corpuscles. Vibrios and bacteria also are seen.

The chief distinction between the lesions of acute intestinal catarrh and typhoid fever are these: In typhoid fever the number of Peyer's patches involved is larger; there will be a chain of enlarged glands from the ileo-cæcal valve throughout the ileum, those nearest the ileum being the most altered. Near the valve there is usually some ulceration, so that the gland acquires a ragged appearance. In catarrh of the bowel there is a more irregular distribution of enlarged glands; they project less above the surface, and if ulcerated have one or two spots of erosion. In typhoid fever the Peyer's patch has the most prominence. In catarrh of the bowel the solitary glands are the most enlarged. In catarrh the large intestine may be the seat of the most advanced lesion; in typhoid fever, except with rare exceptions, the lesions in the ileum are most advanced.

(f) The mesenteric glands are enlarged, but not so uniformly so or to the same extent as in typhoid fever. The stomach is sometimes found inflamed, the mucous membrane being reddened, thickened, or softened. The liver, spleen, and kidneys are normal or present accidental conditions of disease. In the respiratory organs pulmonary congestion, pleurisy, and pneumonia are found. The heart contains clots which are fibrinous or soft and red; they are found on both sides, but when one cavity alone is filled the right is the common seat. The brain is usually normal; fluid may be in the subarachnoid space, and thrombi in the cerebral sinuses.

PATHOLOGICAL HISTOLOGY.—In the genesis of catarrh of the intestinal mucous membrane the first effect of the exciting cause is an over-distension of the capillaries and small vessels; this congestion is most marked in the meshwork of vessels around the closed follicles. A transudation of serum takes place into the mucous layer, and in more marked congestion into the submucous layer also; these tissues become more or less oedematous and swollen. Transudation of serum into the intestinal tube follows. From over-stretching the walls of minute vessels may rupture and small extravasations take place, staining the tissue red. These subsequently become black pigment-spots. Post-mortem extravasations are due to decomposition of the wall of the vessel. Rupture of vessels on the surface leads to escape of blood into the bowel, which is mixed with the transuded serum. The proper secretion, intestinal juice, is diminished as a result of these changes, but an excess of the mucus with which the mucous membrane is always coated immediately follows. The origin of the mucus is not to be sought for in the activity of the glands alone, but in the transformation of the protoplasm of the epithelial cells.²¹ The varying proportions of serum, mucus, and blood cause the stools to be serous, mucous, slimy, or bloody, hence the terms serous, mucous, and bloody diarrhoea.

²¹ Rindfleisch, Path. Histology, Sydenham ed., vol. i. p. 412.

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

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

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

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

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

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

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

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

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

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

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

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

The normal brown color, which is due to hydrobilirubin, changes as the movements become thinner to yellowish-brown or pale yellow from dilution of the fecal matter with water. An excess of serum or mucus renders them colorless. A greenish-brown, greenish-yellow, or green hue is due to the presence of bile. The rapid descent of the contents of the bowel delays or prevents the reabsorption of bile,²² or the fluid is expelled before the usual transformations in color take place.²³ The bile-pigment is also absent in duodenal catarrh from closure of the opening of the ductus choledochus.

²² L. Brunton, "On the Action of Purgative Medicines," The Practitioner, London, June, 1874, p. 403.

²³ The reaction of bile-pigment with nitric acid, which does not take place in the contents of the colon or in normal feces, is seen in the green stools of acute intestinal catarrh, especially in children.

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

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