Volume 2 — DISEASES OF THE DIGESTIVE SYSTEM. (continued 17)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Paralysis has been observed to occur after dysentery ever since the days of Galen, and, disregarding the observations of ancient and of the older periods of modern times, we find occasional records of cases in our own days. Leyden,⁶ in reporting a case of paresis and rheumatic pains following an attack of dysentery, says that although post-dysenteric paralysis is now rarely mentioned, it was frequent in the older reports, and claims it as an admitted fact that it occurs not at all infrequently now. Joseph Frank quotes some observations of this kind, and refers especially to the dissertation of Fabricius.⁷ These paralyses, Fabricius observes, have been seen after the premature suppression of malignant epidemics of dysentery by opiates and astringents. Observations were afterward recorded by Graves in which paralysis occurred after colics and inflammation of the intestines; and English veterinary surgeons mention the fact that paralytic weakness of the posterior extremities of horses and cattle follow attacks of intestinal inflammation. The paralysis, when it occurs, is usually confined to the lower extremities, but may extend to and involve the upper extremities, by preference in the form of paralysis transversa (opposite arm and leg). Brown-Séquard attributes it to reflex contraction of the blood-vessels; Jaccoud, to exhaustion of the nerve-centres; and Röser, to the contact of the inflamed transverse colon with the solar plexus. Remak first suggested the idea of an ascending neuritis—a view which would seem to be corroborated by the paralysis observed after the experiments, by Lewisson, of crushing the uterus, kidneys, bladder, or loop of intestine, and which finds additional support, as Leyden remarks, in the length of time which lapses before it appears. Landouzy⁸ says that Finger found diffuse myelitis in a patient affected with paralysis supervening upon cancer of the intestine, and that Delioux and Savignac saw spots of softening in the cervical and lumbar region of the cord in the case of a man affected with post-dysenteric paralysis. Weir Mitchell suggests the possibility of other factors—long marches, malaria, bad diet, and injuries to the spine—in the genesis of the cases, mostly paraplegias, observed by him; and Woodward calls attention to lead-poisoning (as by treatment) in explanation of a certain number of cases.

⁶ "On Reflex Paralysis," Volkmann's Sammlungen.

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

⁸ Des Paralysies dans les Maladies aigues.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Remarkable testimony as to its efficiency soon began to appear. Ewart⁹ recommends ipecacuanha in every form and type of acute dysentery, as well as in the acute attacks supervening upon chronic cases. Its advantages are simplicity, safety, comparative certainty, promptitude of action, decrease of chronic cases and of complications, especially abscess of the liver, and great reduction of mortality. "It produces all the benefits that have been ascribed to bloodletting, without robbing the system of one drop of blood; all the advantages of mercurial and other purgatives, without their irritating action; all the good results of antimony and other sudorifics, without their uncertainty; all the benefits ascribed to opium, without irritating, if not aggravating or masking, the disease." To the objections urged against it he replies that the nausea is only temporary and evanescent—that vomiting is exceptional and of but short duration; moreover, it permits nourishment and assimilation and produces sleep. If uncontrollable sickness and vomiting occur, they are probably due to abscess of the liver, malaria, some other cachexia, Bright's disease, strumous mesenteric glands, hypertrophy of the spleen, peritonitis, or extensive sloughing.

⁹ Indian Annals Med. Science, April, 1863.

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

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

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

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

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

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

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

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

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

Dilatation may suffice to overcome a stricture in the rectum, the result of cicatricial contraction, or colotomy may be necessary in cases more refractory or situated higher in the bowel. Post¹⁰ reported a successful colotomy, with the formation of an artificial anus in the left lumbar region, in such a case.

¹⁰ New York Med. Record, 1879, xvi. 24, p. 260.

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

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

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

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

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

TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS.

BY JAMES T. WHITTAKER, M.D.

HISTORY.—Typhlitis ([Greek: typhlos], blind), inflammation of or about the head of the colon, more especially the vermiform process, is a disease of modern recognition. Individual cases had been reported as curiosities where foreign bodies or fecal accumulations had excited inflammation in this part of the intestine, but it is undoubtedly to Dupuytren¹ that the credit is due of having first individualized this disease as a separate affection. About the same time (1827) Longer Villermay published his communications in the Archives gén., t. v. 246, on the diseases of the vermiform process, to be followed in the same year by Mêlier² and Hussar and Dance with observations on inflammation of the connective tissue in the region of the cæcum. These affections, which had been hitherto described as inflammatory tumors in the right iliac region, now received from Puchelt³ the distinct name perityphlitis.

¹ Leçons oral de Cliniq. chirurg., t. iii. art. xii.

² Arch, gén., Sept., 1827.

³ Heidelberg klin. Annal., i. 571 and viii. 524.

Perhaps the most remarkable events in the history of these affections since this time are the contributions of Stokes and Petrequin (1837) on the value of opium in the treatment of perforation of the vermiform appendix, of Albers,⁴ who first distinguished the special form of typhlitis stercoralis, and of Oppolzer (1858-64), who set apart, perhaps as an unnecessary refinement in differential diagnosis, a paratyphlitis, an inflammation of the post-cæcal connective tissue. Matterstock⁵ (1880) deserves especial mention for having given such prominence to anomalies of the vermiform appendix in the etiology of the affection; and Kraussold⁶ (1881) has connected his name with the therapy of the disease by the boldness with which he expresses his convictions regarding the necessity of early evacuation, by incision, of inflammatory products, as first practised by Willard Parker in 1843.

⁴ Beobacht. aus dem Gebiete der Pathologie, ii. 1.

⁵ Handbuch d. Kinderkrank., Bd. iv. p. 893.

⁶ Volkmann's Sammlung., No. 191.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The means of earlier detection and readier relief of accumulated pus have also contributed much to reduce the mortality of typhlitis. In 1872, Bull of New York had to report of 67 cases of perityphlitic abscess collected by him, mostly treated without operation, a mortality of 47½ per cent., while ten years later (1882) Noyes of Providence was able to report of 100 cases treated by operation a mortality of only 15 percent. (Pepper⁷).

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

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

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

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

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

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

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

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

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

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

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

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

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

INTESTINAL ULCER.

BY JAMES T. WHITTAKER, M.D.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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