{664} to the back. Tender spots can usually be detected by pressure on
the umbilical or hypogastric regions or on the spinous processes of the
vertebræ. In dermalgia the soreness is superficial, and light pressure
gives more pain than deep compression, while nervous and hysterical
symptoms are constantly associated with this form. Gastralgia is more
frequent than enteralgia, and the pain is located about the ensiform
cartilage. In myalgia of the abdominal parietes pressure causes pain,
as do also movements of the body, coughing, sneezing, etc. Rheumatic
pains would likely be felt in other muscles. In ileus the pain is more
continuous, the tenderness localized; there is constipation of a most
obstinate character, and vomiting of stercoraceous matter. The patient
has an anxious expression and a rapid, feeble pulse. In renal calculus
the pain is situated in the course of the ureter and shoots down to the
pubes and thighs. There is frequent desire to urinate, accompanied by a
scanty discharge of urine, and a copious flow of urine is followed by
cessation of pain. The maximum of pain in hepatic colic is situated in
the right hypochondrium, and is often reflected into the shoulder of
the same side. Icterus may also be expected. Colic arising from
lead-poisoning is usually associated with sufficiently characteristic
symptoms to render the diagnosis easy. When syphilitic the pain is apt
to be most severe at night.
In catarrh of the bowel the skin is hot and dry, the pulse accelerated,
and other indications of a symptomatic fever are presented. The pain is
more constant, more localized, and pressure causes it to be increased.
Tenderness on pressure is not invariably met with, but the rule holds
good that when deep pressure increases the pain inflammation rather
than enteralgia is indicated.
If colic is due to indigestible food, a sensation of weight will be
complained of at the epigastrium, griping pains occur at short
intervals, with flatulence, vomiting, and later diarrhoea. If the
attack be wind colic, the abdomen is enlarged by tympanitic distension;
borborygmi and belching occur. If it is the result of accumulation of
feces, there would be a previous history of constipation, and the lump
of feculent matter can be located by palpation and percussion.
PROGNOSIS.--The prognosis of idiopathic enteralgia is favorable, the
disease generally terminating after a variable period. Attacks are very
apt to recur, and each one will, in all probability, prove more severe
than the preceding. In symptomatic enteralgia the prognosis will depend
upon the nature of the fundamental disease.
Colic terminates favorably in nearly every case. Death has rarely
occurred from complications, as convulsions, and rupture of the bowel
has been observed from great distension.
TREATMENT.--If attacks of enteralgia are associated with hysterical
symptoms, it would be proper to employ antispasmodic sedatives. The
compound spirit of ether is very useful in these cases, especially if
they are accompanied with flatulence. Rubbing the spine with
stimulating or anodyne liniments frequently promises well. The
hypodermic dose of morphia gives relief more quickly than can be got in
any other way, but in pure enteralgia with frequently recurring
paroxysms care must be taken not to create the demand for the remedy by
giving it often. The radical cure of the disease is a more important
matter than the treatment of the acute attacks.
{665} If the cause of enteralgia be located in some of the solid
viscera or in the nervous system, remedies should be addressed to these
parts, and the reflex nervous impressions allayed by the bromides or
other nervous sedatives. The valerianate of zinc in doses of one grain
three or four times a day is extremely useful in neuralgia from reflex
irritation of the female pelvic organs. Constitutional remedies are
indicated in the cases due to a morbid condition of the blood--iodide
of potassium and mercury if a syphilitic poison or if of a rheumatic or
plumbic origin; colchicum if gouty; quinia if malarial; and iron when
an anæmic state is presented. H. C. Wood states that alum is used with
success; being of service when there is no lead in the primæ viæ, it
must act in some other way than as a chemical antidote. Arsenic is very
highly recommended in idiopathic enteralgia. Excellent results have
been reported from the use of nitrate of silver,[22] hydrocyanic acid,
belladonna,[23] and iodoform. Change of climate and travel may have to
be resorted to in obstinate cases.
[Footnote 22: Nauman, _Deutsche Klinik_, Bd. iii., 1851, p. 388.]
[Footnote 23: _Lancet_, vol. i., 1867, p. 81.]
The objects of treatment in colic are to relieve suffering and
terminate the attack as soon as possible. For this purpose the various
anodyne and antispasmodic remedies, as opium, hyoscyamus, chloral,
ether, chloroform, Indian hemp, and camphor, may be employed.
Carminatives are most useful, alone or combined with anodynes and
cathartics. Oleum cajuputi often affords immediate relief. Warm teas of
chamomile, ginger, valerian, or peppermint sometimes do good. When the
suffering is very acute nothing acts so promptly as a hypodermic
injection of morphia, either alone or combined with atropia.
The surface of the body should be kept warm, and hot applications to
the abdomen assist in relieving pain. The heat may be conveniently
applied by means of poultices, hot salt- or sand-bags, or rubber
bottles filled with hot water. Cold,[24] used externally, is more
grateful in some cases, and is preferable if there be much tympanites.
Sinapisms, turpentine stupes, and stimulating and rubefacient liniments
answer well in some cases, and should be tried. Anodyne applications to
the spine occasionally do good, and cold, applied by means of the
spinal ice-bag, is recommended by Ringer.
[Footnote 24: Roux, _Journal de Médecine_, Paris, 1765, p. 48.]
In order to treat the disease successfully and bring the attack to an
end, its cause should be ascertained if possible, and remedies directed
to its removal. If it be the result of indigestion, the contents of the
stomach should be removed by emetics. Drastic or powerful cathartics
will only tend to aggravate the disease, and on that account mild
laxatives are to be preferred in all cases. Castor oil, calomel, pil.
rhei comp., senna, etc. may very properly be prescribed.
In flatulent colic means should be directed to expel the gas.
Anodynes--preferably chloroform--and carminatives should be
administered by the mouth, and enemata containing turpentine or
asafoetida injected into the rectum. In severe cases a clyster with ten
or fifteen drops of liquor ammoniæ is said to do good. If distension of
the bowel be so great as to threaten rupture, it may with propriety and
safety be relieved by puncturing the colon with an exploring-needle or
a fine trocar. In cases of flatulent colic where the gas arises from
the decomposition of food {666} remedies to check fermentation, such as
alkalies, creasote, carbolic acid, or the sulphites, would be
indicated. Good sometimes results from pressure and massage of the
abdomen. Rubbing with etherized oils and electricity have also been
used successfully. If the attack be from fecal impaction, it may be
possible to liquefy and remove the mass by using saline cathartics, as
sulphate of magnesium, aided by large oily or mucilaginous clysters,
which in obstinate cases should be injected through a flexible rubber
tube passed up the rectum as far as possible. Injections of an infusion
of tobacco are now seldom used for this purpose, on account of the
dangerous symptoms which often supervene. If pain or tenderness be
present at the seat of impaction, cathartics should be used very
cautiously or not at all, and opium given instead. The administration
of this drug, by relieving pain and allaying spasmodic action, is often
followed by free catharsis.
Persons subject to attacks of colic may diminish the intensity, or even
prevent the recurrence, of the disease by employing during the
intervals such remedies as would be indicated in their individual
cases. Phosphate of sodium has been highly recommended for preventing
the recurrence of attacks of colic. R. N. Taylor states[25] that his
experience with the use of the drug is quite extensive, and he found
the treatment uniformly successful. Thirty grains dissolved in a
glassful of water may be taken three times a day--preferably before
meals--and this quantity should be reduced if it causes any irritation
of the stomach. The bowels should be regulated and strict attention
given to diet. A milk diet is of course best in obstinate cases. Any
article of food known to disagree must be excluded, and tea, coffee,
and alcoholic drinks should also be prohibited.
[Footnote 25: _Med. Herald_, Louisville, 1880-81, ii. p. 348.]
{667}
ACUTE INTESTINAL CATARRH (DUODENITIS, JEJUNITIS, ILEITIS, COLITIS,
PROCTITIS).
BY W. W. JOHNSTON, M.D.
SYNONYMS.--Enteritis, Catarrhal enteritis, Mucous enteritis,
Endo-enteritis, Ileo-colitis, Entero-colitis, Diarrhoea. Older
synonyms: Chordapsus, Cauma enteritis, Enterophlogia, Enterophlogosis,
Colica acuta seu inflammatoria, Ileus inflammatorius, Enteralgia
inflammatoria, Febris intestinorum seu Iliaca inflammatoria, Colique
inflammatoire.
HISTORY.--It is interesting to start at the fountain-head of the two
streams of inquiry--the clinical and the anatomical--and to follow each
in its widely-diverging wanderings until they unite to give to the
phenomena of intestinal inflammation a just interpretation.
The symptom diarrhoea was fully described by the earliest writers in
medicine.[1] The symptomatic differences between diarrhoea, dysentery,
and lientery and the different forms of diarrhoea (bilious, watery,
etc.) were given in detail by the Greek and Roman physicians. The
Arabians had a much more elaborate classification of the fluxes.
Avicenna made seven varieties of simple diarrhoea. European writers
followed closely in these footsteps. Sennert made twelve and Sauvages
twenty-one varieties of diarrhoea, depending upon as many different
causes, as undigested food, worms, the bile, etc. Many recent writers
have adhered closely to the older authors in their method of treating
of diarrhoea, regarding it as a disease and dividing it into varieties
based on the causes or on the appearances of the stools. Among them may
be mentioned Cullen (1789), Good (1825), Tweedie (1841), G. B. Wood
(1852), Trousseau (1865), and Habershon (1879).
[Footnote 1: J. J. Woodward, _Med. and Surg. Hist. of the War_, Part 2,
Medical Volume, foot-note, p. 273 _et seq._]
It was only after many years of laborious investigation that the
appropriate lesion was affixed to a symptom so well understood and
described in its clinical aspects. The first conception of abdominal
and intestinal inflammation had no relation to diarrhoea. Under the
name [Greek: eileos], Hippocrates described abdominal symptoms of
intestinal obstruction and inflammation. For Sennert (1641)
inflammation of the intestines meant peritonitis. Bonet (1679), Hoffman
(1710), and Boerhaave (1758) included under this head peritonitis,
ileus, and all febrile and painful abdominal affections. Sauvages
(1763) and Morgagni (1779) gave in detail the symptoms of peritonitis
and called the disease intestinal inflammation--enteritis. In 1784,
Cullen made an advance in subdividing {668} enteritis into e.
phlegmonodoea and e. erythematica--the one involving the entire wall of
the intestine and the peritoneum, the other the mucous membrane lining
the intestine. John Hunter (1794) first fixed the place of peritonitis
as a distinct affection from inflammation of the mucous membrane of the
intestines.[2]
[Footnote 2: J. Hunter, _A Treatise on the Blood, Inflammation, and
Gun-shot Wounds_, London, 1794, p. 284.]
Up to this time constipation was the chief symptom of enteritis. The
meeting of the streams, the affixing the symptom diarrhoea to its
appropriate lesion, was brought about hypothetically at first by J.
Carmichael Smith in these words: "I think it is probable (for we can
have no positive evidence of the fact) that in diarrhoeas from catching
cold the villous or interior coat of the stomach is sometimes slightly
inflamed."[3]
[Footnote 3: Paper read Jan. 8, 1788, _Med. Communications_, London,
vol. ii., 1790, p. 168.]
On the Continent enteritis soon after this was limited in its meaning
by Pinel (1798) to inflammation of the mucous membrane of any part of
the intestines. He gave the name catarrhal diarrhoea to the same
condition. A still further restriction of its meaning was made by
Broussais (1821), who defined enteritis to be an inflammation of the
mucous membrane of the small intestine; he gave the name colitis to the
same disease in the colon. This distinction was adopted by Rostan
(1826), Andral (1836), C. H. Fuchs (1846), G. B. Wood (1852),
Wunderlich (1856), Grisolle (1865), Flint (1866), and Aitkin (1868).
According to the views of some authors, chiefly English, as Copland
(1844), Bristowe (1871), Roberts (1874), Habershon (1879), enteritis
includes inflammation of the serous as well as of the mucous coat of
the intestines.
Niemeyer (1864), Jaccoud (1869), Leube (1875), Bartholow (1880), and
most German and French authors prefer the name intestinal catarrh as
applied to inflammation of the mucous coat; inflammation of the serous
coat is peritonitis; the word enteritis is abandoned as involving a
pathological error.
NATURE AND CLASSIFICATION.--Catarrh of the intestines is an
inflammation of the mucous membrane of the intestinal tract. There are
various peculiarities of the catarrhal process due to the anatomical
structure of the parts involved, the presence of open glands, lymphatic
follicles, etc. This disease is to be distinguished from inflammation
of the serous coat of the intestine (peritonitis). The two are quite
distinct in their etiology, pathological anatomy, and symptomatology,
although they have been often confounded under the same name,
enteritis.[4] As so much confusion prevails as to the proper meaning of
enteritis, it is best to abandon the word altogether.
[Footnote 4: For cases called enteritis in which the lesions of
peritonitis were found, see Hamilton, _Edin. Med. Journ._, vol. ii.,
1857, p. 304; also Breed, _Chicago Med. Examiner_, Oct., 1869, p. 579.]
Diarrhoea is still regarded by some authors (J. J. Woodward) as
synonymous with intestinal catarrh; by others it is considered
separately as a disease distinct from catarrh. Habershon describes the
lesions of catarrhal diarrhoea and mucous enteritis almost in the same
words.[5] It is an unscientific method to take one symptom of a
pathological state, to {669} erect it into a disease, subdividing it
into varieties which are but differences in the intensity of its
manifestation, and to assign to it no fixed lesion. Diarrhoea is in
reality but a sequence and symptom of hyperæmia or inflammation of the
intestinal mucous membrane.
[Footnote 5: Such a method of treating the subject involves a
repetition, with an inversion, of the same description. Thus, catarrhal
diarrhoea has as its lesion mucous enteritis; mucous enteritis has for
its symptom (catarrhal) diarrhoea.]
ETIOLOGY.--Intestinal inflammation is more prevalent in the Northern,
Middle, and Western than in the Southern States. There is no relation
between the distribution of malarial and intestinal diseases: in some
regions where malarial disease is rife there is very little disease of
the intestines. Limited areas in Lower Mississippi, Eastern Kentucky,
Eastern North Carolina, etc. have a special predisposition to diseases
of this class.[6]
[Footnote 6: F. A. Walker, _Statistical Atlas_, 1874, table v. p. 3;
also plates xlii. and xlv.]
During the Civil War diarrhoea and dysentery were more frequent and
fatal in the central region than in the Atlantic and Pacific regions.
It is difficult to compare the relative liabilibity of the native and
foreign-born populations in the United States to intestinal disease.
Inasmuch as children, among whom the bulk of such cases occur, bear
such a small proportion to the adult foreign population, allowing for
differences due to this cause, statistics show that the foreign-born
race has a very distinct predisposition to these forms of disease.[7]
The Swedes, Norwegians, and Danes have a marked susceptibility to
intestinal diseases; the English and Welsh have the same tendency; but
the Irish have a comparative immunity. The colored race is more prone
to intestinal than to malarial diseases in the Middle States, but there
is the reverse susceptibility in the Northern and Southern States.
[Footnote 7: The number of children under ten to 1000 native population
is 306; number of children under ten in 1000 foreign population, 47 (F.
A. Walker, "Relations of Race and Nationality to Mortality in the
United States," _Statistical Atlas_, 1874, p. 213).]
Under ten years more males than females have enteritis, in the
proportion represented by the figures 362 and 299. After ten the
predisposition of the two sexes is about the same.
The summer is the season when diarrhoea is most prevalent and most
fatal. June, July, and August are the months in which the greatest
number of cases occur and in which there is the highest mortality. The
extraordinary death-rate in these months in cities is of course due to
the influence of summer heat on children, and the death-rate from
diarrhoea and entero-colitis is chiefly among infants under one year.
But among adults the same rule holds. The highest monthly mortality
from acute diarrhoea among the U.S. troops (white) between 1861 and
1866 was 147, in July, 1862; the next highest was 114, in August, 1862.
June and September were after these the most fatal months. According to
the census of 1870, the most fatal month is August.
Elevation of temperature in the summer months is the cause of the
prevalence of intestinal catarrh and of its great mortality among
infants and children. The number of deaths bears a direct ratio to the
degree of heat, the highest death-rate occurring in seasons of unusual
high temperature.[8] The effect of excessive or prolonged heat is to
arrest or weaken the digestive processes; undigested masses in the
stomach or the intestines act as foreign bodies and produce
inflammation.
[Footnote 8: Among the numerous publications bearing on this subject,
those contained in _The Sanitary Care and Treatment of Children and
their Diseases_ (Boston, 1881) are of especial value. S. C. Busey's
article contains much valuable matter on the relation of summer heat to
illness and mortality among children.]
{670} Sudden changes of temperature from cold to heat or from heat to
cold develop diarrhoea. If the air is at the same time saturated with
moisture, the effect of a change in temperature is greatly intensified.
In the first hot days of June there is on the Atlantic coast,
especially in cities, a rapid increase in the number of cases of
gastro-intestinal disturbance. A larger number of children are taken
ill in June than in August. The child in time becomes habituated to
heat, and if not attacked early runs less risk of illness in the later
months. A sudden or unusual exposure to low temperature, as in lying on
damp ground, leads to the same result. The check to perspiration after
violent exercise is especially provocative of diarrhoea. In these
instances the congestion and consequent inflammation of the mucous
membrane are brought about through the effect of heat or cold upon the
peripheral nervous system. Cold may act more directly by the driving of
suddenly-cooled blood from the surface of the body to the interior.
External burns belong to the same category, as they lead to extensive
inflammation, sometimes to ulceration, of the duodenal mucous membrane
through reflex influence. A case is reported of a boy aged twelve years
who after an external superficial burn of the left thigh was taken with
profuse diarrhoea which ended fatally in three hours (Ziemssen).
Contamination of the atmosphere with emanations the result of the
overcrowding of many human beings together, as in prisons, camps, or
asylums, especially where decomposition of organic matter is going on,
is of great influence in causing diarrhoea. Persons living in
badly-ventilated houses, or in houses improperly drained where the air
is vitiated by escaping gas from sewer-pipes, are especially prone to
be attacked. But sewer-gas, per se, does not cause diarrhoea any more
than it causes diphtheria or scarlatina.[9] It is a step backward to
hang upon this ready explanation all our doubts and our ignorance of
the origin of disease. The specific germ of the zymotic diseases may be
conveyed in the gases from sewers, but there are other and more direct
modes of communication which should receive equal attention.
[Footnote 9: Longstaff (_Brit. Med. Journ._, London, 1880, vol. i. p.
519) believes that summer diarrhoea has a specific poison which is
intimately connected with the process of putrefaction, and that the
infective material has its source in the public sewers.]
Children are much more liable to intestinal inflammation than adults.
This is due to the greater susceptibility of the mucous membrane in
them to congestion and catarrh from external influences and from direct
irritation. In infants fed upon an unsuitable diet--cow's milk or other
substitutes for mother's milk--this susceptibility is much increased.
The age most liable to attack is under one year, or from the first to
the second year, when, in consequence of dentition, weaning, and a
change from a diet chiefly or almost wholly liquid to one of solids,
there is a great liability to a disturbance of the normal equilibrium.
Intestinal catarrh forms almost one-third of the total number of the
affections of childhood. According to the census of 1870, 761 out of
every 1000 deaths from diarrhoea, dysentery, and enteritis occurred
under the tenth year. In old age a similar predisposition exists, and a
mild attack will in old persons induce more serious symptoms than in
middle life. Epidemics of diarrhoea among the aged in asylums and
hospitals are not uncommon.
{671} Temperament and idiosyncrasy are causes of differences in
predisposition. Many persons in consequence of taking cold invariably
have diarrhoea, while others as invariably have nasal catarrh or
bronchitis. Certain articles of food, as oysters and eggs, lead always
in some persons to intestinal disturbance. An exaggerated sensibility
of the mucous membrane to particular impressions is the cause of this
peculiarity.
Previous attacks of intestinal inflammation render the individual
liable to recurrences from very slight causes. The suppression of the
menses and of hemorrhoidal discharges and the healing of eruptions are
said to be followed by serious diarrhoea, but such an occurrence is
probably more often a coincidence than a result.