catarrh which by their short duration and benignant character point to
a mild degree of inflammation. They correspond to the following
anatomical states: hyperæmia of the mucous membrane of parts of the
small or large intestine, or of parts of both simultaneously; slight or
moderate swelling of the membrane from serous saturation; transudation
of serum into the canal; increase of lymphoid cells in the mucous and
submucous tissues; and increased manufacture of epithelial cells, but
without any marked tumefaction or ulceration of the closed follicles.
The termination is by resolution, which is reached in a few days
usually, and the membrane is rapidly and entirely restored to the
normal state. Between the normal condition of the mucous membrane, with
its recurring periods of physiological hyperæmia, and the hyperæmia
with exaggerated secretion and peristalsis which leads to diarrhoea,
there is no well-defined border-line. Diarrhoea may be regarded as the
most certain sign of the catarrhal process. Whenever the frequency and
fluidity of the stools are such as to be regarded as pathological, some
stage or other of catarrhal inflammation may be assumed to exist.
In a large number of mild forms the onset is sudden. After a meal of
indigestible food or an unusual excess pain will be felt in the
abdomen, recurring in paroxysms, which start in the neighborhood of the
umbilicus and radiate throughout the abdomen. The pain is accompanied
by borborygmi, and is succeeded sooner or later by a desire to go to
stool. The first one or two movements, which follow each other in quick
succession, are more or less consistent or moulded, but in a short time
diarrhoea is established by frequent discharges of watery fluid,
containing perhaps some undigested fragments of food, which may have
been the exciting cause of the illness by mechanical irritation. Each
stool is preceded by colics, griping pains in the abdomen, which are
relieved by the evacuation. An attack beginning in this way and from
such causes may cease in a few hours, and be unattended by any general
symptoms if proper precautions are taken. A slight dryness and coating
of the tongue, with loss of appetite and occasional griping pains or a
tendency to looseness of the stools, may continue for a day or two.
Indiscretions in diet or other imprudences, as fatigue, may prolong the
mildest attack during one or more weeks, but the character of the
illness is here due not to the nature of the disease, but to the
addition of fresh causes which delay the natural progress toward
recovery.
Severer forms either begin suddenly, as in the milder forms just
described, or are preceded for a time by symptoms of gastric or
intestinal indigestion. The patient may have complained of distress
after eating, flatulence, colicky pains, distension of the abdomen and
tenderness on pressure, loss of appetite, with a general feeling of
ill-health--symptoms which point to the existence of a condition of the
mucous membrane of the gastro-intestinal canal favorable to the action
of an exciting cause.
A feeling of chilliness ushers in the attack. This is accompanied by
fever, which at first, and sometimes throughout, is of a marked
remittent type. {679} The griping pains, colics, which at first are
infrequent and dull, now recur at short intervals and become sharper.
They are sometimes attended with vomiting of food or of a greenish
fluid. The intensity of suffering may be so great as to cause pallor of
the countenance, a feeling of faintness, and coldness of the surface
with sweating. The paroxysm usually precedes a movement. The more
severe pains extend to the lower extremities and the scrotum.
Movement of gas in the intestines produces rumbling, gurgling, or
splashing sounds, called borborygmi. They are paroxysmal, lasting a few
moments, or are coincident with pain, and frequently are the immediate
precursors of an evacuation. The cause for their production is the
quick propulsion of the fluids by strong peristaltic action from one
part of the bowel to the other or the rapid movement of gas within the
bowel. Relief is obtained both from the pain and from the sense of
distension by expulsion of flatus.
Tympanites is closely connected with the symptoms just described. An
excess of gases within the bowel is not primarily a result of the
inflammation of the mucous membrane, but is an early phenomenon due to
the decomposition of indigestible food in its transit through the
intestine. Later, the gases are developed very readily by the
decomposition of even the most digestible articles of food, the mucus,
which is the product of the catarrh, acting as a ferment.
The distension of the intestinal canal produces an intumescence of the
abdomen which is commonly uniform, but may be greater in some portions
of the tract than in others. Thus the transverse and descending colon
are more projecting and more distinctly outlined than other portions of
the canal.
Sensibility of the abdomen to pressure exists along the line of the
colon or over a considerable area. But no defined limitation of the
affected part can usually be made by the location of pain to the touch.
If there is any local tenderness, it is over the descending colon. In
one form of enteritis--typhlitis--the localization of the inflammation
in the cæcum produces subjective pain and pain on pressure in a
restricted region--a peculiarity which results no doubt from the early
intensity of the inflammation and the implication of the connective
tissue behind the bowel. But this is not true of inflammation of any
other part of the intestinal canal.
A sensation of soreness on movement, as in turning in bed, standing, or
walking, is not uncommon, even when the attack is of no great gravity.
The patient on standing bends forward to relieve tension, and he may
feel nervous when the bed is shaken.
Diarrhoea is the most important symptom, as it is directly related to
catarrh. The number of evacuations varies from one or two to twenty or
more in the day. In cases of medium intensity there are from six to ten
in twenty-four hours, the interval between the movements being two to
three hours during the day and somewhat longer at night. The matters
passed in quantity range from two ounces to a pint; the average is
about four fluidounces. This, however, is subject to great variations,
depending upon the intensity of the disease; the more choleriform the
attack the greater the amount of fluid passed. The weight of the
evacuations varies from five ounces to forty pounds in twenty-four
hours; this increase does not depend upon the greater quantity of water
only, but the solid constituents are in greater amount.
{680} The normal brown color, which is due to hydrobilirubin, changes
as the movements become thinner to yellowish-brown or pale yellow from
dilution of the fecal matter with water. An excess of serum or mucus
renders them colorless. A greenish-brown, greenish-yellow, or green hue
is due to the presence of bile. The rapid descent of the contents of
the bowel delays or prevents the reabsorption of bile,[22] or the fluid
is expelled before the usual transformations in color take place.[23]
The bile-pigment is also absent in duodenal catarrh from closure of the
opening of the ductus choledochus.
[Footnote 22: L. Brunton, "On the Action of Purgative Medicines," _The
Practitioner_, London, June, 1874, p. 403.]
[Footnote 23: The reaction of bile-pigment with nitric acid, which does
not take place in the contents of the colon or in normal feces, is seen
in the green stools of acute intestinal catarrh, especially in
children.]
The coloration of the stools further depends upon the character of the
food and drink and upon the drugs given. From an exclusive milk diet
the discharges are pale or contain undigested whitish lumps of casein.
The preparations of bismuth and iron give a black color and the
sulphate of copper a dark-green hue. A green or greenish-brown tint is
observed after the use of calomel, and while the experiments of the
Edinburgh committee demonstrated that no increase of bile follows its
administration in dogs, yet the opinion is still general that the green
stools contain an excess of bile.
Blood appears in three forms in the stools: as a coffee-ground or black
powder from hemorrhage in the stomach or upper bowel; as a reddish
fluid with small coagula in flakes, which come from intense congestion
or ulceration of the intestine; or an abundant hemorrhage may result
from deep ulceration in the duodenum or elsewhere.
The characteristic odor of the feces is altered in several ways. As the
movements become less solid they acquire a nauseous or sour smell, due
essentially to the volatile products formed in connection with the
decomposition of fatty matters.[24] When very thin and containing
little or no feculent matter the discharges lose odor, as in cholera,
or they become excessively offensive--cadaveric--in intense and fatal
inflammation and in ulceration of the bowels. After exposure to the air
the stools of diarrhoea undergo decomposition and develop offensive
smells more rapidly than in health. The absence of bile, whether there
is diarrhoea or not, gives rise to a peculiar and unpleasant odor,
showing that this secretion is to some extent an antiseptic. The escape
of fetid gas from the anus is rarely an accompaniment of a decomposed
state of the rectal contents. In children the stools are more variable
in quantity, color, and odor than in adults, and are more readily
affected by the ingesta.
[Footnote 24: Guttmann, _Physical Diagnosis_, Sydenham Soc. ed., p.
404. The odor of normal feces is due to a substance isolated by
Briequer, called scatol, which is a final product of the putrefaction
of albumen (Ewald, _Lectures on Digestion_, New York, 1881, p. 106).]
In the diarrhoea of old persons the discharges are thin, yellow,
offensive, and often frothy.
The disorder of the digestive apparatus is attended with other
symptoms. The tongue is normal in some cases; in others red at the
point and edges with a central whitish coat, or the surface is red,
polished, and dry. Marked change in the appearance of the tongue is due
to a complicating gastric catarrh. There is thirst, with loss of
appetite, and a tendency to {681} nausea and vomiting in children and
feeble persons. The breath has a peculiarly offensive odor (spoken of
as fecal) in some instances.
Fever is not always present. In cases of moderate severity it occurs in
the beginning of the illness, but declines rapidly under treatment by
rest and diet. The course of fever does not conform to any type even in
severe cases, although it so nearly resembles that of typhoid fever in
its first week as to lead to mistakes in diagnosis. The height of the
fever and its duration are measures of the extent of the lesions and
their gravity. Sudden outbursts of fever point to some complication. In
catarrh of the bowel due to cold the fever is higher than when
indigestion is the cause. In very feeble persons, in children, and in
any case from neglect and improper feeding the body-heat may be very
high.
The urine is diminished and high-colored. Very little disturbance of
the nervous system is seen except in young and old patients; some
headache and restlessness are all that may be observed. Moderate
delirium at night accompanies very acute attacks. In children
convulsions are not unusual in the onset and at the end of the attack.
In the aged exhaustion from the illness soon lapses into stupor or
coma.
Paraplegia and contraction of the muscles of the extremities are
referred by some observers to gastro-intestinal inflammation.[25]
[Footnote 25: Potain, _Le Praticien_, Paris, 1879-80, p. 88.]
In uncomplicated mild cases of intestinal catarrh there is a movement
toward recovery after a few days' illness. The stools become less
frequent, smaller, and more consistent. In a week to ten days the
tongue cleans, the thirst ceases, the appetite returns, the tympanites
and pain diminish. The fever declines, and ceases before the diarrhoea
is completely arrested. There are always more or less emaciation and
loss of strength from the fever and arrest of nutrition. The liability
to relapse is great, and the patient by indiscretions reproduces the
same symptoms, thus prolonging the attack for several weeks. Acute
intestinal catarrh may pass into the chronic form by a disappearance of
fever and amelioration of all the abdominal symptoms. The patient
begins to take solid food, gains strength and flesh, but complete
recovery does not come. The diarrhoea recurs at variable intervals as
the result of indulgences in a mixed diet, over-exercise, or exposure
to cold, and in time we have some degree of chronic catarrh permanently
established.
Very mild cases may be prolonged by the neglect of the patient to
consider his painless diarrhoea of sufficient moment to need attention.
In inflammation of the more intense kind the picture is somewhat
different. The prodromes are longer and the general symptoms more
severe. Restlessness, a sense of prostration, delirium, and high fever
mark the early stages and continue for a longer time. The patient loses
flesh and strength quickly. The features express anxiety and illness,
the skin is hot and dry, and the thirst great. Vomiting is repeated.
Borborygmi, the tension of the abdomen, pain, and sensibility to
pressure are all intensified. The stools are at first yellow and thin,
but change much from day to day. They may be green or very thin and
dark or grayish, and are sometimes very offensive in odor. Blood and
mucus may be seen in them, being slimy or grumous and bloody. When the
patient is very weak the discharges are involuntary; the tongue is
coated white, with bright red tip and edges, and is often dry.
{682} The severer forms last from three to six weeks. After a tedious
period of alternate improvement and relapse the illness becomes chronic
or the patient dies from asthenia, perforation and peritonitis, or some
other complication.
In the most intense varieties which find examples among Europeans and
Americans in intertropical countries, or result from acute mineral
poisoning and from rapidly-progressing cases of acute ulceration of the
intestinal wall, especially in children, there is a sharper and more
violent invasion. The strength is reduced in a very short time, and
there is rapid emaciation; the features assume an anxious expression;
the complexion is leaden or livid; the skin is cold and clammy; the
pulse is small, weak, and rapid; the breath comes quick and short, and
is frequently complicated with hiccough. In the early stages vomiting
occurs, due to a concurrent gastritis; in cases of poisoning vomiting
is incessant.
The pain in the abdomen is intense, and less paroxysmal than in other
forms. The abdomen is tympanitic and excessively tender to the touch,
and the knees are drawn up to relieve the tension of the abdominal
muscles. Thin, black, or reddish stools are passed every few moments.
As the attack progresses the urine is suppressed, the voice becomes
whispering, and collapse is developed. This is marked by cold
extremities, dyspnoea, feeble and finally imperceptible pulse. Death
may end the scene in a few hours or the patient may rally and recover
slowly.
Choleriform diarrhoea occurs chiefly in children during hot weather.
VARIETIES DUE TO SEAT.--The symptoms and progress of acute catarrh of
the intestines present numerous differences depending upon the seat of
the inflammation. The symptomatology already given is that of the most
common form (ileo-colitis), in which the lower part of the ileum and a
considerable portion of the colon are simultaneously involved. Many
cases no doubt occur in which the disease is limited and in which early
recovery is the rule. The pathological anatomy of cases of generalized
catarrh is better known, as they form the bulk of the fatal cases.
I. Acute Duodenitis.--The most common form of duodenitis is that in
which the inflammation spreads by continuity of tissue from the stomach
to the duodenum, as in acute gastric catarrh after a debauch. The
prominence of the gastric symptoms disguises the intestinal lesion,
unless the catarrh, as is frequently the case, extends into and
obstructs the common bile-duct and its branches, and suddenly develops
icterus with clayey stools and altered urine. Besides icterus, a
careful isolation of symptoms will show that some cannot be attributed
to the stomach: there is a dull pain seated in the right hypochondrium,
extending to the right shoulder or shoulder-blade, which is increased
by pressure upon the region of the duodenum. As the gastric symptoms
improve there is no change in the icterus, which continues for some
days or weeks longer. The connection between burns of the integument
and ulcer of the duodenum is well known. Symptoms of perforation, with
death, may be the first sign of this lesion, but vomiting of blood,
icterus, purging of blood, indigestion, and cardialgia occur from
duodenal ulcers.
The typical acute duodenitis described by authors as an independent
{683} affection is of rare occurrence. An epidemic of duodenitis[26]
has been reported where many persons were simultaneously attacked, all
the cases having had the same traits--headache, pain in the line of the
duodenum at the left edge of the right hypochondrium, pain in the first
and second lumbar vertebræ, constipation, jaundice, slow pulse, and
mental depression. Gangrenous inflammation of the duodenum[27] has been
once seen, and produced a chill, a severe sense of weight and pain in
the epigastrium, retching and eructations of gas, tenderness on
pressure, frequent pulse, and high temperature. There was obstinate
constipation, with dyspnoea, death ensuing in a few days. At the
autopsy gangrenous inflammation of the duodenum was found, which ended
abruptly twelve inches from the pylorus. There was a large gall-stone
in the gall-bladder.
[Footnote 26: McGaughey, _Philada. Med. Times_, Aug. 1, 1872, ii. p.
407; also, T. N. Reynolds, _Detroit Clinic_, June 7, 1882, p. 181.]
[Footnote 27: Eskridge, _Philada. Med. Times_, Feb. 15, 1879, ix. p.
239.]
A fatal case of duodenitis is recorded[28] in which the following
symptoms were observed: sudden and severe pain in the right
hypochondrium, increased by pressure; rigors, vomiting and purging of a
green flocculent fluid, and later of blood; jaundice, fever, delirium,
collapse, and death. The pylorus and two-thirds of the duodenal mucous
membrane were much inflamed and the orifice of the bile-duct closed.
[Footnote 28: _Die Krankheiten des Duodenums_, Mayer, quoted by Leube
in _Ziemssen's Cyclopædia_, Am. ed., vol. vii. p. 373.]
II. Acute Ileitis, Acute Jejunitis.--When the ileum, with or without
the jejunum, is the seat of catarrh, diarrhoea may not be present,
provided the inflammation is slight and there is no increase of colon
peristalsis. The symptoms then are borborygmi, pain and fulness about
and below the umbilicus or between it and the right ileum, especially
after eating, and the general symptoms arising from indigestion and
malnutrition. Fever is slight or absent; there are malaise and loss of
strength. The feces give important indications. They contain unaltered
bile and fragments of muscular fibre and starch-granules in excess of
the quantity found in health. An increased quantity of mucus, diffused
evenly in a fluid evacuation, or globules of mucus stained with bile,
or bile-stained epithelium, denote inflammation confined to the small
intestine. A larger amount of indican in the urine than is normally
present is a sign of the same lesion.[29]
[Footnote 29: These conclusions are based upon the results of one
thousand examinations of feces made by H. Nothnägel, and reported in
_Zur Klinik der Darmkrankheiten; Zeitschrift für klin. Medicin_, iv.,
1882, p. 223.]
Intense inflammation of the small intestine may exist without diarrhoea
or other symptoms betokening the real nature of the attack. Flint[30]
mentions having met with three such instances, and Goodhart[31] records
thirteen cases of enteritis with marked lesions in which no diagnosis
had been made before death. Rilliet and Barthez report twenty-four
autopsies in children with intestinal lesions in which no symptoms had
been observed.[32]
[Footnote 30: _Clinical Medicine_, Philada., 1879, p. 280.]
[Footnote 31: _Guy's Hospital Gazette_, Sept., 1878, p. 98 _et seq._]
[Footnote 32: _Maladies des Enfants_, Paris, 1861, tome i. p. 748.]
III. Acute Colitis.--Fifty years ago colitis was synonymous with
enteritis, and not with dysentery, as at a more recent date.[33] The
older {684} signification expressed the fact that inflammation in the
colon is essential to diarrhoea. Later the term was used synonymously
with dysentery.[34]
[Footnote 33: _Journal général de Médecine_, Paris, 1825, t. xci. p.
18.]
[Footnote 34: Tweedie, _System of the Practice of Medicine_, 1841.]
The colon is a conducting tube; the contents are composed of matters
unabsorbed in the small intestines. At first the mass entering the
colon is fluid, but by the gradual absorption of its watery part it
approaches solidity. The discharge from the rectum of a fluid shows
that the propulsion through the large intestine is so rapid that the
process of drying does not take place, or that from inflammation of the
colon there is an excess of fluid transudation from the intestinal
wall. The superficial position of the colon, its great size and length,
expose it to the action of external cold, to blows, etc.
In catarrh limited to the colon there are essentially the same symptoms
as in ileo-colitis, inasmuch as the inflammation of the colon gives to
that form its characteristic features--borborygmi, diarrhoea, and
tympanites. When the disease in the colon preponderates or exists
alone, the pain and tenderness are more superficial and confined to the
line of the large intestine. The distended colon projects and the
abdominal swelling is not so uniform. If the attack is subacute or
mild, the stools contain normal feces mixed with a great deal of mucus;
when the inflammation is in the sigmoid flexure, pure mucus is passed.
Blood mixed with mucus and tenesmus accompany inflammation low down.
Blood may, however, come from intense inflammation of the ascending and
transverse colon without disease of the lower bowel.[35]
[Footnote 35: In a case seen by the writer of colitis terminating
fatally from perforation of the transverse colon this point was
illustrated. A woman aged fifty was taken with diarrhoea in August,
1873. In November the symptoms became worse: tongue dry and red;
abdominal pain; tympanites; frequent stools, ten to seventeen in
twenty-four hours; quantity large, of a yellow or brownish-red color
with floating flakes. General symptoms grew worse; blood in stools from
time to time. November 24, sudden cessation of discharges from the
bowels, and the following day sudden collapse and death. Autopsy:
Descending colon and sigmoid flexure comparatively healthy. Transverse
colon adherent to stomach; deposits of lymph on colon and small
intestines; fluid and feces in the peritoneal cavity. The mucous
membrane of the ascending and transverse colon in a state of black
pulpy disintegration. In the transverse colon the walls were thinned by
ulceration and easily torn; gangrenous appearance of mucous coat;
perforation of the colon wall below greater curvature of the stomach.]
IV. Proctitis.--The rectum may be the seat of simple catarrh, which
differs in its symptoms from catarrh of other portions of the canal. By
many this form is called simple, non-infective dysentery. But as it is
a form of intestinal catarrh, it is right that it should be considered
in connection with colitis. The first indication of its onset is a
frequent desire to go to stool, with an unsatisfied feeling after each
effort. Normal fecal matter is first expelled in solid form, coated
with mucus which may be streaked with blood. Soon, however, the
discharges consist of jelly-like mucus, alone or mixed with blood. A
small quantity of this is passed with tenesmus at short intervals. The
patient complains of a burning feeling in the rectum and a constant and
irresistible desire to strain. The same spasmodic contraction may
involve the bladder.