recovery spontaneously or under treatment by the cessation of the mucus
and blood and the discharge of normal fecal matter.
DIAGNOSIS.--A combination of the symptoms described as belonging to
inflammation of the small and large intestine gives the most common
{685} form of intestinal catarrh, ileo-colitis. This union is diagnosed
by the following symptoms: fever; general distension of the abdomen;
paroxysmal pains starting from the umbilicus, but having a general
distribution; noisy movements of gas; diarrhoea, the stools being
large, thin, stained more or less with bile, containing more or less
mucus intimately mixed with fluid matter and with particles of
partially-digested or unaltered food. It is possible in many cases to
recognize the part of the intestinal canal which is the seat of disease
from differences in symptoms which have already been described. But
great care in observation is needed, combined with a minute inspection
and microscopical examination of the stools, to arrive at accurate and
well-founded conclusions.
Acute follicular ulceration may be thought to have begun if after a
week or more of illness thin and sometimes putrescent stools are passed
containing small blood-coagula, with mucus and pus.[36] This opinion
would be confirmed by an increase in abdominal tenderness and the
persistence of the diarrhoea or tendency to relapse notwithstanding
careful treatment and diet. The transition of the disease into the
chronic form would give additional support to this view of the nature
of the lesion.[37]
[Footnote 36: "The intestinal mucous membrane, especially that of the
small intestine, scarcely ever produces pus without ulceration"
(Virchow's _Cellular Pathology_, Philada., 1863, p. 492).]
[Footnote 37: For a more detailed account of the symptoms and diagnosis
of follicular ulceration see article on CHRONIC INTESTINAL CATARRH.]
Some or all of the symptoms of acute intestinal catarrh are, however,
found in other diseases. It is well, therefore, to devote some
attention to differential diagnosis, giving a résumé of the salient
points of distinction.
Typhoid fever in many of its features resembles intestinal catarrh, and
in many cases is confounded with it. Until within quite recent times
the symptoms of typhoid fever were grouped under the names
gastro-enteritis and follicular enteritis. In the first week of the
illness there is reasonable ground for delay in making a positive
diagnosis. Etiological data are here of great help. The occurrence of
the symptoms in children under two years and in adults beyond fifty
years points strongly to intestinal catarrh. Spring and early summer
are the seasons for diarrhoea; typhoid belongs to late summer and to
autumn. A sudden onset after errors in diet or exposure to cold, with
the early development of pain in the bowels, rumbling of gas,
diarrhoea, would be easily recognized as a local disorder. In typhoid
fever there is a less sudden onset, with prodromal debility, anæmia,
indigestion, and nocturnal fever. To these symptoms the diarrhoea,
which is attended with little or no pain, plays a very subordinate
part. In many cases of mild typhoid the development is sudden, with
rigors. A week's study of the temperature, if no rose-spots appear,
will be needed before the diagnosis can be made. There is not much
difficulty in making the distinction when the attack has reached its
second week. At this period in catarrh of the bowel the high fever,
with regular morning remissions and evening exacerbations, is not
constant, as in typhoid fever; there is tenderness on pressure over the
abdomen and gurgling, but no great meteorism; sibilant râles are not
heard in the chest; there are no rose-spots; rarely cerebral symptoms
except insomnia; and delirium is uncommon. The spleen is not enlarged.
The prostration is proportioned to the diarrhoea, and is by no means as
{686} great as at the same period in enteric fever. The colicky pains
preceding and accompanying the stools are a more marked feature of
intestinal catarrh; they are absent in enteric fever or have a feeble
intensity.
In children between the ages of two and seven years there are certain
peculiarities which augment the difficulties of diagnosis. Intestinal
catarrh in them is accompanied by an abundant, frequently painless
diarrhoea, by tympanites, cerebral disturbances, a dry and coated
tongue, with sordes on the lips and gums, and by a rapidly-developed
anæmia, emaciation, and exhaustion. Typhoid fever in children of this
age is generally benignant; vomiting is more common than in adults;
high grades of meteorism are infrequent; tenderness of the cæcal region
is determined with greater difficulty; and severe nervous phenomena and
fatal intestinal complications rarely occur.[38] In other words, in
young children intestinal catarrh by its severity and enteric fever by
its benignity more nearly approach each other than in adults; in many
instances the diagnosis must be undecided until late in the attack.
[Footnote 38: Consult "Diseases of Children," Henoch, _Wood's Library_,
New York, 1882, p. 300.]
Typhoid fever can of course be known if rose-spots, a splenic tumor, or
the characteristic delirium are manifested, or if the fever-curve
conforms to the type; but in children all these symptoms may be
negative; even the fever has great variability. If fever is continued
beyond ten days, and is accompanied by progressive anæmia and
emaciation and debility, the attack is enteric fever if all local
causes of fever can be excluded. There is no minimum limit to the
temperature in typhoid fever, and no matter how low the maxima of the
fastigium may be, typhoid fever cannot be excluded.[39]
[Footnote 39: Johnston, "On the Diagnosis of Mild Cases of Typhoid
Fever," _Am. Journ. Med. Sci._, Oct., 1875, p. 372; also, "On the Mild
Forms of Continued Fever in Washington," _Am. Journ. Med. Sci._, Oct.,
1882, p. 387.]
The large watery stools and the absence of tenesmus mark the difference
between diarrhoea and dysentery. Blood may be present in colitis, owing
to a high grade of inflammation and to ulceration. Simple catarrh of
the rectum, proctitis, is not readily distinguished from infective
dysentery. Small mucous and bloody stools may be catarrhal. In the
present state of our knowledge dysentery would be known by marked
tenesmus, by the grave general symptoms, the reddish fluid stools with
flocculi, and by its occurrence in epidemic form.
Enteralgia presents the following features which distinguish it from
intestinal catarrh: The tongue in enteralgia is clean or coated white,
but with no red tip and edges; the appetite is capricious, but not
lost; the bowels are constipated; the pain bears no relation to the
ingestion of food or drink, as in enteritis. Fever is accidental, and
there are other nervous phenomena. In lead colic there is no fever,
tympanites, nor diarrhoea. In rheumatism of the abdominal walls the
pain is superficial and sharp, not griping, and is increased by
movements of the trunk. The digestive system is in no way disordered.
From peritonitis intestinal catarrh is distinguished by a less degree
of illness and by its usually favorable result, by diarrhoea, a greater
freedom in movement, and by a less degree of suffering on palpating the
abdomen. Tympanites, constipation, great tenderness on pressure over
the abdomen, and a small, quick pulse, point to peritonitis.
{687} PROGNOSIS.--A simple intestinal catarrh of the form first
described involves no danger, and if treated by rest and diet soon
recovers. The more severe form, beginning as a primary disease, when
rationally treated ends in recovery in most instances.
Unfavorable predisposing causes are--a hot climate (India, the West
Indies, and intertropical climates in general); very hot weather of the
summer and autumn months; a very early or very advanced age; the
contaminated atmosphere of prisons, camps, etc.; all bad hygienic
influences; and previous or coexisting illness. When diarrhoea occurs
as a complication of the acute infectious diseases it has a special
gravity. In typhoid fever, scarlatina, measles, acute tuberculosis,
etc. it adds another element of illness and danger. During the progress
of chronic general diseases (malaria, scurvy, tuberculosis) it becomes
an obstinate and sometimes a fatal complication. Among the exciting
causes mineral poisons induce the most dangerous form of intestinal
catarrh. Unfavorable symptoms occurring during the course of acute
diarrhoea are the early development of high temperature, cerebral
disturbance, great sensibility to pressure over the abdomen, thin and
bloody or highly offensive stools, involuntary discharges, and very
rapid emaciation and loss of strength.
TREATMENT.--There have been many fluctuations of opinion as to the
relative value of modes of treatment in this disease. Various
therapeutic measures have been suggested which, after enjoying favor
for a time, have been abandoned, and revived after long periods of
disfavor. Venesection was alternately recommended and forbidden.
Emetics and evacuants, mercurials, diuretics, diaphoretics, have been
in turn warmly supported and vigorously opposed. Opium, belladonna, the
various astringents, and cinchona-bark have run through many changes of
favor. Individual drugs give curious evidence of inconstancy. Oxide of
zinc, suggested by James Adair in 1785 and by Hendy in 1784, after a
hundred years of weak approval is commended highly by Penrose (1863),
Brakenridge, and Mackey (1873),[40] and by more recent writers. Acetate
of lead, which dates back to Paracelsus, had varying fortunes of repute
and disrepute. In the end of the seventeenth century it had a name for
curing diarrhoea, but in the following century it was spoken of by
Boerhaave as a deceitful and destructive poison, and Cullen in 1789
said that hardly any one then thought of using lead internally.[41] In
1799 it had warm advocates in this country; among them, Thomas Ewall of
Washington, who wrote in 1808. Since then it has come into very general
use and favor, which it still holds.
[Footnote 40: J. J. Woodward, _op. cit._, p. 776.]
[Footnote 41: Ibid., _op. cit._, p. 780 _et seq._]
In view of the many changes of faith in systems of treatment and in
drugs, we have no right to assume that we have as yet reached the
perfection of treatment. In fact, experience brings the conviction that
our systems are quite imperfect and that drugs fail in our hands when
they are most needed.
The prophylactic treatment is of importance, especially in children,
delicate persons, and in those suffering from disease or predisposed by
idiosyncrasy to intestinal catarrh. Directions must be given by the
physician as to the food for children appropriate to their age and
digestive capacity. Summer heat and city life being so fatal to them,
they should {688} be sent to the cool climate of the seashore or
mountains during the first and second years of life. In warm weather
laxatives should not be given to children, except with precautions
against their acting too freely; the same rule applies to the aged. Too
great care in diet in older children predisposes to indigestion and
diarrhoea. Variety in food is of service, therefore. It is not well to
give children food prepared so as to do away with the necessity for
mastication and for active gastric movements. The stomach gains
strength by exercise. All reasonable care should be used not to take
food in excess of the individual's power of digestion. Unripe fruit,
stale vegetables or fruits, cheese, pork, shellfish which are not
absolutely fresh, are among the aliments which may produce diarrhoea,
and are to be avoided. Many people have to be told what food is
unsuited to them, and certain articles of food in individual cases
invariably excite diarrhoea. Alcohol is often to be blamed for
diarrhoeas which are attributed to indigestible food, and frequent
recurrences of intestinal catarrh can only be prevented by abandoning
stimulants altogether. The bad effects of sudden changes in temperature
are warded off by wearing flannel next to the body. This is an
important rule for adults as for children. Even in summer thin flannel
or gauze gives protection. Well-ventilated rooms, good house-drainage,
personal cleanliness, with all other hygienic aids, are means of
prevention. Persistent disinfection of sources of air- and
water-contamination should be practised, especially in hot weather. In
the country the open privies and wells need frequent clearing out.
Cases of fatal diarrhoea are met with in elevated regions where the
continued low temperature renders it improbable that heat could have
anything to do with their causation.[42] Water should not be used which
could in any way be tainted with soakage from privies, barnyards, or
other places where animal decomposition is going on.[43] Avoiding the
use of cathartics in the onset of acute illness, the nature of which is
not known, is a useful prophylactic measure. A fatal diarrhoea may
result from injudicious purging in such cases. Care in the use of
laxatives should be observed in the chronic wasting
diseases--tuberculosis, rachitis, cancer, etc.
[Footnote 42: The yearly occurrence of typhoid fever and diarrhoea at
seashore hotels shows that there is great danger in crowding persons
together and saturating the soil with the excreta. In the summer of
1882 in a boarding-house in the mountains of Maryland, where the
temperature was never above 75°, there were three fatal cases of
diarrhoea in children, and several others of diarrhoea and dysentery
which recovered.]
[Footnote 43: The drinking-water supplying a country boarding-house
visited by the writer passed through iron pipes imbedded in the
manure-heap of a barnyard.]
The selection of a plan of treatment for intestinal catarrh will depend
upon the nature and cause of the symptoms. The diagnosis of the case is
incomplete and the treatment irrational until the indications furnished
by etiology have been obtained.
If cold has been the exciting cause, the patient should be confined to
bed. In the beginning a full dose of pilocarpin, hypodermically,[44] or
of the fluid extract of jaborandi by the mouth, may cause a powerful
diversion from the bowel to the skin. A hot-water or vapor bath has the
same object in view. Hot fomentations or mustard poultices can be next
applied to the abdomen. This should be succeeded by a febrifuge {689}
mixture containing the tincture of aconite-root, to which an opiate
(the deodorized tincture of opium or morphia) is to be added if there
is much pain or diarrhoea. A hypodermic injection of morphia given on
the first day of the attack immediately after a hot bath will give a
quiet night and diminish the intensity of the illness. The subsequent
treatment is that common to all the acute forms.
[Footnote 44: Atropia can be given with pilocarpin to diminish its
effect on the heart; atropia is the antidote for pilocarpin. (See
Schuk, _Centralb. f. d. med. Wissen._, Bd. 20, 1882, p. 357; also,
Frohnmüller, _Med.-Chir. Centralb._, July 14, 1882.)]
If summer heat has been the cause in adults or children, artificial
cooling of the temperature of the room by the evaporation of ice-water
or by one of the refrigerating machines yet to be perfected meet the
indication. If there is much body-heat (thermic fever), cold sponging,
the application of cold to the head, or the giving of pounded ice to
satisfy the intense thirst, are all advisable. Such cases are benefited
by a change of climate when the acute symptoms subside. The form of
diarrhoea due to malaria is to be treated by quinia and change of air
to a more healthful climate. Iron, with quinia or arsenic, is needed in
obstinate cases.
Intestinal catarrh which proceeds from the presence of undigested food
or hard fecal lumps in the bowel is benefited by early removal of the
irritating cause. It is not often that substances of this kind are
retained when the stools are large and frequent. The peristalsis is
here as active as it need be, and no good, but only harm, can come from
over-stimulating the contractile muscles. In those instances where
there is a distinct history of the taking of indigestible food,
especially fruit with seeds or skins, and where the efforts at stool
are frequent, ineffectual, and accompanied by colic and borborygmi, or
where scybalæ are found floating in the fluid passed, a large enema of
warm water given slowly will excite the bowel to successful expulsive
efforts. If this does not give a certain amount of prompt relief, a
moderate dose of castor oil, calomel, Rochelle or Epsom salts ought to
be prescribed, and repeated after some hours until a free fluid or
semi-fluid stool results; one or two doses will usually suffice. If the
inflammation is localized in the cæcum (typhlitis), as indicated by
local pain, tenderness on pressure in the right iliac or right lumbar
regions, constipation, flexing of the right thigh on the trunk, and
vomiting, a purgative should not be given, nor should prolonged efforts
be made to empty the bowel by injection through long rectal tubes. If
there is doubt as to whether typhlitis or undigested food and fecal
impaction is the cause of the local pain, it is better to err on the
safe side, and not to give a purgative unless the case is seen in the
onset before the more pronounced symptoms appear; then calomel or
castor oil may be tried once, but not repeated in case of failure.
As the diarrhoea of Bright's disease is salutary, no effort should be
made to arrest it. Its periodical recurrence prolongs life. In
tuberculosis the special character of the diarrhoea must be considered,
and every effort must be made to control it. In the eruptive fevers an
early diarrhoea, as in scarlet fever, does harm; it delays or prevents
the normal development of the eruption. In the later stages it is of
service sometimes, as in measles, when it leads to a rapid fall of
temperature. The course of action depends upon the nature of the
specific disease and upon the time of the appearance of diarrhoea.
There are certain principles, founded on the knowledge derived from
pathological study and from the experience of the past in the treatment
{690} of intestinal catarrh, which guide us to a treatment which is
more or less rational in all cases.
Rest is essential to the cure of the inflamed intestine, but absolute
inertia of the bowel is undesirable, even injurious. The retention of
fluids, transuded serum, bile, intestinal juices, and partly-altered
food is hurtful. Decomposition sets in and gas is developed, which by
distending the bowel causes great suffering and increases the
inflammation. The movements of the intestine are not entirely under
control; the patient must be fed; digestion and assimilation involve
the activity of inflamed parts. The stomach can be made to do most of
the work, but the sympathy of action is so close between the stomach
and intestines that one cannot function without the other being excited
into activity.
The first rule of treatment is to put the patient to bed and to keep
him in a horizontal position. Even in mild cases time will be saved by
resorting to absolute rest at once. If the attack is at all severe, the
bed-pan should be used; the effort to rise and the straining at stool
exaggerate peristaltic movement, increasing the frequency of the
evacuations. Additional rest can be given to the intestines by applying
a flannel binder around the trunk, compressing the abdomen; broad
strips of adhesive plaster could be used for the same purpose. In cases
where the diarrhoea, tympanites, and griping pain are not relieved by
other measures this suggestion may be of service.
In order to lessen intestinal hyperæmia and allay suffering,
counter-irritants and soothing external applications are employed.
Local blood-letting, although in vogue during more than two centuries,
has fallen into disuse. Recent authors still continue to advise the
application of leeches to the anus in order to deplete the portal
circulation,[45] but it is a decided objection to this remedy that the
fluid stools irritate the leech-bites and cause much discomfort.
Sinapisms or turpentine stupes may be of some service apart from the
relief which they give to pain. Blisters might be more generally used
than they are when the tenderness on pressure is confined to the colon.
In intense inflammation they should always be tried. Hot poultices of
flaxseed meal or hot fomentations of any sort applied over the entire
abdomen have a soothing and beneficial effect. A flannel compress
saturated with alcohol and covered with gutta-percha cloth makes a most
agreeable application.
[Footnote 45: Niemeyer, _Practice of Medicine, Intestinal Catarrh_.]
The directions for diet should be carefully and explicitly given. In
the onset of the attack entire deprivation of all food for twenty-four
or forty-eight hours is expedient. To relieve thirst, cracked ice,
carbonic-acid water, Apollinaris, Seltzer, or Deep Rock water can be
ordered; barley- or rice-water is slightly nourishing and relieves
thirst, but all liquids should be given in moderation. When it becomes
necessary to give food, the stomach must be made to do the work of
digestion, and, as far as possible, of absorption also. Such substances
are to be chosen as are converted in the stomach into peptones, and
which do not require contact with the intestinal juices for their
absorption.
The peptones transformed in the stomach from nitrogenous alimentary
principles are highly soluble and diffusible. Milk is better suited to
the conditions of intestinal catarrh than any other nitrogenous food.
It is palatable, relieves the thirst, and can be taken for a long time
without {691} aversion. By removing the cream, the fat, which would
require intestinal digestion, is partly got rid of. Skimmed milk does
not produce a feeling of distaste and what is called biliousness, as
does milk unskimmed. In cases where there is gastric catarrh the milk
can be made more digestible by adding an equal quantity of barley-water
or rice-water. The casein is then more slowly acted on by the gastric
juice and more thoroughly digested. Milk should be given in small
quantities at short intervals, as in this way the stomach performs the
entire work more thoroughly. If a large quantity is given, a portion of
it passes into the intestine unaltered. Buttermilk contains less fatty
matter than skimmed milk, and is a pleasant substitute for it. Koumiss,
if it could be properly prepared, would be an excellent food for
diarrhoea. Even the imperfect imitations are retained and digested when
other aliments fail. The whey of milk contains lactin, salts, a little
casein, and fatty matter. It may be made by adding to milk rennet,
sherry or other wine, cream of tartar, tamarind-juice, or alum.
Milk-whey is slightly nourishing, and is said to be sudorific; when
prepared with wine it is a mild stimulant well suited to the cases of
children.
Where it is desired to give as little work to the digestive organs as
is possible, milk and other foods can be given already partly digested,
as peptonized milk prepared according to the formulæ of Roberts and
Fothergill.[46] Eggs are changed quickly in the stomach. Egg albumen is
more easily digested by artificial gastric juice than by pancreatic
extract (Roberts). A solution of egg albumen boiled in the water-bath
is swiftly and entirely transformed by pepsin and hydrochloric acid.
Raw eggs have been thought to be the most digestible, but Roberts found
that a solution of egg albumen when raw was very slowly acted on by
pepsin and acid, but after being cooked it was rapidly and entirely
digested. Eggs are best given, therefore, boiled slightly at a slow
heat; when an egg is plunged in boiling water the white sets hard,
leaving the yelk soft. The albumen of the white and the yelk should be
equally cooked throughout.