discussing the claims of Battey of Georgia to priority in the discovery
of the permeability of the entire alimentary canal by enema (see paper
by Battey in _Virginia Med. Monthly_, vol. v., 1878, p. 551), quotes
from A. Guaynerius, who lived in the fifteenth century, from J. M. de
Gradibus (1502), Sennertus (1626), and from others among the older
writers to show that it was well known that suppositories and enemata
introduced into the rectum are sometimes thrown up by the mouth. He
mentions experiments by Alfred Hall (1845), G. Simon (1873), and F.
Köster (1874) which demonstrated that large quantities of water may be
forced from the rectum into the stomach. (See Woodward, _op. cit._,
foot-note, p. 836.)]
When ulcers are thought to be present, the remedies of particular value
are nitrate of silver, bismuth or turpentine, and the mineral acids,
given in conjunction with a rigid system of diet.
In hemorrhagic diarrhoea ice externally or ice-water injections, opium,
acetate of lead in large doses (ten to fifteen grains), gallic or
tannic acid, and ergot are the appropriate remedies.
Some modifications of treatment are required for the choleraic form (in
children, cholera infantum); the danger here is imminent from the drain
of water and collapse. For the vomiting of the early stages, pounded
ice eaten freely, potassium or sodium bromide in ice-water, and
counter-irritants over the abdomen, with cold sponging or cold baths
and ice to the head if there is much body-heat. Brandy, whiskey, or
coffee in full doses is called for early. Iced coffee can be given to
children. Spirit of camphor in five-drop doses every ten minutes aids
in averting collapse. Small doses of calomel every hour or two may
benefit nausea and vomiting. Arsenic is said to do well for vomiting
and profuse watery diarrhoea. For adults, morphia hypodermically is
perhaps the best remedy for the vomiting and purging; even for
children, minute doses given in this way are best for alarming illness.
Hypodermic injections of ether have also been suggested.
For the relief of duodenitis means are used to relieve the digestion of
the want of the biliary and pancreatic secretions. Nitrogenous food is
to be taken, but no fats or starch. Counter-irritation over the
epigastrium and right hypochondrium by a blister or iodine is of direct
service. If icterus accompany duodenitis and catarrh of the bile-ducts,
all treatment must be directed to the duodenum. For ileo-colitis and
colitis the rules already given apply.
{699}
CHRONIC INTESTINAL CATARRH.
BY W. W. JOHNSTON, M.D.
ETIOLOGY.--Chronic intestinal catarrh has many of the same causes as
the acute form; it is the expression of a large number of different
pathological states and complicates many general and local diseases.
It is very common in children under two years of age, and is associated
with change in diet in weaning and with the irritability of all the
tissues during dentition. It is also a frequent disease in old persons,
being due to imperfect mastication, the weakness of digestion, portal
congestion, the gouty diathesis, and other causes.[1] Men have the
disease more frequently than women. Hereditary influence and
idiosyncrasy predispose to chronic catarrh of the bowel as to catarrh
of the bronchi. Bad hygiene, want of cleanliness with an unhealthy
condition of the skin, constant breathing of foul air due to want of
proper ventilation, animal decomposition, or overcrowding predisposes
to chronic diarrhoea. The chronic diarrhoeas among soldiers in
camps,[2] among the inmates of prisons, workhouses, and asylums, are
examples of these influences. Overwork, especially mental overwork with
anxiety, and privation of sleep act in the same direction. In the
chronic constitutional diseases and in many chronic diseases of organs
diarrhoea sooner or later appears, and very generally is the immediate
cause of death. In phthisis pulmonum, whether tubercular or not, simple
catarrh of the bowel is nearly always present.
[Footnote 1: _La Diarrhée chez les Viellards_, Paris, Thèsis, 1865, No.
112. See also works of Durand-Fardel and Charcot and Loomis.]
[Footnote 2: According to the statistics prepared in 1871 by T. B. Hood
of the U.S. Pension Office, chronic diarrhoea was the disease for which
a pension was granted in 20 per cent. of all cases of disability from
disease and in 75 per cent. of all the diseases of the digestive system
(_Report of Commissioner of Pensions_, 1871).]
During the course of chronic Bright's disease, more frequently in the
cirrhotic form, lesions are developed in the intestine which cause
obstinate diarrhoea. The discharge of urea into the intestine, and its
conversion into carbonate of ammonium, which acts as an irritant to the
mucous membrane, is the reason of the diarrhoea in this disease,
according to Luton and Treitz;[3] and in so far as the discharge
represents the escape of urea by the bowel, it may be regarded as
salutary. In gout, especially in old persons, periodical diarrhoea
gives relief. Chronic gouty subjects assert that they are not benefited
by colchicum until it has purged them. The {700} lithic-acid diathesis,
pyæmia, septicæmia, scurvy,[4] diabetes, leucocythæmia, Addison's
disease, and syphilis[5] have diarrhoea during some part of their
progress. The malarial cachexia is often attended with a diarrhoea
which quinia alone will relieve; this symptom may occur periodically or
be constant.
[Footnote 3: A. Luton, _Des Séries morbides, Affections urémiques de
l'Intestin_, Paris, Thèsis, 1859, No. 38, p. 45; also, Treitz, "Ueber
urämische Darmaffectionen," _Prager Vierteljahrschrift_, Bd. 64, 1859,
S. 143.]
[Footnote 4: See testimony as to the influence of scurvy in promoting
diarrhoea (Woodward, _Med. and Surg. History of the War_, Part 2,
Medical Volume, p. 638).]
[Footnote 5: A. Trousseau, "Comments on a Case of Syphilitic Diarrhoea
cured by Mercury," _Clinique méd._, Paris, 1868, t. iii. p. 123.]
Disease of the liver, heart, or lungs, by retarding the circulation in
the portal system, causes venous stasis and catarrh in the
gastro-intestinal mucous membrane. The chief conditions which bring
this about are tumors compressing the mesenteric veins, cirrhosis of
the liver, tumors pressing on the ascending vena cava, valvular disease
of the right and left heart, fatty degeneration or dilatation of the
heart, cardiac debility from chronic exhausting diseases, fibroid
phthisis, chronic pneumonic phthisis, chronic pleurisy, and pulmonary
emphysema.
An unsuitable diet may not set up an acute catarrh, but may slowly
induce changes of a chronic nature in the mucous membrane. This is the
case in infants fed upon artificial food instead of breast-milk, or
when the digestion is overtaxed after weaning. In adults food difficult
of digestion and over-eating bring about the same result. Alcohol,
spices, and condiments, if taken in excess, and the habitual use of
purgatives, lead to chronic inflammation of the intestine.
Foreign bodies, such as fecal concretions, gall-stones, stones of
fruit, bones, coins, and pins, by remaining in contact with the mucous
membrane for a length of time, determine inflammation and
ulceration.[6]
[Footnote 6: Lothrop, "Case of a Child in whom seventeen plum-stones,
three cherry-stones, and seven small bones were impacted In the cæcum
and ileum for a year. Inflammation, ulceration, and perforation of the
bowel resulted" (_Buffalo Med. and Surg. Journ._, March, 1882, p.
346).]
Neglect in the treatment of acute catarrh, the prolongation of an acute
attack, from its intensity and the incurability of the lesions,
establish chronic disease.
All chronic lesions of the bowel are complicated with chronic catarrh,
as chronic tubercular ulcer, neoplasms in the wall, pressure of a tumor
from without, etc.
PATHOLOGICAL ANATOMY.--The alterations in the intestines in chronic
catarrh involve the walls to a much greater extent than in the acute
form.
The intestinal tube is dilated, contracted, or irregularly dilated and
contracted. When the calibre is increased the walls are thinned.
Hypertrophy and hardening of the tunics, chiefly of the muscular and
submucous tissue, are accompanied by a narrowing of the canal, and this
change, most common in the rectum and sigmoid flexure, sometimes
involves a very considerable extent of the colon. Lebert records the
case of a woman who had diarrhoea for six weeks; constipation and
vomiting with abdominal tenderness ensued. There was hypertrophy of all
the coats of the stomach and of the ascending colon and rectum. The
rectum was so narrowed by the thickening of its wall that a female
catheter could not be passed through it.[7] In chronic catarrh the
mucous membrane {701} of the colon and of the lower part of the ileum
is the seat of the most characteristic lesions. The colon was alone the
seat of disease in 9 out of 99 cases analyzed by Woodward; in the
remaining 90 the two were involved together. In these the lesions in
the colon (especially in the rectum and sigmoid flexure) were always
more advanced and more serious than in the small intestine.
[Footnote 7: Lebert, _Path. Anat._, t. ii. pp. 247, 248; another case,
Laboulbène, _Anat. path._, Paris, 1879, p. 194.]
Gastric catarrh may by extension become duodenal catarrh, and from the
duodenum the disease may extend into the common bile-duct and its
branches. The duodenitis and catarrh of the ducts may persist, and
become chronic after the stomach lesion is gone.
The mucous lining of the intestine is changed in color, form,
thickness, consistence, and in the appearance of its glandular
structures. The shades of color in chronic inflammation are dark red,
livid, brown, drab, or slate-color, light blue, and greenish. The
coloration is not uniform. Dark-red and gray spots are seen on a pale
and uniform red ground; grayish streaks and patches are mingled with
red or whitish areas, giving rise to a mottled or marbled
appearance.[8] In some cases red predominates, in others the
slate-color.[9] Dark-brown, almost black, patches are also seen. These
different tints depend upon the intensity and character of the
inflammation and the stage which it has reached. Diffused bright-red
discolorations belong to acute inflammation, and are rarely seen in the
chronic form. Acute hyperæmic patches appearing in the midst of a
slate-colored membrane indicate intercurrent acute attacks. Dark-red
streaks or spots are caused by extravasations. Brown and slate-colored
areas represent the changes in old extravasations or pigment-deposits
where inflammation or ulceration has existed. Where the inflammation is
progressing toward the destruction of tissue the membrane is
dark-purplish or black in color, mottled with patches of dull reddish
hue and minute spots of bright red. Black dots are seen in the small
and large intestine isolated or in close proximity. They are due to
minute specks of black pigment deposited in the apices of the villi, in
the centres of solitary glands, in rings around them, or in the glands
of a Peyer's patch. The juxtaposition of pinhead black points gives
rise to the shaven-beard appearance[10] of the mucous membrane. Dark
streaks or wavy lines of pigment are also seen.[11]
[Footnote 8: For illustration of color of mucous membrane in chronic
inflammation see the following illustrations in color: _Med. and Surg.
Hist. of the War_, Part 2, Medical Volume--plates facing pp. 308, 518,
and 520; also, _Illustrations of Morbid Anatomy_, J. Hope, London,
1834, figs. 128, 129.]
[Footnote 9: For an excellent illustration of slate-color of chronic
inflammation, with supervening acute inflammation and hemorrhagic
patches, see Carswell, _Path. Anat._, Plate ii. fig. 4; also, Lebert,
_Path. Anat._, t. ii. Pl. cxiv. fig. 7.]
[Footnote 10: For an excellent illustration of this change see _Med.
and Surg. Hist. of the War_, volume cited, plates facing pp. 298, 304;
also, _Atlas d'Anatomie path._, Lancereaux, Paris, 1871, Pl. iii. figs.
3 and 4.]
[Footnote 11: See colored plates _Med. and Surg. History of the War_,
volume cited, facing p. 308.]
In the ileum the mucous folds are obliterated or swollen and thickened.
Obliteration of the folds occurs in connection with a dilated
intestine; when the intestine is contracted they are elevated,
tortuous, and close together. The villi are hypertrophied, looking
often like minute polypi. The mucous coat is usually thickened,
measuring from one-fifth to one-fourth of an inch. It is softened, and
more easily scraped off,[12] but quite {702} frequently there is
induration instead of softening. The solitary glands of the ileum are
hypertrophied and appear scattered over the mucous surface as small
rounded elevations. They are quite numerous or a few only may be seen.
A ring of vascular injection usually surrounds each enlarged follicle.
Peyer's patches may be unchanged or from swelling of the follicles are
more prominent than is normal, but relatively the enlargement of the
solitary glands is greater. In chronic catarrh the follicles acquire
greater size than in the acute form. The apices of the solitary glands
in the small intestine may be broken down, leaving small follicular
ulcers, with swollen rings around them formed of the undestroyed and
hypertrophied gland-structure. Here and there one or two of the
follicles in the Peyer's patch may have its centre indented by
ulceration. These changes are usually in the lower part of the ileum
near the cæcum.
[Footnote 12: The mucous membrane is often tumefied and softened in
cases where there are thickening and contraction of the intestine with
great reduction of its calibre (Elliot Coues, _Med. and Surg. Rep._,
Philada., 1863, vol. x. p. 207).]
In the colon the enlarged solitary glands are in greater number, and
are dotted about more closely in the descending colon and sigmoid
flexure.[13] When there is ulceration the large intestine has many more
ulcers than the ileum, and they are more numerous in the lower part of
the colon. They appear as sharply-punched openings, and give to the
mucous surface a honeycombed look; their diameter varies from one-tenth
to one-fourth of an inch. Large ulcers formed by the confluence of
smaller ones measure from one-fourth to one inch in diameter; they may
be so deep as to have the muscular tunic for their base, and quite
often the bottom of the ulcers is black. A ragged or uneven appearance
is given to the surface by the ulcers being close together. Such
extensive destruction sometimes takes place that no normal mucous
membrane seems to be left. Perforating ulcers are occasionally seen in
the large intestine or ileum. Perforation occurred in two of Woodward's
ninety-nine cases. Healing ulcers[14] are found by the side of others
which are growing. Healed follicular ulcers are known by a puckered,
stellated appearance[15] of the mucous membrane, which is pigmented and
of a slate-gray or marbled-brown color[16] if the process has been long
completed. Larger dense cicatrices, pigmented also, mark the site of
more extensive ulcerations.
[Footnote 13: Illustration, _Kupfertafeln zu_ DR. LESSER _über die
Entzündung und Verschwärung du Schleimhaut des Verdauungskanales_,
Berlin, 1830, Bei Enslin, Tab. ii. fig. 4.]
[Footnote 14: Illustration, J. Hope, _Illustrations of Morbid Anatomy_,
figs. 168, 169.]
[Footnote 15: Illustration, _Med. and Surg. Hist. of the War_, _tom.
cit._, p. 528.]
[Footnote 16: Illustration, Cruveilhier, _Anat. path._, xxx. livraison,
Pl. iii.; also, J. Hope, _Illustrations of Morbid Anatomy_, figs. 128,
129.]
Besides follicular ulcers the mucous membrane is disorganized by ulcers
which have their origin in a loss of epithelium and superficial
erosion. These deepen and may attain considerable size.
In addition to the lesions already described, the inflamed and
ulcerated surface is sometimes covered with a pseudo-membranous layer
of greenish-yellow color.
Chronic catarrh of the duodenum is the cause of dilatation of the
vessels and thickening of the coats. A varicose condition of the veins
may give rise to hemorrhage without ulceration.[17] The orifice of the
common bile-duct and the ducts for some distance are narrowed by
swelling of their lining membrane.[18] Ulcer of the upper part of the
duodenum {703} is found rarely in connection with external burns and
chronic Bright's disease. It is more common in men between thirty and
forty years of age. An embolized artery is the starting-point of the
lesion. The mucous layer, deprived of its nutrition in a limited area,
dies or is destroyed by the acid gastric juice; a round ulcer with
terraced edges is left, its base being the muscular or serous coat.
Adhesions may form between the peritoneum near the ulcer and the liver,
gall-bladder, or pancreas, or an opening may take place posteriorly in
the right seventh intercostal space or into the peritoneal cavity.
Cicatrization of the ulcer may lead to narrowing of the canal of the
bowel or of the pancreatic and common bile-ducts.[19]
[Footnote 17: G. Coulon, _Bull. de la Soc. Anat. de Paris_, 1879, p.
690.]
[Footnote 18: Duodenitis was made much of by Broussais and his
followers, and a great deal has been written about it. (See Boudin,
Paris, Thèsis, 1837, No. 76, _Essai sur la Duodenite chronique_.)]
[Footnote 19: _Ziemssen's Cyclopædia_, Amer. ed., vol. vii. p. 404.]
Suppuration in the wall of the duodenum is still rarer. One case only
is on record of pus being found in the intestinal wall.[20]
[Footnote 20: Picard, _Bull. de la Soc. Anat. Paris_, t. xv., 1840-41,
p. 393. See also microscopic view of suppuration in wall of duodenum,
Thierfelder, _Atlas d. path. Histologie_, 2 lief., Tab. x. fig. 6.]
Chronic proctitis or inflammation of the rectum may exist by itself.
The mucous membrane is swollen, hyperæmic, and the walls may be
indurated and thickened so as to reduce the calibre of the tube.
Superficial erosions or deep ulcers and perforation are due to the
retention of hard fecal matter in the distended pouches of the rectum.
Inflammation in the tissue around the rectum (periproctitis) is excited
by inflammation of the wall without perforation; abscesses form and
burst externally or into the bowel, thus establishing fistulæ.
PATHOLOGICAL HISTOLOGY.--The essential primary feature of chronic
catarrh is the increase and persistence of cell-accumulation in the
reticular connective tissue of the mucous and submucous layer. After an
acute or subacute attack some time elapses before the large number of
cell-elements are disintegrated or absorbed. By remaining they offer a
constant invitation to causes of irritation, hence the necessity for
prolonged care in diet after acute attacks. Fresh causes--imprudence in
eating, etc.--induce additions to the number of cells, and the tissue
becomes overcharged with active elements of growth. Hypertrophy of
tissues results, the mucous and submucous tissues thicken, and the
glandular structures are stimulated to a condition of morbid activity.
The glands of Lieberkühn elongate, the number of acini increases, and
the contained cells multiply. Accidental closure of the gland-openings
from outside pressure or over-accumulation of the contents leads to
cyst-formations. The lymph-cells in the reticular tissue of the closed
follicles undergo rapid increase; the follicle is over-distended,
projects above the surface, bursts, and a small ulcerating cavity is
left. This is now enlarged by the breaking down of the remaining tissue
of the follicle, then of the submucosa. The overhanging roof of mucous
membrane, deprived of its nutrition, sloughs off at the edges and the
exposed ulcerated surface is increased. By the confluence of two or
more burrowing ulcers more extensive destruction of the mucous and
submucous layers is brought about. The large deepened ulcers have the
mucous layer for their base. Cicatrization of the ulcers takes place by
the formation of cicatricial tissue at their base; the excavation is
filled up partially, by contraction the edges are brought together, and
the tissue solidifies. No villi or epithelium covers these cicatrices.
{704} There are rarer pathological changes. In catarrh of long duration
cysts are found, especially in the large intestine. They are about the
size of a small pea, projecting above the mucous surface. They have a
yellow or amber color, and contain a jelly-like yellow fluid which can
be pressed out. They originate in the distension of the dilating glands
of Lieberkühn; according to Woodward, they find a favorable nidus for
their growth in the softening tissue of the solitary glands; hence the
cystic forms are seen occupying the interior of follicles undergoing
disintegration.[21] The presence of the glands of Lieberkühn in the
interior of the closed follicles has been observed by other
pathologists, some of whom are unable to explain so remarkable a
lesion.[22] Around the edges or in the midst of healing ulcers in the
intestine granulation-like excrescences or polypoid growths are
observed as a rare lesion. These seem to be projections from
undestroyed islands of mucous membrane, being surrounded by the
ulcerated surface. The minute polypi originate in a process of growth
of the undestroyed mucous tissue. Cicatricial contractions around their
bases give them peculiar forms; they are club-shaped, simple, or
branched. This lesion has been described by Johann Wagner,[23] Carl
Rokitansky,[24] and J. J. Woodward[25] from original specimens.
According to Woodward, the growths (pseudo-polypi he calls them) are
composed of a central portion of connective tissue continuous with the
submucous connective tissue of the intestine and a peripheral portion
of diseased mucous membrane. The central connective tissue was filled
with large and numerous cells, and the glands of Lieberkühn in the
mucous covering were elongated and branched and showed evidences of an
active hyperplasia.
[Footnote 21: J. J. Woodward, _op. cit._, pp. 570, 571.]
[Footnote 22: A. Laboulbène, _Anat. path._, Paris, 1879, p. 186.]
[Footnote 23: "Einige Formen von Darmgeschwüren; iii., die
Dysenterische Darmverschwärung," _Med. Jahrb. des k. k. öst. Staates_,
Bd. xi., 1832, S. 274.]
[Footnote 24: "Der dysenterische Prozess auf dem Dickdarme und der ihm
gleiche am Uterus, vom anatomischen Gesichtspuncte, beleuchtet,"
_ibid._, Bd. xxix., 1839, S. 88.]
[Footnote 25: "Pseudo-polypi of the Colon," _Am. Journ. Med. Sci._,
Jan., 1881, p. 142.]
Polypi of the colon have been seen and figured by other pathologists,
but they were not connected with ulceration and cicatrization of
ulcers. Luschka[26] saw the mucous membrane from the ileo-cæcal valve
to the end of the rectum covered with polypi, club-shaped, the size of
a hempseed or bean, and made up of glandular tubes simple or branched.
Other cases have been described by Lebert, Heuriet, and others,[27] in
which polypi were distributed in the rectum, colon, cæcum, or about the
ileo-cæcal valve. This is the condition described by Virchow as colitis
polyposa.
[Footnote 26: _Virchow's Archiv_, vol. xx. p. 133.]
[Footnote 27: Heuriet, _Bull. de la Soc. Anat. Paris_, t. xlviii.,
1873, p. 250; _Tr. N.Y. Path. Soc._, vol. ii., 1877, p. 172. For
illustration of multiple polypi of colon and rectum, Lebert, _Path.
Anat._, tome ii., Pl. cxxii. figs. 1 and 2; granular elevations in
ileum, _idem_, Pl. cxxi. fig. 1. Also, mucous polypi of rectum,
Thierfelder, Tab. xiii. figs. 3, 3_a_, 3_c_; also, intestinal polypi of
rectum, Lancereaux, _Atlas Path. anat._, 1871, Paris, Pl. iv. fig. 4.
Polypi are rarely seen in the small intestine; see Böttcher, "Polypöses
Myom des Ileums," _Archiv der Heilkunde_, xi. Jahrgang, 1870, p. 125.]