supervenes upon catarrh. It is confined to certain areas, the rest
being normal or in a state of chronic catarrh. It is found in 80 per
cent. of the cases examined either in the large or small intestine. The
cæcum is the most frequent seat; next in the order of frequency it is
seen in the ascending {705} colon, the lower part of the ileum, the
other parts of the colon, and is least common in the upper part of the
ileum. In children the lesion is more common in the small intestine
than in adults. The changes in the mucous membrane of the colon are a
diminution in its thickness and disappearance of the glands of
Lieberkühn. The mucous layer is reduced to one-fifth of its normal
size, and no trace of the glands may be left; a layer of connective
tissue with imbedded round cells is all that remains. The surface of
the membrane is irregular and colored with yellowish pigment. In the
ileum the villi are shrunken, with few cells; in some cases they
disappear altogether. The muscular tunic may share in the atrophy.[28]
[Footnote 28: Nothnägel, "Zur Klinik der Darmkrankheiten," iii.
Abtheilung, Darmatrophie, _Zeitschr. f. klin. Med._, Berlin, 1882, iv.
p. 422; Virchow, "Ueber den Gang der amyloiden Degenerationen,"
_Virchow's Archiv_, Bd. viii. S. 364; E. Neumann, "Neue Beobachtungen
über amyloide Degeneration," _Deutsche Klinik_, Bd. xii., 1860, S. 337,
353, and 373; Lambl, "Ueber amyloide und colloide Degeneration im
Allgemeinen und die des Darmsinsbesondere," _Beob. und Studien_ (_aus
dem Prager Kinder-Spitale_), Prag., 1860, S. 319; Frerichs, "Diseases
of the Liver," New York, 1879 (_Wood's Library_), vol. ii. p. 180; M.
G. Hayem, "Note sur la Dégénérescence amyloide du Tube digestif,"
_Compte Rend. des Séances de la Soc. de Biologie_, Nov., 1865, 4me
Série, t. ii. p. 191; also, _Gaz. méd. de Paris_, t. xxi. p. 99.]
Lardaceous (amyloid or waxy) degeneration of the intestinal mucous
membrane is met with in chronic catarrh. The small arteries of the
villi and submucous layer, the muscular and other tissues, are
infiltrated with a new material allied to fibrin. The membrane to the
eye is paler than normal. When iodine is applied, a characteristic red
staining of the infiltrated parts is noticed. This lesion is a cause of
diarrhoea and of hemorrhage,[29] from the greater permeability and
greater fragility of the arteries. It is also associated with
follicular ulceration, and is probably a cause of disintegration of the
mucous membrane.[30]
[Footnote 29: T. Grainger Stewart, "On Hemorrhage from Waxy or Amyloid
Degeneration," _Br. and Foreign Med.-Chir. Rev._, vol. xli. p. 201.]
[Footnote 30: Frerichs, "Diseases of the Liver," New York, 1859
(_Wood's Library_), vol. ii. p. 180; also, E. Aufrecht, _Berl. klin.
Woch._, 1869, p. 315.]
The abdominal organs present other lesions in chronic intestinal
catarrh, few of which have any distinctive character. The peritoneum
shows signs of old or recent inflammation. The former is subacute or
chronic, and is recognized by the adhesions of opposed surfaces in a
limited area, frequently corresponding to the seat of intense
intestinal inflammation. Fatal perforations are delayed or prevented by
these adhesions. General peritonitis with soft lymph or sero-purulent
effusion is found with perforation. The mesenteric glands may be
enlarged. The liver is larger or sometimes smaller than normal, and its
tissue is softened and may be fatty. Abscess of the liver[31] is a very
rare result of chronic intestinal catarrh, with ulceration. The
gall-bladder is usually filled with bile. The spleen is small and firm
in texture; less commonly it is soft and friable. The pancreas is
healthy. The kidneys are large and pale; the cortical substance is
relatively increased and the tubules contain granular epithelium.
[Footnote 31: It occurred in 4 per cent. of Woodward's cases of chronic
follicular ulceration. See case reported by the writer in which the
ulcers healed before the death of the patient from hepatic abscess
(_Maryland Med. Journ._, March 15, 1883, p. 562).]
In the thorax the heart is flabby, pale, and small; clots are found in
the right and left side extending into the pulmonary artery and aorta.
Sudden death has been attributed to cardiac thrombosis. That coagula
{706} do form in the heart during life is shown by the sudden
occurrence of cerebral embolism with aphasia.[32]
[Footnote 32: The writer has seen one case of this kind occurring
during the effort at stool in a patient who was very feeble and very
anæmic from chronic intestinal inflammation with ulceration.]
Pneumonia is the most frequent pulmonary lesion; it may be single or
double. It was found in 18 of the 99 cases of Woodward, and in 21 out
of H. A. Allen's 41 cases. Inflammation of the pleura is not
infrequent. The brain and its membranes may be congested, and fluid is
found in the subarachnoid space, in some instances in cases which have
had a sudden termination. The cornea is ulcerated, and the eye
destroyed by opening of the anterior chamber in a small proportion of
cases. The sloughing process begins in the lower part of the cornea and
in the sclerotic.
SYMPTOMS.--When chronic intestinal catarrh succeeds the acute form, the
transition is marked by the disappearance of fever and an amelioration
of all the symptoms, with apparent recovery. The patient begins to go
about, but diarrhoea returns whenever there is any unusual fatigue or
excess in eating. In some cases there is no improvement in the
diarrhoea, but in the general symptoms only. When the malady is chronic
from the beginning, the onset is characterized by symptoms of
indigestion and occasional diarrhoea, which become more and more
pronounced according to the severity of the illness.
Mild forms of catarrh have constipation, or diarrhoea alternates with a
normal or constipated state of the bowels. The form in which
constipation is continuous is associated with mechanical stasis from
liver and heart lesions and with the gouty and uric-acid diathesis. The
mucous membrane is in a state of passive hyperæmia, an excess of mucus
being the product of the inflammatory process. Mucus coats the lining
tunic, lessens its irritability, interferes with digestion and
absorption, and acts as a ferment, exciting decomposition in the food.
The bowel is atonic and is distended with contained gas; there is great
feebleness of peristaltic contractions.
Intestinal indigestion and constipation are therefore the symptoms of
this form. The signs of indigestion occur one to three hours after
eating, according to the location of the maximum of catarrh and the
time taken by the food to reach this point. They are a sense of fulness
or distress in the abdomen from gaseous distension, slight colicky
pains, and a rumbling of gas, which may be prolonged during several
hours after a meal. The constipation is indicated by the spontaneous
passage of dry masses or scybalæ coated with layers of mucus which are
clear or cloudy, or the mucus may be intimately mixed with solid
matter. Pure mucus is also expelled without fecal matter. There may be
no stool without a purgative, and then softened matter with scybalæ and
mucus is passed. Altered mucus in the form of membraniform shreds or
cylinders occasionally pass in the so-called membranous enteritis.
The abdomen is full and not sensitive to pressure. The tongue is coated
and usually pale and flabby. In appearance the patient exhibits a
general want of tone; the skin is white or muddy, the muscles are soft,
and the expression indicates the depression of spirits, the lassitude,
and the inertia which he feels. Hemorrhoids are very likely to {707}
exist. Such a condition may last for months or years without much
change. Under proper treatment recovery may take place, but if entirely
neglected or improperly treated the disease inevitably becomes worse.
In a second mild form there is no permanent disease, only an
impressionability of the mucous membrane of the bowel to causes which
induce hyperæmia and excessive secretion ending in diarrhoea. Exposure
to cold, fatigue, or slight indiscretions in diet may bring it on; even
an emotional cause may do it. The attacks last one or several days, and
may at times assume some gravity. This predisposition to diarrhoea
lasting through a lifetime is analogous to the tendency to inflammation
of the nasal and other mucous membranes.
In severer and typical forms the symptoms point to permanent lesions.
The tongue is smooth, shining, or glazed, sometimes with a central
brown streak, but it may be also pale and covered with a white coat.
The appetite is diminished or lost, or it is capricious, craving
unsuitable food. If there is no gastric catarrh, the chief distress
does not come until some hours after eating, but the taking of food
sometimes excites pain and brings on an evacuation of the bowels
through reflex influence.
There may be slight tympanites or a retracted abdomen. The imperfect
digestion of food and the fermentation of the intestinal contents
develop gas which keeps the abdomen distended and causes slight pains
and borborygmi. Pain may, however, be entirely absent. A feeling of
abdominal soreness is not unusual; it is increased by coughing,
sneezing, or any sudden movement. Sensibility to pressure is usually
wanting; when it exists it is found along the line of the colon in most
cases.
The diarrhoea is the characteristic symptom. The number of the stools
varies from one to eight in twenty-four hours; four is about the
average number. They occur usually in the early morning hours, from two
to six o'clock, but food may at any time bring on peristaltic
contraction, so that a motion after every meal is not uncommon. In
quantity there is much variability; two to four ounces of fluid matter
is the rule perhaps, but a very much larger amount than this is often
passed with each evacuation. As a rule, the larger the quantity of
fluid the more extensive is the catarrh and the more advanced are the
lesions. The matters passed are composed chiefly of fecal matter
varying in consistence from a solid or semi-solid mass to a watery
fluid. In the soft stool, like thickened gruel, the consistence is due
to the presence of mucus; in the thinner evacuation water is the chief
element. Liquid stools are sometimes frothy. In color the dejecta are
brown, yellow, red, green, slate-color, or white. They may be colored
dark by medicines, as iron or bismuth, or by blood. The presence of
blood gives a pinkish, bright-red, dark-brown, or black color,
depending upon the amount of blood and the changes it has undergone in
the bowel from a longer or shorter retention. Blood, when it comes from
the rectum, is in bright-red streaks or small coagula. When its source
is higher up, it is much altered, being dark and granular.
Coffee-ground sediment in a fluid stool is blood from the upper part of
the intestine or stomach. The spreading of an ulcer may open a vessel
of some size, and a fatal hemorrhage follow. A yellow tint like that of
a child's movement may arise from a mixture of pus and fecal matter.
Pus, as a milky or creamy fluid which may be {708} streaked with blood,
is a frequent appearance in disease of the rectum and sigmoid flexure.
The odor of the stools is fecal, sour, or sickening from fermentation
or offensive from decomposition. In bad forms of chronic diarrhoea in
children the black watery stools have a most offensive odor.
Mucus is the most constant ingredient of the diarrhoeal stool, and is
in itself a sufficient evidence of catarrh, as it is not seen in normal
stools except as a temporary phenomenon. It is present in flakes in
watery evacuations, giving a jelly-like character to the fluid if it is
in excess, or it is mixed with semi-solid feces. Pure mucus may be
passed, if the catarrh is low down, in clear, glairy, or opaque masses.
The frog's-egg or boiled-sago particles supposed by Niemeyer and others
to point to follicular ulceration, and by Traube to be the swallowed
bronchial secretion, are said by Virchow to be partly-digested starch,
and also by Nothnägel to be of vegetable nature.[33] The stools may
contain small yellow or brownish masses which are mucoid in nature,
being yellow from bile-staining. Pavement epithelial cells are found in
the coating of mucus around a hard fecal lump. Cylindrical epithelium
is passed uncolored or stained with bile. These cells are separated,
and are deformed and shrunken, with a granular protoplasm and
indistinct nucleus. Goblet-cells are also seen. Round cells in the form
of mucus-corpuscles or giant-cells are mixed with shreds of mucus or
float in the thin stools. Crystals of triple phosphate, of neutral
phosphate, oxalate of lime, and other lime salts, and of cholesterin,
are also seen.
[Footnote 33: _Virchow's Archiv_, v. S. 329; Nothnägel, "Zur Klinik der
Darmkrankheiten," _Zeitschrift für klin. Med._, iii., 1881, p. 241.]
Micrococci and bacteria have no pathological importance; they are seen
in different diseases and in health.
Unaltered food may be expelled (lientery) by rapid peristaltic
movements. But the microscope will detect what cannot be seen by the
eye--unaltered starch-granules, filaments of meat-fibre, or fat in
drops or in needle-shaped or feathery crystals.
The nervous system is disturbed after a certain time. There is languor,
with depression of spirits, mental weariness, and inaptitude for work
of any kind. The patient is querulous, morose; his sleep is restless,
but sometimes profound until disturbed by the demand to empty the
bowel. Melancholia is attributed to this as to other diseases of the
abdomen, but their influence in producing insanity is doubtful.[34]
[Footnote 34: Griesinger, _Mental Path. and Therap._, Am. ed., New
York, 1882, pp. 137, 138.]
No decided symptoms are exhibited in the respiratory and circulatory
systems. Even slight exertion will cause shortness of breath and
increased frequency or palpitation of the heart. This irritability of
the heart is a marked feature of the disease.[35]
[Footnote 35: DaCosta found that of 200 cases of irritable heart, 61
were in patients who had suffered from or still had diarrhoea (_Am.
Journ. Med. Sci._, vol. lxi., 1871, p. 37).]
The appearance of the urine is normal; it may be abundant, with
phosphatic deposit, or it is scanty and high-colored. In bad cases
albumen and casts have been found.[36]
[Footnote 36: Alonzo Clark, "Proc. of New York Path. Soc.," _Med. and
Surg. Reports_, vol. ix., 1862-63, p. 312.]
The symptom indicative of atrophy of the mucous membrane is believed by
Nothnägel to be the persistent passage of one soft, unformed stool
daily. Mucus and fat, which diminish the consistence of the stool, are
{709} excluded by microscopical examination. One stool daily shows that
there is no exaggerated peristalsis which hurries the food along so
rapidly that water cannot be absorbed.[37]
[Footnote 37: Nothnägel, "Zur Klinik der Darmkrankheiten," _Zeitschrift
für klin. Med._, iv., 1882, p. 422.]
PROGRESS AND TERMINATION.--As the disease advances it is marked by
progressive emaciation and debility. The skin gradually acquires great
pallor, indicating profound anæmia. The loss of flesh is very rapid. An
exacerbation of the disease will in a few days cause the cheeks to grow
hollow, the eyes to appear sunken with dark rings around them. In all
cases of long duration the progress is intermittent; frequent relapses
occur from which the patient may rally and regain a moderate degree of
flesh. Recovery may take place in weeks or months--eighteen months is
the average duration[38]--but in most instances a tendency to a
recurrence of the diarrhoea from cold, fatigue, or indiscretions in
diet will continue throughout life. An incomplete recovery may take
place by the cessation of the diarrhoea and formation of a stricture
from the healing of an intestinal ulcer. In the worst cases there is no
rule as to the rapidity or regularity of the march of the disease.
[Footnote 38: C. H. Ralfe, Seamen's Hospital, London: see Aitken's
_Handbook of Treatment_, New York, 1882, p. 116.]
When the advance is toward a fatal issue the emaciation progresses
until it becomes extreme; nothing but skin and bone are left. The
cuticle is hard and dry, pale or brownish in color. The muscular
strength is so reduced that the patient is unable to move from bed. The
voice may sink to a whisper. The nervous depression and moroseness
assumes a more marked character. Among the soldiers during the Civil
War who had undergone great privations with insufficient or improper
diet the mental phenomena were those of dementia.[39] In them the
disease was modified also by the symptoms of scurvy and malarial
poisoning.
[Footnote 39: W. Kempler, "Entero-Colitis," _Am. Journ. of Med. Sci._,
vol. lii., 1866, p. 337.]
Fever is seen in the late stages; it is nocturnal at first, and later
assumes the features of hectic. The pulse grows more frequent and
thready; aphthous deposits appear on the inside of the mouth and
pharynx. Toward the end the discharges may become more frequent and
very abundant; they are more fluid, lighter colored or black, with
floating particles of blood and mucus. There may be a loss of odor or
they may have a cadaveric smell.
Death takes place in a few weeks or after years of alternate suffering
and relief. The immediate causes of death are exhaustion, marasmus from
starvation, collapse from perforation of an intestinal ulcer and
consecutive peritonitis, syncope from sudden exertion, pneumonia, or
acute pulmonary congestion, pleurisy, or subarachnoid effusion in the
brain, with coma and convulsions.
COMPLICATIONS.--General dropsy results from the hydræmia and languid
circulation of the late period of the disease. Other causes of this
symptom are coincident diseases of the liver, kidney, or the malarial
cachexia. Oedema of one extremity follows a thrombus in the crural
vein. Chronic bronchitis and pulmonary phthisis are sometimes met with.
Acute pneumonia[40] and acute pulmonary congestion are occasional {710}
causes of death. Peritonitis may occur with and without perforation.
The latter variety begins as a local inflammation of subacute or
chronic nature, and spreads slowly until it becomes general. Extensive
adhesions and abundant accumulations of serous, sero-purulent, or
purulent fluid in the abdominal cavity result.
[Footnote 40: Pneumonia (8 double and 12 single) occurred in 20 out of
41 fatal cases reported by Harrison Allen, _Tr. Path. Soc. Philada._,
1867, vol. ii. p. 161.]
The causal conditions which have been enumerated may be considered as
complications. They are tuberculosis, Bright's disease, cirrhosis of
the liver, abdominal tumors, scurvy, tubercular and other neoplasms in
the wall of the intestine; attacks of intercurrent, intermittent, or
remittent fever arise from the malarial influence to which the
intestinal catarrh is due. These fevers and rheumatism and
pseudo-rheumatism are complications in soldiers from the exposure to
malarial influences and to cold and dampness.[41]
[Footnote 41: Woodward, _op. cit._, p. 495.]
Ulceration of the cornea, escape of the aqueous humor, and collapse of
the eye were observed in quite a number of cases occurring among
soldiers.[42]
[Footnote 42: Elliot Coues, _Med. and Surg. Reporter_, Philada., 1863,
vol. x. p. 207, and H. Allen, _Tr. Path. Soc. Philada._, 1867, vol. ii.
p. 161.]
SEQUELÆ.--The alteration of structure from long-standing inflammation
leaves the mucous membrane prone to recurrence of inflammation. Chronic
intestinal indigestion and permanent malnutrition come from the same
cause. The glandular and lymphatic structures of the intestine and the
mesenteric glands are so changed by disease that they imperfectly
perform their function. Tabes mesenterica is the ultimate phase of this
change. Constipation succeeds chronic diarrhoea, and is due to atony of
the muscular wall from long-continued distension, and probably from
degeneration of the muscular structure. A more serious cause of
constipation, and sometimes of intestinal obstruction, is found in
stenosis of the bowel from the healing of the ulcers of long-standing
chronic catarrh. Stricture is more common in the colon, sigmoid
flexure, and rectum. How frequently such a result follows the
cicatrization of intestinal ulcers is not definitely known. Woodward
concludes from a careful search of books and pathological museums that
stenosis from this cause is very rare.[43] Syphilis is the most common
cause of ulcer. Local or general peritonitis leads to the formation of
adhesions or fibrous bands uniting neighboring links of intestine. By
the contracting of these narrowing of the intestinal canal may result.
Paralysis, hemiplegia, paraplegia, etc. have been found to follow upon
diarrhoea of long standing.[44]
[Footnote 43: Woodward, _op. cit._, p. 504.]
[Footnote 44: Potain, "Parésie des Membres inférieurs ayant succedé à
un Catarrhe gastro-intestinal," _Rev. de thérap. Med.-Chir._, Paris,
1880, xlvii. p. 562; "Paralysis spinale sécondaire à une Diarrhée
chronique," _Journ. des Conn. méd. Prat._, Paris, 1880, 3, S. ii. p.
57.]
DIAGNOSIS.--The mild form of chronic catarrh of the intestines
associated with constipation has been confounded with hepatic
disorders, and the obscure symptoms attending it have been attributed
to excess or diminution of bile, and medicines to regulate the liver
have been given accordingly. In the absence of lesions in the liver, in
cases where symptoms such as have been described have preceded death,
the opinion is not justified that disease of this organ has existed. On
the contrary, alteration in the mucous membrane is almost always found,
which points to the true nature of the disease. The diagnosis is based
upon the accompanying {711} gastric catarrh and upon the symptoms of
intestinal indigestion and malnutrition. Greater sensibility to
pressure over the right hypochondrium and along the line of the colon,
pain one to two hours after eating, with distension of the abdomen, the
passage of well-formed and somewhat indurated feces mixed or coated
with mucus, are symptoms peculiar to these mild forms.
The tendency to diarrhoea from cold, indigestible food, etc. which
marks the second form of mild catarrh is easily recognized.
The characteristic symptom of the severe form is the persistent
diarrhoea. Paroxysmal pains, tympanites and rumbling of gas, tenderness
on pressure over the colon, the alternate periods of improvement and
relapse, with the constitutional signs of impaired nutrition and
progressive anæmia and debility, point out the nature and the seat of
the lesion with sufficient clearness. It is futile to attempt to
distinguish chronic intestinal diarrhoea from chronic dysentery. The
lesions of the two conditions are essentially the same; it depends upon
the fancy as to which name is given to the lesions described here under
the title chronic intestinal catarrh. A greater amount of blood and
mucus in the stool with tenesmus would more properly be called
dysenteric, but the same case may present at one time diarrhoeal, at
another dysenteric, symptoms.
Primary must be distinguished from secondary diarrhoea. Therefore the
liver, heart, and lungs must be examined to discover diseases which
might cause portal congestion. Any constitutional malady may be a cause
and an explanation: tuberculosis or pulmonary phthisis stands first in
its influence; next, chronic Bright's disease, septicæmia, scurvy,
syphilis, and gout are attended by intercurrent diarrhoea. If all
general disease can be excluded and the morbid process be located in
the intestine alone, its cause may be known by studying the habits,
occupation, and diet of the patient. Foreign bodies--hardened feces,
gall-stones, fruit-stones, etc.--are possible causes which the history
of the case may point to.
Having located the disease in the intestine and decided upon its
primary or secondary nature, it remains to determine more precisely
(_a_) the locality of the lesion, and (_b_) the stage of the
inflammatory process.