soft, and granular, of a more or less yellow color, slightly adherent
to the mucous membrane, and when stripped off forming a yellow
pultaceous mass. He says it is first deposited in small, irregular,
sparsely-scattered patches, located on the summits of the intestinal
folds; afterward these patches increase, and cover the folds entirely
and almost the whole calibre of the intestinal canal. The mucous
membrane, he remarks, beneath the deposit is greatly inflamed.
[Footnote 28: _Op. cit._, p. 105.]
Powell believes that at times the deposit extends as high as the
duodenum, his opinion being solely based upon the clinical features of
the disease. In the first of his cases the membrane was found in
perfect tubes, some of them full half a yard in length, and certainly
sufficient in quantity, he says, to have lined the whole intestinal
canal.
In examining the membranes it is always best to float them from the
fecal or other foreign material by passing the discharges in a clean
vessel containing water. Their physical characters can then be readily
studied. They are best preserved in a 10 per cent. solution of alcohol.
The exudate consists usually of a single lamina, but at various points
in certain cases several superposed laminæ may be observed, enclosing
between them particles of undigested food of various kinds. In most
cases the superficial layers are more opaque, drier, less elastic, and
friable than the deeper.
The configuration of the exudate varies greatly. The more common
variety is that occurring in loose, transparent, jelly-like masses,
like the white of an egg or glue, tinged often with various hues of
yellow. In three of my cases I noticed also the frequent occurrence of
a thin, serous, yellow discharge. In some cases the discharge resembles
pieces of macaroni, tallow, or wax; in others it assumes a shreddy or
ribbon-like form; and in a still rarer class it is tubular, being an
exact reprint of the surfaces from which detached. These tubular pieces
are, however, more or less torn and broken into smaller fragments of an
inch or two in length when discharged.
Its thickness also varies: sometimes it does not exceed that of the
thinnest film, and at others it is a quarter of an inch or more.
Its consistence ranges from that degree of loose aggregation that
permits elongation into stringy, breaking masses when fished up from
the water in which it floats, to a firmness and tenacity that will
enable it to be handled without fear of breakage.
The color differs in different cases. It is usually yellowish-white,
but this is often modified by tints dependent upon admixture with
extraneous matters from the intestinal canal--biliary coloring, blood
from the rupture of the vessels beneath the exudate, or with blood and
pus. It exhales a feculent odor.
The surfaces of the membranes are ordinarily smooth and uniform, but
sometimes reticulated. Certain observers have described the outer {771}
surface of the tubular exudate as uniformly smooth, and the inner as
broken and flaky at some points, at others ragged and flocculent, and
in many places thrown into shallow folds, lying in some situations
across, but chiefly along, the axis of the gut.
The microscopic characters of the exudate are pretty uniform. Wilks and
Clark[29] describe the surface of the tubes, examined with a linear
magnifying power of forty diameters, as exhibiting the appearance of a
gelatinous membraniform matrix traversed by a coarse network of opaque
yellow lines, studded at their points of intersection by similarly
colored rounded masses. From the larger network proceeds a smaller
secondary network, and in the recesses of this were found, at close and
regular intervals, well-defined round or oval openings, with elevated
margins, resembling in size and appearance the mouths of the follicles
of the great gut. With higher powers the exudate was found in many
cases to consist of a structureless basement membrane, which in certain
points showed a fibrous appearance, owing doubtless to the presence of
filaments of mucin. Numerous irregular granular cells, as well as
granules from the breaking up of these cells, thickly studded the
surface of the membrane. In the specimens of Wilks and Clark the
surface, besides being marked by the opaque yellow lines and dots,
presented various foreign matters, such as bile-pigment, earthy and
fatty granules, portions of husks of seed, gritty tissues of a pear, a
peculiar form of elastic tissue, stellate vegetable hairs, and a
mucedinous fungus. Clark, in describing the fibres found between the
layers of the exudates, says that they exhibited a very distinct and
regular transverse striation, approaching in character that found in
the ligamentum nuchæ of the giraffe. Quekett and Brooke have met with
the same fibres in the feces. The transverse division depends probably
upon beginning decay. The division is sometimes so distinct and
complete as to lead, according to Beale,[30] to their confounding with
confervoid growths. Farre[31] actually describes the formation as of a
confervoid character.
[Footnote 29: _Op. cit._, p. 232.]
[Footnote 30: _The Microscope in Medicine_, p. 194.]
[Footnote 31: _Trans. Microscopical Society_.]
Here and there, in my specimens, were observed scattered epithelial
cells which were occasionally gathered in patches. Small colored masses
of irregular shape, doubtless of fecal origin, were also noticed. The
cells imbedded in the matrix, according to the above-quoted observers,
consisted of two kinds--one more or less spherical, the other more or
less cylindrical. In size the spherical cells varied from 1/2000 to
1/800 of an inch in diameter. The smaller cells had no distinct
cell-walls. Some of the larger cells were filled with fat-granules, and
represented granular cells; others had a single or double vesicular
nucleus; a few were acuminated at two opposite points and somewhat
compressed. All the other cells possessed demonstrable cell-walls. The
cylindrical cells resembled in their general characters those which
normally coat the mucous membrane of the larger gut, but they were much
more elongated, compressed, and firmly matted together. Many of the
more elongated cells were constricted in the middle, and exhibited a
nucleus on each side of the constriction. The more or less spherical
cells occupied the attached, and the cylindrical cells the free,
surface of the membranous tubes.
The perforations in the matrix were of uniform size and appearance,
{772} surrounded by elevated margins formed of closely-grouped
cylindrical cells, and led to two kinds of pits--one short and
flask-shaped, the other long and uniformly cylindrical. The
flask-shaped pits were about one-tenth of an inch in diameter and
distinctly hollow. The wall of each pit was made up of one or two
layers of subspheroidal cells, held together by an amorphous stroma. A
few of these follicles contained a deposit which was opaque in situ,
and which when broken up was found to consist of large flattened
nuclear cells, analogous to those met with in epithelial growths.
The cylindrical pits were also for the most part hollow, about
one-sixteenth of a line in length and one-thirty-first of a line in
breadth. These walls, devoid of membrane, were composed of small, more
or less spherical cells in various stages of development, imbedded in a
gelatinous matrix.
In examining the chemical characters of the specimens obtained in my
cases the membranes were thoroughly washed, when they were nearly as
colorless as the water in which they floated. They were drained on a
sieve, and presented a gelatinous appearance, much like the white of an
egg. Their specific gravity was about that of distilled water. When
treated with strong alcohol, the membranes shrank and assumed a
striated appearance. Chemical tests of tincture of guaiacum, peroxide
of hydrogen, and others failed to show the presence of fibrin or
albumen. Treated with ether, globules of fatty matter were obtained,
which were identified by their microscopical characters and by their
reaction with osmic acid. By boiling the liquid in which the membranes
had been soaked it became faintly hazy, indicating a trace only of
albumen. Faint evidence of the presence of this body was also presented
by picric acid and Mehu's test. Treated with a weak solution of caustic
potassa and heat, the membrane dissolved, leaving a little haziness.
The liquid was then filtered, and exactly neutralized with acetic acid,
and plumbic acetate added, when a copious precipitate was formed.
Mercuric chloride and potassic ferrocyanide failed to produce this
effect. From these and other tests used the conclusion was reached that
these membranes were composed essentially of mucin.
Both the microscopical and chemical characters of the exudates of the
disease under consideration show that they are widely different in
nature from those of other diseases. They are evidently a production of
the muciparous glands (follicles of Lieberkühn) of the intestinal
canal, and consist essentially of mucin. Perroud[32] concluded from his
analysis that they contain a small quantity of albumen, but are
principally formed of the same substance as that which enters into the
composition of the epidermis. The exudates of other diseases of the
alimentary mucous membrane contain albumen and fibrin, as well as
molecular or homogeneous filaments. The ordinary croupous exudate,
according to Cornil and Ranvier, always contains filaments of fibrin,
sometimes mucin and pus-corpuscles mingled with the cellular
constituents, which vary in character with the locality of the
inflammation. The filaments form a reticulum in the meshes of which are
contained the other elements.
[Footnote 32: _Journal de Médecine de Lyon_, 1864.]
Diphtheritic exudates, as shown by Lehmann,[33] consist of fibrin, a
large {773} quantity of fatty matter, and 4 per cent. of earthy
phosphates, while its structure is made up of epithelial cells united
together, which, becoming infiltrated with an albuminous substance and
gradually losing their nuclei and walls, are finally converted into
homogeneous branching masses. The cells of these masses are liable to
undergo fibrinous degeneration. The inflammation determining the
exudate is not confined to the conglomerate glands, but involves all
the textural elements of the part affected, and the material of the
membrane originates from the capillary disturbance in them.
[Footnote 33: _Lehrbuch der Physiolog. Chemie_, Leipzig, 1855.]
Andrew Clark[34] states that he has observed in his studies of exuded
blastema, the product of diseased action in mucous membranes, three
varieties. The first is clear, jelly-like, and imperfectly membranous.
The second is yellowish, semi-opaque, flaky, and usually membranous.
The third is yellowish-white, dense, opaque, distinctly membranous,
tough, and rather firmly adherent to the subjacent surface. The first
contains only the merest trace of albumen, and no fibrin; the second
contains an abundance of albumen, and no fibrin; the third contains
both albumen and fibrin in abundance, the latter in a fibrillated form.
They all contain the same cell-forms. Yet it is to be noticed that in
the first variety there is no evidence of transudation or exudation; in
the second, no evidence of a true exudation; and that in the third, in
which the existence of a true inflammatory exudation is undeniable, the
only additional structural element present is fibre.
[Footnote 34: _Op. cit._, p. 133.]
DIAGNOSIS.--The diagnosis of membranous enteritis can never in its
advance, and rarely in its early stages, present much difficulty. Its
chronic course, irregular exacerbations, lack of febrile excitement,
the persistent derangement of the intestinal canal, the mental
depression, the gradual impairment of health, the various visceral
complications, and, lastly and chiefly, the peculiar character of the
alvine discharges,--stamp the disease with an individuality entirely
its own.
The mucous discharges of certain forms of chronic diarrhoea and the
membranous discharges of infective dysentery are all so different in
physical character, and are associated with such a different complex of
general symptoms, that they cannot be confounded with those of the
diseases in question. The peculiar irritative quickness of the pulse of
ordinary enteritis, according to Powell and Good, suffices to
differentiate this disease from membranous enteritis. The peculiarities
of the physical and chemical properties of these exudates, already
fully dwelt upon, not only distinguish them from those of the above
diseases, but also from such dejecta as may contain fragments of
undigested connective tissue, of hydatids, or of worms. The flakes of
mucus discharged from the bowels in protracted constipation, fissura
ani, and in the later stages of cirrhosis of the liver are composed of
mucus in which are found imbedded epithelial cells from the colon and
mucus-corpuscles. The microscope will also reveal the character of the
fatty discharges that may be associated with diseases of the pancreas,
liver, and duodenum. The mucous flakes of cholera stools are composed
of masses of intestinal epithelium mixed with amorphous and granular
matter, crystals of different substances, and, according to Davaine, of
parasitic forms, particularly the Circomonas hominis.
{774} Membranous casts from the upper part of the digestive track are,
in rare cases, passed by the bowels. One of the most curious instances
of this sort is reported by Villermé:[35] A woman swallowed a
tablespoonful of nitric acid, and seventy days afterward a long
membranous exudate, one or two lines thick and of a brown color, was
discharged, which corresponded in form with the oesophagus and stomach.
The patient died a few days later.
[Footnote 35: _Dictionnaire des Sciences médicales_, tome xxxii. p.
264.]
PROGNOSIS.--The prognosis of the disease as regards life is not
unfavorable, but as regards permanent restoration to health and
strength the case is entirely different. Theden[36] and Hoffman[37]
have, however, stated that the disease is not an unfrequent cause of
sudden death.
[Footnote 36: _Remarques et Experiences_, tome ii.]
[Footnote 37: _Med. Ration._, vol. v.]
Abercrombie[38] records a case of death from phthisis complicated with
this disease, and Wright another case in which the patient died in an
extreme state of marasmus. The acute and subacute forms are more
amenable to treatment, and the chances are correspondingly greater of
permanent recovery, though in all cases there is a strong tendency to
relapse. The chronic forms may almost be enrolled among the opprobria
medicorum when once they have made deep inroads upon nutrition and the
vital powers, and produced that condition named by Todd the pituitous
cachexia (cachexia pituitosa). These cases may, however, be alleviated
by judicious treatment, diet, and climatic changes, but repeated
relapses may be expected as the rule under slight exciting causes or
even without apparent cause. Patients under these circumstances drag
out a life of valetudinarianism, but it may be cut short at any time by
the supervention of some intercurrent disease, as phthisis, renal
degeneration, etc., or, according to Grantham, atrophy of the
intestines. Broca[39] records two cases of this disease, one of which
lasted ten and the other fifteen years. Three of my cases have endured
over six years.
[Footnote 38: _Inflamm. Affec. of Mucous Memb. of Intestines_, pp. 213,
279.]
[Footnote 39: _Bullétin de la Société Anat. de Paris_, 1854.]
TREATMENT.--The treatment of membranous enteritis embraces medical and
hygienic measures. The medical means have for their object, first, the
removal of the membranous exudation when it has once formed; and,
second, to correct the conditions upon which its formation depends by
improving nutrition and invigorating the nervous system. The severe
sufferings of the paroxysms are greatly alleviated and the duration of
this stage cut short by freely emptying the bowels. The best means to
do this is by the injection of hot water with the long elastic bougie
three or four times a day, and to assist this with laxatives. Instead
of water, solutions of potassa, soda, and lime-water are preferred by
some practitioners. As a rule, the enemata cause considerable
discomfort, but in the end are followed by improvement in the condition
of the bowels. The best laxative is emulsion of castor oil, but
occasionally a mercurial, guarded by the extract of belladonna, will
furnish more marked relief. Powell and Copeland say that they have
employed with decided advantage a purgative consisting of the compound
infusion of gentian and infusion of senna, to which were added ten or
twenty minims of liquor potassæ. This was repeated, so that four stools
in the twenty-four hours were obtained. Clark preferred to regulate the
bowels, when needed, with rhubarb, soda, and {775} ipecac, conjoined or
not, as required, with mercury and chalk. Good recommends four grains
of Plummer's pill every night, and the bowels kept open by two drachms
of sublimed sulphur daily. It should always be borne in mind that all
active or irritating purgatives are harmful. The bowels by this
treatment will not only be disembarrassed of the membranous exudates,
but also of any fecal collection the retention of which would surely
cause irritation, as occasionally happens even when there is an
apparent diarrhoea. This condition may be easily determined by
abdominal palpation. The relief from pain procured by free evacuation
of the intestine will be enhanced by the employment of hot fomentations
to the abdomen. Despite these means, its severity may, however, demand
the administration of narcotics. The best form will be a hypodermic
injection of a sixth or a quarter of a grain of morphia; enemata of
starch and laudanum are also beneficial. Burrows mentions a case in
which he succeeded in allaying nervous irritation by the nightly use of
thirty drops of laudanum. The patient noticed that the habitual
constipation was increased when the accustomed narcotic was omitted.
Bromide of potassium in large doses long continued will also be found
useful for the same purpose.
During the intervals of the paroxysms local medication of the bowels
and medical and hygienic measures should be had recourse to to prevent
the re-formation of the exudates by modifying the vital activities of
the intestinal mucous membrane and by restoring the general tone of the
constitutional powers. For local treatment the nitrate of silver,
sulphate of zinc, the sulphate of copper dissolved in glycerin, the
tincture of iodine, and carbolic acid cannot be over-prized. From five
to ten grains of the metallic salts, fifteen drops of tincture of
iodine, ten of the acid, administered through the long rubber tube, are
suitable doses to begin with. I am also in the habit of using stronger
solutions by mopping it on to the bowel through the endoscopic tube.
Kaempf made frequent and large injections of decoctions of various
plants--saponaria, taraxacum, etc.--which he imagined possessed
dissolvent and resolvent virtues. Cumming[40] speaks highly of the
efficacy of electricity.
[Footnote 40: _Lond. Med. Gazette_, 3d Series, vol. ix.]
For the purpose of improving the general health the preparations of
iron are advisable, of which the best are the tincture of the chloride,
pernitrate, pyrophosphate, lactate, and potassio-tartrate. Habershon
advises infusions of the bitter tonics with hydrocyanic and
nitro-muriatic acid. I have found a combination of these acids with
henbane and infusion of serpentaria useful. I also employ hot solutions
of the latter acid as a local bath over the abdominal region, applied
with a large sponge. Clark speaks favorably of the extract of nux
vomica and astringent remedies. Simpson praises the oleo-resins under
the form of pitch pills and tar, while Clark and others laud copaiba
and turpentine. Good advises the copaiba to be given by enema when it
cannot be borne by the stomach. Brodie used cubebs in small doses.
The alterative effects of small doses of arsenic, corrosive sublimate,
sulphate of copper, etc. may be tried in obstinate cases. Grantham in
the early stages of the complaint advises the use of ten grains of
iodide of potassium combined with one-quarter of a grain of morphia at
bed-time. He {776} also strongly urges the use of cod-liver oil, which,
he says, improves the strength and increases the flesh, lessens the
spasmodic pains, but does not check the discharges.
Counter-irritation of the abdominal region with tincture of iodine, fly
blisters, mustard, etc. has afforded little if any advantage. Dunhill
kept a blister open for six months without any good results.
The mineral waters of Pyrmont, Harrogate, and Carlsbad have been found
serviceable; the latter, Henoch[41] says, should be preferred before
all.
[Footnote 41: _Klinik der Unterleub. Krankheiten_, p. 668.]
The case will amend more speedily and surely by the adoption of those
sanitary measures, as regards clothing, diet, bathing, exercise, and
change of climate, which have such important influences upon health.
The healthy performance of the functions of the skin is of such
paramount necessity in maintaining that of the intestinal canal that
the patient should endeavor to avoid any exposure likely to lead to
checked perspiration, and should use flannel underwear and stimulate
the skin by friction with the hand or the flesh-brush. The diet should
be graded to the ability of the stomach to digest and the body to
assimilate. Our chief reliance will be upon milk, plain or peptonized,
eggs, and beef given in the various forms of acceptable preparations,
so as not to impair the tone of the stomach nor clog the appetite by
sameness. Such vegetables and fruits as agree with the patient may be
allowed. I have tried exclusive diets of milk, farinacea, and meat
without marked benefit. All stimulants, tea, and coffee should as a
rule be interdicted.
Systematic exercise in the open air and change of climate to a cool,
dry, bracing atmosphere will contribute to comfortable existence, if
not lead to recovery.
{777}
DYSENTERY.
BY JAMES T. WHITTAKER, M.D.
DEFINITION.--Dysentery is the clinical expression of a disease of the
large intestine, of specific and non-specific (catarrhal) origin and
form; characterized by hyperæmia, infiltration, and necrosis
(ulceration) of its mucous membrane; distinguished by discharges of
mucus, blood, pus, and tissue-débris; and attended with griping and
expulsive pains (tormina and tenesmus).
ETYMOLOGY.--The name is compounded of the two Greek words [Greek: dys
enteron], which, though untranslatable literally into English, have
long since received the exact Latin equivalent, difficultas
intestinorum. With appropriate alteration the same name is still
employed in every civilized language in the common as well as the
classical description of the disease. The French synonym, colite,
locates the anatomical seat of the disease, while the German Ruhr and
the English flux express one of its cardinal symptoms, the frequency
(flow) of the evacuations.
HISTORY.--Ancient.--In its clinical history dysentery is one of the
oldest known diseases, the name being found in common use before the
time of Hippocrates, as in the often-quoted passage from Herodotus (443
B.C.), who relates that it and the plague reduced the army of Xerxes on
the desert plains of Thessaly.