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of varieties that take a widely diversified range of time for normal digestion, gastric or intestinal; crude fruits and vegetables; articles of diet opposed to the idiosyncrasy of the individual; iced beverages taken when the system is heated; acescent or fermented drinks, or any article of food that produces severe mechanical or chemical irritation; these are among the frequent causes of intestinal catarrh. Imperfect mastication can frequently be referred to as the cause of an attack of acute catarrhal irritation and inflammation of the stomach or small intestine. A common cause depends upon the vicissitudes of the weather; as a high temperature prolonged until the general system is debilitated, or cold and damp weather, driving the blood from the surface to the intestines, producing active hyperæmia resulting in a copious effusion into the intestines from the venous radicles, at first serous, afterward accompanied by mucus, forming the sero-muculent dejections. The potency of this aetiological factor I have often witnessed on a large scale in camp-life. Fatigued troops, exposed to a cold rain-storm during the night while sleeping upon the ground, are sometimes attacked on the following day by an almost painless serous diarrhoea, which results in chronic intestinal catarrh.

Chronic intestinal catarrh occurs secondarily from morbid conditions of the stomach, permitting imperfectly digested matters to remain here for an abnormal length of time, and to undergo chemical changes that irritate the intestinal mucous membrane after leaving the pyloric ring, and from diseases of the liver, of the pulmonary system, of the portal circulation, or any abnormal conditions inducing passive congestion of the intestinal mucous membrane. Extensive burns of the skin are sometimes followed by inflammation of the intestines. Failure of the pancreatic secretion will slowly produce catarrhal irritation or inflammation of the intestinal mucous membrane, from indigestion of amylaceous articles of food. Malarial poisoning may also be recognized as an occasional cause of diarrhoea.

SYMPTOMATOLOGY.-The symptoms of chronic intestinal catarrh, as a general rule, are not so sharply defined as to prevent errors of diagnosis, particularly when the disease is not of pro

nounced severity. The acute form, however, is easily recognized by the ordinary disturbances of digestion suddenly following a surfeit of food or exposure to cold and damp, and by the diarrhoea that generally accompanies it.

Acute pain is rarely present; but, instead, there is a vague general sense of distress in the hypogastrium, extending to the dorsal region; a sense of fullness of the abdomen, and moderate tenderness upon pressure of its walls; loathing of food; a moderate rise of temperature; and a high-colored and scanty urine, irritating in its passage through the urethra.

When there is pain in the right hypochondrium, and bile is vomited, the duodenum is probably implicated; and when the bile is mixed with mucus, accompanied with great thirst, the stomach is involved. The vomiting in the latter case is very often a pronounced symptom, and we can readily understand that the chemical changes of the ingesta, that have necessarily taken place in the small intestine, cause increased peristaltic action and irritation in the large intestine, producing frequent alvine dejections. The stools are composed of serum, mucus, bile, changed epithelial cells, peptones, and indigested food. When tenesmus with mucous dejections and scybala are present, the rectum is involved in the affection.

Chronic intestinal catarrh follows the acute form of the disease; and very often the symptoms of the latter exist in so mild a degree as to pass unheeded as trivial, until the chronic form becomes insidiously established. Abnormally increased peristaltic action is an essential factor in the production of diarrhoea, and this is often irregular, weakened, and slower than normal, especially in cases of long standing; diarrhoea, therefore, is not a necessary symptom of chronic catarrh. On the contrary, the number of the alvine dejections is often diminished, alternating in consistence from fluid to semi-solid or solid stools. Occasionally mucus occurs in the dejections in the form of coherent masses, or in cylindrical casts of the intestines, of from one to several inches in length, with colicky pains. This form and quality of the dejections occurs in nervous females, and I have noticed the same in the male. Stools composed of

mucus, almost or entirely unmixed with fæcal matters, and attended with tenesmus, are diagnostic of rectal catarrh. Abdominal pain is not a strongly marked subjective feature, except at times when the colon is temporarily obstructed by hardened fæces; but, on the other hand, a sense of pressure from fullness and a dull, unpleasant sensation, not amounting to pain, is felt in the abdomen. When pain is very pronounced, it quite accurately points out the special seat of inflammation, as in the cæcum, flexures of the colon, or the rectum.

The colon may be the seat of a greater number of pathological changes of structure that can be tolerated than the small intestine, as the colon is concerned in digestion in a slight degree only. Its normally slow peristaltic movements and sharp anatomical flexures combine, in cases of chronic disease, to weaken its functional efficiency, permitting the impaction of fæces that irritate the mucous membrane, and creating new points of catarrhal inflammation aggravating and extending those already existing.

A symptom or sign of no little significance relating to the transverse colon, in chronic intestinal catarrh, is its displacement downward out of its normal position in the abdomen. This is attended with a transverse depression of the abdominal walls at or immediately above the umbilicus; and dullness on percussion over the displaced bowel, when filled, will confirm the diagnosis. The abdomen below the umbilicus is tumid and overhanging. In eighty-one ex-soldiers of the late war, with chronic diarrhoea of twenty years' duration, whom I examined for the purpose of rating their degrees of physical disability, I found forty-two with this physical sign strongly pronounced. All were suffering from the effects of chronic intestinal catarrh ; the greatest number being reduced in weight to less than two pounds to the inch in height.

Patients suffering with chronic intestinal catarrh are frequently disturbed by melancholy and hypochondriasis, anæsthesia or hyperæsthesia of the skin, paresis of the muscles, and darting pains in the legs and feet, resembling those occurring in the earlier stages of locomotor ataxia.

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The diarrhoea of infants at the period of the first dentition may be considered in the number of first causes of chronic intestinal catarrh, in no small ratio of the cases found in adult life. Irritation of the nervous system from teething, as well as fright or other psychological conditions, may act as a cause of acute intestinal catarrh. The production of diarrhoea by teething seems to be conservative, by removing the irritating ingesta from the intestines. If relief be not obtained early by this means, the colon becomes implicated in the first of the series of ætiological factors leading to pathological conditions of this bowel that often become obstacles to complete recovery; especially, if the hygienic and dietetic treatment be defective. By the additional causes of damp, cold weather or insufficient clothing, active congestion of the gastro-intestinal mucous membrane is produced, which is recognized by increased temperature, vomiting, thirst, sero-mucous discharges of yellow or greenish color from the bowels, with indigested casein or other articles of food, accompanied by a suppressed outery or moan occurring with each expiratory act. When increased peristaltic action has not extended the colon, a distended or tympanitic condition of the abdomen ensues, due to putrefaction of the albuminoids in the intestines. This is symptomatic of approaching extension of the catarrh to the rectum, with the attendant tenesmus.

DIAGNOSIS.-The diagnosis of catarrhal inflammation of the intestines is usually not attended with as much difficulty as is experienced in locating the part involved, as between the small and the large intestine. When there has been for a few days gastric disturbance, with icterus duodenalis, tenderness and tumidity of the hypogastrium, more pronounced to the right of the mesial line, and alvine dejections composed of altered bile, mucus, and unchanged ingesta of the hydrocarbonaceous class, we may reasonably conclude that the small intestine is the seat of disease. When we observe a sense of weariness, a dull, heavy pain in the lumbar and sacral regions, tumidity and sense of pressure in the lower portion of the abdomen, with scanty, highly-colored urine, the dejections characterized by scy

bala covered with mucus, alternating with a mixture of fœtid mucus and undigested particles of food with a small quantity of blood, and attended by tenesmus, the large intestine is the seat of catarrhal inflammation.

The chronic form is characterized by diminution of strength and weight, constipation, a tumid or a tumid and pendulous abdomen, and, in some cases, disturbances of the sensory nerves of the skin and muscles, indicated by hyperesthesia or anæsthesia. In other words, when the clinical history shows an attack of acute diarrhoea, several months or years before, followed by a train of general dyspeptic symptoms, with alternating constipation and diarrhoea, uneasiness in the hypogastrium one and a half or two hours after meals, accompanied by flatulence, weary, aching, or rheumatoid sensations in the lumbar muscles, dizziness, disturbed sleep, the tongue thick, foul at the base, with exaggerated papillæ and frequently gashed or fissured, irregular appetite, and generally craving for hot, pungent articles with the food at meals, and general mental despondency, it is quite safe to diagnosticate chronic intestinal catarrh.

Again, the disease in question may be secondary; the ætiological factors resting upon diseases in remote organs, important in the general economy, but not in direct or proximate relation to digestion and assimilation. Thus, a general passive hyperæmia of the intestinal mucous membrane may be a result of inefficiency of the heart's action; and a less general or a local impression upon the circulation may be produced by cirrhosis of the liver or by obstruction of some of the principal branches of the portal vein by a tumor. Consequently, it is important to give attention to these organs and systems for diagnostic purposes, when seeking for causes of the disease.

Typhoid fever may be, and often is mistaken for intestinal catarrh, acute or chronic. The differential diagnosis will be aided by the thermometer in noting the range of temperature, and by a mild cathartic having special effect on the colon, for the removal of the semblance of tympanites of the abdomen, which is peculiar to typhoid.

PROGNOSIS. The prognosis in severe cases of intestinal ca

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