Chapter XLIV: Front Matter (44)

{712} The lower part of the duodenum below the opening of the bile-duct, the jejunum, and the ileum can be taken together as forming the small intestine. Chronic catarrh of the small intestine is attended with pain about the umbilicus, which comes on immediately or in one hour after taking food. Tympanitic distension gives a full, rounded prominence to the abdomen, which is more central than lateral, and greater below the umbilicus than above it. It is accompanied by a sense of oppression, which is greater after eating. Inability to digest food consisting largely of starch or sugar, as well as tardiness in the digestion of all foods, with resulting loss of flesh, are signs of intestinal indigestion. There may be no diarrhoea; if there is, important help to diagnosis can be gained by examining the stools. They contain undigested or partly-altered meat-fibre and starch-granules, discoverable only by the microscope. The discharges are soft and pulpy from an intimate admixture of mucus. To the naked eye no mucus is visible, but a thin layer under the microscope shows clear islets of pure mucus, or mucus may only be detected by the adhesion of the covering-glass to the slide. Bile-stained epithelium and globules of stained mucus are seen in the liquid stools from catarrh of the small intestine and of the ascending colon. There is the characteristic reaction and play of color on testing for bile-pigment. These are evidences that the stool with the bile has been hurried along the ileum and colon, and expelled before the transformation in the coloring matter has had time to take place.[45]

[Footnote 45: "II. Abtheilung, Diagnostische Bemerkungen zur Localisation der Catarrhe," _Zeitschrift für klinische Medicin_, Berlin, 1882, iv. p. 223.]

In catarrh of the large intestine there is sensitiveness to pressure along the line of the colon; the distension of the abdomen is not uniform, depending upon the prominence of the transverse or descending colon. The pains are more severe and precede the stools, which are more frequent and larger than in catarrh of the ileum. The discharges are pulpy or watery. Globules of mucus are visible to the naked eye, and mucus is intimately mixed with fecal matter.

If the lower half of the colon is chiefly the seat of the disease, pure mucus coats the more solid stool and is in its substance. With catarrh limited to the descending colon scybalæ are imbedded in mucus. From the sigmoid flexure and rectum larger masses of mucus, without fecal matter or with it, are expelled. Pure lumps of mucus, mixed or stained with red blood and without fecal matter, indicate catarrh of the rectum--proctitis.

(_b_) The stage of the process of inflammation is diagnosed by the condition of the patient, the course of the disease, and the character of the stools. As long as there is a pulpy fecal diarrhoea, with no blood, pus, or fragments of tissue and no marked emaciation or fever, and with a tendency to improvement under favorable conditions, there is every reason to believe that there is no ulceration.

In follicular ulceration the course of the disease is essentially chronic, and is marked by periods of improvement under careful treatment, with exacerbations and relapses from slight causes of irritation. There is progressive emaciation and debility, with fever of hectic character, which is worse in the later stages. The abdomen may be retracted. The movements are frequent and liquid, and are without odor or fetid. They {713} contain mucus, glassy-gray or green, pus-cells imbedded in masses of mucus, blood in small amount, but sometimes abundant, and shreds of the tissue of the mucous membrane. This last is an important aid to diagnosis.

The higher the ulcer the less marked is the diarrhoea. The lower its situation the greater is the frequency of the stools and the more liable are they to be accompanied by tenesmus and to contain blood and pus. Toward the last, ulceration is accompanied by rapid emaciation, fever, sweats, a feeble circulation, a dry tongue, great thirst, and oedema of the feet and ankles. Death takes place by gradual exhaustion, more rarely from perforation and peritonitis or from intestinal hemorrhage.[46]

[Footnote 46: Nothnägel, "Die Symptomatologie der Darmgeschwüre," _Klinische Vorträge Volkmann_, No. 200, Aug. 24, 1881.]

Duodenal ulcer is with difficulty recognized during life.[47] The following are the symptoms which have preceded death from this lesion: Profuse hemorrhage from the bowel, vomiting of food as well as blood, icterus, dysphagia, hiccough, oppression in the epigastrium after eating, attacks of cardialgia with tenderness on pressure in the right hypochondrium, and sudden death with symptoms of collapse. If these symptoms follow an extensive burn of the skin, they are easily referred to a duodenal ulcer.

[Footnote 47: W. L. Loomis, "Perforating Ulcer of Duodenum and Sudden Death." For two years the patient had suffered with dyspepsia and epigastric pain after eating, was gouty, and had lost flesh. Autopsy: atheroma of arteries, beginning cirrhosis of kidneys, walls of stomach thickened, perforated ulcer one inch below pylorus (_Med. Record New York_, 1879, vol. xv. p. 188; also _Boston City Hospital Report_, 1882, p. 374).]

Tuberculous ulcers are distinguished from follicular ulcers by the history of hereditary predisposition, the existence of pulmonary tuberculosis, higher fever, and more rapid emaciation and debility.

A cancerous ulcer may be the cause of bloody stools; it is usually within reach of the finger in the rectum; the mass exercises pressure upon the prostate, and at times occludes the bowel, causing obstruction. The cachexia and rapid decline are not seen in catarrhal ulceration.

PROGNOSIS.--Chronic catarrh of the intestine is most fatal in children. Among infants artificially fed, when the illness develops and continues during hot weather, the mortality is very great. Recovery in the young is rendered less probable if chronic diarrhoea is associated with rickets, scrofula, or tuberculosis.

If the catarrh in adults is a complication of some previously existing constitutional disease, as Bright's disease or scurvy, or is connected with lesions of the liver, spleen, heart, or lungs, there is less hope of cure. In old persons this disease has a special gravity.

The longer the disease has lasted before treatment is begun, and the longer it continues without being influenced by treatment, the more unfavorable will be the prognosis. Discouraging symptoms are an uninterrupted loss of flesh and strength, lientery, hectic fever, relapses notwithstanding care in diet, and the signs of ulceration--blood, pus, and tissue-shreds in the stools, with an odor of decomposition.

Favorable promises may be based upon a hearty willingness of the patient to submit to the strictest regimen and to subordinate his life to the plans of treatment, the absence of other diseases, early improvement in his general condition and local symptoms under rest and diet. A {714} complete cure cannot be assumed to exist unless the patient has passed one or more years without a relapse.

TREATMENT.--As chronic intestinal catarrh is a complication of so many conditions, the prevention of it becomes a matter of great importance and of very general application. All rules for preserving health--temperance in eating and drinking, bathing, exercise, good ventilation, the avoidance of overwork, both mental and physical--are so many means for escaping an intestinal catarrh which may present itself as an indigestion with constipation or as a diarrhoea.

The special liability of infants and children, and to a less extent of very old persons, and the greater dangers they run, call for the most careful selection of appropriate diet at these periods of life.

Where there is hereditary predisposition, idiosyncrasy, chronic diseases of organs, or constitutional diseases, an easily-digested dietary should be supplemented by precautions against chilling of the surface by the wearing of flannel underclothing and woollen socks.

The etiology of each case may at once suggest a line of treatment. Among the causes which point to appropriate measures are--the continued presence in the bowel of indigestible or undigested food, constant exposure to cold or to changes of temperature, chronic cardiac disease and portal congestion from any cause, chronic cachexiæ, as syphilis, malaria, tuberculosis, or Bright's disease, the crowding together of individuals in prisons, asylums, etc.

1. The mildest form of intestinal catarrh characterized by intestinal indigestion and constipation or by the passage of fecal matter more or less solid, mixed or coated with mucus, is best treated by a diet such as is advised for intestinal indigestion, bathing with friction, outdoor life, exercise on horseback or by walking, pleasurable occupations, and travel. Iron if there is anæmia, and strychnia if there is a sluggish capillary circulation, with cold hands and feet, are available and useful in many cases. Massage and the Swedish movement treatment find useful application in feeble men and in women who are not strong enough for outdoor exercise. To aid the digestion the liquor pancreaticus as advised by Roberts, a teaspoonful one hour and a half to two hours after each meal, with ten to twenty grains of the bicarbonate of sodium, is, theoretically at least, to be warmly recommended. The Rockbridge alum water, a small glass three times daily between meals, has astringency enough for the hyperæmic membrane and is of good service without increasing constipation.

Purgatives should be avoided as much as possible. An enema of cool water, not more than a tumblerful, taken each morning after breakfast if persevered in, may do all that is needed in this direction. If it fails to empty the bowel completely, a larger enema of warm water--one pint--holding in solution sulphate of zinc or alum in the strength of one grain to three or four ounces, can be thrown high up with a rubber tube once daily. This acts upon the mucous surface, constringes mildly the congested vessels, and when expelled brings away the retained fecal matter. These astringent rectal injections offer promise of cure in many obstinate cases where the colon is chiefly the seat of disease. Belladonna is advised for cases of this kind in combination with strychnia for the constipation. Mild laxatives are often necessary. Bedford mineral water, Hunyadi water, or other salines and the less active vegetable {715} cathartics, can be given alternately. Ipecacuanha has had quite a reputation in combination with purgatives in intestinal catarrh. Aloin pills empty the bowel without much attendant irritation.

2. The form of catarrh which shows itself in a tendency to diarrhoea from indiscretions in diet or from exposure to cold must receive prophylactic treatment. Especially in this form is it important to improve the activity of the skin by bathing and friction, and to lead a temperate life in all things, regulating the diet according to the rules already stated. Tonics are called for in such cases. Fowler's solution of arsenic (one drop before each meal, Ringer), the potassio-tartrate or the tincture of the chloride of iron, dilute sulphuric acid, nitro-muriatic or hydrochloric acid, are efficient in improving digestive activity or in opposing the anæmia which is nearly always present. Quinia is indicated in malarial anæmia with a disposition to loose bowels. Quassia or other vegetable bitters can be given if the appetite is languid; the bitters are, as a rule, of little benefit, and may do harm if diarrhoea exists. Strychnia with quassia or columbo stimulates the appetite and the gastric digestion. When intercurrent attacks of diarrhoea come on with coated tongue, flatulence, distress about the umbilicus after eating, bismuth given on an empty stomach in full doses is serviceable. Small doses of morphia or of opium in some form can be added to the bismuth if there is much pain or when the stools are frequent.

In this and in other forms of intestinal catarrh mineral waters are profitably employed. They are best taken at their sources; and here, as in the case of sea-bathing, the benefit is largely due to the change of air and scene and to the more simple mode of life. Any of the watering-places where alkaline-saline waters or ferruginous waters are found may be of benefit. A trip to Europe and a stay at Carlsbad will break up many an obstinate case of chronic abdominal disorder; but other beneficial waters in Europe are Tarosp, Rohitsch, Marienbad, Kissengen, and Plombières.

In this country the comfort and conveniences of the summer hotels and climate are as much to be considered as the chemical composition of the waters. For milder forms of catarrh with constipation a season at Saratoga, with a life of temperance there, is a wise procedure. Bedford Springs, Pa., offer the same advantages in part, but the waters are best suited to catarrh with constipation. Many of the Virginia springs benefit health-seekers who do not place too much reliance upon the virtues of the waters, and who trust to the value of pure air, exercise, diversion, and rest.

3. All plans of treatment for the more severe form of catarrh with chronic diarrhoea (follicular enteritis) must be based upon a knowledge of the lesions. Bearing in mind the alterations in the mucous and submucous tissues, it is clear that no treatment can be successful which is not carried out with the most careful attention to details, and which is not continued for some time after all the symptoms of the disease have ceased. The complete resolution of hypertrophied glandular tissue, the scattering of cell-accumulations, and the healing of ulcers can only be secured in this way. It is best to present the whole case before the patient, so as to enlist in the task his intelligent co-operation.

Directions for the guidance of cases of this kind must include every {716} detail of the patient's life. The question of residence is of importance to begin with. A cool and dry climate is better than a wet and warm one, and where other means fail change of climate is sometimes the only cure. A sea-voyage, a residence in a mountain-region, will oftentimes promptly and effectually cure an obstinate diarrhoea. House-drainage and ventilation should be examined into and improved. The occupation may have developed the disease; in overwork may lie the origin and the cause of its continuance. Rest from work is therefore in some instances the one thing needed. In all cases the energies and the brain should not be overtaxed. The bath to keep the skin active can be combined with friction. The hot bath, as hot as can be borne, is the best. It is a stimulant, not a depressant, as is the tepid bath, and it is safer than the cold bath.

The cold sitz bath or the application of cold compresses diminishes abdominal plethora, and is wisely advised in strong persons who are not depressed or chilled by external cold. Sea-bathing is another hydro-therapeutic measure which is of unquestioned advantage in all forms of intestinal catarrh.

Permanent baths have been found very serviceable in many chronic diseases, and there are many reasons for advising them in obstinate diarrhoeas. There can be no better means for bringing to bear a strong and continued influence upon the intestinal mucous membrane. The patient should be kept in the warm bath for one, two, or three weeks, according to his strength and the effect upon the disease. Systematic hot bathing under the direction of a physician at Richfield, Sharon, the Hot Springs of Virginia or Arkansas, is an invaluable aid.

Rest in the recumbent position for cases where the symptoms indicate marked tissue-alteration is very often the most important part of the treatment. Rest and diet are alone necessary to cure many cases, and without these combined means relief is often impossible. The rest should be absolute, the patient using a bed-pan and lying down all the time. The contraindications for this method are a slight diarrhoea which yields to other treatment, and loss of strength and appetite from the deprivation of air and exercise.

If rest is not advisable, or does no good after a fair trial of two to four weeks, outdoor life in fair weather by driving or walking slowly can be suggested. A long drive will bring back a diarrhoea which has taken many weeks to relieve.

The rules for diet must be clearly given and strictly enforced. An exclusive milk diet should have a trial in every case. Skimmed milk can be taken in larger quantities and with less repulsion, and is therefore to be preferred. The exclusive milk diet can be varied with buttermilk, koumiss, or wine-whey; and fruit-juices, as orange-juice, lime-juice, or tamarind-water, please the patient without doing harm. In the case of adults as well as children the milk is made more digestible by diluting it with barley- or rice-water or by adding transformed farinaceous food to milk in the form of Mellin's food and other foods of this class.

Animal broths, as chicken-soup and beef-tea, are well digested if properly made and given in small quantities. Raw meat scraped, beef or mutton rare and thoroughly masticated, the breast of poultry, game, broiled fish, raw oysters, raw or very slightly boiled eggs, or sweetbread, are foods from which selection can be made to add variety to the dietary. {717} Saccharine, starchy, and fatty foods are to be given as little as possible. Vegetables may be added to the list as the condition improves. Rice and fine hominy (grits) are to be thought of first, as being easily digested and nourishing. Good wine in moderation is not hurtful; the red wines diluted with water are the best, but good port, tokay, and whiskey well diluted find application in particular cases.

Whatever food be given, it should be taken in the quantities and at hours prescribed by the physician, who by careful inspection of the stools judges of the necessity of changes in his regulations and of the success of his treatment.

The further treatment of chronic diarrhoea has for its object by the aid of drugs to change the anatomical state of the mucous membrane. Manifestly, the choice depends upon the state of this tissue. In the earlier stages the increased vascularity and hypersecretion call for mild astringents or for medicines which are believed empirically to oppose these conditions. When drugs can be dispensed with, it is better to do so; they should always be made subordinate to the careful regimen already described.

Bismuth in large doses (ten to thirty grains) is a safe and efficacious remedy in this stage. Nitrate of silver in pill form (one-sixth to one-fourth of a grain) has the endorsement of Wm. Pepper and many other practitioners. It should be continued for two or three weeks at least, but it may be given in small doses during several months, with intermissions, without danger of silver staining.[48]

[Footnote 48: A case is recorded of silver staining of the skin after four weeks' administration (Woodward, _op. cit._, p. 780).]

A routine administration of any drug or class of drugs is reprehensible, and from the numerous remedies which are advocated in chronic diarrhoea selection can be made for trial in the course of intractable cases. The list would include sulphate of copper (one-fourth to one-half a grain), the liquid preparations of iron (liquor ferri nitratis, tinct. ferri chloridi), dilute nitric and sulphuric acids, gallic acid and other vegetable astringents, oxide or sulphate of zinc, alum, precipitated phosphate of calcium, salicin, corrosive sublimate (1/100 gr. every hour), the Indian bael-fruit, etc. No remedy should be abandoned until it has been continuously given for one or more weeks.

The Rockbridge (Va.) alum water is markedly astringent, is not unpleasant, and may be used as a substitute for water with advantage. In fact, there is no better way of introducing in quantity a mild astringent into the intestine than by the drinking of this water.

Cold-water rectal irrigation has a sedative and astringent influence, and when properly used is of great advantage to both children and adults.[49] The patient should be placed in the proper position, and the water made to enter the rectum as high up as possible. The number of stools lessens almost immediately after this treatment, peristalsis being inhibited thereby.

[Footnote 49: A long rectal rubber tube, such as advised by Surgeon-General Wales, U.S.N., serves this purpose well.]

To the water used in irrigation astringents may be added in small doses. Sulphate of zinc, sugar of lead, or alum may be given in this way in the strength of one grain to four or six ounces of water. This {718} method of treatment promises more and is more rational than the internal administration of drugs.

Opium and its preparations should be avoided except to control frequent or watery discharges or to relieve pain, but it is not often that this is called for if wiser measures are first employed. Any of the remedies spoken of may be given in the form of suppositories with greater advantage often than by the mouth.

In that more severe class of cases called follicular ulceration, in which the follicles are known to be ulcerated from a prolongation of the illness, the obstinacy of the diarrhoea, the character of the discharges, and the effect upon the general health, other measures are to be adopted. The diet should be most strictly regulated and the digestive power of the patient carefully studied. Cod-liver oil is added with advantage to other foods if there is a lack of nutrition. Aids to gastric digestion are called for.

The intestinal lesion is to be reached through the stomach or the rectum. Nitrate of silver in small doses is more especially applicable, and is to be preferred to all other drugs in this stage. It is to be given in small doses and for several weeks.

Turpentine and copaiba have something in their favor in ulceration. Ergot has been suggested, and where there is much hemorrhage from the bowel may be prescribed.

Irrigations with solutions of nitrate of silver seem to be a direct and certain remedy in cases where ulceration has existed for a long time. Two and a half to three pints of distilled water, holding in solution five grains of nitrate of silver, should be thrown up the rectum as high as possible with a rubber tube; the effort should be made to secure immediate exit to the fluid. This procedure is to be repeated after the bowels are moved--once every day or every other day if the rectum becomes irritable.[50]

[Footnote 50: See case reported by the writer to the Medical Society of the District of Columbia, and published in the _Maryland Medical Journal_, March 15, 1883, p. 562.]

{719}

CHOLERA MORBUS.

BY W. W. JOHNSTON, M.D.

SYNONYMS.--Cholera nostras, Sporadic cholera, European or English cholera, Spasmodic cholera, Cholera biliosa, Passio cholerica, Cholerhagia, Trousse-galant, Die Gallenruhr, Brechruhr.

DEFINITION.--An affection of the gastro-intestinal mucous membrane characterized by violent abdominal pain, nausea, and sudden, violent, and incessant vomiting, and by purging of a watery fluid containing little albumen and bile; attended with spasms of the muscles of the abdomen and extremities, a pinched and sunken countenance, pallor, cyanosis, and coldness of the surface of the body; a feeble and rapid pulse, oppressed respiration, and great restlessness; dryness of the tongue, great thirst, and diminished or suppressed urinary secretion and a state approaching collapse, which may rarely prove fatal, but is, as a rule, followed by reaction.

HISTORY.--The term cholera has been in use since the time of Hippocrates, but he confounded with it every disease which seemed to him to come from acridity or corruption of humors, as colics and meteorism with constipation.[1] He well described cholera morbus in saying that "it is a disease which appears in summer, due to imprudence in eating, at the same time as intermittent fever."[2] If Celsus be correct in deriving the name from [Greek: cholê] "bile," and [Greek: reô] "I flow," it is more applicable to the disease now under consideration than to the Asiatic disease, as it is the bile which is absent in the colorless rice-water discharges of Asiatic cholera. Trallian and Ruysch, however, ascribe it to [Greek: cholêra] the rain-gutter of a house.

[Footnote 1: _Append. au Traité du reg. les Maladies aigues_, 19, ii. p. 495, ed. Littré.]

[Footnote 2: _Epidémies_, lib. v., ed. Littré, 71, p. 247.]

In the Old Testament mention is made of a disease resembling cholera morbus.[3] Its true pathogeny was known to Galen, and it was accurately described by Celsus,[4] and Aretæus[5] mentions the nature of the discharges and its frequency among young people and children.

[Footnote 3: _Hist. Méd. des Maladies epidémiques_, Paris, 1825.]

[Footnote 4: Lib. iv. cap. 2.]

[Footnote 5: Lib. ii. cap. 5.]

The first mention of epidemics was in the sixteenth century. Various epidemics in 1695, 1717, and 1718 in Germany were probably cholera morbus. Forestus[6] reports seven observations from 1559 to 1565 of attacks due to indigestible food or drastic medicines. F. Hoffman,[7] {720} J. Frank,[8] and L. Rivière speak of the benignity of the disease as contrasting it with its apparently dangerous symptoms.

[Footnote 6: _Opera Omnia_, Rothomagi, 1633, "De stomachi affectibus," lib. xxviii.]

[Footnote 7: _Medicina rationalis systemica_, t. iv. pt. 3, 1734.]

[Footnote 8: _Praxeos medicæ universæ præcepta_, Leipzig, 1826, p. 43.]

Sydenham's[9] description of the epidemics in England in 1669-72 is the earliest account of the disease in modern literature, and it was he who gave it the name cholera morbus.

[Footnote 9: Sydenham Soc. edition, vol. i. p. 163.]

NATURE.--There prevails at the present time a great diversity of opinion in regard to its nature; the want of uniformity in the appearances presented by post-mortem examinations may in some measure account for this. The present state of our knowledge, derived both from pathological anatomy and a study of the symptoms, will not warrant a positive opinion in regard to it.

Niemeyer,[10] in common with most German and some French authors, considers cholera morbus to be a variety of gastro-intestinal catarrh. Leube[11] thinks it a variety of gastric catarrh with simultaneous inflammation of the intestines and running a peculiar course. It is certainly not identical with the specific Asiatic disease, although in some cases the symptoms and morbid anatomy are exactly similar, and any differentiation is impossible. By some it is believed that cholera morbus is due to surviving germs implanted by previous epidemics of Asiatic cholera.

[Footnote 10: _Pract. Med._, 1879, vol. i. p. 480.]

[Footnote 11: _Ziemssen's Cyclopædia_, New York, 1876, vol. vii. p. 146.]

The slight changes found in some fatal cases would lead to the belief that the effect of the exciting cause is something more than a mechanical irritation of the gastro-intestinal mucous membrane.

The sudden onset, rapid development of symptoms, and dangerous collapse justify the theory that there must be some previous change in the individual or some peculiar result of food-decomposition. The nervous system may be so enfeebled by prolonged heat that an irritant quickly destroys its equilibrium and brings about vaso-motor paralysis of the intestinal vessels and abundant serum transudation. Or the irritation may be specific, depending upon the development of poison germs in food which has been subjected to heat influences. There is a close relationship between cholera morbus and cholera infantum in their etiology, symptoms, and pathology.

ETIOLOGY.--Predisposing Causes.--The disease is more common in the tropics, but is not confined to any climate. In temperate latitudes it is more likely to occur in July and August, when the variation of temperature between day and night is great, although the other months of summer and autumn are not entirely exempt. It is said to be more frequent and fatal in Southern Europe than in the northern and temperate climates. In periods immediately preceding and following epidemics of Asiatic cholera many persons are attacked, although there is great liability to errors in diagnosis at these times.

It occurs more frequently in youth and adolescence than in advanced life, and males seem to be more liable to attacks than females, but difference in occupation may assist in this predisposition. Persons endowed with an extreme sensibility of the nervous system and who are subject to frequent attacks of intestinal catarrh are much more liable to the disease. The exhaustion of the nervous system by heat, which is the {721} probable explanation of the phenomena of cholera infantum, has no doubt much to do with the development of cholera morbus. Mental anxiety or overwork in summer increases this nerve-exhaustion and renders the termini of nerves and the centres very susceptible to peculiar irritation.

Exciting Causes.--It is probable that the cause of most attacks is a septic material generated in the fermentation and decomposition of food. This poison acts as an irritant upon the gastric and intestinal nerves and gives rise to excessive peristaltic movements and vomiting. Hence the quality of the food is an element of more importance in the causation than the mere quantity ingested; and herein may reside the chief difference between cholera morbus and Asiatic cholera, the latter being due to a specific, imported, or acclimated poison which invariably produces the same specific form in those exposed to its action.[12] Unripe fruits, partially cooked or decaying meats and vegetables, shellfish and fish some time from the water, may produce the disease in those predisposed to it. The intemperate use of ice-water and other cold drinks after a full meal or when the body is exhausted by heat and fatigue, exposure to showers at the close of a hot day, or passing from a heated room into damp cellars and outbuildings, are frequent exciting causes.

[Footnote 12: "Bias the pugilist, naturally a great eater, had a sudden choleraic attack after having eaten of succulent food" (Hippocrates, lib. v. p. 247, ed. Littré).]

At times there exists a certain condition of inactivity of the digestive organs when the gastric juice is not secreted in sufficient quantity, and perfectly sound food may undergo fermentation and set up an attack.

The offensive exhalation from a filthy alley which had been recently cleaned was the exciting cause of a fatal epidemic in a London school,[13] and Levier recounts an epidemic caused by the drinking-water during the winter in Berne.[14]

[Footnote 13: _Lond. Med. and Surg. Gaz._, 1829, iv. p. 375.]

[Footnote 14: _Schweiz. Zeitschr. f. Heilk._, iii., 1864, p. 140.]

Nervous disturbance from other diseases may act as a cause. Leube reports a case of intermittent fever which was followed by an annual attack of cholera morbus preceded by febrile symptoms.[15]

[Footnote 15: Leube, _Ziemssen_, 1876, vol. vii. p. 148.]

Malaria, sewer-gas, and sudden and powerful mental emotions are credited with the causation of some attacks.

PATHOLOGICAL ANATOMY.--In a few cases an examination of the body has revealed no phenomena sufficient to account for the symptoms, even when they have been the most severe during life. In these cases either the inflammation has not passed the first stage of development and the resulting hyperæmia has disappeared after death, or the irritation of the gastro-intestinal nerves has been sufficiently intense to cause death before the alimentary tract has undergone any consequent structural change.

Usually, however, there are evidences of a general gastro-intestinal catarrh: the mucous membrane is congested throughout and denuded of epithelium. The solitary glands are enlarged and Peyer's patches swollen and prominent. The blood is thickened and dark in color, and the serous membranes dry, sticky, and covered with desquamated epithelium. Indeed, the appearances may be identical with those observed in true Asiatic {722} cholera. The kidneys are congested, sometimes enlarged, and the tubules devoid of epithelium. In protracted cases the general muscular system shows a beginning of granular degeneration.

In no case, however, can a positive diagnosis between Asiatic cholera and cholera morbus be made from post-mortem appearances.

SYMPTOMS.--The attack is usually sudden in its onset, but in some cases is preceded by nausea, thirst, loss of appetite, and slight general distress for some hours, or it may come on in the course of some gastro-intestinal disturbance. Frequently it is developed during sleep, particularly after midnight, the patient being aroused by a feeling of pressure at the pit of the stomach, which is followed by nausea and violent and incessant vomiting with intense pain, the contents of the stomach being ejected with great force.

The matters first vomited consist mainly of the food last eaten, little altered or mixed with gastric mucus and tinged with bile. In a certain proportion of cases the amount of bile is increased, although it is difficult to judge of the relative proportion by the color and taste of the vomited liquid. The general belief that the liver is implicated and the bile secreted in morbid quantity rests upon conjecture alone, and has no solid basis. After a time only yellow, brown, or greenish mucus, with more or less bile, is ejected, and in protracted cases hiccough is most distressing.

Following the vomiting or at the same time with it purging comes on, and it is usually preceded by borborygmi. In rare cases there is no vomiting, but only intense pain in the bowels and copious alvine discharges from the beginning to the end of the attack. The stools in the beginning are normal in color, but soon become pulpy or semi-fluid. As they increase in quantity they become watery, consisting of blood-serum with mucus, cast-off epithelium and pus-cells, and are nearly odorless, and sometimes resemble very closely the discharges of Asiatic cholera, but almost invariably retain the yellow or green color of the bile. Colorless rice-water discharges are observed in undoubted cases of cholera morbus outside of any epidemic influence. The discharges are acrid and irritating, and the neighboring parts become red and excoriated.

At the same time there is intense burning or tearing pain in the abdomen, generally centring at the umbilicus, great thirst and painful contractions of the muscles of the abdomen and extremities, particularly in the calves of the legs, and of the flexors of the thighs, forearms, fingers, and toes. In the beginning there may be tympanites, but this soon disappears, and the abdomen becomes retracted and the muscles drawn up into knots. The cramps usually come on after each act of vomiting and purging, but they may appear spontaneously. Abdominal tenderness is either wanting or slight. As the transudation continues the thirst becomes intense, the tongue cold, dry, and coated, and the tissues shrivelled from loss of water. The skin is cold, clammy, or covered with a viscid sweat, and the surface of the body is cyanosed, violet, or in the extremities it may have a marbled appearance. The nose is pointed, the eyes dark and sunken, and there is a general appearance of collapse.

The mind may be clear throughout, but in protracted cases there is great nervous prostration. The patient becomes dull and lethargic, passing into stupor after great restlessness and jactitation. The voice is faint {723} or whispering, the breath cold, and the respiration sighing. The pulse in the beginning may be depressed, but soon becomes rapid and often imperceptible, and there is great præcordial anxiety.

As the blood becomes thickened the urine is highly colored, small in quantity, and it may be suppressed. An examination shows traces of albumen, casts and desquamated epithelium, and a decrease in the amount of urea and salts. In the last stages there may be a slight rise in temperature, but it has no definite course and it is usually absent. In collapse the temperature of the surface of the body sinks below normal, but the temperature of the interior may rise as high as 101° or 102° F., as shown by the thermometer in the rectum or vagina.[16]

[Footnote 16: _London Hosp. Reports_, 1856, vol. iii. p. 457.]

PROGRESS AND TERMINATION.--But, fortunately, the course of the disease tends toward recovery in the large majority of cases. The discharges gradually decrease in quantity, the intervals are longer, the appearance becomes more natural, and a profuse perspiration is followed by a refreshing sleep. The surface becomes warmer, the pulse slower and more full, and the skin regains its normal color.

If the case has been a severe one or if it occurs in a person much enfeebled by disease, it pursues a different course. The discharges become almost uninterrupted, and at last are passed involuntarily. The cramps are almost continuous or are convulsive, the pulse grows rapidly weaker and is finally lost, coma succeeds stupor, and death follows in collapse.

The duration of the disease varies from a few hours to two or three days; death has occurred within twelve hours.

Recovery is generally complete after a few hours; and this rapid return to the normal condition shows that there have been no textural change of organs. Sometimes great emaciation, irritability of the stomach, and slight diarrhoea persist for a few days, or symptoms of a general gastro-enteritis may supervene.

DIAGNOSIS.--In making the diagnosis of cholera morbus it is necessary to carefully differentiate it from epidemic cholera and the effects produced by irritant poisons, such as the metallic salts, poisonous fungi, etc.

Occurring during an epidemic of Asiatic cholera, it is not possible to make a diagnosis, as the symptoms of cholera morbus and of mild cases of the Asiatic disease are identical. From severe cases it is to be distinguished by the absence of antecedent diarrhoea, by the presence of bile in the vomited matters, and by the color and fecal odor of the stools. The nausea and abdominal pain are more marked, while the dyspnoea, cyanosis, and shrunken condition of the skin are less marked. The mortality of cholera morbus is slight, whilst about one-half of those attacked with epidemic cholera die.

In irritant poisoning the vomiting follows quickly after the ingestion of a meal or poisonous matter; it continues for some time before purging begins, and is out of all proportion to the diarrhoea. The vomited matters contain blood and mucus and are never serous in character. Corrosive poisons may cause redness, charring, or ulceration of the mouth and throat and a burning sensation in the stomach. The pain over the stomach is more constant and severe, particularly in the intervals of {724} vomiting, and there may be abdominal tenderness and bloody discharges. The expression is more anxious and the pulse rapid and weak.

Elaterium and tartar emetic will bring on vomiting and purging which resemble the symptoms of cholera morbus. Choleriform attacks due to uræmia simulate cholera morbus. The distinction is to be made by the previous history--pain and purging being relatively less prominent in uræmia--by the presence of albumen and casts in the urine, and by the early tendency to coma.

Acute peritonitis, attended by copious vomiting and purging, has been mistaken for cholera morbus, and the true nature of the affection only revealed by the autopsy.

PROGNOSIS.--As a rule, cholera morbus occurring in persons otherwise healthy ends favorably in a few hours. Cases of secondary fever, with gastro-intestinal catarrh, may prolong the attack from a few days to two weeks. Should treatment have no effect in lessening the vomiting and purging, and should the evidences of heart-failure become apparent, a fatal result may be feared. Death has occurred within twelve hours, and the mortality is 3 per cent. of uncomplicated cases.[17]

[Footnote 17: Bartholow, _Pract. Med._, New York, 1880, p. 58.]

Cases occurring in the course of other diseases possess a special gravity.

TREATMENT.--During the summer months, and particularly in August and September, when the hot days are succeeded by cool nights, iced drinks should be used in moderate quantities; the diet should be light, nutritious, and easy of digestion. Unripe fruits and articles of food liable to fermentative changes should not be indulged in.

Exposure to the night air, particularly after a full meal, should be especially avoided, and the clothing ought to be so arranged that additions may be made as night approaches. Slight attacks of indigestion should not be neglected, and any irregularity of the bowels must receive immediate attention.

The period when the physician is called upon to prescribe for an attack of cholera morbus is usually when the stomach has been emptied of food and the patient is vomiting incessantly, purging, and writhing in pain. If vomiting has not occurred and violent epigastric pain is the only symptom, the stomach should be emptied by an emetic of hot water and mustard repeated until the overcharged organ is completely emptied. Partially-digested food in a state of acid fermentation will thus be got rid of, and the sufferings may be immediately but not wholly relieved.

If spontaneous vomiting has expelled the food, and the matters vomited are green and watery, while pain and frequent stools with muscular cramps, heart feebleness, and threatening collapse are the symptoms presented, the remedy par excellence is a hypodermic injection of sulphate of morphia (gr. 1/8 to 1/3) with sulphate of atropia (gr. 1/120 to 1/100). If one dose is not followed by decided mitigation of suffering, the injection is to be repeated in a half hour or an hour, not giving above one grain of morphia in divided doses. At the same time, and while waiting for the full effect of the narcotic, efforts can be directed to giving ease to the muscular spasms and pain by brisk friction with stimulating lotions or by mustard poultices to the abdomen and extremities. The morphia will be the best and quickest stimulant which can be used; it will therefore be useless in most cases to administer brandy, camphor, chloroform, {725} or other remedies of that sort. Waiting and giving nothing by the mouth is the wiser course. In twenty minutes to half an hour the most perfect bien être succeeds to the previous agony and exhaustion. In some cases the vomiting, purging, and cramps cease more gradually, and six hours will pass before the patient is at ease. The intense thirst is best treated by the giving of cracked ice sparingly at first, more freely later.

Nothing substitutes morphia hypodermically with success, but in some instances or when the stomach is not very irritable it may be necessary to give medicine by the mouth. In this case chloroform (xv to xxx drops), chlorodyne (x to xx drops), or spirits of camphor (v to x drops) every quarter or half hour in ice-water may be directed. Chloroform and camphor can be combined with the deodorized tincture of opium in ten- to twenty-drop doses. Time is wasted in expecting relief from remedies which are inevitably rejected as soon as taken; it is only when the stomach is very tolerant that it is judicious to begin with them.

The weakness of the heart's action must be combated by brandy or whiskey, given by the mouth with pounded ice or administered hypodermically. A considerable quantity of brandy or diluted alcohol may be introduced by repeated injections beneath the skin. Iced champagne may be tried with good effect. H. C. Wood quotes Hall[18] as recommending hypodermic injections of chloral in the cold stage of cholera. Five to eight grains in twenty minims of distilled water can be thus given, and repeated at intervals of fifteen to twenty minutes until some effect is perceived.

[Footnote 18: _Lancet_, May 2, 1874.]

If vomiting persists after the other symptoms--pain and muscular spasms--are relieved, it is due to the intense gastric hyperæmia; giving nothing which is not necessary is the wiser plan. Carbolic acid, hydrocyanic acid, bismuth, bromide of sodium, or small doses of calomel are remedies which meet the indication. Food should be withheld as long as possible; then iced barley-water, followed by milk and lime-water in very small quantities at short intervals, will test the power of the stomach to retain and digest food.

{726}

INTESTINAL AFFECTIONS OF CHILDREN IN HOT WEATHER.

BY J. LEWIS SMITH, M.D.

Entero-Colitis.

The summer affections of the intestines in children are chiefly of a diarrhoeal character. Diarrhoeal attacks, as is well known, are much more frequent and severe in the summer months than in other portions of the year. Moreover, the diarrhoea of the summer season occurs chiefly among children under the age of two and a half years, and is much more common and fatal in the cities than in the country. In the large cities this malady has heretofore been the annually-recurring scourge of infancy, but of late years its prevalence has been in some degree diminished and its severity controlled by the establishment of health boards and the enforcement of sanitary regulations. Still, it remains an important disease in all our cities, and one that largely increases the aggregate mortality. The truth of this statement is shown by the statistics of deaths taken at random from the mortuary records of any large city. Thus, in New York City during 1882 the deaths from diarrhoea reported to the Health Board, tabulated in months, were as follows:

Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec.
Under
five 34 32 50 50 72 231 1533 817 362 195 68 35
years.
Over
five 14 15 14 20 15 19 131 149 84 55 31 24
years.

Therefore, in 1882--and the statistics of other years correspond in this particular--it is seen that nine times as many deaths of children under the age of five years occurred from diarrhoea during the five months from June 1st to October 31st as in the remaining seven months of the year. It is also seen, in corroboration of the statement that diarrhoea due to hot weather is chiefly a disease of infancy and early childhood, that during these same five months, which embrace the summer season, the number of deaths from diarrhoea under the age of five years was seven and a half times greater than the number over that age. These statistics agree with the general experience of physicians in city practice. The summer diarrhoea would indeed be comparatively unimportant were its death-rate as low in the first five years of life as subsequently.

The following statistics show how great a destruction of life this malady causes even under the surveillance of an energetic health board; and before this board was established it was much greater, as I had abundant opportunities to observe. The last annual report of the New York Board of Health was made in 1875, since which time weekly bulletins have been {727} issued. The deaths from diarrhoea at all ages in the three last years in which annual reports were issued were as follows:

1873. 1874. 1875.
January 94 43 46
February 84 34 52
March 97 40 58
April 114 47 45
May 95 61 89
June 220 144 157
July 1514 1205 1387
August 967 1007 1012
September 424 587 608
October 213 255 185
November 87 105 57
December 53 56 50

Thus, in these three years the aggregate deaths from diarrhoea during the months from June to October inclusive, in which months the summer diarrhoea prevails, were 9885, while in the remaining seven months the number was only 1407. How large a proportion of these deaths in the warm season occurred in children we may infer from remarks made by the Health Board in regard to another year. In their annual report for 1870 the board state: "The mortality from the diarrhoeal affections amounted to 2789, or 33 per cent. of the total deaths; and of these deaths 95 per cent. occurred in children less than five years old, 92 per cent. in children less than two years old, and 67 per cent. in those less than a year old." Every year the reports of the Health Board furnish similar statistics, but enough have been given to show how great a sacrifice of life the summer complaint produces annually in this city.

What we observe in New York in reference to this disease is true also, to a greater or less extent, in other cities of this country and Europe, so far as we have reports. Not in every city is there the same proportionate mortality from this cause as in New York, but the frequency of the summer diarrhoea and the mortality which attends it render it an important disease in, I believe, most cities of both continents. In country towns, whether in villages or farm-houses, this disease is comparatively unimportant, inasmuch as few cases occur in them, and the few that do occur are of mild type, and consequently much less fatal than in the cities.

The comparative immunity of the rural districts has an important relation, as we will see, to the hygienic management of these cases.

ETIOLOGY.--In the causation of this disease two distinct factors are recognized--the one atmospheric, the other dietetic.

The prevalence and severity of the summer diarrhoea correspond closely with the degree of atmospheric heat, as may be inferred from the foregoing statistics. In New York this disease begins in the month of May--earlier in some years than in others--in a few scattered cases, commonly of a mild type. Cases become more and more numerous and severe as the weather grows warmer until July and August, when the diarrhoea attains its maximum prevalence and severity. In these two months it is by far the most frequent and fatal of all the diseases in cities. In the middle of September new patients begin to be less common, and in the latter part of this month and subsequently new cases do not occur, unless under unusual circumstances which favor the development of this malady. In New York a considerable number of deaths {728} of infants occur from the diarrhoea in October. October is not a hot month in our latitude--its average temperature is lower than that of May--and yet the mortality from this disease is considerably larger in the former than in the latter month. This fact, which seems to show that the prevalence of the summer diarrhoea does not correspond with the degree of atmospheric heat, is readily explained. The mortality in October, and indeed in the latter part of September, is not that of new cases, but is mainly of infants, as I have observed every year, who contract the disease in July or August or earlier, and linger in a state of emaciation and increasing weakness till they finally succumb, some even in cool weather.

The fact is therefore undisputed, and is universally admitted, that the summer season, stated in a general way, is the cause of this annually-recurring diarrhoeal epidemic, but it is not so easy to determine what are the exact causative conditions or agents which the summer weather brings into activity. That atmospheric heat does not in itself cause the diarrhoea is evident from the fact that in the rural districts there is the same intensity of heat as in the cities, and yet the summer complaint does not occur. The cause must be looked for in that state of the atmosphere engendered by heat where unsanitary conditions exist, as in large cities. Moreover, observations show that the noxious effluvia with which the air becomes polluted under such circumstances constitute or contain the morbific agent. Thus, in one of the institutions of this city a few years since, on May 10, which happened to be an unusually warm day for this month, an offensive odor was noticed in the wards, which was traced to a large manure-heap that was being upturned in an adjacent garden. On this day four young children were severely attacked by diarrhoea, and one died. Many other examples might be cited showing how the foul air of the city during the hot months, when animal and vegetable decomposition is most active, causes diarrhoea. Several years since, while serving as sanitary inspector for the Citizens' Association in one of the city districts, my attention was particularly called to one of the streets, in which a house-to-house visitation disclosed the fact that nearly every infant between two avenues had the diarrhoea, and usually in a severe form, not a few dying. This street was compactly built with wooden tenement-houses on each side, and contained a dense population, mainly foreign, poor, ignorant, and filthy in their habits. It had no sewer, and the refuse of the kitchens and bed-chambers was thrown into the street, where it accumulated in heaps. Water trickled down over the sidewalks from the houses into the gutters or was thrown out as slops, so that it kept up a constant moisture of the refuse matter which covered the street, and promoted the decay of the animal and vegetable substances which it contained. The air in the domicils and street under such conditions of impurity was necessarily foul in the extreme, and stifling during the hot days and nights of July and August; and it was evidently the important factor in producing the numerous and severe diarrhoeal cases which were in these domicils.

In another locality, occupied by tripe-dealers and a low class of butchers who carried on fat- and bone-boiling at night, the air was so foul after dark that the peculiar impurity which tainted it could be distinctly noticed in the mouth for a considerable time after a night visit. In the street where {729} these nuisances existed and in adjacent streets the summer diarrhoea was very prevalent and destructive to human life. Murchison states that twenty out of twenty-five boys were affected with purging and vomiting from inhaling the effluvia from the contents of an old drain near their school-room. Physicians are familiar with a similar fact showing this purgative effect of impure air--that the atmosphere of a dissecting-room often causes diarrhoea in those otherwise healthy.