CHAPTER VI.

MUCO-ENTERITIS AND ENTERITIS.

THERE has been considerable confusion in the application of this term; Broussais considered it as inflammation of the colon, Abercrombie as inflammation of the peritoneal and muscular coats; others, again, more particularly apply it to the small intestine as an inflammatory disease, commencing in the mucous membrane, and extending in severe cases, so as to involve all the coats of the intestine, even its peritoneal investment. These latter and more severe instances correspond to the enteritis phlegmonodea of Cullen; the former, when the mucous membrane only is affected, to his enteritis erythematica.

Watson, Barlow, &c., apply the term only to the more severe cases, inflammation of all the coats, but we shall in this chapter also consider those in which little more than the mucous membrane is affected, called muco-enteritis, and closely allied to the gastro-enterite and gastric remittent fever. Dr. Copland describes follicular enteritis, and ileo-colitis ; the former we consider in the remarks on strumous and typhoid disease of the intestine, the latter with dysentery.

Enteritis, then, manifests itself under two forms: 1. That involving only the mucous membrane, and which has a disposition to extend in the course of the mucous membrane-mucoenteritis; and, 2. That in which the disease extends in depth, rather than on the surface, and implicates the muscular, peritoneal coats and the connecting tissues: both commence in the mucous membrane.

In hernia, whether external or internal, acute enteritis is set up, and there may be symptoms in common with enteritis, as constipation, vomiting, &c., but their pathology and treatment are so diverse, that a separate consideration of them is required.

It would be difficult to draw a defined separation between cases of inflammatory diarrhoea, as described by Dr. West, and the simplest forms of enteritis; they pass the one into the other. Diarrhoea, however, is not an ordinary symptom of enteritis. The bowels in that disease are frequently constipated.

We shall first consider enteritis in the form of muco-enteritis or enteritis erythematica. It is very frequent among children during dentition or weaning, or after exanthemata; but in many cases of infantile diarrhoea and colic, a more transient condition is set up, twisting pain in the bowels, the evacuation of watery or green motions, with fretfulness, &c., which pass away in a very short time, and which consist in irritation of the bowels rather than inflammation of the mucous membrane.

In muco-enteritis a child is found to be fretful, without its usual playfulness and mirth. The lips are dry, and it has a circumscribed flush on one or other cheek; the skin is dry or roughened; the abdomen is somewhat enlarged, or considerably distended and tympanitic, and varies in degrees of tenderness; but the restlessness of the child causes it to cry when no pain is produced; it is unwilling to be disturbed; the appetite is irregular and capricious, either craving for cooling drinks, as cold water, or for unsuitable food, which is oftentimes the cause of the malady. The bowels are irregular, constipated for several days, or there is diarrhoea, offensive, pale, or greenish motions, slimy mucus, or food scarcely changed, and these conditions alternate; the tongue has whitish fur, and often its substance or papillæ are much injected; vomiting may easily be induced, and probably often arises from extension of the disease to the stomach, when the disease is called gastro-enteritis. In the evening the child becomes still more restless, the skin hot, and even pungent, its sleep disturbed, and accompanied with grinding of the teeth or starting, it awakes alarmed; in the morning the febrile disturbance is less, and the child may be cheerful and playful.

This aggregation of symptoms constitutes gastric remittent or infantile remittent fever, and many look upon it in the same light as typhoid fever, considering that the inflammatory condition of the intestine is a concomitant, not the essential part, of the disease. This is, I think, incorrect; the intestinal disturbance is

the source and the cause of the continuance and extension of the disease; and not, as in typhoid fever, the manifestation of a previously existing and general condition.

When the symptoms persist severely for several weeks greater prostration ensues, the child wastes sometimes to an extreme degree, appears haggard and aged, the lips have dry sordes upon them, the tongue is more injected, and often aphthous. There is less remission in the morning; the child will scarcely sleep at all, or, in very young children, be placed out of the arms of its nurse; the diarrhoea increases, watery evacuations or food unchanged are discharged a short time after having been taken; the pulse becomes very rapid, the eyes half closed, and the child dies from exhaustion, almost before the nurse is aware of any change; or the brain becomes oppressed, and a drowsy, torpid condition, or convulsions sometimes precede death. The convulsions and coma, to which we refer as coming on at the close of this intestinal condition, are closely allied to those produced by ́exhaustion, as the hydrencephaloid disease of Dr. Marshall Hall.

Muco-enteritis is frequently followed by tympanitis, and by strumous disease of the peritoneum or mesentric glands. Although the more prominent symptoms of vomiting and purging subside, the child remains wasted, the abdomen enlarged, the appetite ravenous, and exhaustion steadily progresses to a fatal termination. (See Strumous Disease.)

In young persons we sometimes find a similar state of mucoenteritis as that described, but without phthisis or strumous disease; the eyes are sunken and bright, the lips parched, the tongue exceedingly injected, red, and beef-like; the cheek occasionally flushed by a circumscribed patch on one or other side; the pulse is compressible, but frequent; the skin dry at one time, at another perspiring; there is thirst, generally loss of appetite, and sometimes great irritability of the stomach; the bowels are constipated, or diarrhoea alternates with constipation. The urine is scanty and high coloured. This condition may persist for many weeks, with gradually increasing exhaustion, and in some cases terminates fatally; in very many instances it yields to judicious treatment, but there is great danger of relapse. In young women this state is sometimes associated with painful or deficient menstruation, or with leucorrhoea, and

may be accompanied with severe neuralgic pain in the abdominal parietes, or below the mammæ, and may lead to a more unfavourable prognosis than the case warrants.

There is scarcely any condition of muco-enteritis from which patients do not recover, especially among infants.

The second form of enteritis is more severe, and all the coats of the intestine are involved. The symptoms are exceedingly acute, and too frequently advance to a fatal termination with great rapidity; or they may be extended over many weeks or months. The small intestine alone may be affected, or the cæcum and colon are also implicated.

Several instances which have come under my own observation will illustrate the disease.

CASE LXXV.-Acute Enteritis.-A child about 7 years of age, after eating freely of raw apples, was seized with pain in the abdomen around the umbilicus; the bowels were constipated; the abdomen was tender and distended; the countenance was expressive of much distress; the pulse was rapid; the tongue had slight white fur upon it. The constipation continued, the abdomen became more tender and distended, and the child was found lying on its back, with the legs drawn up in severe pain, and with occasional vomiting. This state continued for several days; the bowels then were freely acted upon, but the child became prostrate, and shortly died, four or five days from the commencement of the disease. On opening the abdomen, the intestines were found much distended with flatus,-the peritoneal surface intensely injected where the coils were in contact, and were covered with lymph. The mucous membrane of the small intestine was found congested, and contained portions of undigested apples.

The inflammation had been set up by crude undigested food; it extended rapidly from the mucus to the muscular and connecting tissues, and to the peritoneum. The inflamed intestine was unable to propel its contents, and hence the constipation; so marked sometimes is the constipation, that it is the most prominent symptom.

Where the disease is less severe, the constipation, pain, and distress subside, and the patient is quickly convalescent; or they continue to recur, exhausting the strength and power of the patient. The severe pain in this form of enteritis contrasts with the absence of it where the mucous membrane only is affected. The symptoms in other instances closely resemble mechanical obstruction.

AL

CASE LXXVI.—Enteritis simulating mechanical obstruction. Henry V—, æt. 17, was admitted into Guy's July 24th, 1850. Hs was a tall, thin lad, who had been employed in a tobacconist's shop, and a week before admission had had diarrhoea, which was checked by an opium pill. The day before admission he felt well, and whilst walking out of doors, he ate some apples and cherries; a few hours afterwards severe pain in the abdomen came on; some rhubarb, with compound chalk powder and opium, was prescribed; the bowels were opened twice during the night; at seven in the morning severe pain in the abdomen returned; his countenance was expressive of great distress; the eyes sunken, the bowels confined; the tongue furred and clammy; he was rolling himself from one side of the bed to the other from the intensity of the pain; the recti muscles were rigid, but pressure could be borne; an emetic was administered, and some undigested apples and cherries were vomited. Calomel gr. v. with opium gr. jss. were given, but at once returned; a turpentine injection was then administered. Vomiting then came on, at first of bilious fluid, afterwards stercoraceous; the injection brought away some scybalous matter, but without relief to the pain. The calomel and opium were repeated, but at once returned. At 5 p.m. he was placed in a warm bath, the tongue was clean, the pulse 130, the abdominal muscles rigid, and the paroxysms of pain in the abdomen very severe. Calomel and opium, of each 1 gr., were given every three hours, and to relieve the intense pain, chloroform m xx. were prescribed. His pulse became exceedingly rapid, and he died at eleven the next morning, about thirty-six hours from the commencement of the pain.

On inspection, the intestines were found very much distended; the peritoneum injected, and delicate portions of lymph passed between the coils; on turning aside the small intestines, the cæcum, colon, and about three feet of ileum were found collapsed, pale, and empty; at this point there was a sudden cessation of the intense congestion and distension, giving the appearance of constriction; but no constriction or twist could be detected; the mesentery, however, attached to this part, and connected with the last lumbar vertebræ, contained several hard and calcareous glands, and appeared slightly contracted; on raising the intestine, and placing it in a straight line, air at once passed, and the constriction disappeared. The intestine was full of pale yellow fluid fæces, and contained some undigested matter; no ulceration existed, and the other viscera were healthy.

In this case severe colic came on after taking indigestible food; inflammation of the mucous membrane of the small intestine was produced; this extended to the muscular and peritoneal coats, and was followed by intense pain, distension and vomiting; it appeared that the slight interference with the movement of the ileum opposite to the calcareous mesenteric glands, led to the limitation of the disease at that part, and that over-distension following inflammation was the principal cause of the obstruction. The abdomen for several hours was tolerant of pressure, and the