230
INDIAN MEDICAL GAZETTE.
ENTERO-SEPTIC FEVERS. By
Surgeon-Captain R. ROSS,
i.m.s.
In a former paper in the Indian Medical Gazette I gave some cases of febricula accompanied by tenderness in various parts of the abdomen and cured simply by purgatives, without the use of quinine. The tenderness could be at-
tributed
to
slight
only
muco-enteritis or enlargement of the mesentric glands; and I ventured to maintain that in these cases the fever was consequent on the intestinal lesions and not vice versa as is generally held ; that it was due to absorption of toxic ptomai'us from the contents of the gut, and not to any primary blood infection such as that of malaria. As very many cases of fever and other disorders in India are accompanied or preceded by abdominal tenderness or pain, tympanitis, diarrhoea or constipation, it may reasonably be asked how far in these the constitutional symptoms are dependent on the intestinal troubles. For, it is clear, if we can attribute many forms of fever to such an origin, we shall be forced to reconsider in great measure our notions of the etiology of Indian fevers in general; and to effect a discrimination between true malarial fevers and those which are dependent 011 intestinal sepsis. In the very important practical point of treatment moreover, we shall be 110 longer allowed to confound the two classes; for in the blood fevers our treatment will have to be directed toward purifying the blood, while in the eutero-septic fevers we shall have to attend primarily to the intestines. In the one case we shall depend 011 our quinine aud our defervescents ; in the other on dieting, laxatives and
intestinal
antiseptics.
Before venturing however upon a further clinical study of the point, I beg to offer some remarks which may help to clear the way and isolate the various issues 011 hand. We shall not be in a position to interpret our cases rightly unless we know clearly and exactly?(1) What is meant by septic poisoniug from the intestines? (2) What are the facts which may make us consider such poisoning to be likely or unlikely ? (3) What will probably be the symptoms of diseases issuing from such a cause ; and how shall we diagnose and treat those diseases? First, what do we mean by entero-septic poisoning? There are seven vice of general Bystemic poisoning or infection?the skin, the genital,urinary, respiratory, aud digestive tracts, wounds, and the ?post-partum uterus. Of these the three last, however, differ from the others in the important point that they contain, to a greater degree, natural discharges, highly putrescible and easily accessible to organisms from the outer air. We know for certain what a large part confined discharges play iu the production This part is of septic fevers from wouuds.
[Aug.
1892.
the case of the respiratory but it is indeed highly so in the case of the digestive* tract, full as it is of food residues and secretions which are constantly exposed to the presence of septic ingesta, and which are often retained for days in the bowel. Hence as a via of systemic poisoning the digestive tract must be classed with wounds and the post-par turn uterus, rather than with the respiratory and genito-urinary tracts ; and we shall perceive that there should be a powerful analogy between diseases issuing from uterus wounds, and possibly from the digestive tract. Thus we shall mean by entero-septic poisoning a condition analogous to traumo-septic and utero-septic poisoning. In all three the condition will be generally one of fever, caused by absorption of ptoma'ins from inflamed tracts or from septic discharges, and rapidly relieved by removing the local inflammation or the vitiating fluids. In fact the entero-septic fever will be
scarcely possible in tract for example ;
precisely parallel
to
traumatic,
inflammatory
and septic fevers arising from confined pus or retained lochia}; but it will not be comparable to septic infections, such as pyaemia due to the proliferation of specific organisms in the blood itself. We must make the usual distinction
septic poisoning xand septic infection. Having made this definition, we may proceed to ask Is entero-septic poisoning possible ?" Considering the highly absorbent nature of
between
"
the intestinal surface and the
nature of the food residues
we
highly putrescible
shall indeed expect
easy septic absorption. But we are at once confronted with the fact that nature herself has expected the same thing and jealously guarded against it. Not only are the mesenteric glauds which control the lacteals very large and numerous, but almost all the venous blood coming from the whole tract is carefully filtered through a large organ, especially provided for the purpose. Besides this the food no sooner enters the stomach than it is submitted to a powerful disintegrating process which probably acts on most living organisms as easily as on dead substances ; and no sooner does it leave it than it is mixed with the antiseptic bile. Further, the walls of the whole iutestine have probably a powerful germicidal action similar to that possessed by the clean cut surface of a wound. The finely disintegrated food mingled with a multitude of secretions, churned by the peristaltic action and winnowed by the villi, is exposed to all these antiseptic influences, while
septic materials or particles which escape into the lacteals or capillaries are destroyed by the
or returned into the bile by the liver. Nevertheless, notwithstanding these precau-
glands
tions, we know as a fact that organisms do live and thrive not only in the food residues but in the intestinal tissues themselves, and not only in disease but even iu health [see for instance
Aug.
ROSS ON ENTERO-SEPTIC FEVERS.
1892.J
231
the circulation.
entering pathoMicro-organisms ami Disease, 3rd Ed., freely forms, when especially virulent or when genic often faeces are et p. 241, seq.] Highly putrid in sufficient force, have this power undoubtedly, passed, and the gases of the alimentary canal though many other forms apparently do not are attributed to fermentation of the chyme ; so it. We have no right therefore to asthat it is quite impossible to deny that intestinal possess that such a process is impossible altosume sepsis often exists. in the case of the digestive tract, simply Three conditions may exist which probably gether there is an additional safeguard, the because cause such sepsis. First, the ingestion of large liver, imposed there. If in the one case certain numbers of organisms in food and water. In are capable of overcoming two safePortions orgauisms India this is very common obviously. the glands and the germicidal action of the guards, of tough tissue, only partially or not at all it is quite possible that in the other case blood, are the on sterilized by cooking, passed by certain organisms are capable of overcoming stomach without disintegration, aud traverse the three safeguards, the glands, the blood, and the whole canal without their interior beiug touched liver. When we consider the absorbent power by the antiseptic fluids round them. Multi- of the mucous membrane of the intestines tudes of spores, more than possibly quite untogether with the putrescible nature of their hurt by these fluids, follow the same course and Klein's
await
only
a
favourable moment for develop-
ment.
Secondly, any delay in the intestinal probably at once induce an increase
will
sis.
stream
of sep-
the food takes from twenty-four hours in traversing the whole tract. If from any cause the food residues are delayed, if they accummulate, if they become so massed that the centre of the mass escapes the antiseptic influences, rapid putrescence That intestinal stasis such must be the result. as this may be caused by want of stimulation of the peristaltic action by deficiency of exercise, as during sickness, or by excess of food to
Ordinarily
forty-eight
residues owing
to
over-feeding or being over-fed, which I can only touch
important point
is
an
on
here.
The third cause of intestinal sepsis is possibly deficiency of antiseptic influences within the body, owing to previous sickness, &c. I must here leave to the reader a deeper consideration of these causes, premising only their possible importance in the productions of disease and, especially, of sequel? in the sick-room. It seems then that the chief causes are septic food,
Certain
shall indeed understand what a liver plays in controlling septic the large part absorption. But we dare not assume for that reason that the liver is absolutely impermeable to every form of organism or ptomai'n, which we must assume if we contend that no septic poisoning or infectiou can occur from the digestive tract. Why, moreover, should we not grant that chemical ptomai'ns may be absorbed as readily as mineral or vegetable poisons ? When, however, we look further and consider the possibility of absorption from already inflamed tracts of the intestines, or from ulcers, It we shall see the subject still more clearly. is not necessary to assume that the organism which has attacked the mucous membrane is the same as that which produces the toxic ptomai'n or which invades the blood through the abraded patch. The contiguity of highly putrescent food to such abrasions must, we think, be very likely to produce septic fever. When there is a stasis in the bowel-stream (such as often exists for days together) this likelihood is increased. The inflamed part, already deprived of its resisting power, gives easy ingress to bacteria and their contents,
we
as a diphtheritic patch indigestible food, over-feeding, bodily inaction, ptomai'ns, just precisely the local trouble be intense in Nor need does. and as in the sickness. previous supine position, ; a mere hypersemic tract covered with Constipation, of course, generally produced by any wayresidues may, we can imagine, cause one or more of these, is very dangerous. septic severe systemic poisoning. Finally, the same of intestinal the possibility sepsis, Granting stasis aud the the bowel suite of circumstances, for we what reasons have considering it possible that the products of the sepsis or the micro- entero-sepsis, may induce both the local inflamas confinement of disand the fever,
organisms themselves
pass into the syspoint can only be proved by clinical study, but we have some reasons for assuming the possibility, from our analogy with the traumatic septic fevers. It is true that fluids returning from the digestive tract are doubly guarded by the lymphatic glands and the liver, whereas those returning from wounds have only the former, the venous blood being poured at once into the systemic circulation. But we know that, in the case of wounds, certain organisms or their ptomai'ns are capable of overcoming all systemic resistance aud of temic circulation ?
ever
This
just
mation
charges produces post-partum
both in wounds and in the
uterus.
be useful to construct a port of hypothetical pathology for such entero-septic fevers; and the reader will note how our imagined symptoms agree with those continually The first thing is an enteroseen in practice. in any of the ways I have mensepsis produced tioned; as for instance, in the case of children by an embolism of indigested casein in the large gut, or, in the case of natives, one of rice taken during a feast. The check in the bowel-stream It may
now
232
INDIAN MEDICAL GAZETTE.
gives immediate opportunity for ment of multitudes of organising,
pathogenic. forms
At spots where the
multiply,
a
more more
less virulent or
slight muco-enteritis
mences, and in these
from the
develop-
the
spots (or perhaps
com-
at once
septic food-residues) there takes place a ptomainic absorption. If now the bowel-stream flows on again the offending fluids are swept
if fresh if they down, pathogenic organisms have affected a lodgement in the enteritic spots, the absorption continues and overcomes the resistance of the glands, and the toxic agents pour into the blood. The liver and mesenteric glands meanwhile become tender, just as the glands connected with a septic wound. The local action may be limited or diffuse: the virulency of the toxic action may be quite independent of the local action, since it may depend on another organism, whose poison merely gains ingress through the abrasions. Thus, a small enteritic spot may lead to severe fever, or extensive enteritis may give rise to hardly any. Resolution may now occur?(1) by relief of the bowel stasis; (2) by the local irritation giving rise to diarrhoea. In both cases the offending residues being swept away, the local hyperajmia is resolved, and ptcmainic absorption ceases. But the fever need not depart at once. From the analogy of traumatic sepsis we imagine that it may remain some hours after removal of the In the case of retained lochi?, for cause. example, the fever continues often for some little time after complete syringing has been resorted The poison has to be slowly eliminated. to. But after resolution a second danger awaits the patient?the return of nil the symptoms. During the first constipation and fever there is generally loss of appetite, during which the patient takes but little nourishment. As soon however, as diarrhoea or a purgative has cleaned the bowel, he takes more, with the result, that fresh food residues come down upon the inflamed tracts, become septic with the same organisms, and give rise to the same fever, to be expelled again in the" same way. In cases which are continually fed up" in spite of the loss of appetite, there is a slow constant stream of septic residues flowing on and causing a lingering fever similar to that caused by sinuses and ill-treated wounds. In some cases there is a regular alternation between fever on the one hand, and diarrhoea on the other. In others, the enterosepsis works up, as it were, at intervals of a week, a fortnight, and more. In a third class there is immediate and permanent resolution; and it will depend merely on adventitious circumstances or on the treatment to what class a case will belong. Hence, we shall expect enteroBeptic fever to take on itself many types, now simulating ague, now enteric, now lasting for an hour or two, aud now for weeks; while the only away and health returns.
But if not,
come
or
or
constant
[Aug.
1892.
symptom will be fever accompanied by
bowel symptoms,
constipation, diarrhoea, tendertympanitis, pain, extensive, slight or almost imperceptible. Again, we may expect regular septic infection sometimes, that is, a fever due to presence in the blood of the organisms themselves. But we cannot expect to find enteroseptic fever precisely the same as traumo-septic fevers. The conditions under which organisms ness,
live in the intestines are different to those under which they live in wounds, and hence we must look for different species. As a matter of fact, however, idiopathic pyajmia is not uncommon. Can this form be possibly due to intestinal infection ? With respect to the diagnosis of entero-septic fevers, the reader must be led by the foregoing remarks. The precedence or concomitance of abdominal symptoms will be his chief guide. Above all, he must search carefully for spots of abdominal tenderness, which are often obscure and easily missed. In stout persons it is often impossible to detect them. He must use deep but gentle palpation, and must exclude the more superficial muscular tenderness common in persons with violent coughs. Tympanitis, diarrhoea, and constipation are valuable signs, especially when they precede the fever; as also is diarrhoea preceding defervescence. But in enquiring into the history of a case, it must be remembered that a patient is often quite unconscious of a limited intestinal tenderness, and will often declare that there is none, until palpation reveals The effect of laxatives must be closely it. watched, for it is more or less'pathognomonic. If there is no permanent defervescence after gentle but complete perpurgation, and if meanwhile the dieting has been carefully attended to, we may expect a primary blood poisoning due to malaria or approaching small pox, say. Again, the reader will see how readily entero-sepsis may supervene on other diseases, especially prolonged ague, and hence how commonly entero-septic fevers may arise on the top of other disorders. On the points of the differential diagnosis between these fevers and enteric, and of enterosepsis, as a predisposing cause to the latter, I have 110 space to touch. It is with respect to treatment that the great importance of making the diagnosis between malarial and septic fever comes in. It is now an established dogma that the first point in the treatment of traumo-septic fevers is to thoroughly cleanse the wound; and it is a matter of universal experience that when this is doue the fever abates, unless, indeed, it has gone on to blood infection. Hence, if entero-septic fevers really exists, our first care in their treatment must be to remove all the alvine discharges, and A our second to diet the patient properly. often irritates not only single strong purgative the bowel excessively, but as often acts only on
Aug.
1892.]
ROSS ON ENTERO-SEPTIC FEVERS.
the contents of the lower gut. Nevertheless, it may be given to strong patients sometimes, with immediate results. Generally, however, repeated doses of a laxative, such as cascara sagrada, are more useful. Small doses of castor-oil constitute the best form in my experience ; unfortunately, it is a disagreeable form. But in weak patients and in severe cases, 110 laxatives at all should be exhibited until the lower bowel has been exhausted by means of the glycerine syringe and other enemata. In all cases, the medical man must satisfy himself that the offensive matters, which are often in large quantity, are got rid of. It is perfectly useless in most cases to depend upon the fact that one or two motions have been passed. The continued use of the glycerine syringe will soon reveal whether there is more faecal matter behind. When perpurgation has been effected, there is generally more or less immediate relief. We may now proceed to our intestinal antiseptics. Small doses of quinine (1 or 2 grs.) dissolved in acid, and combined with vegetable bitters, such as gentian and quassia, are very effective when given every three hours. Vegetable bitters have a peculiar effect in this way even without the quinine. In fact, one is tempted to attribute their undoubted tonic effect to their depurant properties, though they are very little antiseptic, I believe. At all events they often expel thread-worms. Perchloride of mercury, sulphurous acid, &c., may be given according to the fancy of the practitioner; but whatever we give, we must give in a constant stream, attend' ing meanwhile carefully to the bowels, our object being to conquer the sepsis entirely, and to preIn fact, our vent further ptomai'uic absorption. treatment must be precisely parallel to that adopted in traumatic and uterine septic fevers. Any attempt to crush the fever by large doses of quinine and by diaphoretics is only likely to succeed accidently, unless the bowels are first cleared. ludeed, before this, the quinine is only vomited, which perhaps helps to explain the disrepute into which this valuable drug has fallen with those who mistake entero-septic for I do not see how the use of malarial fevers. in is any way indicated in these diaphoretics Until the fevers. Dieting is very important. bowels are cleared almost nothing should be given in ordinary cases. The quality should be varied and simple?bread and butter, broth and softly boiled rice, &c. But here, as in certain other fevers, the quantity is the important point. I think it should vary with the appetite. When there is 110 appetite it is more thau likely that there is no absorption, or very little, however we peptonize or zyminize the food. Hence, excess of food is simply passed on into the intestine by the stomach. For this reason milk, with its property of forming accretions of casein, is such a dangerous diet. More than half a v
pint should,
I
day.
think, rarely
233 be
given
in
the
the more salieut points of the are many others 1 have been forced to omit. The present is only a part of the larger subject of. entero-sepsis as a cause of disease, and as the product of disease, &c. Notably, certain forms of dyspepsia, anaemia, diarrhoea, hepatitis, &c., may be possibly traced to this cause, and that singular and highly important fact, the interdependence of these with Indian fevers, be perhaps explained from it, as well as some obscure points The treatin the epidemiology of those fevers. ment of the whole group of entero-septic fevers, moreover, will probably follow the lines of the antiseptic treatment of enteric fever which, indeed, is possibly only one of the forms of enteroSuch
subject:
septic
infection.
We have only touched here however
following points 1. 2.
on
the
:?
That intestinal sepsis may exist. That septic absorption from the bowel is
possible. 3. That, until proved impossible, such absorption may cause general septic fevers, which, from the fact of the seat of poisoning or infection being, so to speak, hidden away in the bowels, we may mistake for primary blood
?
fevers.
4. That we should pay every attention to abdominal complications occurring in cases of Indian fevers, with a view to discovering which is primary, the fever or the bowel trouble. 5. That if the existence of entero-septic fevers become established, the term malarious fever will probably have to be much limited in its application.
It may be useful for the reader to study again in the light of the above remarks the controversy in the Indian Medical Gazette for 1887, June, July, August, December, and 1888, February, August, November, and December waged or maintained by Drs. Younge,Fairland,Hamilton, Riordan, and Macphersou, on enteric, malarial fevers, hill diarrhoea, hepatic exhaustion, &c.
/
INDIAN MEDICAL GAZETTE.
ENTERO-SEPTIC FEVERS. By
Surgeon-Captain R. ROSS,
i.m.s.
In a former paper in the Indian Medical Gazette I gave some cases of febricula accompanied by tenderness in various parts of the abdomen and cured simply by purgatives, without the use of quinine. The tenderness could be at-
tributed
to
slight
only
muco-enteritis or enlargement of the mesentric glands; and I ventured to maintain that in these cases the fever was consequent on the intestinal lesions and not vice versa as is generally held ; that it was due to absorption of toxic ptomai'us from the contents of the gut, and not to any primary blood infection such as that of malaria. As very many cases of fever and other disorders in India are accompanied or preceded by abdominal tenderness or pain, tympanitis, diarrhoea or constipation, it may reasonably be asked how far in these the constitutional symptoms are dependent on the intestinal troubles. For, it is clear, if we can attribute many forms of fever to such an origin, we shall be forced to reconsider in great measure our notions of the etiology of Indian fevers in general; and to effect a discrimination between true malarial fevers and those which are dependent 011 intestinal sepsis. In the very important practical point of treatment moreover, we shall be 110 longer allowed to confound the two classes; for in the blood fevers our treatment will have to be directed toward purifying the blood, while in the eutero-septic fevers we shall have to attend primarily to the intestines. In the one case we shall depend 011 our quinine aud our defervescents ; in the other on dieting, laxatives and
intestinal
antiseptics.
Before venturing however upon a further clinical study of the point, I beg to offer some remarks which may help to clear the way and isolate the various issues 011 hand. We shall not be in a position to interpret our cases rightly unless we know clearly and exactly?(1) What is meant by septic poisoniug from the intestines? (2) What are the facts which may make us consider such poisoning to be likely or unlikely ? (3) What will probably be the symptoms of diseases issuing from such a cause ; and how shall we diagnose and treat those diseases? First, what do we mean by entero-septic poisoning? There are seven vice of general Bystemic poisoning or infection?the skin, the genital,urinary, respiratory, aud digestive tracts, wounds, and the ?post-partum uterus. Of these the three last, however, differ from the others in the important point that they contain, to a greater degree, natural discharges, highly putrescible and easily accessible to organisms from the outer air. We know for certain what a large part confined discharges play iu the production This part is of septic fevers from wouuds.
[Aug.
1892.
the case of the respiratory but it is indeed highly so in the case of the digestive* tract, full as it is of food residues and secretions which are constantly exposed to the presence of septic ingesta, and which are often retained for days in the bowel. Hence as a via of systemic poisoning the digestive tract must be classed with wounds and the post-par turn uterus, rather than with the respiratory and genito-urinary tracts ; and we shall perceive that there should be a powerful analogy between diseases issuing from uterus wounds, and possibly from the digestive tract. Thus we shall mean by entero-septic poisoning a condition analogous to traumo-septic and utero-septic poisoning. In all three the condition will be generally one of fever, caused by absorption of ptoma'ins from inflamed tracts or from septic discharges, and rapidly relieved by removing the local inflammation or the vitiating fluids. In fact the entero-septic fever will be
scarcely possible in tract for example ;
precisely parallel
to
traumatic,
inflammatory
and septic fevers arising from confined pus or retained lochia}; but it will not be comparable to septic infections, such as pyaemia due to the proliferation of specific organisms in the blood itself. We must make the usual distinction
septic poisoning xand septic infection. Having made this definition, we may proceed to ask Is entero-septic poisoning possible ?" Considering the highly absorbent nature of
between
"
the intestinal surface and the
nature of the food residues
we
highly putrescible
shall indeed expect
easy septic absorption. But we are at once confronted with the fact that nature herself has expected the same thing and jealously guarded against it. Not only are the mesenteric glauds which control the lacteals very large and numerous, but almost all the venous blood coming from the whole tract is carefully filtered through a large organ, especially provided for the purpose. Besides this the food no sooner enters the stomach than it is submitted to a powerful disintegrating process which probably acts on most living organisms as easily as on dead substances ; and no sooner does it leave it than it is mixed with the antiseptic bile. Further, the walls of the whole iutestine have probably a powerful germicidal action similar to that possessed by the clean cut surface of a wound. The finely disintegrated food mingled with a multitude of secretions, churned by the peristaltic action and winnowed by the villi, is exposed to all these antiseptic influences, while
septic materials or particles which escape into the lacteals or capillaries are destroyed by the
or returned into the bile by the liver. Nevertheless, notwithstanding these precau-
glands
tions, we know as a fact that organisms do live and thrive not only in the food residues but in the intestinal tissues themselves, and not only in disease but even iu health [see for instance
Aug.
ROSS ON ENTERO-SEPTIC FEVERS.
1892.J
231
the circulation.
entering pathoMicro-organisms ami Disease, 3rd Ed., freely forms, when especially virulent or when genic often faeces are et p. 241, seq.] Highly putrid in sufficient force, have this power undoubtedly, passed, and the gases of the alimentary canal though many other forms apparently do not are attributed to fermentation of the chyme ; so it. We have no right therefore to asthat it is quite impossible to deny that intestinal possess that such a process is impossible altosume sepsis often exists. in the case of the digestive tract, simply Three conditions may exist which probably gether there is an additional safeguard, the because cause such sepsis. First, the ingestion of large liver, imposed there. If in the one case certain numbers of organisms in food and water. In are capable of overcoming two safePortions orgauisms India this is very common obviously. the glands and the germicidal action of the guards, of tough tissue, only partially or not at all it is quite possible that in the other case blood, are the on sterilized by cooking, passed by certain organisms are capable of overcoming stomach without disintegration, aud traverse the three safeguards, the glands, the blood, and the whole canal without their interior beiug touched liver. When we consider the absorbent power by the antiseptic fluids round them. Multi- of the mucous membrane of the intestines tudes of spores, more than possibly quite untogether with the putrescible nature of their hurt by these fluids, follow the same course and Klein's
await
only
a
favourable moment for develop-
ment.
Secondly, any delay in the intestinal probably at once induce an increase
will
sis.
stream
of sep-
the food takes from twenty-four hours in traversing the whole tract. If from any cause the food residues are delayed, if they accummulate, if they become so massed that the centre of the mass escapes the antiseptic influences, rapid putrescence That intestinal stasis such must be the result. as this may be caused by want of stimulation of the peristaltic action by deficiency of exercise, as during sickness, or by excess of food to
Ordinarily
forty-eight
residues owing
to
over-feeding or being over-fed, which I can only touch
important point
is
an
on
here.
The third cause of intestinal sepsis is possibly deficiency of antiseptic influences within the body, owing to previous sickness, &c. I must here leave to the reader a deeper consideration of these causes, premising only their possible importance in the productions of disease and, especially, of sequel? in the sick-room. It seems then that the chief causes are septic food,
Certain
shall indeed understand what a liver plays in controlling septic the large part absorption. But we dare not assume for that reason that the liver is absolutely impermeable to every form of organism or ptomai'n, which we must assume if we contend that no septic poisoning or infectiou can occur from the digestive tract. Why, moreover, should we not grant that chemical ptomai'ns may be absorbed as readily as mineral or vegetable poisons ? When, however, we look further and consider the possibility of absorption from already inflamed tracts of the intestines, or from ulcers, It we shall see the subject still more clearly. is not necessary to assume that the organism which has attacked the mucous membrane is the same as that which produces the toxic ptomai'n or which invades the blood through the abraded patch. The contiguity of highly putrescent food to such abrasions must, we think, be very likely to produce septic fever. When there is a stasis in the bowel-stream (such as often exists for days together) this likelihood is increased. The inflamed part, already deprived of its resisting power, gives easy ingress to bacteria and their contents,
we
as a diphtheritic patch indigestible food, over-feeding, bodily inaction, ptomai'ns, just precisely the local trouble be intense in Nor need does. and as in the sickness. previous supine position, ; a mere hypersemic tract covered with Constipation, of course, generally produced by any wayresidues may, we can imagine, cause one or more of these, is very dangerous. septic severe systemic poisoning. Finally, the same of intestinal the possibility sepsis, Granting stasis aud the the bowel suite of circumstances, for we what reasons have considering it possible that the products of the sepsis or the micro- entero-sepsis, may induce both the local inflamas confinement of disand the fever,
organisms themselves
pass into the syspoint can only be proved by clinical study, but we have some reasons for assuming the possibility, from our analogy with the traumatic septic fevers. It is true that fluids returning from the digestive tract are doubly guarded by the lymphatic glands and the liver, whereas those returning from wounds have only the former, the venous blood being poured at once into the systemic circulation. But we know that, in the case of wounds, certain organisms or their ptomai'ns are capable of overcoming all systemic resistance aud of temic circulation ?
ever
This
just
mation
charges produces post-partum
both in wounds and in the
uterus.
be useful to construct a port of hypothetical pathology for such entero-septic fevers; and the reader will note how our imagined symptoms agree with those continually The first thing is an enteroseen in practice. in any of the ways I have mensepsis produced tioned; as for instance, in the case of children by an embolism of indigested casein in the large gut, or, in the case of natives, one of rice taken during a feast. The check in the bowel-stream It may
now
232
INDIAN MEDICAL GAZETTE.
gives immediate opportunity for ment of multitudes of organising,
pathogenic. forms
At spots where the
multiply,
a
more more
less virulent or
slight muco-enteritis
mences, and in these
from the
develop-
the
spots (or perhaps
com-
at once
septic food-residues) there takes place a ptomainic absorption. If now the bowel-stream flows on again the offending fluids are swept
if fresh if they down, pathogenic organisms have affected a lodgement in the enteritic spots, the absorption continues and overcomes the resistance of the glands, and the toxic agents pour into the blood. The liver and mesenteric glands meanwhile become tender, just as the glands connected with a septic wound. The local action may be limited or diffuse: the virulency of the toxic action may be quite independent of the local action, since it may depend on another organism, whose poison merely gains ingress through the abrasions. Thus, a small enteritic spot may lead to severe fever, or extensive enteritis may give rise to hardly any. Resolution may now occur?(1) by relief of the bowel stasis; (2) by the local irritation giving rise to diarrhoea. In both cases the offending residues being swept away, the local hyperajmia is resolved, and ptcmainic absorption ceases. But the fever need not depart at once. From the analogy of traumatic sepsis we imagine that it may remain some hours after removal of the In the case of retained lochi?, for cause. example, the fever continues often for some little time after complete syringing has been resorted The poison has to be slowly eliminated. to. But after resolution a second danger awaits the patient?the return of nil the symptoms. During the first constipation and fever there is generally loss of appetite, during which the patient takes but little nourishment. As soon however, as diarrhoea or a purgative has cleaned the bowel, he takes more, with the result, that fresh food residues come down upon the inflamed tracts, become septic with the same organisms, and give rise to the same fever, to be expelled again in the" same way. In cases which are continually fed up" in spite of the loss of appetite, there is a slow constant stream of septic residues flowing on and causing a lingering fever similar to that caused by sinuses and ill-treated wounds. In some cases there is a regular alternation between fever on the one hand, and diarrhoea on the other. In others, the enterosepsis works up, as it were, at intervals of a week, a fortnight, and more. In a third class there is immediate and permanent resolution; and it will depend merely on adventitious circumstances or on the treatment to what class a case will belong. Hence, we shall expect enteroBeptic fever to take on itself many types, now simulating ague, now enteric, now lasting for an hour or two, aud now for weeks; while the only away and health returns.
But if not,
come
or
or
constant
[Aug.
1892.
symptom will be fever accompanied by
bowel symptoms,
constipation, diarrhoea, tendertympanitis, pain, extensive, slight or almost imperceptible. Again, we may expect regular septic infection sometimes, that is, a fever due to presence in the blood of the organisms themselves. But we cannot expect to find enteroseptic fever precisely the same as traumo-septic fevers. The conditions under which organisms ness,
live in the intestines are different to those under which they live in wounds, and hence we must look for different species. As a matter of fact, however, idiopathic pyajmia is not uncommon. Can this form be possibly due to intestinal infection ? With respect to the diagnosis of entero-septic fevers, the reader must be led by the foregoing remarks. The precedence or concomitance of abdominal symptoms will be his chief guide. Above all, he must search carefully for spots of abdominal tenderness, which are often obscure and easily missed. In stout persons it is often impossible to detect them. He must use deep but gentle palpation, and must exclude the more superficial muscular tenderness common in persons with violent coughs. Tympanitis, diarrhoea, and constipation are valuable signs, especially when they precede the fever; as also is diarrhoea preceding defervescence. But in enquiring into the history of a case, it must be remembered that a patient is often quite unconscious of a limited intestinal tenderness, and will often declare that there is none, until palpation reveals The effect of laxatives must be closely it. watched, for it is more or less'pathognomonic. If there is no permanent defervescence after gentle but complete perpurgation, and if meanwhile the dieting has been carefully attended to, we may expect a primary blood poisoning due to malaria or approaching small pox, say. Again, the reader will see how readily entero-sepsis may supervene on other diseases, especially prolonged ague, and hence how commonly entero-septic fevers may arise on the top of other disorders. On the points of the differential diagnosis between these fevers and enteric, and of enterosepsis, as a predisposing cause to the latter, I have 110 space to touch. It is with respect to treatment that the great importance of making the diagnosis between malarial and septic fever comes in. It is now an established dogma that the first point in the treatment of traumo-septic fevers is to thoroughly cleanse the wound; and it is a matter of universal experience that when this is doue the fever abates, unless, indeed, it has gone on to blood infection. Hence, if entero-septic fevers really exists, our first care in their treatment must be to remove all the alvine discharges, and A our second to diet the patient properly. often irritates not only single strong purgative the bowel excessively, but as often acts only on
Aug.
1892.]
ROSS ON ENTERO-SEPTIC FEVERS.
the contents of the lower gut. Nevertheless, it may be given to strong patients sometimes, with immediate results. Generally, however, repeated doses of a laxative, such as cascara sagrada, are more useful. Small doses of castor-oil constitute the best form in my experience ; unfortunately, it is a disagreeable form. But in weak patients and in severe cases, 110 laxatives at all should be exhibited until the lower bowel has been exhausted by means of the glycerine syringe and other enemata. In all cases, the medical man must satisfy himself that the offensive matters, which are often in large quantity, are got rid of. It is perfectly useless in most cases to depend upon the fact that one or two motions have been passed. The continued use of the glycerine syringe will soon reveal whether there is more faecal matter behind. When perpurgation has been effected, there is generally more or less immediate relief. We may now proceed to our intestinal antiseptics. Small doses of quinine (1 or 2 grs.) dissolved in acid, and combined with vegetable bitters, such as gentian and quassia, are very effective when given every three hours. Vegetable bitters have a peculiar effect in this way even without the quinine. In fact, one is tempted to attribute their undoubted tonic effect to their depurant properties, though they are very little antiseptic, I believe. At all events they often expel thread-worms. Perchloride of mercury, sulphurous acid, &c., may be given according to the fancy of the practitioner; but whatever we give, we must give in a constant stream, attend' ing meanwhile carefully to the bowels, our object being to conquer the sepsis entirely, and to preIn fact, our vent further ptomai'uic absorption. treatment must be precisely parallel to that adopted in traumatic and uterine septic fevers. Any attempt to crush the fever by large doses of quinine and by diaphoretics is only likely to succeed accidently, unless the bowels are first cleared. ludeed, before this, the quinine is only vomited, which perhaps helps to explain the disrepute into which this valuable drug has fallen with those who mistake entero-septic for I do not see how the use of malarial fevers. in is any way indicated in these diaphoretics Until the fevers. Dieting is very important. bowels are cleared almost nothing should be given in ordinary cases. The quality should be varied and simple?bread and butter, broth and softly boiled rice, &c. But here, as in certain other fevers, the quantity is the important point. I think it should vary with the appetite. When there is 110 appetite it is more thau likely that there is no absorption, or very little, however we peptonize or zyminize the food. Hence, excess of food is simply passed on into the intestine by the stomach. For this reason milk, with its property of forming accretions of casein, is such a dangerous diet. More than half a v
pint should,
I
day.
think, rarely
233 be
given
in
the
the more salieut points of the are many others 1 have been forced to omit. The present is only a part of the larger subject of. entero-sepsis as a cause of disease, and as the product of disease, &c. Notably, certain forms of dyspepsia, anaemia, diarrhoea, hepatitis, &c., may be possibly traced to this cause, and that singular and highly important fact, the interdependence of these with Indian fevers, be perhaps explained from it, as well as some obscure points The treatin the epidemiology of those fevers. ment of the whole group of entero-septic fevers, moreover, will probably follow the lines of the antiseptic treatment of enteric fever which, indeed, is possibly only one of the forms of enteroSuch
subject:
septic
infection.
We have only touched here however
following points 1. 2.
on
the
:?
That intestinal sepsis may exist. That septic absorption from the bowel is
possible. 3. That, until proved impossible, such absorption may cause general septic fevers, which, from the fact of the seat of poisoning or infection being, so to speak, hidden away in the bowels, we may mistake for primary blood
?
fevers.
4. That we should pay every attention to abdominal complications occurring in cases of Indian fevers, with a view to discovering which is primary, the fever or the bowel trouble. 5. That if the existence of entero-septic fevers become established, the term malarious fever will probably have to be much limited in its application.
It may be useful for the reader to study again in the light of the above remarks the controversy in the Indian Medical Gazette for 1887, June, July, August, December, and 1888, February, August, November, and December waged or maintained by Drs. Younge,Fairland,Hamilton, Riordan, and Macphersou, on enteric, malarial fevers, hill diarrhoea, hepatic exhaustion, &c.
/
