can be made in treatment. He also states that it is essential to health that the digestive organs be trained to handle all types of food, including, those difficult of digestion as well as the easily digested, as it is only in this way that the normal secretions can be maintained. The first essential in the successful treatment of chronic enterocolitis, or, for that matter, any other affection of the human race, is confidence of the patient in the physician. Without this one is truly treading upon thin air, while with it he is astride the top of the world, with half the battle won. The treatment proper is based upon the relief of the attack itself and the removal of the causes of the disease. As we all know, the prime essential in the treatment of any inflammatory condition is rest of the part in so far as it is practicable. This is obtained by putting the patient to bed, with warm applications to the abdomen, careful regulation of the diet, and the administration of such remedies as may be necessary to allay the intestinal irritation. At the beginning of the treatment no mistake can be made in administering castor oil and following this with a saline soap enema, or perhaps a better method is transintestinal lavage, using a hypertonic saline solution. In this way a very quick emptying of the intestinal canal is obtained and at the same time the associated toxemia is decreased. Bromides, to allay nervous irritability, are indicated, but no opiates should be used if it is possible for the patient to get along without them. Nothing should be given by mouth for the first 24 hours, and when the patient begins to take food it should be in the form of a simple normal soft diet of an anticonstipating type, taken three times a day, with nothing between meals. There is no question that diet constitutes at least 90 per cent in the successful treatment of chronic inflammation of the intestinal tract, and the physician who is able to prescribe in detail one that can be assimilated and at the same time supply the necessary calories will undoubtedly meet with the greatest measure of success. Constipation, of course, is the rule in these cases and has to be overcome. This is best obtained through the medium of diet and proper training of the individual rather than through the use of cathartics. The cases in which there is disturbance of the endocrine system have to be treated along the line of the apparent defect if we are to get results in the other direction. The neurological group are naturally the most difficult of all to treat, inasmuch as they are usually of a social type that are very difficult to impress with the necessity of carrying out instructions and frequently persist in doing the things which are prohibited. These are the cases that frequent the foreign spas and are greatly benefited thereby, due to the fact that they follow there a correct regimen of living which they utterly fail to do at home. In conclusion, it must be borne in mind that any surgical condition associated with chronic inflammation of the intestinal tract should receive appropriate treatment and, if practicable, all foci of infection removed prior to the beginning of the medical treatment. This would, of course, include such conditions as chronic appendices, gallstones, ulcer of the rectum, etc. The psychic effect of the operation is frequently of great benefit to the patient, to say nothing of that derived from removal of the irritative lesions themselves. In some cases where there is a tremendous output of mucus with an irritative diarrhea, colonic irrigations are indicated, and these may be followed by starch enemata to allay the excessive irritability of the lower bowel. Intestinal antiseptics are of very little, if any, value in this condition; and if any are used, phenyl salicylate is the one of choice. Operative treatment is of no value in mucous colitis and should never be advised. CHOLECYSTITIS OF CHEMICAL ORIGIN IN MAN FOLLOWING INHALATIONS OF POISON GAS. By H. M. STENHOUSE, Lieutenant Commander, Medical Corps, United States Navy. In January, 1921, F. C. Mann1 published the results of his experimental work on the chemical production of cholecystitis in dogs. By the injection of Dakin's solution into the general circulation he was able to produce a definite destructive process in the gall bladder. The reaction was rapid, selective, and severe, which indicates that it was the result of a chemical change in the blood vessels as they traversed the organ. It was stated that the work had been done "not because of the possibility of its having any direct bearing on the condition as it occurs in man, but because it offered an opportunity to observe the production by a chemical of an inflammation of a particular organ." The purpose of this paper is to show that chlorine inhalations from poison gases used in recent warfare cause the same chemical reaction in the human gall bladder. Evidence of chemical origin.-Among 1,832 admissions to League Island Hospital after the wounded had begun to come back there were found 28 histories with symptoms suggestive of gall-bladder disease. Eighteen of this number showed that the persons had 3 F. C. Mann, Annals of Surgery, January, 1921, p. 55. Case histories 14776 to 16608, League Island Naval Hospital, Philadelphia, Pa. Case histories on which statements are based, Nos. 14776, 14891, 14893, 14907, 14967, 15344, 15439, 15496, 16468, 12109, 12669, 15247, 16200, 15310, 16310. E. M. B., B. G. F., J. MacD., J. J. J. 5 attached some importance to or connection between their symptoms and their injury by the gas. These were all routine ward histories taken by various physicians and can be regarded at least as an unprejudiced coincidence. The examining physicians were not seeking to corroborate my hypothesis. The notations regarding exposure to gas were manifestly the voluntary statements of the patients. Certain writers have touched upon the acute sequelæ of gas indicating abdominal complications. Levin has published a case history illustrating clearly that his patient dated his gall-bladder trouble back to the day he was gassed. Gilchrist tells of vomiting and epigastric pain coming on within four to eight hours after mustard-gas attacks, appearing "together as a rule, and are apt to be persistent and intractable." Sandall" mentions the "persistence of gastric symptoms" among the late effects of gas. We have found men suffering from abdominal cramps in cruising submarines where the air is contaminated at times with chlorine gas. Then we knew less about gall-bladder conditions and perhaps did not recognize them. We reported that it probably was due to the “absorption of acid fumes from the batteries with a consequent lowering of the alkalinity of the blood." We have seen or reviewed carefully four operated cases and five unoperated cases of cholecystitis which resulted from inhalations of poison gas during the war. We base the conclusions reached below chiefly on these nine. Nature of gas causing symptoms. It is not possible to determine with any degree of certainty the exact nature of the gases mentioned by the various victims. Five said it was chlorine, two phosgene, and one mustard gas. From a chemical standpoint, however, this is not so important as at first it might seem. Free chlorine gas needs no description. Phosgene has the formula COCl2, the resemblance of which to Dakin's solution (NaOCl) is apparent. Mustard gas, dichlorethylsulphid, while a more complex molecule, presents also an available chlorine radical. In these three gases, all of which are involved in this series of cases, we find what Mann considered the active principle in the chemical reaction he describes, available chlorine. Illustrative case.-Our attention was aroused in this subject by a patient from whom we got the following history. It has been abstracted for the sake of brevity. No. 15247. Age 24. Admitted August 2, 1921. Formerly anthracite miner. Chief complaint: A. L. Levin, Southern Medical Journal, March, 1922, Vol. XV, No. 3, p. 175. T. W. Sandall, Lancet, London, Oct. 21, 1922, No. 5173, p. 856. Personal communication to assistant to Bureau of Medicine and Surgery, Navy Department, from Asst. Surg. H. M. Stenhouse, medical officer of K-Boat Submarines, Oct. 3, Pains in belly and head. Past history unimportant. Family history: Father died at 55, "miner's asthma "; mother and six brothers living and well. Is married and has two children living, one dead. Physical examination.-Pulse, 72; systolic blood pressure, 108; dyastolic blood pressure, 78 (in bed). Breath sounds distant over both lower lobes. Tactile fremitus increased. Anemic looking and pooly nourished. Heart sounds normal. Abdomen very sensitive and walls thin. Lymphatics enlarged. Reflexes normal. Belches gas frequently during examination. Wassermann negative. Stools negative for hookworm. Sputum negative for tubercle bacilli. Urine normal. Differential blood count shows 50 per cent lymphocytes. History of present illness.-In October, 1918, was gassed in the Argonne with "chlorine." Had sickness in stomach, nausea, vomiting, dizziness, and pains in the head. After three months in hospitals in France was sent home. Started to work in the mines again. After two days he "went down in a heap." Fainted, felt sick at the stomach, vomited, had pains in belly, head, and back. That was in March, 1919. After various attempts to earn a living as a miner, as a sewing-machine salesman, in a machine shop, and in the mine office he finally came to the end of his resources. He was sent in with a provisional diagnosis of appendicitis, chronic and simple anemia, after a prolonged period of suffering. Feels weak all the time. Has dizziness and pains over eyes and in stomach, sleeplessness at night, belching, and pain under right shoulder. The smell of grease makes him sick and smothers him. Meat and potatoes cause abdominal distress. Complains of a pocket of gas near umbilicus. Vomiting relieves him. Pain not relieved by lying down. Is constipated and has had incontinence of urine. Frequently has night sweats. Once recently vomited blood and has passed bloody, bright red stools. Preoperative diagnosis: (a) Tabes mesenterica, (b) cholecystitis. Operation showed distended, discolored, gall bladder with wall thickened. It could not be emptied. The cystic duct was almost obliterated, not permitting any drainage at all. Clinical features.-Summing up the evidence found in this illustrative case and in the others cited the following features have been deduced: Onset. In six cases the beginning of the digestive trouble can be traced directly to the effect of a poison-gas attack. The immediate sequelæ following exposure remind us of the findings of Mann in his experimental surgery. One case gave no history of immediate symptoms, but the acute, typical, gall-bladder attack in a man of his age, with a precise memory of exposure to mustard gas three years previously, suggests that the gall bladder may have been in jured at the time. In two cases there was no mention made in the record as to the subjective signs which followed exposure. Course. As in cholecystitis from usual causes we found in our patients some who had had periods of comparative or absolute freedom from symptoms but more commonly the victims were chronic complainers and probably truly chronic sufferers. They felt badly early in the day. They were subject to dizziness and headaches. They found it necessary to exercise the greatest caution as to the nature and amount of food eaten. Little indiscretions might precipitate acute attacks of old-time "dyspepsia." Some patients had lost weight while others seemed at least not to have lost any. Specific features.--(a) Skin: Acne was noted in one-third of the cases. This was in those who seemed well nourished. There was nothing to indicate that this was more significant than it is usually considered in persons of the same age. One patient had scars from mustard-gas burns. (b) Nervous symptoms: Over half of the records had notations or descriptions of "nervousness." The complaints of this nature included insomnia, irritability, undue excitability, jerky movements of the limbs during sleep, muscular twitchings, incontinence of urine, gagging, and tremors. Vasomotor weakness is perhaps the most outstanding feature of this so-called "nervousness." There is more commonly than otherwise a low systolic pressure, a relatively high diastolic, and a pulse rate that is faster than it should be. The reflexes were inclined to be hyperactive. One patient complained of dreaming. In no case was there any evidence of a psychosis. (c) Age: The average age was 27.7 years in nine cases. The youngest was 24; the oldest 39. In the other group 12 of 16 were under 30; 5 were under 25. This number of cases of gall-bladder trouble in young men is not usually expected. (d) Blood findings: The white count was normal. There was usually a relative increase of the lymphocytes, as has been reported by Miller. The red count showed in some cases a reduction of cells, but this was not uniformly so. (e) Pathology: All of the operated cases were of the chronic type. All showed definite pathology of the gall bladder. In three the viscera were otherwise normal. In one there was a concretion of the appendix and macroscopical hepatitis. The findings in one case described above showed that the gall bladder had been put completely out of business. In the case which showed hepatitis the gall bladder measured 6 centimeters in length and 2.8 in width. The color of the wall was of a yellowish cream 8 J. Miller, Lancet, London, May 26, 1917, p. 793. |