Etiology. The influences said to cause this disease, or relate to it, are so many that it is a question as to our having any satisfactory idea of its true origin. In my practice I have always considered the nearest and most practical way was to regard the cause of this strophic catarrh condition as one of syphilitic origin, either inherited or acquired, or the result of the degeneration of a hypertrophy inflammation.

Some constitutional weaknesses seem almost certainly to be a cause. Environment, overwork, poor health, poor ventilation, improper feeding, either over-eating or poorly selected diet of childhood are other causes. This disease and its complications collectively form a large percentage of the cases of catarrh conditions which the rectal specialist is called upon to treat, bringing it to the foremost rank of importance, and requiring the greatest circumspection to find the cause.

Symptoms

Constipation is naturally the first cause of complaint, as the weakened tissue wall and the loss of the physiological mucous secretion would suggest. The stool is dry. hard and lumpy, sometimes coated with mucus or blood. The atrophy extends to the anal margin, in some cases causing numerous small fissures and hemorrhoids. Flatulence and indigestion are almost constant symptoms. The patient feels languid, complains of loss of sleep, loses flesh, and suffers from general nervous disturbances, making him fear a general breaking down in health, as the nature or extent of the trouble is not understood.

Treatment. First, the constitutional treatment, directed to the probable underlying cause. For a routine treatment the syrup ferric iodide, the suggestion of an open air life, the use of plain digestible foods, and the regulation of the bowels so as to make the bowel empty the entire lower contents at one. or at the most two, movements each day. The stimulation of intestinal peristalsis with cascara seems to be the ideal method. Sugars and starches should be used with moderation, on account of their tendency to fermentation. Tea, coffee, and alcohol are to be discouraged and if possible not used.

The local treatment must first be to relieve the distressing symptoms about the anal margin, such as prurient, fissures. or hemorrhoids. Nitrate of silver, in one form or another, stands almost invariably in the foremost rank, with all authorities, for the treatment of fissures. My experience has been that nitrate of silver is the best. The prurient is very often present with the fissures or hemorrhoids, and can best be relieved by controlling the mucous discharge from the rectum or sigmoid.

Strophic proctorial or sigmoid should be treated on the theory of a lam-nutrition, and methods which cause a reasonable degree of congestion in the parts are indicated. The irrigation of the rectum and sigmoid, if possible, for fifteen or twenty minutes each day with simple hot water or one to two thousandths solution of silver nitrate will be most useful; or five to ten per cent. ichthyology solution. The application of nitrate of silver or ichthyology is best after the bowel has been cleansed by the plain water. Sometimes the fluid extract of Kramer in twenty per cent. solution will be most beneficial in soothing the irritated mucus membrane until the more stimulating treatment can be instituted, which can be determined by the amount of tenements or pain after the injection with the nitrate of silver. A one-half per cent.

solution may be applied with the proctorial or kaleidoscope and by the use of an ordinary hand ball atomizer the desired soul hon is thrown into the bowel. The window of the proctorial is then put on and with the air insufferable the fluid is blown upward. Several applications may be necessary before the entire area is thoroughly treated. Care should be exercised on the withdrawal of the proctorial that the window is left on so that the air already in the bowel will not force the solution out on the withdrawal of the instrument. This can be avoided by the prompt application of a gauze sponge, and the quick withdrawal of the proctorial

Chronic Hypertrophy Catarrh Colitis (Chronic Colitis, Mucous Colitis, Membranous Colitis). All of these names are used to describe the hypertrophy form of catarrh colitis, which consists of a hypertrophy of the glandular and sub mucous elements. The mucous glands and follicles (Lieberman ) are distended with mucous. The epithelial cells undergo fatty degeneration. The lumen of the gut may be narrowed, caused by the over-production of tissue and swollen glandular apparatus.

Ordinarily, the gut wall remains the same, or slightly thickened. There may be small abrasions or excoriations due to the ease with which the membrane is injured from the feces, or on the introduction of the kaleidoscope Ulceration is found in the severer forms. The membrane presents the appearance noted in the pharynx with the same form of catarrh; inflamed and swollen, with occasional bleeding points. The pain prior to the expulsion of the mucus, technically called the mucous crisis, is probably caused by the intestinal peristalsis bruising the swollen and inflamed mucous membrane.

This disease probably begins during infant life, from poorly selected diet in some cases, and continues unabated to old age. It is probably the forerunner of the strophic type in which it terminates. The relation of these diseases to hemorrhoids will be discussed in that chapter.

Symptoms. Pain at defecation, with the discharge of mucus and possibly blood, associated with chronic intestinal indigestion and the discomforts produced by it, such as flatulence, loss of appetite, lassitude and mental depression, are the subjective symptoms which alarm the patient and lead him to seek the advice of the physician. Constipation may alternate with diarrhea; the hard fecal mass is coated with mucus and the loose diarrhea movements resemble the castor oil defecation so familiar to all of us.