Etiology And Symptomatology

Diarrhoea, meaning too frequent and usually too watery movements of the bowels, is always due to increased intestinal peristalsis. Diarrhoea may be the result of various morbid conditions of the intestines, but here we shall describe the form of diarrhoea which exists without any apparent anatomical lesions.

Diarrhoea may be classed under three groups: 1. Nervous diarrhoea (Trousseau).1 2. Dyspeptic diarrhoea. 3. Stercoral diarrhoea.

1. Nervous Diarrhoea

Although all the three groups of diarrhoea are primarily produced by increased peristaltic action of the bowels which is in turn caused by exaggerated action of the nervous apparatus, this group is designated as nervous diarrhoea on account of the predominance of the nervous element. Trousseau was the first to describe nervous diarrhoea. It originates either through undue stimulation of the accelerating peristaltic nerves or through some nervous influences which cause a serous transudation into the intestinal canal. Frequently both factors are probably implicated.

1 Trousseau: "Clinique de l'Hotel Dieu, " Bd. ii.

In many cases the stimulus may emanate from the centre and reach the intestinal ganglia through the vagus, the sympathetic, or the splanchnic. In some cases, however, the stimulus affects the ganglionic cells of the intestinal wall directly. As characteristic instances of nervous diarrhoea we would mention those cases in which there are several watery evacuations after a strong emotion, thus after fright or fear. Here the stimulus arises in the brain centres supervising intestinal motions. While in these instances we have to deal with an acute transitory condition, nervous diarrhoea can also appear in a chronic form (Nothnagel, Peyer 1). There are persons who are attacked with diarrhoea as soon as they are in a place where a toilet-room is inaccessible. They may then be seized with abdominal pains, tenesmus, and diarrhoea. In other persons, again, the mere sight of a water-closet evokes an intense desire for an evacuation.

Occasionally the diarrhoea is preceded by several other nervous symptoms, as for instance vertigo, giddiness, congestion of the head, a sensation of heat all through the body, fright, shortness of breath, or palpitation of the heart. All these symptoms as a rule rapidly disappear after a satisfactory movement.

1 A. Peyer: "Die nervosen Affectionen des Darmes bei der Neurastlie-nie des mannlichen Geschlechts. " Wiener Klinik, 1893. Heft 1.

This form of diarrhoea is found in persons suffering from neurasthenia or hysteria, in debilitated persons, or in perfectly healthy people after a more or less pronounced shock to the nervous system. Moreover it is met with accompanying affections of the spine. Thus Charcot described attacks of diarrhoea appearing periodically in tabes dorsalis (intestinal crises). Lastly, nervous diarrhoea may exist as a reflex condition in consequence of abnormal processes in the neighboring organs (the genito-urinary tract, uterus, etc.).

As an instance of nervous diarrhoea the following case may be described:

N. S., thirty years old, physician, was always perfectly well. After a year of hard study and a great deal of care and anxiety he had begun to suffer from frequent loose evacuations during the last six months. As a rule the patient had one or two passages a few minutes after each meal. Preceding the evacuation rumbling noises were heard in the lower part of the abdomen, while a slight feeling of discomfort was experienced. The movements were softer and more watery than usual, but did not contain anything abnormal (no mucus, no undigested food). The patient felt perfectly well in every respect, had a good appetite, slept well, and had not lost weight. Examination of the gastric contents showed the stomach to be perfectly normal. The patient was given no medicines and was instructed to respond to nature's call in the morning and to try to suppress the evacuations after meals whenever possible. For the first few days he succeeded in having no movement after some of the meals, and gradually after a few weeks was perfectly free from the desire to evacuate the bowels after eating.

The following case is reported by Fischel:'

A lady, twenty-three years old, complained of a feeling of oppression, cardiac palpitation, and severe attacks of diarrhoea, which appeared periodically independent of the quality of the food. The passages were watery and of a strong alkaline reaction, smelled bad, and contained triple phosphate and considerable amounts of intestinal epithelial cells. The examination revealed a retroflexion of the uterus. After insertion of a pessary the diarrhoea ceased.

1 F. Fischel: Prager med. Wochenschr., 1891.

The diarrhoea appearing after exposure to cold and wet weather is most probably caused by a reflex emanating from the nerves of the skin and producing hypersemia of the intestines. The latter gives rise to transudation into the lumen of the bowel and also to increased peristalsis. This form of diarrhoea disappears very quickly (in twelve to twenty-four hours) and does not produce any anatomical changes of the intestinal walls.

Another group of diarrhoeas takes its origin from an irritation of the intestinal nerves through some abnormal substances contained in the blood. The cathartic action of some remedies subcutaneously injected is the best proof of this possibility. The diarrhoea occurring in cases of septicaemia, of nephritis (with or without uraemic symptoms), and also diabetes is best explained by the theory of irritating products circulating in the blood. The diarrhoea accompanying typhoid fever and dysentery in the first stage before there has been time for the formation of ulcers, is caused by the circulating in the blood of toxic elements produced by the pathogenic micro-organisms.