FECAL Er\KMA AS AN AD.HJNCT TN THE TREATl\'.lENT OF

PSEUDOlVrnMBH.ANOUS ENTEROCOLITIS

B. ErsEMAN, :l\t.n., -vv. SrLE�, ::VLD., c:. s. BM:icoM, M.n., Axn A . .J. KwvAR, l\LD., DKN VEJl., COLO.

(ltrmn the Departments of S-n·r.(l{;Y?f an.11. Medic·in.c, Uni.11ers·it!J of Colorado School of MuUcinc

anfl ihe Vcternns Administrat.ion Hospital)

THE ap1:arcnt in:rcased incidence f�f pseudo1:1e_mbra.nous enterocolitis l

.ia.s r:e­

rwwed mterest rn the patlwgerw�m; and c.lmH'.al management or th1s d1s­

ea1;e."· "· 1�- H Even \Vit.h the aid of modern snpportivc me;1sures, a :mcm1 rno1·­talit.y of 74 per cent js found in 3 recently published scries.·1• s. '� Tlw purpose

of this paper is to report the successful use of fc<'.al <'ncmas in the mana.gemPnt

of 4 such eas(�S iri tlw 110pP tl 1 at. more corn11lcte evaluation of this simple tlwl'a­peutic measure can lw given further c l i ni('.al trial by othm·s.

Finney" in 1893 n�porb'd a <'<1sc of 1werotizing c11t.croeolit.is following gas-

1.roi'ni.<mistomy -for pyloric nicer and since that time many reviews of this subject lrn\'P bcc11 pul1iislied. There; nppcar to he 2 general types of t!w diseaS<'.: the OT1e precipitated by intestinal obstruction, shol•.k, or impairment ol' int<·stinal vascul [ff supply9 and the other eauserl p 111·dy hy an overwhel rning· .'l!ic1·ococc'us

m;ogenes (staphylocoecns) <�ntcritis. A nurnhcr of tl1ese e;L�(!S be ar no relation­

ship to surgical proccd 11J't�s. Al tlrnugh pll r·e cu l t.nres of :1/.i:cmcoccus pyoqenes (staphylococ.cus) al'e Jound in the stooh : in mm1y of tlicse eases, this i!l not an

invariable finding.12 Faulty bacteriologic. isul a ti on iH:hni.q u(•S have hc,0n sng­

gested to account for this discrepancy.'· 13 Jlost of the recently reported {'.as<cs

ha.vc follmved th<� use of oral hroad-spcctrrnn antibiotics,"·"''�' 1.:�. 1" suggesting

that t11e intestinal flora was thus altered to permit an overgrowth of antibiotir·­resista.nt. Microtocc.v.s pyogcnc.s (sl:aphylocou:us) within the gut. The rclation­s11ip of tl1e;;e drngs to the disease 1s 1lebatahlt>. inasmuch as the incidence of the disease may not have increased since their use.11

Because the mortality ratt� fron1 pscuclomcrnhranons entcrocolitis remains

distressingly high despite the usn of modr:rn snpportive measures and antibiotics

nffoctivc against JIIicroooccus pyor;cnes, nn attempt was made to re-establis}1 the

uormal intestinal bacteria] tlora by tlw aflminist.ration of normal i'cccs into tlH\

c'.olon o:f patients with the disease. This thera.py is 11as<'d upon the fact. tl1ut

staphyloeoecal OVl�l'gl'owth oceurs when other organisms d isappe;iT a.ncl that l'C­

introduction of 1.lrn bact<!ria, viruses, and baetcriophagc normally -found in the

colon might l'tH�sta blish t.hc balall<'.<·� of mi.tu 1·e with su bsidance of staphylococcal pn!<lomi.nance an d the distressing sy1nptoms caused 1.h(m·!h,Y.

Rcceiv€d fo1· publication June 23, 1908.

854

���''1!i't'l�1' '�;1;·:1fszy���f f t-.",;h· .�-. ��.�.'l.:/54 :FECAL ENFJMA l''OR l'SEl."DOMEMBR. A�OUSt�N%1:� �!?>.0Q . ··. : 1� -.:�?:-'}..::"�;. i'.;_�:�:� ... :�

CASE REPOH'l'S . ;; -. - .. -.,�_:.::K:��i ·'(.��!J... '�· . CA Sr; J .. -A. R., a 46-yeur·old Spanish-American, imclenven.t :t BiUroth 'lf:'�:t\��J:[�;;: �e��ll-f�

scc;t1on on _April 28, 1957, bccau�c of umssivc bleeding l'rom a iJiJIU��(j hc11iorJ-h:'lgi�'Jga$fi.�tis':'�'.i'.<:; Postopei·ati vely lie had elevated tcmpei-aturc and received a mixed :mtibiotic 1;e.girn� 1aiji)u;��;�$-�' . . · . .

tn�terl in F' ig-. 1. On the fifth posto11erativc tfay he developed abdominal distenticiii, \7o n�itili�i\.!��;:•:;;t�;:g;�j, bloody dit1r:rhea, and markcu l1ypotcusiou •lm1 wns given vasopresso1·s 1ind l1ychocortisoi1e: Qn;, ,'.1.;:;'.;\-s'·;r}t• the SCVCHteenth postoperative Jav IL lapnro LL)lllV W!L$ performed bccanse of tL qn(�St.ion' o'f''smaiJ · .. ·.:. � ·::(;·;:.<; ,{ bowel obstruction, but 1Hme was fouwl. 'l'wo tli1ys followiag- this operat.ion he aga.in ·,ie�·:doJ)�·i:l·' .:. ·> .. (-.1,�;\j� copiou8 blo od.y diarrlu!a 1nul the diag·n o�is of pseuclo1i:wmbnrnous cnterocoli.tis was iirst eii�u/ .. � ,;;· .. . :;:';:::;:;]'.' :�· tn.irrn11. In:-. 1.neclint� stool cult.me reve:�led ,l:lforococcYiis pyogtnes (hemolytic, coagnl:i8e }io�ihvii.: ·

. · _: f'V:: ;.

8taphylococc-1.(-s m�nnt·s). Despite ao'lwpmte :A.uid thc.:rnpy, 1;ortisonc, awl Albamycin, his diar· · ·-...�

;

rhea. cont.in. ued unabated and he a.ppea.rcd t.o be in th<i wrminai stiig·cs of his critica.l illness: On May 23, 1957, after another �tool culture grnw out pure Jli.c1·ot,oCN'11.S pyoge11.c.�, a. ret;en1iou fecal enema was administered nsing donor f��es from a uorma.l sub;jcct who had TCCeivcd no antibiotics during the previous scver:il month�. On the following- •fay there wn.s ma.rkcd im· provcment in his general concli1;ion a.nd l1is l>looc1y diarrhea eca�ed. Stool cult.me on the fol· lowing day, 1-ia.y 24, revealed no l11'i.c1·ococcM·S lY.IJO.qrmes, and a110Lhcr fecal enema was ad· ministcreil on that !lay. 'fhc J):lticnt improved very rapidly :rnd was discharged :from the hospital JO days lnt1!r, eou1pletely usympt.omat.i<:.

FECAL ENEMAS

STOOL CULiURE

] ] STAPHYLOCOCCUS STAPH. NO STAPHYLOCOCCUS

t �� 1V�8ER OF STOOLS PER DAY ] 0 0 0 3 0 I I 0 0 0 I I 2 0 0 I 4 0 3 I 4 2 5 I I I I 3 2 I I 0 t I

IGHEST OAILY TEMP.

=���. .. IOQ] HYOROCOflTISONE • m9m.,OAY 0

SULFADfAZINE :� CHLOROM YC E TIN

--<I> � :i I c --� 0 .. ... � CHROMVCIN 0 ., ; I-

c

z 1; TR(PTONYCU< .. RY THRO MY ClN

ALBA�YCIN

PENtCILLIN MIU .• . OF U"41TSJDAY

�] • :n I

:� I

:] . 5 la l 7 I

7

• -

I I I 141 ltJA�S �O�T ·��ERIAT�VEI

EXPUlRATORY LAPAROTnMY

Com.·mcmt: There was an inH1wdin.te anJ drama.tic rnspo11se by thi,; eritic:tlly ill µntient t;0 a fc<'.al retention enmua. The bloody dim·rhea. stools whieh grew pure cultnres o:f Mi.cn>­cocc11-s vyogm1es stopped within a fow hours nnc1 staphylococci disappeared from tlw stools.

CASE 2.-0. H., a 65-ye:i.r-nl<1 white umu, underwent subtotal gastrcdomy with a tuhc Juodcrwstomy on D1;c. 24, Hl57, for an :u:ui.: pe1·fomtiug,_ bleeding, an<l ohstrnctiug duodenal

ulcer. His course was unevm1tf.ul until 1J1n fifth pnHl-uperatiYc day, when he devclo_ped �igus of })Critonitis. Exploratory laparotomy rcve.1](>d no leakage :n·c1unu the dnodenootomy tub<!.

; �. ;· ·:·;

i ":i1;

. ,

:F:JSEM.."1.�, SILEN, BASCO!\{, ASll KA.UVAR

FECAL ENEMAS

STOOL CULTURE

TI ]

2. I

tt STAPHYLOCOCCUS NO SUPHYL OCOCCUS

t t NUMBEROF STOOLSPERDAY ]o 0 0 0 I 3 3 7 7 2 4 6 I 0 I

HIGHEST DAILY TEMP

: ::L /°"-100 --...........,,

I .. -- .. � HYOROCORTISONE

tnQm/0.AY

LACT08ACILLUS ACIOOPH ILUSll l'f'O OOSAG£ --J)

ALBAMYCIN

� ACHROMYClk

<> � - 0

� � STREPTOMYCll"t

�0 ,_ "' z ;: ERYTHROMYCIN "' ..

7

..

... !PENICILLIN 2] --

Ml�l..OflJttlrS/CAY o _,.,---.,.-.,.,1-,<T"I -rt -,-1--,---..,.--,--.-, .�, 1

f t DAYS POST OPERATIVE

SUBTOTAL GASTRECTOMY EXPLORATORY LAPAROTOMY

Fig. 2.-(;;,sn 2.

STOOL CULTURE ST APHY LOCOC CUS

i-

FECAL ENEMAS �

NUMSfR OF STOOLS PER 0.0.Y 0 0 1 0 1 000� 3 2 Z l3 I 42 I

HIGHEST DAILY TEMP.

CHLOROMYCETJN

� ACHROMYCIN.

"' "'0 I!' STREPTOMYCIN ;:: 2 "' :I! "' "'

SULFASUXIOINE ;:: "'z "'.. I NEOMYCIN

PENICILLIN C MILl..OF UNITS/Clt.Y)

:� :3 :3 ::

I:]

:� I

• I 2 I • I 4 I. '· I 1 . I I I I '••' I I I

t DAYS POST OP.ERATIVE

LEFT HEMICOLECTOMY

.. ·�1�::'�:·, .�f��jt� · '.�� -�-

-�?�f:� .. 01

S.1rzl'ry N()vrmhcr, 195S:

Vo'.t!rr-l· 44 Kumlier S

P:t:CAL J�NEMA FOil

Twenty-fow· hours l:ttcr the ]Xtiim1t l1cgan having frequent loose, mucoi<l, movements. On the fourth postopeiativ" <'l::ly :ts his cli,inliea. st.ooJs i11ereas1�d, went i1d.o profound shock wh :ieh 1'(,quircd ·1ieroic J1ui<l anil c!cctr(ilyL<� l'epla(:,�mant.

and cull .ur<•s of �toDl at this ti nw u•ve;lleil Mforocoa·ii-s pyo£)<)1l-f:s (hemolyt.ic, coa.gulRse Sia.phylou:·ns a'll!U"iM). Hydrocortiso"e and ('ryilnom_yeiu were adtloc1 to his thenqiy littfo irnp1·overncnt. On J"an. ;-:i, 1958, 8 ft:,;nl retc11tioli miem:1.s were givcu and follo\\'ing- dny. Dia.rrhea stopp ed wiU1in 48 hourn :rn:1 Mi1:i'ooocm1-s pyo1;mu:s had enl.iroly ..,, 11ppea red from the st ool 4 days tcfL1er the :11lrnin i�.tr:<ti@ of tile fh·st fo,�:d ern�ma. Fig. 2 illiiJ­trntcs tlw complex anti.\,iotic. r<:g1rn1'n rnaintai necl on tJ1is patic11t a.w.l his respon:;.; following t:ho J\,cal ,,1u;ums.

Cwmment: 'l'his pr1tient bc1001rne dcR11crn tdy ill with pscculornembri.u1ous ent.erocolitig 9 dn.ys Jollowiug opern.ti1111. His prngr;��sive ru�d 1.ot:dly rosist!Lnt stnphy!oeocc:tl clirL.rrhca rc­sultc;l in profound sho\'.k and lH� npp!',,:nwl Jnorihund. Cliniea.l resp611sc to foccll oneuias w:is·

di-r11natie with ,li,;appcarancc of t:l"' di>enhe» and a 1·et1P·n o:!: uorinal bael.1lJ"i:il flon• in tlw s1;ools.

CARE 3.--C. P_ (l"ig. H), a 68-y1,ru· ulrl white uHc11, uadcrwellt kit hcmir,o](:\,tom_y with

c�nd-1.o·<'!ntl an:istomos i." fm· :i <oHr\'.inom a. of t.l1e de'"crn1iug eolon on .Jan. '.l2, lD.38. Sulfasnxi·

diu1• and neornydn were u;;;(·(l 1m:operatiY"1y Jor 1m•)'aration of tlw <',111011. Ad1rom,\'!:iu1 lh:ni· cilli11, and sb·f�pton1yein \\'cJ·e �-11Jn:tiffi$t(11•1:�d po�U:}_wrativnly. :1-1 )s imnu�tli:ttf� f',Otll'�i1 w:.;,� un· evl'ntfui, !Jut 8 di·,ys J'ollowiHg- surgery lie (kvefo],nd p,.01'mc \l'fLt.•·1·y diilnh.-,a and a Jow-gi·adt• :fc�vcr, "\\-·]1 ieh pcrs.i.-:t.cd for one \\'Cdc Cnltur·es of r.l1e srool :r.·c\"(!:lil�d _)_lli<�ro(:octu.s 11:t/Of11:·ncs (hmnoJytic, (�oagn1ase positi.vc� St.aphylo1�<JC<":11s o.:��re·lL�·) i11 p:1ro c11lt-urc. enc:.u1�t wns g·ivca and \\"ithin -::18 !ionr::; tlic: t11�.LTrl1ea. had eoinplet(�!�y C('�l�i•ti. dis(:l1arg·c1d ;) (la.ys 1:H1�r.

.A fN:n.l rid·-(1ntion The pat.i,·nt wa�

Cvm.m-r:nl.: 'J'his �11au rc�1nc·s•�11rs a lf1i1d (�r varici:y of sti1rih)-�h1·�0·�'.��.1..I on1-.t�r-o(::olitii;. Tlin

l:f��.sat.iu11 uf sy1u_pto1us fdllowi.11g- J11:":l.iturion of thentpy wa;:.; n_br·upr..

FECAL ENEMAS

STOOL CULTURE

]j ]

I I l-J

NO STAPHYLOCOCCUS STAPHYLOCOCCUS

. "'NUMBER OF STOOLS PER DAY]o I I 0 I 0 I t 0 I I 0 1 0 3 6 a 8 3 I 0

104] HIGHEST DAILY TEMP :::�� �

99 ._::::===�.,,___����--=:::-:o�

lACT09ACILLUS >ICIDOPHILUSlJ <NODOSA<l�l _]

� � ACHROMYCj N .... � 0 ., ·:�--

� ! CHLOROMYCETIN ,, 0 ""

1.0 0-•1-,�2�3 �. �.,--r:5::TC7;--,---,---,---,,-,-,.,,.4�.---

t DAYS POST OPERATIVE MAXILLARY SfNUSlTIS

Fi!;·4 4.-C:l.se 4.

CAsg 4.�N. D. (Fig-. 4), a J5-yca1·-old \\"Ombn, re(:eived Achromyein, l Orn. dn.ily, for

ac\lte hPht-h1-:moJyr.·ie �h·1�1Jtoe(>Gcal 11rnxil.la.rv sinusiti�. A.Jt1�1· 2 wel· �k� nf thf•l":ipy i.hc -ft�Vt!r

:md toxi('..ity alJa �cc1, but <l da.ys thereafter: while still rceeiying- a.ntibiotie:;, shJ �u«Jdenly d<�­

vclorwd pro.fuse w;.\r(•ry :rnd b lomly dia1·1hcR and rncunc11ce oJ' Jcver, Stool culiu<'�S.

grew

pun� i\f-i-1,rooocc:us pyogenes (h em ol;ytic, eongu1a.Ee }H1,itive Striphylrn·oc<:ns a.urncs) R<�11sil1ve to

Ch]o1·0111yc<"till. lntram11sn1ll\,e Chlornmyedin \V<l5 a(\minisl.crcd hnt ncitlrnr tks tlmg nui· uci­

dopliilus. milk nffcded the fever, toxicity, or sc1·cre hloo·:"!y tliari-"11ca. lntr:1vcuons ftni<l anrl

Electrolyte re1•l:w"mcnt \1·us n�quii-ed in hei·ojc, proportions.

1:; I•

• . '' q I f ..

·1·:·

Surg<:fY Noveinbcr. itt;�

Four <hivs after the onset of thn blnody di1\nl1ea whc>n a ll. otlH�r tlwr:tpcuti� method;; h:ul f11.ilc;.d, Ft fre;l rHLHHtion enema wu� a.dn:iinist1lrc•d to th" pati<!nt und repna.1· . .:(l tl11: next tlay. Within 24 honr$ of lhc first cncurn. the diarrl1(':·� h:1,l <:c:as,�tl :in<l �tool eulturcs tev1?aled 110 fnrr.hei· liemulytic slaphylococc.i. 'l'he pnt.ient nn1tlc an uncvo:11li:ul rcc.uvery.

(;01n11wnt: '!'his pa.ti('nt lle\'<llnpetl ps<:udonwmbraHon.- ,:.11\,\;rowli li:i f,.,J lo\\'iug a �-we1�k 1�our:-ic of hrOfld·�pectrnn1 ant.ibi1Jtics. Soven.1 and li:h:�-thn��i-ten in� ::;taphyloco{'.<.:nl diarrh<�a wn.s 1·1�sist:rnt to all otl11Jr :fonn� nf !'lot!n\:py lJUt 1·,.�s1in11il<'d. 1lramatieally to i'<'<;id e1w1rnt><.

DISCUSSIO:-\

'l'hrec of the81·� 4 patients with p:;;<�udorn1'1t1 brnnous tm tcnwoli t.is almost suc­

cum bed to disease before foe al f�neinas were employed. In all 4 patit: nts, hemo­

lytic coagulase positive Staphylococcns o.wreu� was found in l;n·g-c m1mlwrs in

the stool, both by smcn r and by cult.urn prior to the fr:c:al rct.(�111.ion enemas, au1l staphylcwocci <lisappeitrcd following this 1.herapy. ln ordct to evaluate scien­

tifically the efficacy of feeal enemas in the therapy oJ psendmnembranous r.n­terncolitis, it would lw necessary to wit.hhol.d oth<:r fo:1•ms of tn�a.1.ment, an un­j n8tifia bly stringc�nt c.xpcrirn.cut in Yiew o:i' the gravity of the ilJness.

In many cases staphyluc:o(:ei set'm to })lay n key r<>lc in t.he pathogenesis of psemlomcrnbranous cnteroculit.is and thci1· <1isnp1h\ill'HIHlC f1·om the stool is accom­

J'><t.nied by clinica.l irnprnvcment. Uhcmothl\r;1peutic mN1s11rcs 1·c!lilai1t relatively

inr.�ffcctive in thii:; as well as othm· t.n>ek of st;iphylococcal intu·.tions, so that other mea.surc�s must be at.1.ernpLe<l

Van Prolrnskn.13 Jrns snggcstecl that staphylococci cannot. llolll'isli in the in­tc;;t.inal t.raet in the in·esc�nce of the normal col onic ii.u1·a. Taking <Lilva.11tage of

this Jaet it seems rc:asonabl.c to a U\:111pt. to rc-csrabJish tht� varil;d bact(·rial Jwhi­un1ts of thl\ h<">wc"I when they have tcinporar-ily heen 1·epliwe<l by ;l pa thogenicstrain of staphylococcus. S11bstitution of eJH\•l'ie no11p11tl1ogl)11s ns a t.hc�rapeut.ic

rncnsurc has heen givcn 1n-(!Viuns trial, b�' feeding of a<":i<lophilus lllil1<.1·1 U11fortunately, t.herc is no melhod for prodncing pstmdomcmbranous en­

l<!I'<wolitis in tlrn experimental nnirnal and tln:is to C!rnluate rlwr;qH�t.lli<\ rnea:':ures

under controlled eondi1.ions. The appil.l'<!llt assoeiation of the use of broad­spcctrum Ol'a l antibiotics with the disease suggests the t.r:ial o.r thr:sc d rugs in p recipit.nting sueh an enteritis. Van Prolrnska"1 }rn.s hN!ll 111whlc tlim; 1·0 produee

the disease in n10nkeys and kittens, a.lHl we }rnvt\ liacl similar unsuccessful results in dogs. Dack' feel large doses of .!.11-icrococc·tlS 1>uogenes to lrnrnnii vol nntner·s u11<l

W<LS seldom able to recover· the organisms in the stools.

Jn the hope of precipitating staphy'lococcal cntrn:itis within a previously

st.l�rilized segment o.1' howcl WC\ eonstructcd a Thiery fistula eonsisting of the large howd from thf! ileocecal valv1� to the signioid flexure in 2 adult <log·s. .After

JlH·:dianical elHf Hrning, t.lrnse isolated s<�gnwnts were l:lVaged twiee daily with .Achromycin solutions for 4 days until. stctility was approached. Largt: doses of a purn broth eolturc of Achromy(:.in-rcsistant Mic.ro,;01;cus p'!JOfFnes (coagulaseposilive hemolytic Staphylocuccus aii.re1is) then were insLiUed into the proximalstoma of the isolated intnstinal segment daily for J days. l�vcn this tec:ltniqne did not produce a progl'i:�ssive enteritis or b lo ody dinrd1ca from t.lw isolated colonic segment.

. ... ,; ..

Volun1e ..:l 4-N�1 1:ibc1- _)

FECAL J�NEMA FOH PSEUD0111EMBllA NO lJ8 El\T '"-' "��,,

Shou l d Jn rtlwr cl i nical (\xpcl'i 1�ne.1! snbstan tia tl! t!w 1H�nellcin1 cncn111s in the l.rl'!;1t.1 1H•nt of psendomcmbr;; nom: en terocol it is," more pr(·!cisc tcl'inJ, vital, o e h :i\'.t.('l'iophagc substit.ntion i.l1<:r; 1py m ight lw (�1111iloyi�d. Sincethe d i sr::1Sl! oeea.;.;i01rnl ly i n volves pans ol' tl!P int(•stirn 1 l tract 1woximal ro the colon, tlic oral admi11ist1·�nion of pure <:Uhllrt's of tlH:Se organisms in (;nteric­(·oatnd ca.psulr:s might be both more aesthetic and 11101·(' df:eeti ve.

SUJ\I'\L\HY

1 . Reten 1.ion cnern:1s composed of nonnal feces suspended in sllliw: have hcen. :id 1 1 1 in istered to >'J. patients with pscudon1(m1 b1·;mous cnt<�1·cwol itis. !11 c�ad1insta.nl:C tlw cd in ieal eont·s(� was m a.1·ked ly irn \H'r>vcd and the 1llicrococc·n811yo9 WIH!S (staph,vlococcus) which g1·1ow in pur(� c u 1 1 1.nc pl'iot LO ttearnrnm clis­n pp(�aJ:ed f1'01n t.hc stool.� H n d was 1·<'pl<1ecd with 1HJi'Jn<t.I <•olonic nonp11thogens l'o l iowing· s1wh t.hcrnpy.

2. Uusn('.C<"ss fu l efforts to p 1·0<1nee th(� d i�(':1se rn CXJH�ri men ta I ;rn i111 : t is 11n:

dese l'ihed.

;3. Jr. is '-;llggcstecl th;li. t.l 1 i s sirnpl <� yd. n1 l iona I thcrn p1·n1.i1• mc1hnd �l!nnkl ! wgiveT1 111orc extensive clini('.al eva l u atio11.

l. :Dack, 0. M. : Food Poisoning-, Ed. :::., Chicago, J 9J9, U1,; ,-,,r;city o l' C:l1i·"<tg"1.i Pr1\'�. '.'. Piudbnil , 1\L, and \Vcinst.eiH, L : Cowpii 1;H.tiom foiln<·.r'(i hy ".\ 1 1 ti n1ic1 0\ 1 ial Ag·eut.s, Xi'\\

.1':11.ghrnd .J. ::\foil. 248: '.'20-�'W, 1 %:l. :1. l''i11ncy, .r. M. 'I'. : Gast.roenterostomy for Cieatri7.ing- Ulu.·1· o:I' tl11: Pylinn;;, l�nl l . ,Tolrns

HnpkinB 11.o.,p. 1: 53 54. 18113.4. J:o"lnulk� L., �1-lH] _A . . vola: T'. A.': J>s(•nd on:iemlH�ll�(·t:::s l�:nrt.�roc�onti;:.; :t.�. a l1o�Lot)t'r:0tt.iv1� Co-111·

plication, Gastrnenterology 29: :.HJ 1 -'.102, Hi5:J.:. . l·\:'erst.:in, H. l\I. : Inlcntiuunl Rcplaccme:nt of Bndcri:1 Yc-llo11·ing An Li biotic '1'111."r:tpy, . I .

Iowa Mi·:fl. Sr1<:. 4 8 : 240, 1 H58.ll. IZicchwr, M. S .. .Tr., J1arg·.,n, J. A., :rn<l Tfa g g·1.�ns1.,1s;;, ..:\. II. : l\;;ul!omembranous Dn­

ti�rn;:ol iti;; : · Cli;1i �1)pr;thologie Study of '1·'orntee·n · ( :a�•'S i 1 1 \\' hit-.11 the Dis<:a�;; \Vets Xot Prece1led by an Operation, Uast»om1l.810'1 o.�y 21 : :'.l:'.·22�, l\\:1:2.

T. J\1arldey, J, c.� Cu:rson, R .. J.: an(} ' llolz.t·rj c. E. :, l's��udornem � ff:HIOllS Er:h1rneolitis: . r·\ Clinicopallwlogie S tudy o f Tl1ll 'h�1·11 \::a�e� Wtt.h a C01111 1 1011 Etiulogie F:u-.':'"" A . !vl . .. \ .An:lJ. Smg. 77: Hl58. . . . . 8. :Newm;i,n. C. R. : J:>seudomcmhrano::s Edcrocolitis �nHl Antibiotic,, A n n . l n t . J\kd. 4f>:400:444, HJJG.

!J. P1�nn er, A., and Bmnhdm, A. T. : Ae11 1:c l)ostop(:rati >'(', J.:atcro(:olitis: A Study on 1:111: Pathologic Natun: of Shoc:k, An.h. Path. 27: !ltHi-98:1, ·rn:1�J.

.l.O. 1�cJ1 1 u.:r, A., a1H] Drud,cnn:tn, L. J . : E11 l!.;roeol i t i ' [LS ' ' l'ost·Or1•1·a\'i"' C11111;1l!i;:1 i . i( • ll :u1J lt.s Sig11 i1i<::rnee, Gasnrwnt('rolDgy 1 1 : 478-437, 1948.

1 1 . Pd:tet, .J. D., Baggen,toss, A. IL, .!)paring, \V. JI., :u1(! .Jud,�, E. S., ,Ji-, : Posl•lp1·ntivcl'scndomcrubranons Enterocol i t:is, Su1·g., Gyiwe .. & 011�L 98: 3,10.;;,-,:.i, I \}�4.

12. Prnlia sbt, .T. V., Govo�t.is, 1L C., nud ·Tn.ubcnha'us, id. ; . Posto1wr:�ti,··c . l':<c11dom!'(lll,rnn<a1� Ente1·ocolitis: Snceessful Tre:Ltmcnt With Co1t.icotropi1t ( A CTH .1 , J . .A. M. A. 10'1:

. 14.

15.

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·�'>[\. 'J'I'\ ] 1Vi4 J> roiu�;ka�'-j .' v:: r:ong, E. 'l'., rrnd Ncbcn, T. S. : Pscu1lonH; ml•ranon� E11teroeol i ti & : Hs

Etio1ogy fl;,a Lhc Mec.ha;1i�m of the ]h;caHc Proc•·�s, A. :M . A. A ieh. S11tg. 72: 077-flSB, rn:rn.

I�einel'. L., S1·.hlc;;i nge,., Jf. .r., and Miller, G. \I. : P�c;ado111''1 1 1br:rnous Cold.is }\•l lowing-1..:u1·eomv1;i11 :c1111 Cldonunph,!11i<;o!, A. ':IL A. Ar\'IL l ':i1 ' 1 1 , 54: :1�1�H7, 1 !1�2.

111!!.tg'l:r, L. }'., and Ch<�plin, IL A . : l.n<-toh1t1·.illus 1\ 1: idopl1 i )us and l h 'l'l1<>rapt:nt.ic Ap··pl ieat io11, Areh. Int M i�<l. ��: '.l:J7, 1922.

I- ]> · J- J' ' l J1 J P t H ;oH1 Lan."kv. H. : Gast.J·oe11h•roeolit.is �:Erplau, \.., . . ann�� , . . -,,,, i'.:-j H! .. . l·�· • • ·.� _ ::.,�·: l l � . , .

Cansc<l bv Staphyl oeou.i : lt;; . Apparent Ci!n11.cd i o 1 1 \\' i l l!. An1.ih ioti..: )lf(,di<"'.Htior1, Gastro•�nternlogy 24: 4/(;·500, 1 95:\.

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