Full Download Management of Inpatient Inflammatory Bowel Disease A Comprehensive Handbook de Joseph D Feuerstein Editor Ebook Online Full Chapter PDF

Management of Inpatient Inflammatory
Bowel Disease A Comprehensive

Handbook De Joseph D. Feuerstein
(Editor)
Visit to download the full and correct content document:
https://ebookmeta.com/product/management-of-inpatient-inflammatory-bowel-disease
-a-comprehensive-handbook-de-joseph-d-feuerstein-editor/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
Management of Inpatient Inflammatory Bowel Disease A

Comprehensive Handbook Joseph D Feuerstein Adam S
Cheifetz Eds
https://ebookmeta.com/product/management-of-inpatient-
inflammatory-bowel-disease-a-comprehensive-handbook-joseph-d-
feuerstein-adam-s-cheifetz-eds/
Inflammatory Bowel Disease 2nd Edition Wilton Schmidt

Cardozo Carlos Walter Sobrado
https://ebookmeta.com/product/inflammatory-bowel-disease-2nd-
edition-wilton-schmidt-cardozo-carlos-walter-sobrado/
Pediatric Inflammatory Bowel Disease 4th Edition Petar

Mamula Judith R Kelsen Andrew B Grossman Robert N
Baldassano Jonathan E Markowitz
https://ebookmeta.com/product/pediatric-inflammatory-bowel-
disease-4th-edition-petar-mamula-judith-r-kelsen-andrew-b-
grossman-robert-n-baldassano-jonathan-e-markowitz/
Small Intestine Disease: A Comprehensive Guide to

Diagnosis and Management Hoon Jai Chun
https://ebookmeta.com/product/small-intestine-disease-a-
comprehensive-guide-to-diagnosis-and-management-hoon-jai-chun/
The Acute Management of Surgical Disease Martin D.
Zielinski (Editor)
https://ebookmeta.com/product/the-acute-management-of-surgical-
disease-martin-d-zielinski-editor/
The Palgrave Handbook of Supply Chain Management Joseph

Sarkis
https://ebookmeta.com/product/the-palgrave-handbook-of-supply-
chain-management-joseph-sarkis/
Nutritional Management of Renal Disease, 4th ed 4th

Edition Joel D. Kopple
https://ebookmeta.com/product/nutritional-management-of-renal-
disease-4th-ed-4th-edition-joel-d-kopple/
Caring for the Hospitalized Child A Handbook of

Inpatient Pediatrics Third Edition Section On Hospital
Medicine
https://ebookmeta.com/product/caring-for-the-hospitalized-child-
a-handbook-of-inpatient-pediatrics-third-edition-section-on-
hospital-medicine/
Teledermatology A Comprehensive Overview Joseph C

English Iii (Editor)
https://ebookmeta.com/product/teledermatology-a-comprehensive-
overview-joseph-c-english-iii-editor/
Management
of Inpatient
Inflammatory
Bowel Disease
A Comprehensive Handbook
Joseph D. Feuerstein
Adam S. Cheifetz
Editors
123
Management of Inpatient
Inflammatory Bowel Disease
Joseph D. Feuerstein
Adam S. Cheifetz
Editors
Management
of Inpatient
Inflammatory
Bowel Disease
A Comprehensive Handbook
Editors
Joseph D. Feuerstein Adam S. Cheifetz
Harvard Medical School Harvard Medical School
Beth Israel Deaconess Beth Israel Deaconess
Medical Center Medical Center
Boston, MA, USA Boston, MA, USA
ISBN 978-1-0716-1986-5 ISBN 978-1-0716-1987-2 (eBook)

https://doi.org/10.1007/978-1-0716-1987-2
© The Editor(s) (if applicable) and The Author(s), under exclusive license to
Springer Science+Business Media, LLC, part of Springer Nature 2022
This work is subject to copyright. All rights are solely and exclusively licensed by
the Publisher, whether the whole or part of the material is concerned, specifically
the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting,
reproduction on microfilms or in any other physical way, and transmission or
information storage and retrieval, electronic adaptation, computer software, or by
similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service
marks, etc. in this publication does not imply, even in the absence of a specific
statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and
information in this book are believed to be true and accurate at the date of
publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with
regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer

Science+Business Media, LLC part of Springer Nature
The registered company address is: 1 New York Plaza, New York, NY 10004,
U.S.A.
Introduction
The management of patients hospitalized with acute severe ulcer-

ative colitis and Crohn’s disease often requires complex multidis-
ciplinary management with hospitalists, gastroenterologists,
inflammatory bowel disease (IBD) specialists, and surgeons. Over
the last decade, the pharmacologic armamentarium and surgical
techniques for managing IBD has evolved dramatically providing
additional new options for managing patients hospitalized with
IBD. We are excited that this book, Management of Inpatient
IBD: A Comprehensive Handbook, provides the readers with
expert reviews on critical topics pertaining to the management of
hospitalized patients with IBD.
The book includes chapters focused on both Crohn’s disease
and ulcerative colitis. Each author was carefully selected for their
clinical and research expertise in the management of hospitalized
patients with IBD and their ability to succinctly summarize the
latest evidence-based medicine approach.
The first four chapters focus on the pharmacologic manage-
ment and surgical management of acute severe ulcerative colitis.
These chapters are authored by Dr. Schwartz, Dr. Farraye, Dr.
Maser, and Dr. Messaris.
Chapters 5, 6 and 7 review the management of hospitalized
patients with Crohn’s disease, with a focus on the pharmacologic
and surgical management of inflammatory, stricturing, and fistu-
lizing Crohn’s disease. These chapters are authored by Drs. Weiz-
man, Flier, and Remzi.
v
vi Introduction
The remaining chapters (Chaps. 8, 9, 10, 11, 12 and 13) focus

on the management of co-infection with cytomegalovirus (CMV)
and clostridium difficile, nutritional management, quality of care,
pediatric IBD, and pregnancy. These chapters are authored by Dr.
Achkar, Dr. Grossman, Dr. Barnes, Dr. Bousevaros, Dr. Israel, and
Dr. Friedman.
We believe this book will provide the reader with a thorough
review of the latest evidence on managing a challenging group of
patients, those hospitalized patients with inflammatory bowel
disease.
Boston, MA, USA Joseph D. Feuerstein

Adam S. Cheifetz
Contents
1 Epidemiology and Risk Factors

for Hospitalization in Patients with Ulcerative
Colitis and Crohn’s Disease�� 1
Robin Dalal and David Schwartz
2 Routine Management of Hospitalized Patients
with Ulcerative Colitis �� 11
Talha A. Malik and Francis A. Farraye
3 Management of Hospitalized Patient
with Ulcerative Colitis Refractory to
Corticosteroids �� 31
Loren Galler Rabinowitz, Stephanie Lauren Gold,
and Elana A. Maser
4 Surgical Management of Hospitalized Patients
with Ulcerative Colitis �� 69
Evan Messaris and Daniel Wong
5 Management of the Hospitalized Patient
with Inflammatory and Stricturing Crohn’s
Disease�� 91
Parul Tandon and Adam V. Weizman
6 Management of Hospitalized Patients
with Fistulizing Crohn’s and Crohn’s-Related
Abscess��109
R. Chibbar and S. N. Flier
vii
viii Contents
7 Surgical Management of Hospitalized Patients

with Crohn’s Disease��133
Michael J. Grieco and Feza H. Remzi
8 Management of Hospitalized Patients
with Inflammatory Bowel Disease and CMV
Infection or Clostridium Difficile Infection ��161
Sara El Ouali and Jean-Paul Achkar
9 Nutrition Management in Patients Hospitalized
with Inflammatory Bowel Disease��181
Trusha Patel, Natalie L. Stoner,
and Andrew B. Grossman
10 Quality of Care in the Management of Hospitalized
Patients with Inflammatory Bowel Disease ��211
Joshua L. Hudson and Edward L. Barnes
11 Management of Pediatric Patients Hospitalized
with Ulcerative��225
Athos Bousvaros
12 Management of Pediatric Patients Hospitalized
with Crohn’s Disease��247
Christopher J. Moran and Esther Israel
13 Management of Pregnant Women Hospitalized
with a Flare of Inflammatory Bowel Disease��263
Punyanganie S. de Silva, Rahul S. Dalal,
and Sonia Friedman
Index��287
Editors and Contributors
Editors
Joseph D. Feuerstein Division of Gastroenterology, Center for

Inflammatory Bowel Disease, Beth Israel Deaconess Medical
Center, Department of Medicine, Harvard Medical School, Bos-
ton, MA, USA
Adam S. Cheifetz Center for Inflammatory Bowel Disease, Beth
Israel Deaconess Medical Center, Department of Medicine, Har-
vard Medical School, Boston, MA, USA
Contributors
Jean-Paul Achkar, MD Department of Gastroenterology, Hepa-

tology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
Edward L. Barnes Division of Gastroenterology and Hepatol-
ogy, University of North Carolina at Chapel Hill, Chapel Hill,
NC, USA
Multidisciplinary Center for Inflammatory Bowel Diseases, Uni-
versity of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Center for Gastrointestinal Biology and Disease, University of
North Carolina at Chapel Hill, Chapel Hill, NC, USA
ix
x Editors and Contributors
Athos Bousvaros Professor of Pediatrics, Harvard Medical

School, Inflammatory Bowel Disease Center, Boston Children’s
Hospital, Boston, MA, USA
R. Chibbar Division of Gastroenterology, Department of Medi-
cine, University of Alberta, Edmonton, AB, Canada
Rahul S. Dalal Division of Gastroenterology, Hepatology, and
Endoscopy, Department of Medicine, Brigham and Women’s
Hospital, Harvard Medical School, Boston, MA, USA
Robin Dalal Vanderbilt University Medical Center, Nashville,
TN, USA
Francis A. Farraye Gastroenterology and Hepatology, Mayo
Clinic Arizona, Scottsdale, AZ, USA
S. N. Flier Division of Gastroenterology, Beth Israel Deaconess
Medical Center, Boston, MA, USA
Sonia Friedman Division of Gastroenterology, Hepatology, and
Endoscopy, Department of Medicine, Brigham and Women’s
Hospital, Harvard Medical School, Boston, MA, USA
Center for Clinical Epidemiology, Odense University Hospital,
Odense, Denmark
Research Unit of Clinical Epidemiology, Department of Clinical
Research, University of Southern Denmark, Odense, Denmark
Harvard Medical School, Brigham and Women’s Hospital, Center
for Crohn’s and Colitis, Chestnut Hill, MA, USA
Stephanie Lauren Gold The Rogosin Institute, Inc, New York,
NY, USA
Michael J. Grieco NYU Langone Health, NYU Grossman
School of Medicine, New York, NY, USA
Andrew B. Grossman Department of Pediatrics, Division of
Gastroenterology, Hepatology and Nutrition, Children’s Hospital
of Philadelphia, Philadelphia, PA, USA
Joshua L. Hudson Department of Medicine, University of North
Carolina School of Medicine, Chapel Hill, NC, USA
Editors and Contributors xi
Esther Israel Department of Pediatrics, Harvard Medical

School, Boston, MA, USA
Talha A. Malik Gastroenterology and Hepatology, Mayo Clinic
Arizona, Scottsdale, AZ, USA
Elana A. Maser Gastroenterology, Mount Sinai Hospital, New
York, NY, USA
Evan Messaris Division of Colon and Rectal Surgery, Beth
Israel Deaconess Medical Center, Boston, MA, USA
Christopher J. Moran Pediatric Gastroenterology, MassGen-
eral Hospital for Children, Boston, MA, USA
Sara El Ouali, MD Digestive Disease Institute, Cleveland
Clinic, Abu Dhabi, UAE
Trusha Patel Department of Pediatrics, Division of Gastroenter-
ology, Hepatology and Nutrition, Children’s Hospital of Philadel-
phia, Philadelphia, PA, USA
Loren Galler Rabinowitz Department of Medicine, Mount
Sinai Hospital, New York, NY, USA
Feza H. Remzi NYU Langone Health, NYU Grossman School
of Medicine, New York, NY, USA
David Schwartz Vanderbilt University Medical Center, Nash-
ville, TN, USA
Punyanganie de Silva Division of Gastroenterology, Hepatol-
ogy, and Endoscopy, Department of Medicine, Brigham and
Women’s Hospital, Harvard Medical School, Boston, MA, USA
Harvard Medical School, Brigham and Women’s Hospital, Center
for Crohn’s and Colitis, Chestnut Hill, MA, USA
Natalie L. Stoner Center for Pediatric Inflammatory Bowel Dis-
ease, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
Parul Tandon Division of Gastroenterology and Hepatology,
Mount Sinai Hospital, Department of Medicine, University of
Toronto, Toronto, ON, Canada
xii Editors and Contributors
Adam V. Weizman Division of Gastroenterology and Hepatol-

ogy, Mount Sinai Hospital, Department of Medicine, University
of Toronto, Toronto, ON, Canada
Daniel Wong Division of Colon and Rectal Surgery, Beth Israel
Deaconess Medical Center, Boston, MA, USA
Epidemiology and Risk
Factors for Hospitalization 1
in Patients with Ulcerative
Colitis and Crohn’s Disease
Robin Dalal and David Schwartz
The inflammatory bowel diseases encompass both ulcerative coli-

tis (UC) and Crohn’s disease (CD). The incidence and prevalence
of inflammatory bowel disease (IBD) have increased with time
throughout the world with the highest annual incidence and
reported prevalence of both UC and CD occurring in Europe and
North America [1]. Between 1970 and 2010, incidence rates for
UC and CD have increased, and it is estimated that there are
approximately 1.6 million persons in the United States (US) with
inflammatory bowel disease (IBD) [2].
Due to the chronic nature of IBD, patients can develop flares or
worsening disease which can result in hospitalizations and need
for surgery. Since the discovery of these entities, trends in hospi-
talizations have changed with time. The most recent interpretation
of widespread data for all IBD admissions worldwide (34 coun-
R. Dalal (*) · D. Schwartz

Vanderbilt University Medical Center, Nashville, TN, USA
e-mail: robin.dalal@vumc.org; david.a.schwartz@Vanderbilt.Edu
© The Author(s), under exclusive license to Springer 1

Science+Business Media, LLC, part of Springer Nature 2022
J. D. Feuerstein, A. S. Cheifetz (eds.), Management of Inpatient
Inflammatory Bowel Disease,
https://doi.org/10.1007/978-1-0716-1987-2_1
2 R. Dalal and D. Schwartz
tries) showed hospitalization rates were highest in North America

and Europe but that the rates had stabilized or decreased over time
and that rates may be increasing in Asia [3].
Specifically for UC, hospitalization rates increased since the
discovery of the disease but have stabilized recently. Early data
regarding hospitalizations dates back to the 1930s. Edwards and
Truelove prospectively followed a series of 624 patients from
1938 to 1962, and during this time, 38% required hospitalization
[4]. Annual incidence rates of hospitalization in UC began to be
more widely reported in the late 1960s and 1970s with rates rang-
ing from 4.6 to 4.8 per 100,000 in Europe and the USA [5, 6]. In
one series, 20.8% of patients required hospitalization within the
first year of diagnosis [7]. Since that time, hospitalization rates
have increased for UC throughout the world but have stabilized
recently.
In the USA, reports using data from the Nationwide Inpatient
Sample showed there was a 3% annual relative increase in the
hospitalization rate for UC with an overall rate reported at 10.8
per 100,000 [8]. When using the National Hospital Discharge
Survey Data in the USA, hospitalization rates for UC were
reported as stable during this time at 8.1–12.4 per 100,000 [9]. In
California, the Kaiser Permanente system reported a 29% decrease
in UC hospitalizations from 1998 to 2005 [10]. Data from
Olmstead County, Minnesota, noted that from 1970 to 2004, the
cumulative probability of a first hospitalization for UC was 29.4%
at 5 years (95% confidence interval [CI], 24.5–34.1%), 38.7% at
10 years (33.1–43.8%), 49.2% at 20 years (42.7–55.2%), and
52.3% at 30 years (45.1–59.7%) [11]. In Canada, age-adjusted
hospitalization rates remained stable from 12.6 to 13.3 per
100,000 [12]. European data from Italy and Portugal also note
stable rates of hospitalization in the 2000s with rates of 4.4–4.9
per 100,000 [13, 14].
For CD, hospitalization rates have increased over time through-
out the world. The annual incidence rate of hospitalization from
Baltimore, Maryland, in the 1960s was reported at 1.8 per 100,000
[5]. Between 1962 and 1987, one series in Denmark reported an
83% overall admission rate within the first year of diagnosis and
then 20% per year over the next 5 years [15]. In Italy, incidence of
1 Epidemiology and Risk Factors for Hospitalization in Patients… 3
first hospitalizations of CD was 2.7 per 100,000 in the late 1980s

[16]. Between 1998 and 2004, using the US Nationwide Inpatient
Sample data, rates of hospitalizations increased for CD in the
USA with a 4.3% annual relative increase in hospitalization rate
(P < 0.0001) [8]. Data from the National Hospital Discharge
Survey showed hospitalization rates ranging from 9.3 to 17.1 per
100,000 with a significant trend for increasing hospital rates from
the 1990s to 2000s [9]. In Canada, when comparing CD patients
in 2000–2001 to 1990–1991, patients were more likely in 2000–
2001 to have an overnight hospital stay (RR 2.32; 95% CI 2.16–
2.49) [17].
While rates have certainly increased since the first descriptions
of CD, more recently, reports indicate that hospital rates for CD
may be decreasing. In Canada, from 1994 to 2001, age-adjusted
hospitalization rates declined from 29.2 per 100,000 to 26.9 per
100,000, and from 2003 to 2014, CD-related hospitalizations
declined 32.4% [12, 18]. Hospitalization costs have also declined
in CD patients over this time significantly [19]. In the USA, hos-
pitalization rates from emergency room visits decreased 12.1%
for IBD in 2014 compared to 2006 (64.7% rate of hospitalization
in 2006 to 52.6% in 2014) [20].
For both UC and CD, intensive care unit (ICU) admissions are
less common. In a retrospective study looking at 5 years of data
from 2003 to 2008 of all IBD patients to one tertiary care center
in the USA, ICU admissions accounted for only 1.43% of IBD
admissions [21]. In this study, over the 5-year period, annual inci-
dence of ICU hospitalizations increased from 0.1% in 2003 to
2.6% in 2008, and the 30-day mortality was calculated at 18.9%.
In Europe, an 18-year prospective study showed that IBD-ICU
admissions accounted for only 0.46% of total ICU admissions
during this time period [22]. The IBD-ICU admissions were due
to either IBD-specific complications, sepsis, or thromboembolic
complications.
Data regarding readmission rates in IBD varies between stud-
ies. For UC, readmission rates have been reported between 14.6%
and 33.7% within 90 days [12, 23–25]. For CD, readmission rates
have been reported between 12.6% and 39.4% within 90 days [12,
24]. In a study of US veterans looking at readmission rates
between 2007 and 2013, the 30-day readmission rate was 17.3%,
and the 90-day readmission rate was 29.2%. Patients with CD had
a higher risk of readmission than UC patients (OR 3.90, 95% CI
1.82–8.90) [26]. For IBD readmissions, predictors that have been
reported include opioid use disorder, younger age, mood disorder
(depression and/or anxiety), and lack of follow-up visit after hos-
pitalization [26–29].
Specific risks for hospitalization in IBD have been evaluated
including demographic factors, environmental exposures, and dis-
ease characteristics. The sex, age, race, and socioeconomic status
of patients have variable impact on a patient’s risk of hospitaliza-
tion for IBD. In CD, women have been shown to have a higher
risk of hospitalization than males, especially during the childbear-
ing period [30–33]. For UC, there is conflicting data with some
studies reporting risk of hospitalization being higher in females
and some with a slight male predominance [32, 33]. As with the
onset of IBD, there appears to be a bimodal risk of age for hospi-
talizations in IBD. In the USA, hospitalization rates for UC are
highest in the 20–29-year-old and 70–79-year-old age groups and
for CD are highest in the 20–29-year-old, 50–59-year-old, and
70–79-year-old age groups [30–32]. Within these peaks, younger
patients are higher risk. Elderly patients only account for 25% of
total IBD hospitalizations and overall have less hospitalization
rates when compared with younger adults for both CD and UC
(CD IRR 0.62, 95% CI 0.59–0.65 and UC IRR 0.64, 95% CI
0.57–0.71) [34, 35].
Data on patient’s race and risk of hospitalization is not consis-
tent overall. Earlier studies noted a twofold higher risk of hospi-
talization for whites than blacks (RR 2.18, 95% CI 2.18–2.19) and
higher rates in both white patients and black patients when com-
pared to Hispanics [31, 36]. A more recent evaluation of over
5000 IBD patients did not note any difference in hospitalization
rates between black and white patients [37]. Other studies have
shown that since the 2000s, hospitalization rates have decreased
for non-Hispanic whites but not for black patients and the ratio of
IBD hospitalizations to prevalence of disease was disproportion-
ately higher among non-Hispanic blacks (7.3% compared to 3%
for non-Hispanic whites and 2% for Hispanics) [38, 39]. Lower-
income levels were associated with higher hospitalization rate. In

a retrospective analysis of CD patients, the incidence rate for hos-
pitalization for lowest-income group was 118 per 100-person
years (CI 91.4–152.3) and for the highest-income group was 29
(CI 21.7–38.9) [40]. In CD, smoking has also been shown to
increase the risk of hospitalization [41].
Geographical variation in hospitalization has also been noted
in IBD. Urban areas have higher rates of hospitalization than non-
urban areas [6, 36, 42]. Two studies have shown that within the
USA, northern states have higher rates of hospitalizations than
southern states establishing a “North to South” gradient for hospi-
talizations in IBD similar to the known gradient that exists with
IBD incidence in general [36, 43]. The first study, in 1991, evalu-
ated Medicare discharges, and the second study used data from
the Nationwide Inpatient Sample. Seasonality has not been found
to be associated with any difference in hospitalization rates [43,
44]. UV exposure has also been examined, and hospitalization
rates were increased for both CD and UC in lower UV exposure
areas [45].
Disease characteristics in CD have been shown to factor into a
patient’s risk of hospitalization as well. An analysis of a cohort of
CD patients showed that patients with structuring or fistulizing
phenotype of disease had a higher risk (58% vs. 41%) of hospi-
talization within the first year of diagnosis [46]. Over 10 years,
admission rate was 2.4% per year (95% CI, 1.4–3.8%) in patients
with inflammatory disease and 13% per year (95% CI, 11.5–
14.6%) in the patients with structuring or fistulizing phenotypes
[46]. An additional analysis from Asia showed that patients with
upper GI location of CD had an 86.9% risk of hospitalization
over 3 years (95% CI 73.8–100%) compared to non-upper GI
location of disease (49.3% risk of hospitalization, 95% CI 39.3–
59.3%) [47].
Similar to the general incidence and prevalence of IBD, the
hospitalization rates for IBD have overall increased since descrip-
tion and discovery of these diseases. In UC, rates have stabilized
in recent years, while in CD, rates have started to decrease accord-
ing to some studies. The risk factors for hospitalization in IBD
vary, akin to the heterogeneity of IBD itself.
References
1. Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prev-
alence of the inflammatory bowel diseases with time, based on systematic
review. Gastroenterology. 2012;142(1):46–54.e42. https://doi.
org/10.1053/j.gastro.2011.10.001.
2. Shivashankar R, Tremaine WJ, Harmsen WS, Loftus EVJ. Incidence and
prevalence of Crohn’s disease and ulcerative colitis in Olmsted County,
Minnesota from 1970 through 2010. Clin Gastroenterol Hepatol.
2017;15(6):857–63. https://doi.org/10.1016/j.cgh.2016.10.039.
3. King JA, Underwood FE, Panaccione N, et al. Trends in hospitalisation
rates for inflammatory bowel disease in western versus newly industri-
alised countries: a population-based study of countries in the Organisation
for Economic Co-operation and Development. Lancet. 2019;4(4):287–
95. https://doi.org/10.1016/S2468-1253(19)30013-5.
4. Edwards FC, Truelove SC. The course and prognosis of ulcerative colitis:
part II Long-term prognosis. Gut. 1963;4(4):309–15. https://doi.
org/10.1136/gut.4.4.309.
5. Monk M, Mendeloff AI, Siegel CI, Lilienfeld A. An epidemiological
study of ulcerative colitis and regional enteritis among adults in Baltimore.
I. Hospital incidence and prevalence, 1960 to 1963. Gastroenterology.
1968;54(4):198–210. https://doi.org/10.1016/S0016-5085(19)34227-1.
6. Linden G, Moller C. Ulcerative colitis in Finland: one-year incidence in
all hospitals. Dis Colon Rectum. 1971;14(4):264–6. https://doi.
org/10.1016/S0031-3955(05)70404-1.
7. Ritchie JK, Powell-Tuck J, Lennard-Jones J. Clinical outcome of the first
ten years of ulcerative colitis and proctitis. Lancet. 1978;1:1140–3.
8. Nguyen GC, Tuskey A, Dassopoulos T, Harris ML, Brant SR. Rising hos-
pitalization rates for inflammatory bowel disease in the United States
between 1998 and 2004. Inflamm Bowel Dis. 2007;13:1529–35. https://
doi.org/10.1002/ibd.20250.
9. Bewtra M, Su C, Lewis JD. Trends in hospitalization rates for inflamma-
tory bowel disease in the United States. Clin Gastroenterol Hepatol.
2007;5:597–601. https://doi.org/10.1016/j.cgh.2007.01.015.
10. Herrinton LJ, Liu L, Fireman B, et al. Time trends in therapies and out-
comes for adult inflammatory bowel disease, northern California, 1998–
2005. Gastroenterology. 2009;137(2):502–11. https://doi.org/10.1053/j.
gastro.2009.04.063.
11. Samuel S, Ingle S, Dhillon S, et al. Cumulative incidence and risk factors
for hospitalization and surgery in a population-based cohort of ulcerative
colitis. Inflamm Bowel Dis. 2013;19(9):1858–66. https://doi.org/10.1097/
MIB.0b013e31828c84c5.CUMULATIVE.
12. Bernstein CN, Nabalamba A. Hospitalization, surgery, and readmission
rates of IBD in Canada: a population-based study. Am J Gastroenterol.
2006;101:110–9. https://doi.org/10.1111/j.1572-0241.2006.00330.x.
13. Dias CC, Santiago M, Correia L, et al. Hospitalization trends of the

inflammatory bowel disease landscape: a nationwide overview of 16
years. Dig Liver Dis. 2019;51(7):952–60. https://doi.org/10.1016/j.
dld.2019.01.016.
14. Kohn A, Fano V, Monterubbianesi R, et al. Surgical and nonsurgical hos-
pitalization rates and charges for patients with ulcerative colitis in Italy: a
10-year cohort study. Dig Liver Dis. 2012;44(5):369–74. https://doi.
org/10.1016/j.dld.2011.11.009.
15. Munkholm P, Langholz E, Davidsen M, Binder V. Disease activity
courses in a regional cohort of Crohn’s disease patients. Scand J
Gastroenterol. 1995;30(7):699–706. https://doi.
org/10.3109/00365529509096316.
16. Cottone M, Cipolla C, Orlando A, Oliva L, Aiala R, Puleo A. Epidemiology
of Crohn’s disease in Sicily: a hospital incidence study from 1987–1989.
Eur J Epidemiol. 1991;7(6):636–40.
17. Longobardi T, Bernstein CN. Health care resource utilization in inflam-
matory bowel disease. Clin Gastroenterol Hepatol. 2006;4(6):731–43.
https://doi.org/10.1016/j.cgh.2006.02.013.
18. Rahman A, Jairath V, Feagan BG, et al. Declining hospitalisation and
surgical intervention rates in patients with Crohn’s disease: a popula-
tion – based cohort. Aliment Pharmacol Ther. 2019;50:1086–93. https://
doi.org/10.1111/apt.15511.
19. Targownik LE, Kaplan GG, Witt J, et al. Longitudinal trends in the direct
costs and health care utilization ascribable to inflammatory bowel disease
in the biologic era: results from a Canadian population-based analysis.
Am J Gastroenterol. 2020;115(1):128–37. https://doi.org/10.14309/
ajg.0000000000000503.
20. Ballou S, Hirsch W, Singh P, et al. Emergency department utilisation for
inflammatory bowel disease in the United States from 2006 to 2014.
Aliment Pharmacol Ther. 2018;47:913–21. https://doi.org/10.1111/
apt.14551.
21. Ha C, Maser EA, Kornbluth A. Clinical presentation and outcomes of
inflammatory bowel disease patients admitted to the intensive care unit. J
Clin Gastroenterol. 2013;47:485–90.
22. Huber W, Herrmann G, Schuster T, et al. Life-threatening complications
of Crohn’s disease and ulcerative colitis: a systematic analysis of admis-
sions to an ICU during 18 years. Dtsch Med Wochenschr.
2010;135(14):668–74. https://doi.org/10.1055/s-0030-1251915.
23. Jalan KN, Smcus W, Card WI, et al. An experience of ulcerative colitis
III. Long term outcome. Gastroenterology. 1970;59(4):598–609. https://
doi.org/10.1016/S0016-5085(19)33714-X.
24. Frolkis A, Kaplan GG, Patel A, et al. Postoperative complications and
emergent readmission in children and adults with inflammatory bowel
disease who undergo intestinal resection: a population-based study.
Inflamm Bowel Dis. 2014;20:1316–23. https://doi.org/10.1097/
MIB.0000000000000099.
25. Poojary P, Saha A, Chauhan K, et al. Predictors of hospital readmissions

for ulcerative colitis in the United States: a National Database Study.
Inflamm Bowel Dis. 2017;23(3):347–56. https://doi.org/10.1097/
MIB.0000000000001041.Predictors.
26. Malhotra A, Phatharacharukul P, Thongprayoon C. Risk factors for
90-day readmission in veterans with inflammatory bowel disease – does
post-discharge follow-up. Mil Med Res. 2018;5(5):1–6. https://doi.
org/10.1186/s40779-018-0153-x.
27. Charilaou P, Mohapatra S, Joshi T, et al. Opioid use disorder increases
30-day readmission risk in inflammatory bowel disease hospitalizations:
a nationwide matched analysis. J Crohns Colitis. 2020;14(5):636–45.
https://doi.org/10.1093/ecco-jcc/jjz198.
28. Cohen-Mekelburg S, Rosenblatt R, Gold S, Shen N, Fortune
B. Fragmented care is prevalent among inflammatory bowel disease read-
missions and is associated with worse outcomes. Am J Gastroenterol.
2019;114:276–90.
29. Barnes EL, Kochar B, Long MD, et al. Modifiable risk factors for hospital
readmission among patients with inflammatory bowel disease in a nation-
wide database. Inflamm Bowel Dis. 2017;23(6):875–81. https://doi.
org/10.1097/MIB.0000000000001121.Modifiable.
30. Garland CF, Lilienfeld AM, Mendeloff AI, et al. Incidence rates of ulcer-
ative colitis and Crohn’s disease in fifteen areas of the United States.
Gastroenterology. 1981;81(6):1115–24. https://doi.org/10.1016/S0016-
5085(81)80021-2.
31. Kurata JH, Kantor-fish S, Frankl H, Godby P, Vadheim C. Crohn’ s dis-
ease among ethnic groups in a large health maintenance organization.
Gastroenterology. 1992;102:1940–8.
32. Primatesta P, Goldacre MJ. Crohn’s disease and ulcerative colitis in
England and the Oxford record linkage study area: a profile of hospital-
ized morbidity. Int J Epidemiol. 1995;24(5):922–8.
33. Sonnenberg A. Demographic characteristics of hospitalized IBD patients.
Dig Dis Sci. 2009;54:2449–55. https://doi.org/10.1007/s10620-009-
0973-3.
34. Ananthakrishnan AN, Mcginley EL, Binion DG. Inflammatory bowel
disease in the elderly is associated with worse outcomes: a national study
of hospitalizations. Inflamm Bowel Dis. 2009;15(2):182–9. https://doi.
org/10.1002/ibd.20628.
35. Nguyen GC, Sheng L, Benchimol EI. Health care utilization in elderly
onset inflammatory bowel disease a population-based study. Inflamm
Bowel Dis. 2015;21:777–82. https://doi.org/10.1097/
MIB.0000000000000306.
36. Sonnenberg A, Mccarty DJ, Jacobsen SJ. Geographic variation of inflam-
matory bowel disease within the United States. Gastroenterology.
1991;100:143–9.
37. Barnes EL, Kochar B, Long MD. Lack of difference in treatment patterns
and clinical outcomes between black and white patients with inflamma-
tory bowel disease. Inflamm Bowel Dis. 2018;24(12):2634–40. https://
doi.org/10.1093/ibd/izy179.
38. Xu F, Wheaton AG, Liu Y, Lu H, Greenlund KJ. Hospitalizations for
inflammatory bowel disease among medicare fee-for-service beneficia-
ries – United States, 1999–2017. Morb Mortal Wkly Rep.
2019;68(49):1134–8.
39. Nguyen GC, Chong CA, Chong RY. National estimates of the burden of
inflammatory bowel disease among racial and ethnic groups in the United
States. J Crohns Colitis. 2014;8(4):288–95. https://doi.org/10.1016/j.
crohns.2013.09.001.
40. Walker C, Allamneni C, Orr J, et al. Socioeconomic status and race are
both independently associated with increased hospitalization rate among
Crohn’ s disease patients. Sci Rep. 2018;8:1–6. https://doi.org/10.1038/
s41598-018-22429-z.
41. Seksik P, Nion-Larmurier I, Sokol H, Beaugerie L, Cosnes J. Effects of
light smoking consumption on the clinical course of Crohn’s disease.
Inflamm Bowel Dis. 2009;15(5):734–41. https://doi.org/10.1002/
ibd.20828.
42. de Boer Visser N, Bryant HE, Hershfield NB. Predictors of hospitaliza-
tion early in the course of Crohn’s disease. A pilot study. Gastroenterology.
1990;99(2):380–5. https://doi.org/10.1016/0016-5085(90)91019-3.
43. Stein AC, Gaetano JN, Jacobs J, Kunnavakkam R, Bissonnette M, Pekow
J. Northern latitude but not season is associated with increased rates of
hospitalizations related to inflammatory bowel disease: results of a multi-
year analysis of a National cohort. PLoS One. 2016;11(8):1–12. https://
doi.org/10.1371/journal.pone.0161523.
44. Don BAC, Goldacre MJ. Absence of seasonality in emergency hospital
admissions for inflammatory bowel disease. Lancet. 1984;2:1156–7.
45. Limketkai BN, Bayless TM, Brant SR, Hut SM. Lower regional and tem-
poral ultraviolet exposure is associated with increased rates and severity
of inflammatory bowel disease hospitalisation. Aliment Pharmacol Ther.
2014;40:508–17. https://doi.org/10.1111/apt.12845.
46. Veloso FT, Ferreira JT, Barros L, Almeida S. Clinical outcome of Crohn’s
disease: analysis according to the Vienna classification and clinical activ-
ity. Inflamm Bowel Dis. 2001;7(4):306–13.
47. Chow D, Sung J, Wu J, Tsoi K, Leong R, Chan FKL. Upper gastrointes-
tinal tract phenotype of Crohn’s disease is associated with early surgery
and further hospitalization. Inflamm Bowel Dis. 2009;15(4):551–7.
https://doi.org/10.1002/ibd.20804.
Routine Management
of Hospitalized Patients 2
with Ulcerative Colitis
Talha A. Malik and Francis A. Farraye
Background
All patients seen with ulcerative colitis (UC) in the ER or in the

outpatient setting should have their disease activity graded and
based on the findings, management options discussed and treat-
ment undertaken. Acute severe ulcerative colitis (ASUC) is a term
used to describe patients with UC with severely active disease
whose symptoms progress rapidly. Patients with ASUC are hospi-
talized for inpatient management. UC is classified as ulcerative
proctitis, ulcerative proctosigmoiditis, left-sided ulcerative colitis,
or pancolitis based on its extent. Disease activity is graded as
mild, moderate, or severe based on several clinical scores includ-
ing the Mayo clinical score that includes only clinical parameters
such as number of additional bowel movements per day, amount
of blood, and physician assessment (Table 2.1). Another clinical
T. A. Malik (*) · F. A. Farraye

Gastroenterology and Hepatology, Mayo Clinic Arizona,
Scottsdale, AZ, USA
e-mail: Malik.Talha@mayo.edu; Farraye.Francis@mayo.edu
© The Author(s), under exclusive license to Springer 11

Science+Business Media, LLC, part of Springer Nature 2022
J. D. Feuerstein, A. S. Cheifetz (eds.), Management of Inpatient
Inflammatory Bowel Disease,
https://doi.org/10.1007/978-1-0716-1987-2_2
12 T. A. Malik and F. A. Farraye
Table 2.1 Mayo UC score

Composite Mayo score
A. Stool frequency
0, Normal number of stools for this patient
1, 1–2 stools more than normal
2, 3–4 stools more than normal
3, 5 or more stools more than normal
B. Rectal bleeding
0, No blood found
1, Streaks of blood with stool less than half the time
2, Obvious blood with stool most of the time
3, Blood alone passed
C. Sigmoidoscopic findings
0, Normal or inactive disease
1, Mild disease (erythema, decreased vascular pattern, mild friability)
2, Moderate disease (marked erythema, absent vascular pattern, friability,
erosions)
3, Severe disease (spontaneous bleeding, ulceration)
D. Physician’s global assessment
0, Normal
1, Mild disease
2, Moderate disease
3, Severe disease
Total
0 = Remission
1–4 = Mild
5–8 = Moderate
9–12 = Severe
score widely used in ulcerative colitis is the Truelove and Witts

clinical score that includes both clinical and biochemical param-
eters (Table 2.2).
The decision to hospitalize a patient for inpatient management
should be based on clinical evaluation and biochemical assess-
ment. In 2019, the American College of Gastroenterology (ACG)
proposed a disease severity scoring system that included clinical,
biochemical, and endoscopic metrics (Table 2.3) [1].
2 Routine Management of Hospitalized Patients with Ulcerative… 13
Table 2.2 Truelove and Witts UC score

Truelove and Witts score Mild Moderate Severe
Bowel movements per day <4 4–6 >6
Blood in stool Intermittent Frequent Continuous
Temperature greater than 37.5 °C No No Yes
Heart rate > 90 No No Yes
Anemia No (Hb) >11 g/dL 10.5–11 g/ <10.5 g/dL
dL
ESR (mm/h) or C-reactive protein Normal <30 >30
(mg/L)
Table 2.3 2019 ACG UC activity index

2019 ACG UC Moderate-
activity index Remission Mild severe Fulminant
Stools Formed <4 6–10 >10
Blood in stool None Intermittent Frequent Continuous
Urgency None Mild, Often Continuous
occasional
Hemoglobin Normal Normal <75% of Transfusion
normal required
ESR (mm/h) <30 <30 >30 >30
CRP (mg/L) Normal Elevated Elevated Elevated
Fecal calprotectin <150–200 >150–200 >150–200 >150–200
(ug/g)
Mayo endoscopy 0–1 1 2–3 3
subscore
UC endoscopic 0–1 2–4 5–6 7–8
index of severity
Epidemiology
Based on a 2010 systematic review of a cohort of 750 UC patients

followed for a median of 12 years, the risk of developing at least
one episode of acute severe ulcerative colitis (ASUC) in these
patients was approximately 25% [2].
Before the routine use of steroids, reports suggested that a
quarter of patients with fulminant UC died but in recent studies,
mortality has been reduced to 1% [3–5]. In regard to rates of

colectomy, the risk is 20% among patients with UC admitted for
ASUC during the same admission [2].
Based on a multicenter retrospective study published in 2020,
of patients with ASUC who responded to intravenous steroids,
their colectomy-free survival was 96% at 1 year and 92% at
approximately 5 years. Relapse-free survival in these patients was
58% at 1 year and 40% at 5 years. Those with ASUC who had <6
loose stools per day at day 3 and a clinical Mayo score of <2 at
day 5 and those who were placed on anti-TNF maintenance ther-
apy were less likely to relapse [6].
Characterizing UC Patients with ASUC
In 2019 the ACG proposed a comprehensive classification for dis-

ease severity in UC though the most common classification used
to characterize patients with acute severe ulcerative colitis
(ASUC) as of the writing of this chapter is the Truelove and Witts
classification of severity of UC. As opposed to the Montreal and
the Mayo classification of disease severity, Truelove and Witts cri-
teria further distinguish between severe disease and fulminant dis-
ease including biochemical parameters as well as objective vital
sign parameters. Based on Truelove and Witts criteria, ASUC is
defined by more than six bloody bowel movements per day and at
least one of the following clinical features: fever (>37.8 °C),
tachycardia (>90 bpm), anemia (hemoglobin <10.5 g/dl), or ele-
vated inflammatory markers (traditionally, erythrocyte sedimenta-
tion rate greater than 30 mm/h or, more recently, C-reactive
protein (CRP) greater than 30 mg/L (ULN 10 mg/L)). It further
classifies those within the ASUC category as having acute severe
fulminant colitis as defined by having more than ten stools per
day, continuous rectal bleeding, abdominal pain, colonic dilata-
tion on abdominal X-ray film, and toxic symptoms that include
fever and anorexia. While the initial management regimen for
both these categories is the same, those with severe fulminant
acute colitis are considered to be at a much higher risk of pro-
gressing to toxic megacolon and bowel perforation and therefore

warrant close monitoring including surgical consultation [1, 3, 7].
Approach to Inpatient Management of ASUC
General Principles
All patients with ASUC are admitted for inpatient management.

Colorectal surgery is consulted. A history and physical examina-
tion is performed and vital signs monitored. Diagnostic tests
including biochemical, radiological, and endoscopic evaluation
should follow promptly. Patients without absolute contraindica-
tions receive DVT prophylaxis with subcutaneous unfractionated
or low molecular weight heparin or fondaparinux. All patients are
allowed to eat a low-fiber diet based on their tolerance, and when-
ever possible, parental nutrition must be avoided. A summary of
the approach to management of ASUC is outlined in Table 2.4.
Table 2.4 Approach to inpatient management of ASUC

History History of the use of NSAIDs, antibiotics, opioid
medications, and recreational drugs. Travel history and
history of exposure to others with infections. Comorbid
illnesses
Physical exam Physical examination including abdominal exam, rectal
exam, and vital signs
Labs CBC, CMP, CRP, fecal calprotectin, stool for C. diff
Radiological KUB in all patients, consider CT abdomen/pelvis with
testing contrast if abdominal tenderness
Endoscopic Flexible sigmoidoscopy with biopsy to assess disease
testing activity and rule out CMV colitis
VTE Subcutaneous unfractionated or low molecular weight
prophylaxis heparin or fondaparinux
Diet Oral low-fiber diet as tolerated; parenteral nutrition only
if severe malnutrition and unable to eat
Hydration Crystalloids, preferably normal saline
Medication Methylprednisolone 60 mg IV daily for 3–5 days
Colorectal Surgery for toxic megacolon, perforation, severe
surgery consult hemorrhage, failure of inpatient medical therapy
History, Physical Examination, and Vital Signs
Medication history for the use of NSAIDs, antibiotics, opioid

medications, and recreational drugs is sought. Travel history and
history of exposure to others with infections is obtained. Inquiry
into potential triggers for disease exacerbation is made and
comorbid illnesses are assessed. Physical examination is com-
pleted promptly and should include abdominal and rectal exam.
Vital signs should be monitored.
Diagnostic Work-Up
Blood and stool studies to assess electrolytes, blood counts,

inflammatory markers, and comorbid illnesses including infection
with C. difficile and other enteric pathogens are obtained on
admission. All patients should undergo flexible sigmoidoscopy to
assess severity of endoscopic inflammation, and biopsies should
be taken to r/o CMV. Imaging to assess for toxic megacolon and
perforation is performed. The entire diagnostic work should be
systematic in order to identify and grade UC severity and rule out
other causes of the patients’ symptoms.
Initial Treatment
Once the diagnosis of ASUC is established, intravenous cortico-

steroids at a dose of 60 mg of methylprednisolone daily for
3–5 days should be instituted. There is no benefit of a dose higher
than 60 mg daily. There is no benefit of continuous infusion over
interval IV dosing [8].
If there is evidence of toxic megacolon, perforation, or severe
hemorrhage, the patient should undergo surgery. If improvement
on 3–5 days of IV steroids occurs, transition to any number of
maintenance therapies should be initiated. If no response to IV
steroids at 3–5 days albeit without significant worsening, one
should consider induction with infliximab or cyclosporine. If
cyclosporine is chosen, concomitant induction with vedolizumab

can be considered. Tacrolimus may be used when cyclosporine is
not an option or not available. Alternatives include considering
ustekinumab or tofacitinib, but evidence for these medications is
limited and evolving.
Monitoring Response
Patients’ response to intravenous steroids should be assessed with

repeat labs including CBC, electrolytes, and CRP daily along with
an assessment of the total number of bowel movements over a
24-h period, with special attention to their overall response after
3 days of treatment [33–36]. The Oxford index is a traditional
index used to assess and monitor response to therapy. Based on
the Oxford index, ASUC patients with eight or more loose bowel
movements or between three and eight loose bowel movements
and a serum CRP of 45 mg/L or greater (ULN 10 mg/L) at the end
of 3 days of intravenous steroids had an 85% likelihood of colec-
tomy. By end of days 3–5 of intravenous steroid therapy, patients
who have not had a response should be considered for therapy
with infliximab or cyclosporine. If medical therapy with these
agents is not an option, then colectomy should be considered.
Delay in institution of medical therapy and/or surgery has been
associated with poorer outcomes. Figure 2.1 provides a simplified
algorithm for the overall approach to UC management.
vidence for Recommended Approach

E
to Inpatient Management of UC
Evidence for Intravenous Steroids
The efficacy of intravenous steroids in severe UC was first dem-

onstrated by Truelove and Jewell in their 1974 case series pub-
lished in the Lancet [9]. In this study, 49 patients hospitalized with
severe colitis were administered prednisolone intravenously at a
dose of 60 mg per day in divided doses along with topical
ASUC
Solumedrol 60 mg
IVdaily for 3-5 days
Response No Response
Infliximab or
Transition tooutpatient
cyclosporine/
maintenance therapy
tacrolimus
No Response
Response
Transition tooutpatient
Surgery
maintenance therapy
Fig. 2.1 Flow chart for therapy
h ydrocortisone enemas. At day 5, 73% of these patients were in

remission. Colectomy rate in these patients was reported as 18%
[9]. Since then, not a single dose-ranging clinical trial for intrave-
nous corticosteroids has been published. Based on a 2007 system-
atic review of 32 trials by Turner et al., among patients who failed
oral steroids, up to two thirds responded to intravenous corticoste-
roids [10]. Their meta-regression failed to demonstrate a steroid
dose-colectomy association [10]. They did note that there was no
evidence of benefit at a dose higher than methylprednisolone
60 mg IV per day [10].
Evidence for Intravenous Fluids
Many UC patients admitted with ASUC have significant volume

depletion and intravenous fluids (IVF) should be administered.
There are no studies comparing one type of IVF to another in this
group, and there are no specific guidelines pertaining to the rate
and amount of IVF.
Another random document with
no related content on Scribd:
BURNING OF THE FRIGATE PHILADELPHIA IN THE HARBOR OF TRIPOLI BY
STEPHEN DECATUR.
Among the exploits of our sailors there is one which for daring is
almost unparalleled in the history of naval warfare. It was a
desperate undertaking, and had the enterprise failed those who
undertook it would probably have been laughed at as foolhardy, but
its success justified the daring of the little band of heroes and
brought not only fame, but reward to all concerned.
The story of the Barbary pirates and their former control of the
Mediterranean is too well known to need repeating. Such was once
the power of the petty states which bordered the southern shore of
the Mediterranean that they levied blackmail on every maritime
nation of the world. No ship entered or left the Mediterranean without
paying tribute to the Moors. The Deys of Algiers, of Tunis, of Tripoli,
became immensely wealthy through the contributions they levied on
Christian vessels and the tributes paid by Christian States for
immunity from piracy. The United States was one of the nations
which officially helped to fill the coffers of these barbarian chieftains,
but even the tribute which was paid did not secure immunity, and in
the early years of this century it was perceived that something must
be done by the government to protect United States commerce in
that quarter of the world. Then came the war with the Algerian
States, a conflict entirely on the sea, for the distance, of course, was
too great for an army to be sent from this country, and the war
practically amounted to a blockade of the ports and the capture of
such corsairs as attempted to enter or leave.
In the autumn of 1803, the Philadelphia, a frigate of thirty-six guns,
in those days a man-of-war of the first class, was blockading the
harbor of Tripoli. A storm came on, the ship was driven to sea, and
on returning after the wind had lulled noticed a brigantine
endeavoring to steal into the port. The Philadelphia gave chase and
pursued the corsair close into the shore and within three miles of the
guns of the forts. Capt. Bainbridge, of the Philadelphia, expressed
his uneasiness at running so close to the shore, but the sailing-
master professed an intimate acquaintance with the neighborhood,
having been there before, and the pursuit was continued. Bainbridge
did not know that he was among reefs, but without a moment’s
notice the ship grounded with such violence that many of the men
were thrown down on the deck. As soon as the corsairs perceived
that the ship was fast they sallied out from Tripoli to attack the
vessel, and during the day of October 31 the fight was kept up while
ineffectual efforts were being made to get off the ship by cutting
away the foremast and throwing overboard all the forward guns, but
toward evening Bainbridge, recognizing the inevitable, and fearing
lest when night came on the ship might be boarded and all on board
massacred by the pirates, he scuttled the ship and surrendered the
vessel.
The pirates swarmed on board, ordered the prisoners, 315 in
number, including twenty-one officers, into their boats and took them
to shore. Day, the American poet, who was one of the crew, thus
describes an experience as the captive of the Moors: “When we
approached the shore, we were thrown headlong into the waves,
foaming from a high breeze, where the water was up to our arm-pits,
and left to strangle, or get ashore as we could. At the beach stood a
row of armed janizaries, through which we passed, amidst cursings
and spittings, to the castle gate. It opened and we ascended a
narrow, winding, dismal passage, which led into a paved avenue
lined with grizzly guards, armed with sabres, muskets, pistols, and
hatchets. Here we halted again a few moments, and were again
hurried on through various turnings and flights of stairs, until we
found ourselves in the presence of his majesty, the puissant Bashaw
of Tripoli.
“The throne on which he was seated was raised about 4 feet from
the surface, inlaid with mosaic, covered with a cushion of the richest
velvet, fringed with gold, bespangled with brilliants. The floor of the
hall was of variegated marble, spread with carpets of the most
beautiful kind. The person of the Grand Bashaw made a very tawdry
appearance. His clothing was a long robe of blue silk, embroidered
with gold. His broad belt, ornamented with diamonds, held two gold-
mounted pistols and a sabre with a golden scabbard, hilt and chains.
On his head he wore a large white turban, decorated in the richest
manner. His whole vestments were superb in the extreme. His dark
beard swept his breast. I should suppose him to be about 40, is
rather corpulent, 5 feet 10 inches in height, and of a manly, majestic
deportment.
“When he had satisfied his pride and curiosity, the guard
conducted us into a dreary and filthy apartment of the castle, where
there was scarcely room for us to turn round and where we were
kept for nearly two hours, shivering in our wet clothes and with the
chills of a very damp night. The Neapolitan slaves, of whom the
Bashaw had more than 150, brought us dry clothing to exchange for
our wet, and we sincerely thanked them for their apparent kindness,
expecting to receive ours again when dry; but the trickish scoundrels
never returned our clothes nor made us any restitution. Our clothing
was new, and what they brought us in exchange was old and
ragged.”
Two days after the ship had grounded the Moors got her off,
recovered most of her guns and brought her into the harbor of
Tripoli, where she formed a substantial addition to the Bashaw’s
fleet. While in captivity Bainbridge found means to communicate
through the Danish Consul in Tripoli with the Americans, and wrote a
letter to Capt. Edward Preble, of the Constitution, then in the
Mediterranean, describing the position of the Philadelphia in the
harbor and suggesting that an expedition be sent to destroy her.
Stephen Decatur was then a young Lieutenant, in command of the
sloop Enterprise. A few days after the letter from Bainbridge was
received he had captured, south of Sicily, a ketch named the
Mastico, filled with female negro slaves, and brought his prize into
Syracuse, where the slaves were liberated and the property on
board was sold for the benefit of the crew. As soon as Decatur heard
of Bainbridge’s suggestion he was eager to undertake the task in his
own ship, the Enterprise. But his proposal was rejected by Preble,
who believed the Mastico better suited for the task, and ordered that
she be employed. “Volunteers for an unusually dangerous service”
were called for, and sixty-two responded, the number being
subsequently increased to sixty-nine, and among them, besides
Decatur himself, then a mere boy of 24, were two other boys
destined to play an important part in naval affairs. One was James
Lawrence, a midshipman of 16 years, the other Thomas
McDonough, of 20.
THE CLERMONT—FULTON’S FIRST STEAMBOAT—1807.
FIGHT WITH ALGERINE PIRATES.
A large quantity of combustibles was prepared and placed in the

ketch, and with his daring crew Decatur left Syracuse for Tripoli in
company with the brig Siren, which was to wait off the harbor and
pick up the Americans in case they should be compelled to take to
the small boats. On February 9, 1804, the expedition sailed from
Syracuse and arrived off Tripoli by night, but a furious gale from the
shore precluded the possibility of making the attack, and for six days
the voyagers were tossed to and fro on the waves of the
Mediterranean, their little vessel being almost swamped by the
heavy seas.
On the morning of February 16 the sun rose fair and clear, the
combustibles were examined and found to be dry and in good order,
and sail was made for the harbor, the ketch and brig proceeding
slowly in order not to arrive before night. As the darkness came on
the brig paused in the offing, while under a brisk breeze the ketch
sailed into the harbor. An hour later the wind lulled and the ketch
slowly drifted toward the Philadelphia, which was plainly visible from
its great bulk, the lighted portholes indicating that the crew was still
awake. As the ketch approached it was guided so as to foul the
Philadelphia at the bowsprit, and the Maltese pilot who had been
taken on board at Syracuse principally because he could speak
Arabic called to the officer on the Philadelphia and requested
permission to make fast to the ship’s ropes, for the ketch had lost all
her anchors in the storm. Permission was given, and a line was cast,
which was caught by the three or four men who appeared on the
little boat. The remainder, stripped to the waist for battle, and with
cutlasses and pistols ready to hand, lay stowed away behind the
bulwarks and invisible to the corsairs.
The Tripolitan officer in command asked the pilot what ship was in
the offing, for the Siren had been seen, and the Maltese replied that
it was an English brig waiting for daylight to cross the bar and enter
the harbor. Not the least suspicion was roused in the minds of the
corsairs, although the rope which made fast the ketch to the
Philadelphia was even then being handled by the men concealed
beneath the bulwarks of the little slaver. As, however, a line must be
fastened from the stern to the larger vessel before boarding could be
effected, it was quite possible that the men would be discovered as
soon as the ketch was brought alongside. The pilot, however, kept
the Moors entertained with narratives of the cargo the ketch
contained, manufacturing very clever stories of the beautiful slaves
and immense wealth on board. A moment later the stern line was
made fast and the ketch brought alongside, when the Moors
discovered the figures beneath the bulwarks and raised the cry of
alarm, “Americanos! Americanos!”
Decatur had divided his men into five crews—one to remain on
board and guard the ketch, the other four were first to storm the
upper deck of the Philadelphia, then three parties were to go below
and fire the ship, while the fourth held the deck against possible
Moorish re-enforcements. The moment the ketch was brought
alongside Decatur gave the word, “Boarders, away!” and the
American boys swarmed through the portholes and up over the
bulwarks of the Philadelphia. So sudden and furious was the
onslaught that the Moors were taken by surprise, and as the
Americans rushed forward, cutlass in hand, fled before them,
jumping into the water to escape the terrible enemy. Of the Moorish
crew of nearly 300 on board, twenty were killed outright, how many
were drowned could not be ascertained, but a number, afraid to leap
from the ship, hid below to perish a few minutes later like rats in their
holes.
In five minutes from the time of boarding the deck was cleared of
the pirate crew, the work being done solely with the cutlass; not a
shot was fired from beginning to end. The parties appointed to do the
firing at once began the work of hauling the combustibles aboard
and passing them to the lower decks, cabin and hold. Fire was set to
the ship in a dozen different places and the flames spread with such
rapidity that some of the Americans had a narrow escape, and one
was severely scorched by being compelled to pass up through a
burning hatchway. The work was well done, and, as the flames
appeared through the portholes, a rocket was sent up from the ketch
to notify the brig outside that the enterprise had been successful.
Their work finished, the Americans hastily let themselves down
into the ketch, and not a moment too soon, for so rapidly did the
flames spread that there was danger of their little boat taking fire.
The Philadelphia was a mass of glowing flames before the ketch
could be disengaged, and such was the draught of air toward the
burning ship that for some moments it seemed uncertain whether the
ketch could be gotten away. The stern and sails did actually take fire,
but a few buckets of water extinguished the blaze, and the men set
to work with a will at the oars, of which there were four on each side.
The capture of the ship had been effected without apparently the
least suspicion on shore of what was going on. The Philadelphia lay
directly under the guns of the largest fort and not quite 400 yards
away. Long before the swimmers from the ship could reach the
shore the blaze warned the garrisons of the forts that something was
wrong. Small boats were immediately dispatched, some of the
swimmers picked up, and thus the truth became known. As the ketch
was in plain view, a heavy fire was at once commenced and from a
hundred guns on each side of the harbor belched forth flame and
iron in vengeance for the daring act. But whether from haste or
inefficiency, the aim of the gunners was bad, and although shell and
shot plowed up the water all around the ketch she was struck but
once, and then only by a ball going through the sail.
More to be dreaded than the artillery fire was the swarm of boats
crammed with corsairs that put forth from the shore in pursuit.
Decatur said afterwards that the little crew of the ketch must have
been chased by a hundred craft of all sizes, containing probably a
couple of thousand men, but the pirates reasoned very correctly that
Americans who could attempt so desperate an act as the burning of
a ship almost within stone’s throw of the forts were not to be trifled
with in a hand-to-hand engagement, so kept at a respectful distance
and contented themselves with a running fire of musketry. The
Americans replied, those not at the oars maintaining a lively
fusillade, while another rocket was sent up as a signal to the brig for
aid. It was responded to by a rocket in the offing, the Siren’s boats,
full of well-armed men, put off to the rescue, and as soon as they
came within firing distance the Tripolitans withdrew.
Thus was achieved what Lord Nelson called the most daring act of
the age. Not an American was killed, only one was wounded, he very
slightly, and a third was, as already stated, severely scorched. Every
participant in this hazardous adventure received his reward. Decatur,
although only a boy, was made Captain; Lawrence and McDonough
received substantial promotion; and every seaman was voted two
months’ extra pay. The exploit had serious consequences for the
crew of the Philadelphia, for the Dey of Tripoli fell into a furious
passion at the loss of the ship and at once consigned the Americans
to the filthiest dungeons in his castle, where they remained until
liberated at the close of the war. The act of Decatur’s expedition had
an important influence in bringing the war to an early conclusion, for,
as the Danish Consul expressed it in an interview with the Dey, “If
the Americans can burn your ships lying under the guns of the fort,
they may undertake to burn your palace over your head,” and the
Dey seems to have taken the same view of it. He did not have long
to reflect upon the matter, however, for in less than six months
Preble’s squadron arrived off Tripoli with better pilots than those of
the Philadelphia, sailed through the intricate channels, entered the
harbor, bombarded the forts and town, and the Dey was glad to
conclude a treaty of peace, releasing all the American prisoners and
promising not to demand nor exact tribute from American vessels.
Decatur’s later career fully justified the reputation he won in his
earliest exploit, but none of his subsequent deeds of bravery
exceeded the burning of the Philadelphia.
McDUGALL’S PLUCKY FIGHT IN SIMONOSEKI STRAITS.
Another of the almost unrecorded chapters in the annals of the

American Navy was the heroic action between the U. S. ship
Wyoming, Commander McDugall, and three Japanese cruisers
supported by six shore batteries, during the Civil War.
The Wyoming had her part in all the hardest of blockading and
cruising service and fought well whenever she had a chance. She
was sent at the same time as her sister ship, the Kearsarge, to
cruise for that scourge of the seas, the Alabama, and just missed her
by the merest chance on two occasions in the China Seas. From
there the Alabama squared away for the Atlantic again and went to
meet her fate under the heights of Cherbourg, while the Wyoming
sailed to her hardest fight with the forces of the Tycoon.
It was in 1863, toward the end of the dual reign of the Tycoon and
the Mikado. Japan was in the throes of civil war, and the foes of the
rebel princes were resisting to the last the passing of the old feudal
system.
The Prince of Nagato was one of these, and from his tiny kingdom
that fronted on the Straits of Simonoseki he declared himself lord of
all he surveyed, including the neighboring seas, from which he took
as generous toll as did ever the pirate chiefs of Tariffa. He had laid
violent hands upon the vessels of various powers, including Great
Britain, France, the Netherlands, and the United States.
Representatives of these powers had protested, but the protests had
been of little moment. The Japanese central government had
disavowed the acts of the pirate prince, but confessed its inability to
deal with him while more formidable matters engaged its attention.
Meanwhile Prince Nagato throve and flourished, and one day fired
on the American merchantman Pembroke, having failed to wring
tribute or blackmail by any other means, and killed two of her crew.
Another diplomatic protest from the combined foreign
representatives followed, but Commander McDugall, who was in port
with the Wyoming, suggested that if the Mikado could not subdue his
rebellious subject the Wyoming could and would without much
urging. Accordingly, McDugall was given carte blanche to settle
accounts with the Prince of Nagato in behalf of all the powers
concerned.
It was the middle of July when the Wyoming found herself in the
Straits of Simonoseki and in sight of the shore batteries, which were
a part of the prince’s defenses to seaward. Before she had time to
open on the batteries two Japanese gunboats loomed up, one ahead
and one astern, in the narrow straits, and presently a third came
cruising out from among the neighboring islands. It was a nasty
place for a fight, McDugall being without charts or pilots, and the
odds were more than enough for Nelson himself, being forty-eight
guns of the three Japanese vessels to the twenty-six of the old
Wyoming, to say nothing of the batteries on shore.
Working to windward of the nearest Japanese ship, the Wyoming
opened at long range, and worked down on her till when close
aboard there was nothing of the enemy left standing above decks.
The other two vessels had come up in the meantime and engaged
the American on either side, but she lay to and gave them shot for
shot, port and starboard, till her gunners were smoke-blind and the
flame of the guns no longer served to light the battle-cloud that rolled
in white billows over the smooth waters of the straits. It was
desperate work in the shallow water, but the Wyoming was the best
vessel and she outmanœuvered her two opponents from the start,
though twice aground and once afire, with as many men disabled
from splinters and heat as from the enemy’s shot.
Fighting themselves out of one smoke-patch into another, the
three combatants circled around till they had drifted down in range of
the shore batteries, which opened upon the Wyoming. But McDugall
ran across the bows of one of his enemies, raked her as he went
and left her a floating wreck, and then turned his attention to the
batteries. The Wyoming’s men rigged the smith’s forge on deck and
tossed hot shot into the works ashore till they set them afire, and the
soldiers fled, and the crew of the remaining cruiser followed their
example.
McDugall mended his rigging and patched his bulwarks, sent word
to the recalcitrant prince to arrange for indemnity, which he did. The
share of the United States was $300,000.
In this action McDugall’s loss was five men killed and six
wounded.
CAPTAIN McGIFFEN AT THE BATTLE OF THE YALU.
On September 17, 1894, the Chinese ironclad Chen-Yuen with her

sister ship, the flagship Ting-Yuen, and nine smaller war vessels,
met the Japanese off the mouth of the Yalu River.
The Chen-Yuen was protected by 12 and 14-inch armor, and
carried four 12.2-inch, two 6-inch, and twelve machine guns. Her
commander was Captain McGiffen of the United States Navy.
Here the famous battle of the Yalu, the first great trial of modern
ironclads, was fought. Owing to the cowardice of several Chinese
commanders, who ran away at the first exchange of shots, eight
Chinese ships did all the fighting against the twelve ships of the
enemy. The battle was altogether a contest of Orientals, except that
one man of European blood, trained in the naval school of a great
Western power, commanded the Chen-Yuen—Philo Norton McGiffin,
of the United States Navy. His fighting that day was the dramatic
climax of a brave and spotless life that had been a nineteenth-
century revival of knight-errantry. The lives of none of the free-lances
and fearless adventurers from Hawkesworth to Gordon were more
romantic than that of McGiffin.
Cruiser Following Torpedo into Action.
The reduction by Congress of the U. S. naval force sent adrift
Lieutenant McGiffin, a graduate of Annapolis in the class of ’82. As
China was engaged in war in Asia, McGiffin straightway tendered his
services to the Chinese Government. The result was eventually that
China took one French gunboat in a war otherwise entirely
disastrous to her. In 1887 McGiffin became the head of the Chinese
Naval Academy at Wei-Hai-Wei. This was the reason for his
command of one of China’s two most formidable warships in the
battle which decided the outcome of the Chino-Japanese war.
The crews of the Chinese fleet had gone through their morning
drill and dinner was nearly ready when smoke from the Japanese
ships was sighted by the lookout. The appearance of Japan’s fleet
had been expected for a week, but nevertheless the blood in every
man’s veins throbbed quick as the call to action sounded throughout
the fleet. The Chen-Yuen had already been stripped for action. The
decks were cleared for the passage of ammunition and for the free
movement of the crew and in order to secure unobstructed arcs of
fire for the guns. The small boats had been abandoned, the ladders
overboard or wrapped in wet canvas. These measures were taken to
avoid the danger from fire and flying splinters, both of which are as
much to be feared in a sea-fight as the enemy’s shot. The gun-
shields, by order of Captain McGiffin, had been removed from the
big guns as affording no protection from heavy shot and as serving
to intercept and cause to explode shells that would otherwise pass
over the heads of the gunners. The ship’s firehose had been
connected and let out and bags of sand and coal placed on deck to
form breastwork against small shot. Ammunition for immediate use
was piled beside the guns. The suggestive hospital appliances,
bandages, and cots and chairs rigged for lowering the wounded to
the sick bay, were in position. Buckets of sand were placed about the
decks and inside the superstructure; for when men are torn to pieces
the flow of blood makes the deck slippery.
In less than an hour after the Japanese ships dotted the horizon
the battle had begun. The Chinese sailors were brave and eager for
the fight. They were prepared neither to give nor take quarter and
expected either to win or go down with their ship.
McGiffin stood motionless on the bridge listening to the reports of
the range announced by the sub-lieutenant in the foretop as the
fleets rapidly neared each other. The ordeal before him and his men
was more terrible than soldiers had been called upon to face in
regular battle since the beginning of human wars. That McGiffin fully
realized the situation was shown by a letter written to his brother
upon starting to meet the Japanese ships. “You know,” he said, “it is
four killed to one wounded since the new ammunition came in. It is
better so. I don’t want to be wounded. I prefer to step down or up
and out of this world.” Not extraordinary words, but splendidly
expressive of a soldier-like way of facing fate.
The closing lines of this letter were sadly prophetic. McGiffin
wrote: “I hate to think of being dreadfully mangled and then patched
up, with half my limbs and senses gone.”
He came home in exactly the condition he had described. and,
true to his determination, chose to step up and out of it all.
There was no sound but the panting of the ship under forced
draught. The men, grouped quietly at their stations, did not venture
to speak even in whispers. “Fifty-two hundred metres,” the range
was called. Then the great yellow flag of China was raised to the
main truck, the quick-firing guns opened fire, and the fight began.
The battle lasted for nearly five hours, with the two Chinese
battleships as its centre.
It was estimated that McGiffin’s ship was hit 400 times and 120
times by large shot or shell. The rain of projectiles visited every
exposed point of the vessel. Early in the fight a shell exploded in the
fighting top, instantly killing every one of its inmates. Indeed, all such
contrivances proved to be deathtraps. Five shells burst inside the
shields of the bow six-inch gun, completely gutting the place. Though
the carnage was frightful, the Chinese sailors, with their commander
to encourage them, stuck to their posts. A chief gunner was aiming
his gun when a shell took off his head. The man behind him caught
the body, passed it back to his companions, calmly finished the
sighting of the piece and fired it.
The Chen-Yuen gave as hard knocks as she received, and until
her ammunition ran low her fire was rapid and more effective than
that of her adversaries. One of the last shells, fired under McGiffin’s
personal direction from a twelve-inch gun, disabled the thirteen-inch
gun on the enemy’s flagship, the Matsushima, and exploded the
powder on deck, killing or wounding more than 100 Japanese
officers and men. Then McGiffin’s Chinamen cheered joyfully.
Throughout the whole fight McGiffin was the dominating spirit of
his ship. He was at once her brains and her inspiration.
Even cowardice itself was moved by his fearless example. At the
opening of the fight he discovered a lieutenant and a dozen terrified
men hidden below one of the engine turrets. McGiffin thrashed the
officer and sent them all on deck, where they afterward fought like
heroes.
The five hours’ strain on the commander was terrific, for there was
no subordinate who could relieve him, and his presence was
required everywhere. Whilst the fight was hottest a fire broke out in
the superstructure above the forecastle. It became necessary to run
out a hose in the range of the starboard guns, which had been
ordered to fire to port across the forecastle. The men refused to do
this until McGiffin called for volunteers and offered to lead them.
Word was sent to the head-gunner at the starboard battery to train
his pieces ahead, and McGiffin and his volunteers started with the
hose for the forecastle. Half of the men were shot down by the
enemy. As the captain stooped over to grasp the hose a shot passed
between his legs, burning his wrists and severing the tail of his coat.
A fragment of a shell that had burst against the tower wounded him a
second time.
Meanwhile men at the forcastle gun were falling rapidly and the
head-gunner was killed. The man who took his place, not knowing
that his comrades were in front of his guns, discharged one of them.
The explosion knocked the captain and his men down and killed
several outright. At the same instant another shot struck McGiffin.
He would probably have remained there unconscious if water from
a gash in the hose had not revived him. His first glance on coming to
his senses was into the muzzle of the starboard gun. It was slowly
moving into position for firing. “What an ass I am to sit here and be
blown to pieces,” thought McGiffin. So he flung himself from the
superstructure and fell eight feet to the deck below. With blood
pouring from his mouth he crawled into the superstructure and told
the men to carry him aft. In a few minutes he was fighting his ship
again.
McGiffin stood very near a large gun when it exploded. He was
almost blinded. His hair and eyebrows were burned off and his
clothes torn and set on fire. There was a series of gashes in his
trousers extending their entire length. Throughout the fight his ears
were stuffed with cotton, as were those of all the gunners, but after
the day’s fighting his ear-drums were found to be permanently
injured by concussion. Several times he was wounded by splinters,
which he extracted himself.
With forty wounds in his body, holding an eyelid up with one hand,
this man of iron nerve led the fighting on his ship until the Japanese
vessels gave up the contest and he alone of all the Chinese
commanders kept his ship in its proper position throughout the fight,
thus protecting the flagship and saving the fleet from total
destruction.
When the Japanese admiral withdrew, McGiffin navigated his ship
to its dock. His mind never lost its effectiveness, though his body
was shattered beyond repair. In fact, his body was described as
being so covered with bruises that it resembled a checker-board.
In this action a new style of sea-fighting was inaugurated and an
American sailor, a young man 34 years of age, set its standard for
daring and fortitude under fire of the modern guns.
After his great battle Captain McGiffin, a mental and physical
wreck, came to America to die. He met death as a brave man
should, with but one regret: He wished that he might have had one
chance to fight for his own country, with a Yankee crew at his back
and a Yankee ship under him.
OUR NEW NAVY.
ince the last of the naval battles recorded in preceding chapters was fought, the
advance in ships, engines, and guns has been such that warships of the past are
considered obsolete; while the introduction of smokeless powder and projectiles
containing heavy charges of dynamite or gun-cotton has increased the efficacy of
modern ordnance.
The use of armor for ships is so recent, only dating from the time of our civil war,
that modern war-ships have been little in action. In fact the war between England and
the United States, in 1812-15, was the last important naval war previous to the
introduction of steam. The revolution in naval tactics caused by steam was very great,
but our civil war afforded little experience in fleet actions, the important naval affairs
being for the most part attacks of fleets upon land fortifications. The only fairly well-
matched, stand-up fight of that war between vessels was that of the Kearsarge and
Alabama.
Steel has come into use for the hulls of vessels—and the invention, by our own
citizens, of nickel-steel, and of the Harvey process for plates, has caused a revolution
in the application of defensive armor.
We may instance the armor for the battle-ship Maine, which vessel carried on her sides alone four
hundred and seventy-five tons of metal—Harveyized nickel steel. The plate which was tried at the Naval
Proving Ground, at Indian Head, on the Potomac, and upon the proof of which depended the receiving
of the whole quantity from the contracting company, was thirteen feet seven inches long, seven feet
wide, and twelve inches in thickness at the top, tapering to six inches. These measurements may give
some idea of the tremendous power of the implements employed in forging and tempering such a mass
of metal.
It successfully resisted four shots from an eight-inch rifled gun, firing, at only a few yards’ distance, the
best armor-piercing shot, breaking the latter to fragments. Then a ten-inch gun was tried upon the same
plate. Again the shot was broken up, and the plate, already hit four times before, was cracked, but
remained still capable of affording perfect protection. It is not at all probable that any one plate would be
hit five times in the course of an action—and so this armor is considered as near perfection as it is
possible for metallurgists to come, in the present state of knowledge. The Maine and Texas, and the
battle-ships of the Iowa class, as well as the great monitors, Puritan and Monadnock, all of which
vessels are of the latest construction, have these plates, thereby saving much weight, and allowing of
additional armor protection to the upper works. The heavy armor extends from one barbette to the other,
in the Iowa being about 180 feet, and from four and a half feet below the water line to three feet above
it. At the level of the belt is a curving steel deck, three inches thick, to deflect plunging shot; while the
mass of coal is so arranged in the bunkers as to protect the boilers and machinery.
The Iowa carries four 12-inch rifles, mounted in pairs in two turrets, eight 8-inch rifles, also mounted in
pairs in turrets, six rapid-fire 4-inch rifles, and an ample secondary battery of twenty 6-pounder and six
1-pounder rapid-fire guns, and two gatlings—all high powered breech-loading guns of the best American
manufacture.
In the last few years there have also been great changes and improvements in different forms of
explosives, the development of torpedo boats and torpedo-catchers, and modes of defence against
such attacks. Almost all the large vessels have double bottoms, divided in many separate cells like
honeycombs—and packed with a preparation of cocoa-nut fibre, which swells when in contact with
water, thus effectually stopping shot holes. There are also many transverse bulkheads, making many
compartments of the vessel’s hull; while the engines are so cut off by them that one is independent of
any injury to the other. There are also many small engines, for various purposes, and electric light
makes the deepest part of the interior of the great ship’s hull as plain as the upper deck, in full sunlight.
Lastly, the great increase in speed and power of engines tend to make the war-ship a very different thing
from what she was at the time spoken of in the previous chapter.
There are, of course, limitations to the range and efficiency of the new Navy, owing to the necessity of
replenishing supplies of fuel,—a most difficult and extremely costly process in many parts of the world.
Such modern cruisers as the Columbia carry, to be sure, an immense quantity of coal—and there are
others, such as the New York and the Olympia, which not only possess great speed, but also carry more
fuel than most vessels of their class. They need to do so, for our coaling stations abroad are very few.
Some nations, especially the Italians, who have a very formidable navy, and one far above their
means, have experimented extensively with petroleum, in its crude form, as a fuel, and, it is stated, with
a certain degree of success. But this for the most part is a consideration for those nations which have no
mines of coal under their own control, and we must remember that, in time of war, the supply of
petroleum might be cut off even more effectually than that of coal. But to return:—The use of steel for
the hulls of vessels, the armor, protective decks, and other purposes of construction, has greatly
multiplied the strength of those parts, while it has made the whole much lighter, so that the same
expenditure of steam will carry the structure much farther and much faster. We have already stated that
nickel-steel is able to resist very effectually the most modern projectiles from the latest guns. When, a
few years ago, such qualities were claimed for it by us, the English experts in such matters rather
sneered at the idea, and said that more extensive trials should be had before they could believe in its
value. The experiments were so triumphantly successful that not only was all opposition withdrawn, but
the object then was to get hold of the process as soon as possible. Nickel-steel is what may be called a
great fact, and subsequent discoveries in metallurgy will never destroy its value for certain purposes.
The Harvey process was another thing upon which the Europeans looked with great doubt until the
perfect success of armor made in that way, in trials against very powerful guns at short range, opened
their eyes. This process consists in the hardening of the outside surface of a thick plate to a certain
depth, leaving the back part of the plate with the toughness of the untempered metal, so that the shot
which strikes it has to encounter obstacles of two kinds—the hardness which breaks it up, and the
toughness which prevents serious entry.
As it is, the contest between gun and armor is continually going on. When armor is found which
resists very powerful guns and the newest explosive, a more powerful gun is built, which makes another
increase in armor necessary. At the present time there is no predicting how long this contest may go on,
for the improvements in guns and armor keep equal pace.
New explosives have the same story to tell. They vary in name and in effect, but most of them are
based upon the same chemical principles. Some keep better than others, and are thus best suited for
preservation in the magazines of ships, where, especially in case of faulty construction, or of prolonged
stay in hot climates, the delicate chemical combination of which the modern explosive consists is very
much more likely to undergo change than the old-fashioned “black power”—especially when the latter
was well made.
There is, therefore, constant experimenting, and constant change in opinion in regard to explosives.
Torpedoes are another source of trouble to experts in naval warfare; the fact being that they have
never been sufficiently tried in actual service to settle completely their respective values. Of the mobile
torpedoes one was used with destructive effect during the Chilean War, and some spar-torpedoes were
effective during our Civil War, and during the Russo-Turkish War, where mobile torpedoes were also
used, but it is still a matter of doubt with many naval officers of experience as to what part the mobile
torpedo is to play in any future contest.
As regards torpedo-boats, which launch their torpedoes one at a time, and directly in the line in which
the boat is pointed, the opinion is that they will prove very useful for coast and harbor defence, but unfit
for severe weather or heavy seas, very wearing upon their crews, liable to accidents of a serious nature,
and only able to carry fuel for short runs. Many of the accidents to this class of boats have involved loss
of life, and, while the French and English have increased their number, other nations, such as the
Italians and the Germans, have rather decided against their increase. At one time within recent years
the Italians encouraged torpedo-boats, and in Germany one of the most successful of all builders is the
Shichau Company, which has built boats for all the world but France, America, and England.
The “torpedo catchers,” so called, are quite different affairs from the ordinary torpedo-boat. They are
quite large and swift vessels compared with the ordinary torpedo-boat, and are intended as “counter-
miners,” and, by speed, and ability to keep the sea better, to prevent the swarm of ordinary torpedo-
boats from doing serious damage. Sufficient experience has not been gained in the experimental trials
to know just how much these vessels will do in case of actual warfare, but much is expected of them.
Very lately a well-known English builder of torpedo boats and other small craft has launched a boat
which is said to have made twenty-seven knots, or about the average speed of a passenger train on a
good railroad.
Submarine torpedo-boats have received much attention of late years, when improvements and
inventions, especially in electricity, have rendered them comparatively easy to handle. In France and
Spain, especially, very successful boats have been experimented with. In our own country, where the
idea originated early in the century, there have been several submarine boats built which have remained
for a long time under water, being directed by the crew in any wished-for course. Not long ago Congress
appropriated a large sum for building a sub-marine torpedo boat; but experiments conducted to show
whether an explosion effected by such means would not be also fatal to the boat herself, led to
hesitation on the part of the authorities as to expending the money in that way, and to a proposal to build
surface torpedo boats instead.
Speed is becoming more and more a factor in naval problems. Speed, fuel capacity, a powerful
battery, and protection, especially to the vital parts and to the crew, are now recognized as the requisites
which go to make a fine, or capable ship, and one most likely to be generally useful in war. Among such
vessels may be mentioned the New York, Olympia, and the Columbia, of our own navy. The battle-
ships, so called, come under a different category—being heavily armored, and supposed to be able to
resist heavy projectiles at close quarters. We have a few of these under construction, but none of the
great size which we see in some foreign navies, principally for the reason that many of our ports will not
admit vessels of such great draught of water—and that our authorities consider smaller vessels capable
of being more readily manœuvered. The largest battle-ships we are building will only measure 10,200
tons, while in foreign navies they have them of 15,000 tons. But the best naval opinion is that the latter
are too large; and experts are advocating a return to smaller size and greater number—just as a
reaction has taken place against 110-ton guns.
The latest completed battle-ships are the Iowa, Indiana, Massachusetts and Oregon, all of 10,200
tons, with twin screws, and carrying sixteen guns in the main battery, beside smaller ones of the most
modern type.
The Maine and Texas are battle-ships of the second class—of about 9000 tons, with twin screws, and
carrying about ten guns in the main battery, and a proportion of rapid-fire smaller guns.
Such great battle-ships as these have never been tried in a close general engagement, and, though
viewed with some distrust—especially since the accidental sinking by collision of the Victoria—nations
go on building them in rivalry, and the end is not yet. In case of a grand battle between fleets of these
giant ships, the force being anywhere near equal, the chances would be in favor of the fleet which is
best handled. That is all that anyone can say at present. It may give the reader some idea of these great
armaments to say that, in 1894, England had in her Mediterranean fleet twenty-four vessels of the first
class, none less than 7350, and most of them above 10,000 tons. Thirteen of these were battle-ships,
and eleven protected cruisers.
France and Russia, combined, had at the same period in those parts thirty-three ships, none of which
were below 4000 tons, and most of which were of 10,000 tons or more.
In addition to this we must count numerous torpedo-boats, despatch vessels and gunboats in such
fleets.
The Italian navy is now a very powerful one, and contains in its list some of the largest men-of-war
afloat; and the German navy has made great strides in advance. The Spaniards have some fine ships,
but mostly of the fast cruiser class, armed with powerful guns.
We have heard very much of late regarding the Chinese and Japanese navies. The vessels which
compose these forces have mostly been constructed in France and England—and a few, of moderate
size, have been built at home. The Chinese have a very fine gun-factory, as well as shops for repairs,
but many of their vessels, especially in what has been called their Southern fleet, are in very bad
condition as to hulls, engines—and especially as to the discipline of the crews. This has become much
worse since they dispensed with the services of European officers. Their Northern fleet is in much better
condition, but time alone can prove what it is worth. Neither China nor Japan have any vessels above
8000 tons displacement, and many are much smaller. Their important fighting craft consist of what are
called cruisers—protected and unprotected—but armed with excellent modern high-powered guns, and
torpedoes of the latest model.
The vessels of the Japanese navy are kept in exceptionally good condition in every respect, and their
officers are considered the more able, and their men, with a natural aptitude for the sea, are in excellent
training and discipline. Thus Japan should prove superior to China, if only on account of the better
personnel. Many of the Japanese officers have passed through our own naval school with credit, and
others have been educated in the German service. Some of them, thus educated, have already attained
high command—and all show great enthusiasm and military ardor.
The battle of the Yalu, between these two fleets and treated in a subsequent chapter, was a most
instructive lesson to the navies of the world at large.
While we do not pretend to say that we need such a navy as England (the national life of which
country depends upon her ability to furnish food and clothing from abroad for her population), it is
evident to anyone who thinks for a moment that a country like ours, with the most extensive coast-line of
any, should have a moderately large and very effective navy, if only as a matter of sea-police for our own
shores, while the protection of our vessels and of citizens living and doing business abroad comes
under another head.
Persons, especially those living in the interior of our great country, are apt to think, and to say, that
there is little chance of our becoming embroiled with any of the nations of whose great navies we have
just been speaking. But we have to go back a very few years to show in what danger we have been of
having our coasts invested by hostile fleets for want of proper force to resist them. Spain was very
threatening in the troubles about Cuba in 1873. The attitude of Italy, with her powerful vessels, at the
time of the difficulty about the New Orleans riots, was disquieting for a time, and, had her financial
condition been better, that country would have certainly made a naval demonstration here. Then there
was the still more threatening attitude of Chili, which might have been very serious. However sure we
might be of eventually putting down that warlike little country, immense damage might have been done
by her in a naval raid on our west coast. There is constant need for ships in China; not only for the
protection of Americans, but to assist in keeping down piracy, a very present danger in that part of the
world. Few months pass that it is not necessary to send ships to Hayti, always on the verge of
revolution, or actually in the throes of civil war; and the same may be said of the countries comprising
Central America. Then Brazil may be added to the list of unsettled countries, and we have a large and
important trade there. Of the troubles in Hawaii, and of the cruising against the seal robbers in the North
Pacific, the whole country has heard more than enough, and everyone knows that without a navy we
should be perfectly helpless in such emergencies. The very establishment and maintenance of great
dock-yards and naval stations at Vancouver, Halifax and Bermuda by England admonishes us to at least
partially prepare to resist the threats of naval coercion which was that nation’s favorite mode of treating
with us not so many years ago.

Full Download Management of Inpatient Inflammatory Bowel Disease A Comprehensive Handbook de Joseph D Feuerstein Editor Ebook Online Full Chapter PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Full Download Management of Inpatient Inflammatory Bowel Disease A Comprehensive Handbook de Joseph D Feuerstein Editor Ebook Online Full Chapter PDF

Uploaded by

Copyright:

Available Formats

Management of Inpatient Inflammatory

Bowel Disease A Comprehensive

Management of Inpatient Inflammatory Bowel Disease A

Inflammatory Bowel Disease 2nd Edition Wilton Schmidt

Pediatric Inflammatory Bowel Disease 4th Edition Petar

Small Intestine Disease: A Comprehensive Guide to

The Palgrave Handbook of Supply Chain Management Joseph

Nutritional Management of Renal Disease, 4th ed 4th

Caring for the Hospitalized Child A Handbook of

Teledermatology A Comprehensive Overview Joseph C

ISBN 978-1-0716-1986-5 ISBN 978-1-0716-1987-2 (eBook)

This Springer imprint is published by the registered company Springer

The management of patients hospitalized with acute severe ulcer-

The remaining chapters (Chaps. 8, 9, 10, 11, 12 and 13) focus

Boston, MA, USA Joseph D. Feuerstein

1 Epidemiology and Risk Factors

7 Surgical Management of Hospitalized Patients

Joseph D. Feuerstein Division of Gastroenterology, Center for

Jean-Paul Achkar, MD Department of Gastroenterology, Hepa-

Athos Bousvaros Professor of Pediatrics, Harvard Medical

Esther Israel Department of Pediatrics, Harvard Medical

Adam V. Weizman Division of Gastroenterology and Hepatol-

Robin Dalal and David Schwartz

The inflammatory bowel diseases encompass both ulcerative coli-

R. Dalal (*) · D. Schwartz

© The Author(s), under exclusive license to Springer 1

tries) showed hospitalization rates were highest in North America

first hospitalizations of CD was 2.7 per 100,000 in the late 1980s

income levels were associated with higher hospitalization rate. In

13. Dias CC, Santiago M, Correia L, et al. Hospitalization trends of the

25. Poojary P, Saha A, Chauhan K, et al. Predictors of hospital readmissions

Talha A. Malik and Francis A. Farraye

All patients seen with ulcerative colitis (UC) in the ER or in the

T. A. Malik (*) · F. A. Farraye

© The Author(s), under exclusive license to Springer 11

Table 2.1 Mayo UC score

score widely used in ulcerative colitis is the Truelove and Witts

Table 2.2 Truelove and Witts UC score

Table 2.3 2019 ACG UC activity index

Based on a 2010 systematic review of a cohort of 750 UC patients

mortality has been reduced to 1% [3–5]. In regard to rates of

Characterizing UC Patients with ASUC

In 2019 the ACG proposed a comprehensive classification for dis-

gressing to toxic megacolon and bowel perforation and therefore

Approach to Inpatient Management of ASUC

All patients with ASUC are admitted for inpatient management.

Table 2.4 Approach to inpatient management of ASUC

History, Physical Examination, and Vital Signs

Medication history for the use of NSAIDs, antibiotics, opioid

Blood and stool studies to assess electrolytes, blood counts,

Once the diagnosis of ASUC is established, intravenous cortico-

cyclosporine is chosen, concomitant induction with vedolizumab

Patients’ response to intravenous steroids should be assessed with

 vidence for Recommended Approach

Evidence for Intravenous Steroids

The efficacy of intravenous steroids in severe UC was first dem-

Fig. 2.1 Flow chart for therapy

h­ ydrocortisone enemas. At day 5, 73% of these patients were in

Evidence for Intravenous Fluids

Many UC patients admitted with ASUC have significant volume

A large quantity of combustibles was prepared and placed in the

McDUGALL’S PLUCKY FIGHT IN SIMONOSEKI STRAITS.

Another of the almost unrecorded chapters in the annals of the

1 Epidemiology and Risk Factors

7 Surgical Management of Hospitalized Patients

Characterizing UC Patients with ASUC

Approach to Inpatient Management of ASUC

History, Physical Examination, and Vital Signs

vidence for Recommended Approach

Evidence for Intravenous Steroids

h ydrocortisone enemas. At day 5, 73% of these patients were in

Evidence for Intravenous Fluids