Abercrombie38 records a case of death from phthisis complicated with this disease, and Wright another case in which the patient died in an extreme state of marasmus. The acute and subacute forms are more amenable to treatment, and the chances are correspondingly greater of permanent recovery, though in all cases there is a strong tendency to relapse. The chronic forms may almost be enrolled among the opprobria medicorum when once they have made deep inroads upon nutrition and the vital powers, and produced that condition named by Todd the pituitous cachexia (cachexia pituitosa). These cases may, however, be alleviated by judicious treatment, diet, and climatic changes, but repeated relapses may be expected as the rule under slight exciting causes or even without apparent cause. Patients under these circumstances drag out a life of valetudinarianism, but it may be cut short at any time by the supervention of some intercurrent disease, as phthisis, renal degeneration, etc., or, according to Grantham, atrophy of the intestines. Broca39 records two cases of this disease, one of which lasted ten and the other fifteen years. Three of my cases have endured over six years.
38 Inflamm. Affec. of Mucous Memb. of Intestines, pp. 213, 279.
39 Bullétin de la Société Anat. de Paris, 1854.
TREATMENT.—The treatment of membranous enteritis embraces medical and hygienic measures. The medical means have for their object, first, the removal of the membranous exudation when it has once formed; and, second, to correct the conditions upon which its formation depends by improving nutrition and invigorating the nervous system. The severe sufferings of the paroxysms are greatly alleviated and the duration of this stage cut short by freely emptying the bowels. The best means to do this is by the injection of hot water with the long elastic bougie three or four times a day, and to assist this with laxatives. Instead of water, solutions of potassa, soda, and lime-water are preferred by some practitioners. As a rule, the enemata cause considerable discomfort, but in the end are followed by improvement in the condition of the bowels. The best laxative is emulsion of castor oil, but occasionally a mercurial, guarded by the extract of belladonna, will furnish more marked relief. Powell and Copeland say that they have employed with decided advantage a purgative consisting of the compound infusion of gentian and infusion of senna, to which were added ten or twenty minims of liquor potassæ. This was repeated, so that four stools in the twenty-four hours were obtained. Clark preferred to regulate the bowels, when needed, with rhubarb, soda, and ipecac, conjoined or not, as required, with mercury and chalk. Good recommends four grains of Plummer's pill every night, and the bowels kept open by two drachms of sublimed sulphur daily. It should always be borne in mind that all active or irritating purgatives are harmful. The bowels by this treatment will not only be disembarrassed of the membranous exudates, but also of any fecal collection the retention of which would surely cause irritation, as occasionally happens even when there is an apparent diarrhoea. This condition may be easily determined by abdominal palpation. The relief from pain procured by free evacuation of the intestine will be enhanced by the employment of hot fomentations to the abdomen. Despite these means, its severity may, however, demand the administration of narcotics. The best form will be a hypodermic injection of a sixth or a quarter of a grain of morphia; enemata of starch and laudanum are also beneficial. Burrows mentions a case in which he succeeded in allaying nervous irritation by the nightly use of thirty drops of laudanum. The patient noticed that the habitual constipation was increased when the accustomed narcotic was omitted. Bromide of potassium in large doses long continued will also be found useful for the same purpose.
During the intervals of the paroxysms local medication of the bowels and medical and hygienic measures should be had recourse to to prevent the re-formation of the exudates by modifying the vital activities of the intestinal mucous membrane and by restoring the general tone of the constitutional powers. For local treatment the nitrate of silver, sulphate of zinc, the sulphate of copper dissolved in glycerin, the tincture of iodine, and carbolic acid cannot be over-prized. From five to ten grains of the metallic salts, fifteen drops of tincture of iodine, ten of the acid, administered through the long rubber tube, are suitable doses to begin with. I am also in the habit of using stronger solutions by mopping it on to the bowel through the endoscopic tube. Kaempf made frequent and large injections of decoctions of various plants—saponaria, taraxacum, etc.—which he imagined possessed dissolvent and resolvent virtues. Cumming40 speaks highly of the efficacy of electricity.
40 Lond. Med. Gazette, 3d Series, vol. ix.
For the purpose of improving the general health the preparations of iron are advisable, of which the best are the tincture of the chloride, pernitrate, pyrophosphate, lactate, and potassio-tartrate. Habershon advises infusions of the bitter tonics with hydrocyanic and nitro-muriatic acid. I have found a combination of these acids with henbane and infusion of serpentaria useful. I also employ hot solutions of the latter acid as a local bath over the abdominal region, applied with a large sponge. Clark speaks favorably of the extract of nux vomica and astringent remedies. Simpson praises the oleo-resins under the form of pitch pills and tar, while Clark and others laud copaiba and turpentine. Good advises the copaiba to be given by enema when it cannot be borne by the stomach. Brodie used cubebs in small doses.
The alterative effects of small doses of arsenic, corrosive sublimate, sulphate of copper, etc. may be tried in obstinate cases. Grantham in the early stages of the complaint advises the use of ten grains of iodide of potassium combined with one-quarter of a grain of morphia at bed-time. He also strongly urges the use of cod-liver oil, which, he says, improves the strength and increases the flesh, lessens the spasmodic pains, but does not check the discharges.
Counter-irritation of the abdominal region with tincture of iodine, fly blisters, mustard, etc. has afforded little if any advantage. Dunhill kept a blister open for six months without any good results.
The mineral waters of Pyrmont, Harrogate, and Carlsbad have been found serviceable; the latter, Henoch41 says, should be preferred before all.