Chronic Catarrhal Enteritis.
Synonyms.—Chronic Intestinal Catarrh; Chronic Enterocolitis; Chronic Diarrhea.
Definition.—A chronic inflammation of all, or a part, of the intestine.
Etiology.—Repeated attacks of acute enteritis, the patient resuming his duties before a complete cure is effected, may be responsible for the disease. Long-continued exposure, with improper food, is perhaps the most common cause; thus we find chronic diarrhea one of the most common diseases of soldier life, and quite a large per cent of the pensions that are to-day being drawn by veterans are due to chronic diarrhea.
The long-continued use or abuse of cathartics may also irritate, and finally impair, the tone of the bowel, so as to give rise to chronic inflammation. Chronic congestion of the portal circulation due to structural change of the liver, or chronic enlargement of the spleen, is often accompanied by diarrhea. Tuberculosis, as well as cancer of the intestine, gives rise to the same condition.
Pathology.—In the earlier stages the changes are similar to those of the acute form; but later, the mucosa assumes a slaty hue, with deep pigmentation in the tips of the villi and around the solitary glands. This gives the mucous membrane the "shaven beard" appearance. The mucous membrane is very much thickened in patches, and at other portions it is very thin, giving it an irregular, sacculated appearance. Some portions are so thickened as to amount to stricture.
In children and old people, there is more apt to be atrophy of the mucous membrane, attended by marked thinning of the walls and great dilatation. As the disease progresses, ulcers form in the lymphatic follicles; these are one-eighth to one-fourth of an inch in diameter, and, where several coalesce, give rise to large, irregular-shaped ulcers, that penetrate the muscular coats, and sometimes the entire intestine.
The ulcers are more frequently found in the descending colon, the sigmoid flexure, and the rectum. In severe cases the bowel is honeycombed with these ulcers. The entire mucous surface is bathed with a dirty, tenacious mucus or muco-pus. As a result of the inflammatory process, adhesions of their peritoneal surfaces often take place.
Symptoms.—Diarrhea is the most pronounced feature, though it varies greatly; thus there may be one copious watery evacuation early in the morning, the bowels remaining in a quiescent state the remaining twenty-four hours; or there may be eight or ten stools per day; or the average daily stools may be three or four in number, but increased if any unusual diet be taken. Each stool is generally preceded by griping pains and severe tenesmus, if the lower bowel be the seat of the disease. There is tenderness in the course of the inflamed tract, and if ulceration be present, deep pressure reveals marked soreness.
The stools are preceded or accompanied by borborygmus. In color they may be of any shade, though usually dark and offensive, and consist of mucus, shreds of mucous membrane, pus, and fecal matter; sometimes more or less blood is present.
Where the stools are frequent, they are usually small in quantity. The general health depends, to a great extent, upon the severity of the case. Where but one or two stools occur each twenty-four hours, the strength of the patient is but little impaired; but where they are frequent, the patient soon loses flesh and strength; the skin becomes dry and harsh, the tongue is coated with a dirty, pasty coating, the breath more or less fetid, and a slight fever may attend, at a late stage of the disease. There is generally melancholy, and life appears as one continual drag.
As the disease progresses, the patient becomes emaciated, the feet become puffy, and, where there is hepatic complications, anasarca develops. The skin now becomes yellow, the pulse feeble, the tongue red and dry, night-sweats occasionally occur, and the patient dies from exhaustion; or typhoid symptoms develop, the patient dying of sepsis.
Diagnosis.—This is usually readily made; the presence of diarrhea, attended by pain, more or less flatulency, tenderness on pressure, the character of the stool—all tend to confirm the diagnosis.
Prognosis.—This depends to a great extent upon the stage of the disease. Where of long standing, and where there is much structural change in delicate and impoverished children and in the aged, there can be but little encouragement given. The earlier the treatment, the more favorable the prognosis.
Treatment.—A strict adherence to a dry diet is one of the essentials of a cure; in fact, more can be accomplished by this than from medication, and unless a patient will agree to a strict observance of these rules, the physician should refuse to take the case.
Tea, coffee, milk, and water should be restricted at mealtime and for two hours after. A sandwich composed of thin, stale bread and scraped beef for breakfast, bread slightly spread with butter and dusted with malted milk for dinner, and a cup of hot malted milk for supper, will do for severe cases, while a somewhat more generous diet may be allowed in milder cases. A small piece of broiled tenderloin and bread, or a soft-boiled egg, may be allowed. Some may eat well-cooked rice or wheat-germ meal. Ice-cream in small quantities may be allowed.
As the patient is very liable to frequent relapses, he should discard coffee, tea, water at meal-time, for at least six months after he is discharged as cured, and some cases need total abstinence throughout life. Starchy, fatty, and sweet articles should be avoided. To add tone to the digestive apparatus, give,—
|Nux Vomica||5 drops.|
|Hydrastin Phosphate||3 - 5 grains.|
|Water||4 ounces. M.|
Sig. A teaspoonful every four hours; this will give good results.
Where the mucous membrane is feeble and relaxed, the stools frequent and watery, the following prescription will do good service:
|Tinct. Geranium||1 - 2 drams.|
|Water||4 ounces. M.|
Or five-grain doses of bismuth subgallate may be given for a day or two, but should not be continued for any length of time.
Epilobium has been successfully used by our school, but should be used for a long time to get the best results.
Where pain is of a spasmodic and colicky character, colocynth will be the remedy.
Where the coating of the tongue is lifted in spots, and the stools are foamy, charcoal will be a good agent, five grains of the first or second trituration, after each meal.
Where there is ulceration, flushing the bowel with a solution of boracic acid will be highly beneficial and where there is catarrh of the sigmoid I have obtained good results by introducing through a sigmoid speculum, a pledget of cotton well covered with balsam of Peru; this is allowed to remain till removed by the patient going to stool. This may be applied, two, three, or four times a week.
The patient should take gentle exercise, daily, in the open air; but severe exertion should be avoided.