PSEUDO-MEMBRANOUS ENTERITIS.
BY PHILIP S. WALES, M.D.
SYNONYMS.—Membranous enteritis; Infarctus (Kaempf); Diarrhoea tubularis, Tubular looseness (Good); Follicular colonic dyspepsia, Follicular duodenal dyspepsia (Todd); Pellicular enteritis (Simpson); Pseudo-membranous enteritis (Cruveilhier); Pseudo-membraneuse entérite (Laboulbène); Painful affection of the intestinal canal (Powell); Mucous disease (Whitehead); Hypochondriasis pituitosa (Fracassini); Fibrinous diarrhoea (Grantham); Mucous disease of the colon (Clark); Chronic, catarrhal, or mucous diarrhoea; Colique glaireuse (of the French); Chronic exudative enteritis (Hutchinson); Diarrhoea febrilis (Van Swieten); Paraplexia rheumatica, Chlorosis pituitosis, Diarrhoea pituitosa (Sauvages); Arthritis chlorotica (Musgrave); Colica pituitosa (Sennertus); Scelotyrbe pituitosa (Perywinger); Mucositas intestinalis colloides, Concretiones gelatiniformes intestinales (Laboulbène); Tubular exudation-casts of the intestines (Hutchinson).
DEFINITION.—The disease is a non-febrile affection, consisting in a peculiar, and usually persistent, morbid condition of the intestinal mucous membrane, marked by the periodical formation of viscous, shreddy, or tubular exudates composed chiefly of mucin, on the discharge of which temporary amelioration of the accompanying acute digestive and nervous symptoms occurs.
HISTORY.—Although no distinct and separate accounts of pseudo-membranous enteritis occur in the medical writings of the ancients, nor even in those dating up to the eighteenth century, yet there may occasionally be detected in some of the descriptions of certain pathological conditions grouped under such titles as colic, passage of gall-stones, tenesmus, coeliac and pituitous affections, diarrhoea, dysentery, etc., the peculiar features of the disease under consideration. This confusion ruled up to a comparatively recent time. J. Mason Good,1 writing in the first quarter of the nineteenth century, groups the disease as a species of diarrhoea—diarrhoea tubularis—and remarks that he had "never hitherto seen this species classified, and not often described, although it occurred frequently in practice."
1 Study of Medicine, 1822.
Aretæus,2 in the second century, in discussing the subject of dysentery, speaks of alvine discharges sometimes occurring of a substance of considerable length, in many respects not to be distinguished from a sound piece of intestine, which he regarded as the inner coating of the bowel. This false interpretation of a fact arose from the circumstance that the membranous exudate occasionally assumes a tubular form, bearing the impress of the inner surface of the bowel upon which it is formed, and was perpetuated up to a comparatively recent period by successive authors. This error befell Simpson,3 Morgagni,4 Lancisi, and Spindler;5 the last of whom describes the material discharged as worked up into a "materia alba, longa, compacta."
2 Lib. ii. cap. ix.
3 Ed. Med. Essays, vol. v. p. 153, 1752.
4 31st Epistle.
5 Actis Nat. Cur., vol. v. p. 483.
Bauer6 under the title of "intestinal moles" describes in Haller's Disputations the discharges of this disease as "concreta fibrosa quædam pro parte pinguedine rara abducta, membranacea molarum ex utero muliebri rejectarum formam accurate sistentia."
6 "De Moles Intestinorum," Disputationes ad Morborum, Dresdæ, 1747, p. 463.
In the same volume Kaempf7 discourses on this subject under the title of "infarction of the intestinal vessels," and also in a separate treatise8 published somewhat later. In the latter he groups the disease with others of a far different nature, their only point of convergence being preternatural alvine discharges.
7 De Infarctu Vasorum Ventriculi, Basiliæ, 1751.
8 Abhandlungen von einer neuer methode der hartnackigsten Krankheiten die ihren Sitz im unterleibe haben, zu heilen, Leipzig, 1784.
Subsequent authors, as a rule, fell into the same error, and it was not until 1818 that membranous enteritis was discriminated by Powell9 from that condition in which we recognize the presence of gall-stones. Since then more correct views have prevailed, and the disease has now a recognized place in nosology.
9 Trans. of Col. of Phys. London, vol. vi. p. 106.
ETIOLOGY.—As in other diseases of obscure nature, so in this, there has been much divergence of opinion as to its cause.
The influence of age is striking, as it is rarely seen in childhood or in persons who have passed the forty-fifth year. Of my own cases, the youngest was forty, and the oldest fifty-four. Rilliet and Barthez10 state that membranous formations in the intestinal canal of children are very rare; that they always occupy the summits of the folds, rarely the intervals, of the mucous membrane; and that they are detached in layers of greater or less extent. They are not diphtheritic. Heyfelder11 has described similar exudations under the name of enteritis exudatoria.
10 Traité clinique pratique des Maladies des Enfants, t. i. p. 677, 1853.
11 Studien in Gabiete der Heilwissenschaft, p. 173.
Sex exerts as marked an influence as age, as the immense preponderance of cases occurs in females. In an analysis of 100 cases, 4 only occurred in males, 2 of which were children. All of my cases were women; with the exception of two cases occurring in males, the same experience is reported by Powell and by Copeland.
In regard to temperament, it is undoubted that the disease invades nervous and hypochondriacal subjects oftener than others, but all temperaments are liable in the presence of those enervative influences that degrade physical health and impair nerve-power. All of my patients belonged to the nervous type. Whitehead says that those of a phlegmatic temperament, not easily excited into action, or persons deficient in elasticity of fibre, compose all but a very small percentage of the sufferers from this complaint, and he had particularly noticed that a large proportion of the women have light flaxen hair, fair complexions, and white skins.
The determinative causes, whatever they may be, occasion perversion of nutrition and innervation of the gastro-intestinal canal, principally, I believe, by their action upon the ganglionic nerves presiding over those functions originating the peculiar exudatory phenomena of this disease. This condition of the nervous system once established, local irritation of any sort may precipitate an attack, and hence the multitudinous influences that have been assigned as exercising a causative agency, as exposure to wet and cold, coarse, bad food, fecal impaction, and the abuse of cathartic medicines, as alleged by Grantham,12 who asserts that the use of mercury, conjoined with a too frequent use of aperient agents, is the cause of the disease in every case.
12 Facts and Observations in Med. and Surg., 1849, p. 205.
Farr considered the irritation of the intestinal canal owing to a parasitic growth of a confervoid type (oscillatoria). This view is supported by no other authority than that of himself and Bennett, as nothing of this sort is recorded as occurring in the discharges of patients of other observers; certainly in mine there was no parasitic development. The presence of it in their cases may then be fairly regarded as accidental, or at least unessential.
Habershon regarded ovarian diseases and painful menstruation in the female, and prostatic diseases in the male, as exciting causes.
SYMPTOMS.—The most characteristic symptoms disclosing the presence of pseudo-membranous enteritis are those arising from derangements of the digestive organs. They are, in the beginning, vague and irregular in occurrence, or so over-veiled by associated disorders of the genito-urinary and nervous systems that their nature and import often escape recognition until, weeks, and even months, of fruitless medication addressed to these secondary phenomena having been expended, the disease assumes such severity and presents such a complex of peculiar symptoms that it no longer eludes identification.
The disease rarely starts as an acute affection; sometimes it is subacute, but in the great majority of cases its course is chronic. Its initiation is marked with symptoms of gastro-intestinal disturbances—irregularity of the bowels, constipation and diarrhoea alternately; and dyspeptic annoyance of one sort or another—capricious appetite, nausea or vomiting, and pyrosis, usually increased by liquid diet. In Dunhill's case there was almost daily vomiting of mucus and pus streaked with blood, and occasionally pure blood. This prominence of gastric derangement supplies an explanation why Todd conferred upon the disease the title of follicular dyspepsia.
There is a sense of discomfort, soreness, or rawness of the abdomen, especially along the line of the colon, and in two of my cases the rectum was tender and raw, which augmented to decided pain in sitting or riding, and the abdominal muscles were tense; a feeling of heat or burning in the bowels often occurs, and almost always more or less lassitude and mental depression. These symptoms aggravate, especially upon indiscretions in diet, exposure to wet, or indeed under any sort of enervative influences, at irregular intervals. Their persistence finally induces grave disorders of nutrition, marked by the blood becoming poor and thin, by sluggish circulation and local congestions in the pelvic and abdominal viscera, and loss of strength and flesh. Yet certain patients seem to retain their flesh for a long time, as I have seen, after suffering several years from the disease. The depression of vital powers is still further manifested in a small, slow, soft pulse and a temperature running below the normal standard. The tongue is usually moist, pale, and flabby, and coated with a pearl-white or yellowish-white coating; sometimes, however, it is raw, red, tender, and fissured, or patchy from exfoliation of the mucous coating. The gums and cheeks are usually pale and bloodless, and often the seat of small roundish painful ulcers, which occasionally invade the palate and throat. Grantham13 says that ulceration of a phagedænic kind sometimes forms on the tonsils. The complexion usually assumes a muddy or flavescent tint, which during the attack may deepen to a jaundiced hue. At other times it presents a transparent or waxy appearance.
13 Op. cit., p. 204.
The skin is dry and furfy, sometimes cold and clammy, or, from over-action of the sebaceous glands, greasy. There is a disposition, especially on the chest, neck, and face, to papular eruptions or even phlegmonous or carbuncular inflammation.
The urine is high-colored and loaded with abundant phosphates, which in cooling precipitate as a heavy deposit. The bladder is often irritable, and discharges more or less mucus. According to Grantham,14 patients occasionally pass urine with evident traces of albumen, and seldom containing a normal quantity of phosphates. On an increase in fever or mental excitement a larger quantity than natural of the lithate of ammonium is found; frequently the mucous membrane of the bladder is found thickened in these cases.
14 Op. cit., p. 204.
The characteristic symptom, however, of this disease is the periodical formation and discharge of mucous exudates varying in physical appearances and frequency. The discharge may occur daily, with every stool, or at irregular intervals—a week, month, or longer—but usually in from twelve to fifteen days. The recurrence may be precipitated by irregularity in diet, exposure to wet and cold, or by excesses of any sort. The paroxysm is marked by tormina or severe pain, which may resemble that of colic or that of the passage of a biliary calculus, extending down the thighs or to the bladder, in the latter case sometimes causing retention, requiring the use of the catheter. The pain is usually referred to some part of the large intestine. In certain cases the paroxysm is announced by chills radiating from some point in the abdomen or even from other parts of the body.
After the paroxysm has endured two, three, or more days—usually a week—membranous exudates, either with a spontaneous or with an artificial movement of the bowels, are voided; after which there is a gradual assuagement of the local and general symptoms, but the patient experiences a sense of exhaustion or lassitude, and the tenderness of the abdomen and the irregularity of the bowels usually persist.
During the attack there is anorexia, but in the intervals the appetite remains fairly good, and the alvine discharges may assume quite a natural condition.
In the course of the disease there is more or less disturbance in the functions of the nervous system. During the paroxysm, when the sufferings are severe, the cast of symptoms running through the case is of a decidedly hypochondriacal type. At times, with the expulsion of the exudates and succeeding respite from suffering, there often occurs a mental rebound which lifts the patient from the slough of despair to the most hopeful anticipations of future health and happiness. In one of my cases this transition was remarkable. This hysterical type is common enough, and the irritability of the nervous system is still further manifested in the occurrence of irregular contractions of various groups of the voluntary muscles, as shown in hysterical tetanus, general convulsions, or chorea in children, or by paralyses of motion.
Copeland15 reports a case of a lady in whom this disease was complicated with the severest symptoms of hysteria, occasionally amounting to catalepsy. The paroxysms of pain recurred at intervals between four and six weeks, followed or attended by the discharge of large quantities of false membrane in pieces, and sometimes in perfect tubes. The menstrual flow was painful and irregular, accompanied with shreds of false membrane—not, however, contemporaneous with those of the intestine. The sensory nerves are often deranged, for in some cases there is paræsthesia—anæsthesia or hyperæsthesia—in limited areas of the skin. There is more or less headache, neuralgic pains in this or that nerve, or in several at the same time.
15 Dictionary of Medicine, vol. ii. p. 669.
The special senses do not escape; they manifest various forms of functional derangement. In one of my cases there were constant buzzing in the ears and perversion of the sense of smell, and in another the vision was thought impaired and the services of an oculist sought.
The uterine functions are always involved in greater or less degree. The menstruation is difficult and painful, and occasionally accompanied with membranous discharges. In one of my cases there was a uterine exudate, though the menopause had occurred several years before. Leucorrhoea and cervical inflammation are common.
PATHOLOGY.—Despite the fact that the disease in question, without being very frequent, is far from rare, little light has been shed upon its pathology. Indeed, even its individuality as an independent and distinct affection has been contested, although it is marked by a complex of symptoms as peculiar and characteristic as those of any other disease in the nosology.
There are those who maintain that the disease consists essentially in an inflammatory condition of the intestinal mucous membrane, either of the ordinary or of some specific type, croupous or diphtheritic. Copeland says the formation of the membranes depends upon a latent and prolonged state of inflammation extending along a very large portion, sometimes the greater part, of the intestinal canal, as is evinced by the quantity thrown off. Valleix16 dismisses the subject summarily with the delivery of the oracular judgment that the greater number of cases of this disease are dysenteric, and the remainder diphtheritic. Habershon is in full accord with this view, having, as he says, seen these membranous exudates "follow severe disease of the intestines of a dysenteric character, and sometimes associated with a state of chronic congestion of the liver, and often perpetuated by the presence of hemorrhoids, polypoid growths, etc." Wilks and Clark,17 after a full examination of the enteric exudates submitted to them, concluded that they are true casts of the large intestines produced by chronic inflammatory action of the mucous membrane and subsequent exudation. Conjectures have been ventured as to the exact anatomical structure in which the process occurs. Thus, Todd18 says that the proximate cause of the disease is dependent upon a morbid condition of the intestinal mucous follicles. Golding-Bird19 holds similar language. He says: "It is probable that the follicles are the principal seat of the disease, for we know that they sometimes secrete a dense mucus differing little in physical qualities from coagulated albumen or even fibrin." Livedey20 attributed the process to a morbid secretion into the mucous crypts.
16 Guide du Médecine practicien, vol. iii. p. 10.
17 Trans. Path. Society, vol. ix. p. 230.
18 Cyclopædia of Practical Medicine, vol. ii. p. 279.
19 Guy's Hospital Reports.
20 L'Union médicale, 1868.
Among those believing in its croupous nature was Powell, who assumed the character of the inflammation to be specific, and the exudate of the same nature and formed in the same manner as that of ordinary croup. This was the view entertained by Cruveilhier and Trousseau and other French authors. Good was misled in a similar manner, as shown by his statement that the exudation bears a striking resemblance to the fibrous exudation thrown forth from the trachea in croup. He says, however, that it is discharged in longer, firmer, and more compact tubes. Serres,21 in a dissertation upon pseudo-membranous colitis, confounds the exudate with that of thrush, muguet, and infective dysentery. Laboulbène,22 a later writer, also remarks that there are found in many treatises and in periodical literature a great number of occurrences of false membranes in the dejecta. Most of these cases are referable to dysentery, to muguet, hydatids, etc., but there remain a certain number which are owing to different inflammatory and non-diphtheritic affections of the digestive tube.
21 Thèse de Paris, No. 39, 1836.
22 Recherches cliniques et anatomiques sur les Affections pseudo-membraneuse, Paris, 1861.
Whitehead, in summing up his conclusions respecting the nature of the disease, compares it with dermic inflammation. He says: "The mucous membrane (intestinal), like the skin (and is not the one looked upon as an inversion of the other?), is prone under certain conditions in certain constitutions to develop products unnatural to its functions. It is not natural for the skin to produce eczema, neither is it natural for mucous surfaces to produce mucus in a concrete form; that the proximate cause of the symptoms referable to this disease is the hypersecretion and accumulation of mucus on the free surface of mucous membranes; such accumulations sheathe and prevent the healthy performance of the functions natural to the part, and thus induce immediate and remote results, the effect of such suppressed functions; that this hypersecretion indicates a want of balance between nerve-force and germinal matter, and that the nerve-force is perverted by irritation."
Simpson held similar views, and regarded the disease as a chronic pellicular or eruptive inflammation of the mucous lining of the bowels.23 Other observers have been inclined to ignore the inflammatory nature of the disease, at least as a primary condition, and have sought the proximate cause in some as yet undefined derangement of the nervous system. Thus, Clark does not regard the membranous exudates as the products of inflammation, properly so called—that is, of capillary blood-stasis which has preceded their formation—as the characteristic of such exudates is that they contain fibrin. He says the abnormal cell-forms present arise in some other way than by free cell-development out of an exuded blastema. Good24 asserts its dependence upon what he calls a "peculiar irritability of the villous membranes of the large intestines, which in consequence secrete an effusion of coagulating fibrin—fibrin mixed with albumen—instead of secreting mucus, occasionally accompanied with some degree of chronic inflammation."
23 Obstet. Works, Am. ed., p. 279.
24 Study of Medicine, op. cit.
Also, DaCosta doubts whether the disease is originally inflammatory at all. "Where inflammation," he says, "occurs, is it not secondary rather than primary, the result rather than the cause?" "Is not the true trouble in the nervous system, in the nerves presiding over secretion and nutrition in the abdominal viscera?"
Bennett and Byford represent the opinions of a very small minority who regard the disease as simply an expression of uterine derangement.
MORBID ANATOMY.—As none of the cases coming under my observation terminated fatally, no opportunity was offered to me of making personal investigation into the anatomical changes occurring in membranous enteritis. Such opportunities have been so rarely met with that, indeed, it may be said that the nature of these changes is wholly unknown.
Simpson alludes to a case of phthisis in which the patient had passed large quantities of "membranous crusts or tubes," and in which the mucous membrane of the colon was covered with an immense number of small spots of a clear white color, or vesicles, which, when punctured, discharged a small quantity of clear fluid; and also refers to the case of Wright, in which the mucous membrane of the colon and of the lower portion of the small intestine was studded everywhere with a thickly-set papular eruption.
My endoscopic examinations revealed, in the living subject, the intestinal mucous membrane of a red, verging into a scarlet color, thickened, and denuded of epithelium in patches of varying extent. This condition does not always invade the ampulla of the rectum, but with the long tube I am in the habit of using it was possible in all my cases to reach a point where it existed. The extent of diseased surface can only be conjectured by an inspection of the exudates and by abdominal palpation.
In most cases the exudate is restricted to the large intestines—colon and rectum—and often to a circumscribed portion of them; but in rare cases its length and quantity would seem to indicate that extensive portions of the surface are covered. One of the most remarkable cases recorded is that of a woman forty years old who had been sick for five years with gastro-intestinal derangement. Suddenly the case became acute, and after much suffering she passed membranous exudates three millimeters in thickness and many centimeters long, weighing in all three kilograms.25
25 Recueil de Mémoires de Médecine, de Chirurgie, et de Pharmacie militaires, tome xxxvii. p. 297, 1855.
Kaempf26 gives another case, in which the length of the membranes discharged was sevenfold greater than the stature of the patient. In Dunhill's27 case the patient had suffered from this disease for a long period, and during two years passed many yards of perfect cylindrical shape, many of them several feet in length, and sufficiently coherent to permit of their being handled, held up, etc. In one of my cases a perfect cylinder three-quarters of a yard long was voided.
26 Op. cit., p. 232.
27 Trans. of Path. Society of London, vol. ix. p. 188.
Laboulbène28 describes the gastro-intestinal false membrane as thin, soft, and granular, of a more or less yellow color, slightly adherent to the mucous membrane, and when stripped off forming a yellow pultaceous mass. He says it is first deposited in small, irregular, sparsely-scattered patches, located on the summits of the intestinal folds; afterward these patches increase, and cover the folds entirely and almost the whole calibre of the intestinal canal. The mucous membrane, he remarks, beneath the deposit is greatly inflamed.
28 Op. cit., p. 105.
Powell believes that at times the deposit extends as high as the duodenum, his opinion being solely based upon the clinical features of the disease. In the first of his cases the membrane was found in perfect tubes, some of them full half a yard in length, and certainly sufficient in quantity, he says, to have lined the whole intestinal canal.
In examining the membranes it is always best to float them from the fecal or other foreign material by passing the discharges in a clean vessel containing water. Their physical characters can then be readily studied. They are best preserved in a 10 per cent. solution of alcohol. The exudate consists usually of a single lamina, but at various points in certain cases several superposed laminæ may be observed, enclosing between them particles of undigested food of various kinds. In most cases the superficial layers are more opaque, drier, less elastic, and friable than the deeper.
The configuration of the exudate varies greatly. The more common variety is that occurring in loose, transparent, jelly-like masses, like the white of an egg or glue, tinged often with various hues of yellow. In three of my cases I noticed also the frequent occurrence of a thin, serous, yellow discharge. In some cases the discharge resembles pieces of macaroni, tallow, or wax; in others it assumes a shreddy or ribbon-like form; and in a still rarer class it is tubular, being an exact reprint of the surfaces from which detached. These tubular pieces are, however, more or less torn and broken into smaller fragments of an inch or two in length when discharged.
Its thickness also varies: sometimes it does not exceed that of the thinnest film, and at others it is a quarter of an inch or more.
Its consistence ranges from that degree of loose aggregation that permits elongation into stringy, breaking masses when fished up from the water in which it floats, to a firmness and tenacity that will enable it to be handled without fear of breakage.
The color differs in different cases. It is usually yellowish-white, but this is often modified by tints dependent upon admixture with extraneous matters from the intestinal canal—biliary coloring, blood from the rupture of the vessels beneath the exudate, or with blood and pus. It exhales a feculent odor.
The surfaces of the membranes are ordinarily smooth and uniform, but sometimes reticulated. Certain observers have described the outer surface of the tubular exudate as uniformly smooth, and the inner as broken and flaky at some points, at others ragged and flocculent, and in many places thrown into shallow folds, lying in some situations across, but chiefly along, the axis of the gut.
The microscopic characters of the exudate are pretty uniform. Wilks and Clark29 describe the surface of the tubes, examined with a linear magnifying power of forty diameters, as exhibiting the appearance of a gelatinous membraniform matrix traversed by a coarse network of opaque yellow lines, studded at their points of intersection by similarly colored rounded masses. From the larger network proceeds a smaller secondary network, and in the recesses of this were found, at close and regular intervals, well-defined round or oval openings, with elevated margins, resembling in size and appearance the mouths of the follicles of the great gut. With higher powers the exudate was found in many cases to consist of a structureless basement membrane, which in certain points showed a fibrous appearance, owing doubtless to the presence of filaments of mucin. Numerous irregular granular cells, as well as granules from the breaking up of these cells, thickly studded the surface of the membrane. In the specimens of Wilks and Clark the surface, besides being marked by the opaque yellow lines and dots, presented various foreign matters, such as bile-pigment, earthy and fatty granules, portions of husks of seed, gritty tissues of a pear, a peculiar form of elastic tissue, stellate vegetable hairs, and a mucedinous fungus. Clark, in describing the fibres found between the layers of the exudates, says that they exhibited a very distinct and regular transverse striation, approaching in character that found in the ligamentum nuchæ of the giraffe. Quekett and Brooke have met with the same fibres in the feces. The transverse division depends probably upon beginning decay. The division is sometimes so distinct and complete as to lead, according to Beale,30 to their confounding with confervoid growths. Farre31 actually describes the formation as of a confervoid character.
29 Op. cit., p. 232.
30 The Microscope in Medicine, p. 194.
31 Trans. Microscopical Society.
Here and there, in my specimens, were observed scattered epithelial cells which were occasionally gathered in patches. Small colored masses of irregular shape, doubtless of fecal origin, were also noticed. The cells imbedded in the matrix, according to the above-quoted observers, consisted of two kinds—one more or less spherical, the other more or less cylindrical. In size the spherical cells varied from 1/2000 to 1/800 of an inch in diameter. The smaller cells had no distinct cell-walls. Some of the larger cells were filled with fat-granules, and represented granular cells; others had a single or double vesicular nucleus; a few were acuminated at two opposite points and somewhat compressed. All the other cells possessed demonstrable cell-walls. The cylindrical cells resembled in their general characters those which normally coat the mucous membrane of the larger gut, but they were much more elongated, compressed, and firmly matted together. Many of the more elongated cells were constricted in the middle, and exhibited a nucleus on each side of the constriction. The more or less spherical cells occupied the attached, and the cylindrical cells the free, surface of the membranous tubes.
The perforations in the matrix were of uniform size and appearance, surrounded by elevated margins formed of closely-grouped cylindrical cells, and led to two kinds of pits—one short and flask-shaped, the other long and uniformly cylindrical. The flask-shaped pits were about one-tenth of an inch in diameter and distinctly hollow. The wall of each pit was made up of one or two layers of subspheroidal cells, held together by an amorphous stroma. A few of these follicles contained a deposit which was opaque in situ, and which when broken up was found to consist of large flattened nuclear cells, analogous to those met with in epithelial growths.
The cylindrical pits were also for the most part hollow, about one-sixteenth of a line in length and one-thirty-first of a line in breadth. These walls, devoid of membrane, were composed of small, more or less spherical cells in various stages of development, imbedded in a gelatinous matrix.
In examining the chemical characters of the specimens obtained in my cases the membranes were thoroughly washed, when they were nearly as colorless as the water in which they floated. They were drained on a sieve, and presented a gelatinous appearance, much like the white of an egg. Their specific gravity was about that of distilled water. When treated with strong alcohol, the membranes shrank and assumed a striated appearance. Chemical tests of tincture of guaiacum, peroxide of hydrogen, and others failed to show the presence of fibrin or albumen. Treated with ether, globules of fatty matter were obtained, which were identified by their microscopical characters and by their reaction with osmic acid. By boiling the liquid in which the membranes had been soaked it became faintly hazy, indicating a trace only of albumen. Faint evidence of the presence of this body was also presented by picric acid and Mehu's test. Treated with a weak solution of caustic potassa and heat, the membrane dissolved, leaving a little haziness. The liquid was then filtered, and exactly neutralized with acetic acid, and plumbic acetate added, when a copious precipitate was formed. Mercuric chloride and potassic ferrocyanide failed to produce this effect. From these and other tests used the conclusion was reached that these membranes were composed essentially of mucin.
Both the microscopical and chemical characters of the exudates of the disease under consideration show that they are widely different in nature from those of other diseases. They are evidently a production of the muciparous glands (follicles of Lieberkühn) of the intestinal canal, and consist essentially of mucin. Perroud32 concluded from his analysis that they contain a small quantity of albumen, but are principally formed of the same substance as that which enters into the composition of the epidermis. The exudates of other diseases of the alimentary mucous membrane contain albumen and fibrin, as well as molecular or homogeneous filaments. The ordinary croupous exudate, according to Cornil and Ranvier, always contains filaments of fibrin, sometimes mucin and pus-corpuscles mingled with the cellular constituents, which vary in character with the locality of the inflammation. The filaments form a reticulum in the meshes of which are contained the other elements.
32 Journal de Médecine de Lyon, 1864.
Diphtheritic exudates, as shown by Lehmann,33 consist of fibrin, a large quantity of fatty matter, and 4 per cent. of earthy phosphates, while its structure is made up of epithelial cells united together, which, becoming infiltrated with an albuminous substance and gradually losing their nuclei and walls, are finally converted into homogeneous branching masses. The cells of these masses are liable to undergo fibrinous degeneration. The inflammation determining the exudate is not confined to the conglomerate glands, but involves all the textural elements of the part affected, and the material of the membrane originates from the capillary disturbance in them.
33 Lehrbuch der Physiolog. Chemie, Leipzig, 1855.
Andrew Clark34 states that he has observed in his studies of exuded blastema, the product of diseased action in mucous membranes, three varieties. The first is clear, jelly-like, and imperfectly membranous. The second is yellowish, semi-opaque, flaky, and usually membranous. The third is yellowish-white, dense, opaque, distinctly membranous, tough, and rather firmly adherent to the subjacent surface. The first contains only the merest trace of albumen, and no fibrin; the second contains an abundance of albumen, and no fibrin; the third contains both albumen and fibrin in abundance, the latter in a fibrillated form. They all contain the same cell-forms. Yet it is to be noticed that in the first variety there is no evidence of transudation or exudation; in the second, no evidence of a true exudation; and that in the third, in which the existence of a true inflammatory exudation is undeniable, the only additional structural element present is fibre.
34 Op. cit., p. 133.
DIAGNOSIS.—The diagnosis of membranous enteritis can never in its advance, and rarely in its early stages, present much difficulty. Its chronic course, irregular exacerbations, lack of febrile excitement, the persistent derangement of the intestinal canal, the mental depression, the gradual impairment of health, the various visceral complications, and, lastly and chiefly, the peculiar character of the alvine discharges,—stamp the disease with an individuality entirely its own.
The mucous discharges of certain forms of chronic diarrhoea and the membranous discharges of infective dysentery are all so different in physical character, and are associated with such a different complex of general symptoms, that they cannot be confounded with those of the diseases in question. The peculiar irritative quickness of the pulse of ordinary enteritis, according to Powell and Good, suffices to differentiate this disease from membranous enteritis. The peculiarities of the physical and chemical properties of these exudates, already fully dwelt upon, not only distinguish them from those of the above diseases, but also from such dejecta as may contain fragments of undigested connective tissue, of hydatids, or of worms. The flakes of mucus discharged from the bowels in protracted constipation, fissura ani, and in the later stages of cirrhosis of the liver are composed of mucus in which are found imbedded epithelial cells from the colon and mucus-corpuscles. The microscope will also reveal the character of the fatty discharges that may be associated with diseases of the pancreas, liver, and duodenum. The mucous flakes of cholera stools are composed of masses of intestinal epithelium mixed with amorphous and granular matter, crystals of different substances, and, according to Davaine, of parasitic forms, particularly the Circomonas hominis.
Membranous casts from the upper part of the digestive track are, in rare cases, passed by the bowels. One of the most curious instances of this sort is reported by Villermé:35 A woman swallowed a tablespoonful of nitric acid, and seventy days afterward a long membranous exudate, one or two lines thick and of a brown color, was discharged, which corresponded in form with the oesophagus and stomach. The patient died a few days later.
35 Dictionnaire des Sciences médicales, tome xxxii. p. 264.
PROGNOSIS.—The prognosis of the disease as regards life is not unfavorable, but as regards permanent restoration to health and strength the case is entirely different. Theden36 and Hoffman37 have, however, stated that the disease is not an unfrequent cause of sudden death.
36 Remarques et Experiences, tome ii.
37 Med. Ration., vol. v.
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.
41 Klinik der Unterleub. Krankheiten, p. 668.
The case will amend more speedily and surely by the adoption of those sanitary measures, as regards clothing, diet, bathing, exercise, and change of climate, which have such important influences upon health. The healthy performance of the functions of the skin is of such paramount necessity in maintaining that of the intestinal canal that the patient should endeavor to avoid any exposure likely to lead to checked perspiration, and should use flannel underwear and stimulate the skin by friction with the hand or the flesh-brush. The diet should be graded to the ability of the stomach to digest and the body to assimilate. Our chief reliance will be upon milk, plain or peptonized, eggs, and beef given in the various forms of acceptable preparations, so as not to impair the tone of the stomach nor clog the appetite by sameness. Such vegetables and fruits as agree with the patient may be allowed. I have tried exclusive diets of milk, farinacea, and meat without marked benefit. All stimulants, tea, and coffee should as a rule be interdicted.
Systematic exercise in the open air and change of climate to a cool, dry, bracing atmosphere will contribute to comfortable existence, if not lead to recovery.