Symptomatology
A Typical Case.—It is very difficult to obtain definite information as to the onset which is characteristically insidious.
There is usually first noted a sensitiveness of the buccal mucosa so that alcoholic drinks and acid or highly seasoned food cannot be taken without marked discomfort. A sense of fulness or distention in the epigastric region is often an early symptom. Frequently there is a history of a rather intractable morning diarrhoea which may alternate with periods of constipation.
The diarrhoeal movements are remarkably copious and soon change from bile-colored, liquid evacuations to the characteristic putty-colored, pultaceous, gas bubble permeated, offensive stool of sprue. While the patient experiences a sense of relief from the evacuation of the fermenting mass yet there is at times an excoriation about the anus which may cause pain when at stool. Neuralgic pains of the region of the anus may be present late in the disease.
When examined microscopically the stools are found to show much fat, yeasts and undigested food. The fats are chiefly in the form of neutral fats and fatty acids rather than as soaps. The reaction is acid. Nausea and vomiting, especially about noon, may be complained of.
While the characteristic stools best show the full development of the disease there are also changes noted in tongue and buccal mucosa. Following the marked sensitiveness of the mouth above noted there soon appears a redness of the sides and tip of the tongue with a glistening coating of the surface. Small vesicles later becoming superficial erosions develop along the tongue borders, frenum and buccal mucosa.
There is also congestion and swelling of the fungiform papillae.
Very characteristic are ulcers at the site of the rear molars (Crombie’s ulcers). Later on the tongue becomes bare, fissured and even glazed, as if varnished.
The gullet may be raw and very sensitive. The appetite is apt to be capricious and the patient may be very intractable, insisting upon dietary indiscretions which he knows will aggravate his condition. There is a progressive loss of strength, weight and energy. The liver progressively diminishes in size but is difficult to map out owing to the bulging, dough-like abdominal contents. The urine is usually free of albumen but shows marked indicanuria. Sprue is characteristically afebrile.
Anaemia becomes marked, the red cells going as low at times as under 2,000,000, per cmm. and the Hb. percentage less markedly reduced (color index above 1). The polymorphonuclears are reduced in percentage.