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.