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."
[Footnote 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. {764} 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."
[Footnote 2: Lib. ii. cap. ix.]
[Footnote 3: _Ed. Med. Essays_, vol. v. p. 153, 1752.]
[Footnote 4: 31st Epistle.]
[Footnote 5: _Actis Nat. Cur._, vol. v. p. 483.]
Bauer[6] 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."
[Footnote 6: "De Moles Intestinorum," _Disputationes ad Morborum_,
Dresdæ, 1747, p. 463.]
In the same volume Kaempf[7] discourses on this subject under the title
of "infarction of the intestinal vessels," and also in a separate
treatise[8] 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.
[Footnote 7: _De Infarctu Vasorum Ventriculi_, Basiliæ, 1751.]
[Footnote 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 Powell[9]
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.
[Footnote 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 Barthez[10]
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.
Heyfelder[11] has described similar exudations under the name of
enteritis exudatoria.
[Footnote 10: _Traité clinique pratique des Maladies des Enfants_, t.
i. p. 677, 1853.]
[Footnote 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 {765} 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.
[Footnote 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 {766} 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. Grantham[13] 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.
[Footnote 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.
[Footnote 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 {767}
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.
Copeland[15] 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.
[Footnote 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. Valleix[16] 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 {768} 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, Todd[18] says that the proximate cause
of the disease is dependent upon a morbid condition of the intestinal
mucous follicles. Golding-Bird[19] 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."
Livedey[20] attributed the process to a morbid secretion into the
mucous crypts.
[Footnote 16: _Guide du Médecine practicien_, vol. iii. p. 10.]
[Footnote 17: _Trans. Path. Society_, vol. ix. p. 230.]
[Footnote 18: _Cyclopædia of Practical Medicine_, vol. ii. p. 279.]
[Footnote 19: _Guy's Hospital Reports_.]
[Footnote 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.
[Footnote 21: _Thèse de Paris_, No. 39, 1836.]
[Footnote 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 {769} 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. Good[24]
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."
[Footnote 23: _Obstet. Works_, Am. ed., p. 279.]
[Footnote 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]
[Footnote 25: _Recueil de Mémoires de Médecine, de Chirurgie, et de
Pharmacie militaires_, tome xxxvii. p. 297, 1855.]
Kaempf[26] gives another case, in which the length of the membranes
{770} discharged was sevenfold greater than the stature of the patient.
In Dunhill's[27] 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.
[Footnote 26: _Op. cit._, p. 232.]
[Footnote 27: _Trans. of Path. Society of London_, vol. ix. p. 188.]