Synonyms

Mucous Colic; Tubular Diarrhoea; Membranous Diarrhoea.

Definition

By membranous enteritis is understood an affection in which more or less large pieces of mucus (usually ribbon-like) are passed periodically with the faeces.

History

This affection seems to have been familiar to the medical world for several centuries. Paulus .AEgineta,1 in speaking of the passage of the inner membrane of the intestine, has certainly dealt with cases of membranous enteritis, and erred only in the explanation of these masses.

1 Paulus AEgineta Cited from Da Costa, American Journal of the Medical Sciences, 1871, p. 321.

Sennertius and Morgagni1 recognized these membranes as mucus, which had been inspissated and moulded in the intestine.

Mason Good2 was the first to describe this affection under the name of "tubular diarrhoea," which name has also been accepted by Woodward.3 The latter author adds that in case the membranes in a given instance have no tubular form, the expression " membranous diarrhoea " is suitable.

F. Siredey 4 contributed a very valuable paper in 1869 in reference to the knowledge of this affection. He described one case of mucous discharge in a man and six cases in women, and arrived at the conclusion that in some instances these mucous discharges occur in patients whose intestinal tract does not reveal any organic lesion whatever. For this reason Siredey regards this affection as an intestinal neurosis, occurring principally in hypochondriacs and hysterics.

Whitehead 5 describes this affection under the name of "mucous disease," cites the entire old literature, and gives detailed rules with regard to treatment and diet. He says: "Exercise, short of fatigue, should be taken daily.

1Sennertius and Morgagni: Cited from J. G. Woodward, "The Medical and Surgical History of the War of the Rebellion," 1879, part ii., vol. i., p. 363.

2 Mason Good: "The Study of Medicine," cl. 1, ord. 1, species 7, vol. i., Philadelphia. 1825, p. 162.

3 Woodward: Loc. cit.

4 Siredey, F.: " Note pour servir a 1'etude des concretions muqueuses membraniformes de l'intestin. " Union med., Nos. 7-9, 1869.

5 Whitehead, W.: "Mucous Disease." British Medical Journal, February 11, 1871, p. 140.

The diet is perhaps the point of all others where the greatest mistake is made. An idea, strongly felt by the patient, that a great amount of strengthening food is required, leads to the further exhaustion of an already enfeebled digestion. Impress upon the patients the fact that it is the quantity absorbed which means strength, and not the bulk swallowed, and it is possible to check the error they are so anxious to commit. Certain articles of diet should be strictly interdicted, the chief of which are the following: Liquid food, excepting milk, aggravates in the majority of cases every symptom; sugar is invariably hurtful; tea, coffee, and alcohol - Burgundy being the only wine from which I have ever derived benefit - vegetables, and fruit also prove injurious."

Cruveilhier l and Laboulbene 2 discuss this ailment under the term "pseudo-membranous enteritis."

One of the best papers upon this disease was written by Da Costa,3 who called it "membranous enteritis." This author gave a full description of this affection, recognized its nervous character, furnished several detailed cases, and put particular stress upon dietetic treatment. Da Costa permits eggs, milk, bread, and solid food, which is better borne than liquids; tea, coffee, and alcoholic stimulants are to be permitted only in very small quantities. As regards vegetables, we must observe whether they pass unchanged in the stools. Fresh meat juice is serviceable; from an exclusive milk diet, even faithfully carried out, he has seen no good. Furthermore, Da Costa recommends that great attention be paid to the action of the skin, and believes baths followed by systematic friction to be very useful. Daily moderate exercise is advocated, particularly in cool weather, and if possible an occasional trip to the mountains and living out of doors in the bracing mountain air. Everything that can be done to invigorate the digestive and nervous systems forms the essential part of the therapeutics.

1 Cruveilhier: Anat. path, gen., t. ii.

2 Laboulbene: "Recherches sur les affections pseudomembraneuses." 1861.

3 J. M. Da Costa: "Membranous Enteritis." American Journal of the Medical Sciences, 1871, p. 321. 22

A few years later there appeared an article by Edwards,1 who coincided with Da Costa's views in most points, being, however, much stricter with regard to diet. He says: "Easily digested or even predigested food should be supplied, and care should be taken that undigested particles of food are not irritating the intestinal canal."

Leyden,2in 1882, directed attention to membranous enteritis in Germany, where also very soon appeared exhaustive publications on this subject. Nothnagel3 suggested the name "colica mucosa," in order to show that a true enteritis need not exist in these cases and that the disease really is a mucous colic. Rothmann4 was the first to publish a case of membranous enteritis - complicated with cancer of the skull - in which an autopsy was made. By means of Weigert's stain, or rather by Ehrlich-Hoy-er's thionin (a specific stain for mucus), double-stained specimens could be obtained, which showed the presence of large quantities of mucus on the surface of the large bowel in the glandular tubules.

1 Edwards: American Journal of the Medical Sciences, April, 1888, p. 329.

2 E. Leyden: Verhandl. d. Vereins f. innere Medicin in Berlin, Deutsche med. Wochenschr., 1882, Nos. 3.6 and 17.

3 Nothnagel: "Colica mucosa." Beitrilge zur Physiologie und Pathologie des Darms. " 12tes Capitel, 1884.

4 Max Rothmann: "Ueber Enteritis membranacea." Deutsche med. Wochenschr., 1893, p. 999.

Ewaldl,1 Boas,2 Kittagawa,3 Pariser,4 and others have added further contributions.

Ewald laid stress on a ptosis of the colon, Boas on atony of this organ as important factors in this affection.

Etiology

Most authors agree that membranous enteritis is quite a rare affection; it occurs much more frequently in women than in men (children being only exceptionally affected).

That the nervous element (hysteria, neurasthenia) plays a great role in the origin of this trouble, no one can doubt, and W. Mendelson5 is right when he asserts that neurasthenia is not absent in any of his cases. Mendelson goes too far, however, when he says: "I believe that the reverse of the proposition may also as confidently be affirmed - namely, that if neurasthenic patients be closely questioned, very few will be found who have not had at some time repeated characteristic passages of stringy mucus, associated with abdominal pains." Membranous enteritis is found in nervous individuals (possibly the affection as such adds much to their neurasthenia); but only a small fraction of the great mass of neurasthenics is afflicted with this ailment.

With regard to the frequency of membranous enteritis, 1 examined my private patients of the year 1897 relative to its presence, and take the following data from my daybook. The total number of patients was 1,315 - 772 men, 543 women. Twenty of these patients suffered from membranous enteritis - two men and eighteen women. The frequency of membranous enteritis among sufferers from digestive disorders expressed in percentages is, in men, 0.25 per cent; and in women, 3.31 per cent. Among these twenty patients, twelve had enteroptosis in a pronounced degree. Ewald has already pointed out that a prolapse of the colon is frequently found in patients with membranous enteritis. My own observations fully confirm this statement, for with the prolapse of the stomach descent of the colon naturally must be presupposed. It appears that enteroptosis certainly creates a fruitful soil for the development of membranous enteritis, although it does not directly cause it. Enteroptosis is, as is well known, very - frequent, while membranous enteritis is rare in comparison with the former.

There must, therefore, be still other factors which are of importance in the causation of membranous enteritis.

1 C. A. Ewald: "Membranous or Mucous Enteritis." Twentieth Century Practice of Medicine, vol. ix., p. 265.

2J. Boas: Deutsche med. Wochenschr., 1893, No. 41.

3 O. Kittagawa: "Beitrage zur Kenntniss der Enteritis membrana-cea." Zeitschr. f. klin. Medicin, 1891.

4 Pariser: Deutsche med. Wochenschr., 1893, No. 41.

5 Walter Mendelson: "Mucous Colitis a Functional Neurosis." Medical Record, January 30, 1897.

With reference to gastric secretion and the motor function of the stomach in this disease, I 1 have made examinations on twelve cases and found the following two points most conspicuous:

1. The motor function (prochoresis) of the stomach - judged from the amount of contents found one hour after the test breakfast - was increased in eight cases and nor-mal in the four remaining.

2. Five cases presented a typical achylia gastrica.

Considering the comparative infrequency of achylia gastrica, which hardly amounts to two.or three per cent of the digestive disorders, this large proportion of achylia in patients with membranous enteritis - namely, five in twelve - is certainly noteworthy.

1 Max Einnorn: "Membranous Enteritis. " Medical Record, January 28. 1899.

Three cases of membranous enteritis with normal acidity revealed, besides the increased prochoresis, still another feature in common with achylia - namely, the extraordinarily small amount of fluid surrounding the scarcely changed particles of roll, one hour after the test breakfast. Although this symptom may occasionally be met with in other cases than achylia, it is nevertheless, as a whole, characteristic of this affection. Therefore we are justified in making the following statement: In many cases of membranous enteritis typical achylia is present, in some it is lacking, but even then some features characteristic to achylia are encountered. In membranous enteritis achylia thus plays a great part. Whether one condition causes the other, or one and the same factor (nervous influences) creates both, is difficult to say. The latter, however, is more plausible.

Symptomatology

The disease is characterized by attacks of rather violent colicky pains in the abdomen, which are followed by the passage of mucous masses with the stools. The mucus may be voided either alone, without any admixture of fecal matter, or it forms a considerable part of the evacuation. Usually the attack is preceded by a period of obstinate constipation, and often followed by diarrhoea lasting a few days, and sometimes accompanied by tenesmus. Gastric symptoms - as loss of appetite, frequent belching, now and again a burning sensation at the pit of the stomach - are generally quite pronounced during the attack. Vomiting may occasionally appear, while fever is, as a rule, absent. The attack lasts three to seven days, and then the pains subside, the diarrhoea ceases, and euphoria reappears. More or less constipation, however, and some other dyspeptic as well as nervous symptoms persist. These free intervals last various periods of time (four weeks to five or six months). In rare instances the mucous discharges may be present continuously.

With reference to the mucous masses, they present a grayish-white appearance, seldom yellowish, and have either a ribbon-like or membranous form; at times the pieces are several feet long; ordinarily, however, they are considerably smaller. Complete moulds of the intestinal lumen have been observed by several authors, and Leyden not unjustly has compared this process with that of croup of the larynx. As already stated by Cornil,1 the false membranes consist of mucus, mixed with dried-up epithelial ovoid cells, which arise from a mucous metamorphosis of the cylindrical cells or the leucocytes. Nothnagel and others have proven the mucous nature of these discharges.

As suggested by Pariser, the mucous nature of these masses can be demonstrated by treating them, first, with sublimate alcohol, and then staining them with Ehrlich's triacid solution. A green color appears, which indicates mucus (fibrin treated in the same manner assumes a red color). Judging from my experience it is unnecessary to dip these membranes first into sublimate alcohol, as the same result will follow when they are put directly into the weak triacid solution Microscopically this substance reveals a somewhat fibrillary nature, and contains many shrivelled cells, so called by Nothnagel. Micro-organisms are found admixed, although they do not seem to play any important part in this affection. In two of my cases microscopically single-celled corpuscles were found in these masses, having a distinct nucleus and a tail-like process. The accompanying drawing shows these corpuscles (Fig. 38). These are most probably metamorphosed goblet cells.

Microscopical Picture of Mucous Masses Found In the Evacuation of Mrs

Fig. 38. - Microscopical Picture of Mucous Masses Found In the Evacuation of Mrs. L, Showing Numerous Cells Having a Nucleus and a Tail-like Process.

1 Cornil: Cited from Siredey. See above.

Diagnosis

The diagnosis of membranous enteritis is, as a whole, simple when the above-mentioned characteristic symptoms, including the mucous discharges, are present. It is, however, necessary to be careful not to mistake for mucus other substances admixed in the faeces, which occasionally resemble shreds of mucous membrane - as, for instance, the fibre of an orange, tendons, pieces of tapeworm. A microscopical examination will guard against all such errors.

This affection will hardly be confounded with real intestinal catarrh, as it presents an entirely different picture and only occasionally may have an abundant secretion of mucus in common with mucous colic. There are, however, cases of chronic intestinal catarrh which are complicated with membranous enteritis - that is, having typical attacks of mucous colic. The following case presents an instance of this kind:

Miss L. N - , twenty-eight years old, had diarrhoea eleven years ago for quite a while, which disappeared after two or three months. The patient was then well until four years ago, when she again began to be troubled with diarrhoea. Soon periods of obstinate constipation appeared, which alternated with diarrhoea. The patient reports having occasionally observed mucus in the passages; at times (about every five or six weeks) there appear abdominal pains for about one or two hours, followed by an evacuation of pure mucus, the quantity being one to two tablespoonfuls. The appetite was always good. Now and again there was belching. The patient lost about twenty-five pounds in weight. Sleep is undisturbed, only at times restless for a few days. Her strength greatly failed. Palpation of the abdomen reveals spots sensitive to pressure in the entire course of the colon. The examination of the faeces in the free interval shows small quantities of mucus well mixed with the fecal matter. The mucous masses voided after an attack of pains are free from fecal matter, appearing grayish-white and staining green when treated with Ehrlich's triacid solution.

Treatment

Diet plays the principal part in the treatment of membranous enteritis. While the older writers laid stress on scanty light food, it is now generally accepted that abundant nutrition is of the greatest value. That a fluid diet is unsuitable, the older authors have already been cognizant of (Da Costa, Whitehead, Siredey), and this axiom holds good in its entirety even to-day.

Recently von Noorden 1 advised a very coarse diet, being guided by the idea that the intestinal tract should be exercised and strengthened by increased work. He recommends per day half a pound of bread containing plenty of chaff, leguminous vegetables, garden vegetables rich in cellulose, fruits with small pits and coarse skin, as currants, gooseberries, grapes - these being foods rich in un-digestible material, thus forming much ballast for the bowel. Among fifteen patients subjected to this treatment by von Noorden, seven were permanently cured, seven improved, and one was unchanged.

1 C. von Noorden: "Ueber die Behandlung der Colica mucosa." Zeitschr. f. practische Aerzte, 1898, No. 1.

This method has certainly much in its favor; it may be better, however, not to institute this diet abruptly, as suggested by von Noorden, but rather gradually.

I, for my part, for some years past have seen to it that my patients partook of an abundant and nutritious diet, without, however, advising substances that were too coarse. As a whole, I recommend ample food and try to keep the patients on a mixed diet containing plenty of vegetables. In patients who have lived on a strict diet (as for instance milk diet or beef and hot water), I arrange the change gradually. The principle here is the same as stated by von Noorden, only not carried to such an extreme. It appears sufficient if the intestines of the patient with membranous enteritis are trained to master the foods customary in healthy persons, and the accomplishment of this object is all that is required. If we subsequently see that the organism amply fulfils its work, a few less digestible foods may then be added. It is not necessary to recommend these immediately from the start, nor are they important for the cure.

With regard to therapeusis, two phases will have to be considered - the treatment during the attack and the treatment during the interval. In severe attacks, rest in bed, warm poultices over the abdomen, a cleansing enema (of ordinary warm water with the addition of some common table salt or essence of peppermint - one teaspoonful to a quart), and afterward the administration of codeine or opium, with or without belladonna, are of value. As long as the pains last it is necessary to give light food (small quantities frequently). In mild attacks a stay abed may not be requisite, nor the administration of an analgesic remedy, and the diet may be the same as during the interval.

In the interval free from pains the treatment consists in a methodical application of olive-oil enemas, as suggested by Kussmaul and Fleiner.1 These enemas are injected into the bowel at night, at blood temperature, the quantity being two hundred and fifty to five hundred cubic centimetres. The patient is then instructed to try and retain the oil in the bowel during the night. The patients seldom assert that they are disturbed in their sleep by these injections and have to answer nature's call. In such an instance the quantity of oil may be reduced to one hundred and fifty or one hundred cubic centimetres. The oil should be injected every night for three weeks; then every other night for three weeks, and twice weekly for four weeks; finally, once weekly for five or six months. Besides, patients must accustom themselves to a regular morning evacuation, by promptly visiting the closet every day at the same hour in the morning.

Next to abundant nourishment the methodical oil cure is of the greatest importance in the treatment of this affection, and the results achieved are, according to my experience, very satisfactory. The administration of oil injections in membranous enteritis is mentioned here and there in recent literature, especially by Ewald, but its value must be placed much higher than heretofore. The oil has not only a favorable influence upon the constipation which is always present in this malady, but at the same time also effects a diminution or a disappearance of the mucous discharges. How the oil brings this about is difficult to say. The favorable effect may perhaps be explained by the circumstance that by means of the oil the intestine is not left in an empty condition during the night, and thereby a spasmodic contraction is avoided, which must be regarded as one, of the principal factors in the formation of mucus.

1 Fleiner. Berliner klin. Wochenschr., 1893, No. 3.

It is evident, according to my statement with regard to the etiology, that enteroptosis and anomalies of the gastric functions (principally achylia) exist in a large number of these cases. It will, therefore, be necessary to bear these points in mind and to treat the cases accordingly. The neurotic symptoms present in these cases should not be neglected in the general plan of treatment. We shall have to pay attention to a regular hygienic mode of living and ample physical exercise. In suitable cases occasional hydrotherapeutic measures will be of value. The tonic remedies, like iron, arsenic, etc., will also prove beneficial.