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.