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Show Sno'rioN V1.1 DISEA S OF THE ORGANS OF DIGESTION. TABLE XIII. Dvsnxrnuv, FNTERic I)1ru'r1nan1.\. INTESTINAL GANGRENE. Flo. I.-Acuic .Iy‘p/u'cnu'c 117mm; (Vina-A man forty years old was taken with severe diarrlnca, oflcring the following symptoms: A high state of delirium, quickly relieved by an opiate. Some fever next day. Seems to gradually improve. Sudden development of very acute parotitis. i I>ies on the eighth day ofthc attack. l'ost mortem: Abdominal ravitv. The liver is lifted up by an cnormouslyalilated gall-bladder, cover- ing in front the ascendingr colon, its fundus reaching down to the coeeum. The small intestines, the coecum, and ascending colon intensely inflamed. The mucous 111embrane is of a very deep red color, covered with a grayish-green exudate in small patches and flakes; and adherent to the membrane. The ileo-coc 'al ‘alve seemed to form the focus of the intense inflammation; the follicles and the mesentery being but little involved. FIG. 2.- The colon of an individual who died frmu an attack of very acute dysentery. The. mucous membrane y'as intensely red, and formed many irregular folds, the crests of which were covered with white flaky exudate. The deep red color was due to extensive imbibition with coloring matter of the blood and bile, and to Inemorrhagic infilt‘ation into the sub-mucous tissues. (A), anus. FIG. 3.-The lower portion of the small intestine presents in the ileo-eoeeal region a state of corrugation of the tissues. forming very thick folds of the exceedingly infilt ‘ated mucous membrane. They Were covered with an exudate, 'ariouslv colored by biliary coloring matter. The ileo-eoeeal valve was exceedingly thick, and raised far above the surface of the membrane. The agminated glands were also very much swollen and raised above the surface; corroded the mortifying destructions never reach the extent of that. of the mucous 111embrane. \Vhen inflammatory and gangrenous disinteg‘ation pass upon the external memb‘ane the result is nearly always fatal peritonitis. The retrogressive, reformative processes may begin at any of the different s As of the disease. \Vhen no sphacelus is formed, or only to a limited extent, the infilt ‘ate in the plaque is soon absorbed, the patches becomes soft and flabby, and static hyj'iera‘mia takes place in the soft tissues, which assumes a very red color from the imbibed blood serum and presence of extravasated red corpusclcs. The whole plaque or solitary follicle, as the case may be, turns either reddish brown, grayish black, or deep red. The edges of the ulcers become thinner, softer, and equally hype ‘iemie. In such conditions very severe hzemorrhages and infiltration with blood into the tissues often place the patient in a dangerous condition. \Vhen reorganization of the tissues commences, the ‘agged and flabby edges drop down upon the fundus of the ulcer, where a tine granular film is formed, which is soon covered with epithelium. Even long after the typhoid process has ceased,the ulce ‘ated places present smooth, dark-colored depressions 011 the surface of the intestine. (Section VI, Table XIV, all fit/arcs.) Neither follicles nor glands are to be found in the dark remnants of the former plaques. Simultaneous with inflammations of the intestinal lymphatics there is an inflammatory process going on in the inesenterie glands. The color of the. inflamed structures is, in the early stages of the disease, a very deep red; later, they assume a g'ayish or grayish-yellow app 1a ‘auce, from the enormous infiltration with lymphoid elements. (Section VI, Table XI, Figures b,c, d, e, t", g.) Still later, the infilt‘ate either becomes absorbed, when the inflammation ceases, or is t'anstormed into a gray-colored sphaeelus, which may, sometimes, also be absorbed, or become Gaseous, or ialcareous. The spleen and the lymphatics of the neck are always more or less inflamed and infilt ‘ated in conjunction with the intestinal lymph apparatus. Intestinal tubercuh‘)sis is one of the most frequent afl'cctions of the tact, and is chiefly located in its lymphatic vessels and glands. (Section VI, Table. XVI, Figure 1.) The colon and rectum are the. next frequent localities for this lesion. The tubercle usually begins in solitary or agminated follicles, as a nodular elevation covered with epithelium. Aftc 'a time there is formed in the center of a tuberculous agglomeration a yellow or yelh>wish-whitc speck (caseous change), from which the caseous and gangrenous dcstruc~ tion extends in the whole mass. Ulcers with thickened and infil- trated edges are formed, and spr‘ad more and more. peripherally, by continuous spread of infiltration, followed by cascation, gangre- nous destruction, and formation of confluent tuberculous abscesses. (Section VI, Table XII, Figures 4, a, b, c, d. g: and Table XVI, Figure 1, same set.) barge ulcers have a very irregular form, and are of various dimensions. Borders of such ulcers are usually infiltrated, but sometimes they are flat: or uneven nodular pro- jections are found both in the fundus and in the edges,of a grayishred or yellowish-red color, singly or in groups. The depth of such ulcers is variable. Not only the mucous, but also the sub-mucous coats are often involved when the tubercular process is very deep. (Sec. VI, Tab. XII.) Very seldom is the destructive process arrested, or does ci 'atrization take place. As a rule, the infilt‘ation is coir tinued in steady process until death puts an end to the destruction. Sup/«dis of Mr In/cslon's. Besides the broad condylomata on and around the anus there is often formed syphilitic ulceration in the rectum of females, occasionally extending from the anus upward, for many inches in extent. It is separated from the healthy tissue by a very sharp line of demarcation. The ulcer presents, generally, a very irregular surface, upon which there are some patches or islands of very boggy mucous tissue. Its edges are similarly undermined. for the inflammation is mainly going on in the sub-mucous tissue. and is the lirst destroyed. The ulcers freely secrete puriform liquid. The cause of the formation of such ulcers seems to be the infectious vaginal secretion. In the colon and the smaller intestines syphilitic ulcers are very rare. 13 in some places, and covered with some exudate. The same was the case with the solitary. Flo. 4,-I'crm-u/c ,1),//.~‘(nt(r]/ wit/1 (Iain/Ivar. I'atient affected with epidemic dysentery, with the following symptoms: Involuntary c‘acuations, blood mixed with nmch niucous, and very lirtid. Small, slow pulse. No hiccough. Died suddenly in a collapse. l'ost mortem: The whole of the large intestine iexccedinglv e11larged and thickened, the mucous 111e1nbranc thrown in‘ thick irregular folds, the. internal surface presenting a gangrenous apj pe: 'ancc and forming a dark, thick ayer, as if afliw'ted by a very Corrosive 111incral acid. The sub»n1ucous and muscular‘itissues although very much infiltrated and very thick, not mortified: Neither the coccum nor th - appendix as niueh injured as the other portions. The small intestine, the least of all injured. The rectum (It) presented the characteristic changes of the large bowels. Fios. 5, G, 7, R show various alte"ations which the smaller intestines had undergone in the disease. Fig. :3, the least affected por- tion of the ileum, shows the mucous membrane to be smooth and even from the infiltrate; only the follicles are aflccted, and the, vessels around them enlarged. Fig. 6, 'alvuhe conniventes of the duodenum covered with exudation, exfoliation of the epithelium, and denudation of the subjacent structure. Fig. 7, the epithelium exfoliated, the tissue below ulcerating, chiefly 11 ~ar the follicles; (AAA), ulcers; (B), the mucous structure, presenting a motley appea 'ance. Fig. (‘4, a portion of the ileum. of whicli the serous tissue (A) is very thick, the sub-mucous, infilt‘atcd and ha‘morrhagic; (B), mucous tissue, covered with dark exudate; (A). I'evcr's plaque in the middle of the figure, undergoing ulce ‘ativc destruc- tion, epithelium exfoliated. i Infrstoml Tmaors. IIyl‘ierplastic formations, both malignant and non-malignant. are very frequent in the intestinal tract. I'olypoid excrescences and vegetations are found of (,lifl'crent sizes and forms. They are cha‘acterized by their containing a great quantity of glandular structure in their make-up, and gene 'ally constitute non-malignant glandular hyperplasia. In the small intestine they are less frequent than in the large, especially in the rectum. (Table XII, Figure (5.) By continuous peristaltic movement of the intestine, they are usually stretched, or the pcdiclc, if it is thin, will stretch very much, and protrude sometimes into the anus. Cystoid enlargements are frequently found in the body of the tumor. Carcinoniata are the most frequent tumors in the "anal, and chiefly in the rectum, the iliac, splenic and hepatic flexurcs, the colon, and the coecum. Rectal carcinoma often extends into the adjacent tissues, either downward, into the anus, or into the higher portions of the bowels. They are very ‘are in the ileum and jejunum. In the duodenum adjacent to or at the orifice of the ductus choledochus they are more freqiu-nt. They appear either as soft fungoid tumors or papillary excrcscences of great extent. The intestinal wall usually suffers, even in the \arly stages of the lesion, extensive 'ancerous infiltration, whereby it becomes thick and dense. "dien the whole circumti-rcncc of the wall becomes thus aflccted, the intestine turns into a rigid tube. The rectum is often found in this condition; the colon not so often. When the neoplasmata have undergone ulceration, their borders are covered with vegetations, after the decay of which the ulcers present an altipea‘ancc not differing much from ordinary ulcers. Their edges and fundus may shrink by cicatrization, especially when the sloughing has involved the, whole circuniterencc. The. adeno-carcinoma is the most fre- quent and the most malignant, for it involves all the tissues of the bowels. I11 small tumors, the cxcrcscenccs still retain their tubular form, lined with cylindrical epithelium. But in further development they lose their original histological character. and form a solid mass of connective tissue. with only a thin epithelial covering. The colloid cancers are the next frequent malignant neoplasms, especially in the rectum. They form extensive vegetation upon its surface, with abundant cellular infiltration, into the intestinal walls. The least frequent is the schirrhus. Mclanosarcoma is only found in the rectum. \Vhen 'arcinomatous ulceration extends into the outer layer of the intestines, hylwrplastic inflam- mations are produced, causing adhesions (by formed vascular or non- 'ascular pseudo mcmb‘anes) of the intestines and the inner abdol'ninal \‘alls. These adhesions often dislocatc the intestines, and, not seldom, give rise. to invaginations, etc. (‘ancerous ulcers are, sometimes the *ause of perto'ation of the boWels, with fatal peritonitis. (dancers also produce metastases in the lymph glands, the peritoneum, and the liver. Sarcomatous tumors are very rare, but lipomata and fibroid neoplasms are frequent. They may originate in any of the intestinal tunics, and often close up the eavity of the bowels or produce invagination and displacement. CHI/[cal (iv/MUYU'H‘)‘ oft/11' [NEW/sins of Ho‘ [Most/ms, and Functional [)f.~'iI(/'/Ir(/o'cs [Ii l/wsz‘ I)/.scu.\'c.\'. As the several parts of the alimentary ‘anal have different functions, of course the functional derangement \vill (litter in 1ts several localities. The duodenum being chiefly an organ of digestion, derangement of its functions will imply. mainly. disturbanc ' of digestioii. Morbid liyperacmia is characterized by hypersccre- tion iof serum and mucus, which will, to a Very great extent, prevent the full action of the digestive liquid. Duodenal ‘atarrh is generally either associated with or consequent upon gastric hyper: :emia or iiitlannnatii'm. The symptoms of disturbance of both of these organs resembling each other so much will often obscure the differential diagnosis. In either there is vomiting. pain inlthe gastric region, and often fever. of course. if the pain be confined to the left side, the region of the duodenal flcxurc duodcnitls mav. with certain probabilitydie diagnosed. Ictcrus. even of a light degree, will still further confirm it: but still it must be considered that either temporaryor permanent dilatation ordisphicenient of the |
