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Show DISEASES OF THE ORGANS OF DIGESTION. [SECTION VI. TABLE XVI. TL‘BI-ZRCI'LAR I'Lcmxrtox or Tin-1 Ixriasrtxics-'l‘vriii.tTIs iixn l'ERI'I‘YI'IIIJTIS-L\'MPIIADENITIS. FIG. 1.-Tubercular ulceration of the intestine of a man thirty~ five years of age, who died of pulmonary tuberculosis. Neal-Iv every viscus of the. body was involved. The intestinal follicles were enormously impregnated with caseous tucerclcs, many of which were ulce 'atcd. The ileo-coe ~al region was the most altered. All of_ the tissues, except the peritoneum. which was but sightlv aflectcd, \vere iii a complete state of mortification. The ileo-coccal valve (V I C) and its adjoining portion of the ileum were sphacelus and involved the whole periphery of the intestine. The ragged portions were detached and hanging in shreds and patches upon The intestinal surface. They Were in a state oftotal decomposition, and very fictid. The muscular coat was bare. The cavitv of the The. mucous tissue was largely exfoliated, the sub-mucous altered verniitiirm appendix (A (5 (J), the colon, and the coccum were spread and thickened and to an enormous extent ulcerated; the coccal folds were enlarged, and the appendix adherent to the intestine. But little traee was left of the internal structure of the intestine. (A A), tiibercnlar ulcers. (B), partly destroyed mucous membrane. (C), ilco-eoe -al fold. Fin. 3.-- Case of a young man of twenty-five years, who was suddenly seized with fainting, shortly after eating. Ile. be *amc speedily delirious, in which condition he remained until death, which took place the next day. Shortly before death he passed blood,black stools, and highly-charged urine. I'ost mortem: The lower portion of the small intestine sunk deep in the pelvis, of a deep red throughout. l'eritoneum very 'ascular. \Vithin the smaller eiiteric cavity some bloody mucus; in the larger, normal contents. The morbid changes confined to the ileo-eoe ‘11] region. The mucous membrane was raised, swollen in large patches.and in many parts perforated. The plaques were the most affected portion in the ileo-coecal region. The. folds (V I (7) were largely involved. Between the raised patches the solitary glands were raised in the form of pustules (l) 1') and fine granulations (F F). The mesenteric glands were enormously infilt 'atcd. Fin. 2.-Gmigrcnous Ulcer/(tin); cf the Follr'clcs. A young man of twenty-four y 'ars, who died after a very short illness, and exhibited well-marked symptoms of highly-acute enteritis. l'ost mortem: There was found follicular ulce'ation, confined to the ileo-coecal region. There were very many follicles in a gangrenous typical course, only they are often overlooked from the very fact of the symptoms not being very prominent, and sometimes mislead the patient and the medical attendant to the great detriment of the former, whose life is thus put in jeopardy. Griesinger was the first to call attention to the lighter forms of the disease. He pointed out that "the short duration qt" the sir/mess, marl not the moderate character of the snuzptmns- of n protrrurtrrl attack of ty/ihm'r/ fcrrr, Ola/ht to be the standard by which to gauge the grat‘ttg/ of the tl/stnst'." The most prominent symptom of enteric typhoid is the presence of fever. From the time of its commencement dates the course of the disease. Eithe ' a shaking chill or a rigor marks its begin- ning. This important symptom is often overlooked in the graver and very g ‘ave forms of the disease. In the lighter forms .l/o'gensrn, found in eighty-seven cases one-half the number to have begun with distinctly marked chills, or often repeated sensations of chilli‘ ness. Seventy-four of the eighty-seven persons affected could distinctly designate the time of its beginning. "A Stit/I/t'tt attire/c characterizes the lz'Ir/hterform qfcntrrtc typhoid." (.Iiii‘geiiseii.) IVMN» dcrltch has recognized three distinct stages of bodily teinpe ‘ature, which he designated as the initial period or first stage, the height, and the deseending or reconvalesceiit stage. The initial stage of well-developed typhoid is marked by a gradual increase of the bodily temperature during the first three or four days. From the morning to the next evening an increase of about one degree centigrade. From the evening to the next morning a decrease of a half degree cent.; in the lighter forms no such oscillation exists. The rise of tempe'aturc is here sudden, and usually alr-ady on the second day. In the second stage the tcinpc'ature iii the lighter forms varies exceedingly. In the greatest number of these cases the typical oscillation of the graver forms are observed, viz: A rise of one to one and a half degree cent. from the morning to the evening, the highest temperature in the evening. the lowest in the later morning hours. The long intervals of remission contrasts in the lighter against the severe shorter periods of remission. Antithermic remedies prolong the cooling periods and often cause irregularities in the typical rise and fall of temperature. A singular deviation from the normal is often met in a sudden rise and continuation of nearly the same height of temperature in the shape state; the follicles Were almost completely destroved (E E). over with irregiilar-shaped ulcers. Fin. 4.-I't'i'f/g/ph/[Hs L'lceration of the mucous and sub-mucous structures of the coecal folds, and a large portion destroved bv nioi‘tification. Quit‘ a quantity of ciratrized tissue in a state of contraction, giving the surface a very uneven :mpea‘z‘incc. The borders of the ulcers ve ' irregular and raised above the denuded muscular coat, which is covered with a very fine film of connective tissue. The whole surface was perfectly unfit for anv function. from the total absence offunetional structures. (A C), vermiform appendix. (VI (7), ileo-coecal fold. (C), coccum. FM. :3. Ertrnsfrr Infiltration into the allrsrntrrtc Glam/s, Follow/[or Flewrutton. Case-R. A., a man of thirty years, was sick three weeks with most pronounced typhoid symptoms; toward the latter part of the disease well-marked enterie symptoms. I'ost mortem: Brain and membranes but very little affected. Thoracic visee'a but slightly altered. In the abdomen a great number of eiiormously-enlarged mesentcric glands, situated in the ileo-coe at] angle. The sub-peri- tonial vessels are exceedingly dilated. The glands are some white, some reddish and injected internally, some form peckets filled with thick pus (G I. O). The coccum (C) and the end ofthc colon present upon their inner surface ulcerated follicles. The ileo-coecal valve (V I C) and adjacent tissue are covered with very thick irregular folds, and show advanced conditions of cicatrization (l' (‘) where the surface has assumed a ruffled appearance (1' 1)). (I Gr), small intestines. (A C), appendix. even in the lighter forms of this fever, but its appearance and continuance depend on the gravity of the dis use. In forty-six per cent. the exantlicina appeared on the tenth day of the sickness. In seventy-five per cent. from the eleventh to the seventeenth (lay. The intensity of the eruption goes hand in hand with the intensity of the disease. In light cases it appears on the second, fourth, or fifth day. As many patients pcrspire very much (in the lighter forms) there is often found miliaria alba; erythcmatous spots are. also some.times observable, which very soon disappear. Bronchial ‘atarrh is, with few exceptions, not very severe. The greater or lesser development of the bronchial catarrh does not seem to depend very much on the intensity of the typhoid process. In light cases there are few symptoms of pulinoiiic de‘angeinents. although very grave lesions often exist in the severe forms, which, however, are plainly manifested in the latter stages of the disease. The eiiterie symptoms greatly differ in different epidemics: in those of 1865 and 1868 only twentyione percent. offered wellsniarked enterie disturbances of any gravity. Only sixteen per cent. of diarrhea. In lighter 'ases, lasting about ten (lays, only twenty-one per cent.. in more severe ones about twelve per cent. only suffered from severe eiitcric trouble. This shows that intensity of the discase is not in exact ratio to the enteric phenomena. Pain in the coecal region is clung/s produced by pressure. Abdominal pains (colics) are very frequent. Lack of symptoms of intestinal trouble must, under no circumstances, he considered as absence of trouble of the intestines. In fact, next to the bodily tenipe 'ature, the intes- tinal lesion requires the utmost attention of the physician in all cases. Il‘ypho-enteric diarrln *a presents a mixed character. The stools, after staying a short time in a vessel, separate into two parts, one containing soluble saline substances (chiefly chlorides. having much affinity with cholera stools and likely of the same derivation) and soluble albumcnates, as in dysentery. The sediment, usually mixed with biliary matter, contains mucous and a great quantity of aninionic-phosphatc of magnesia; the latter not peculiar to typhoid stools alone. \Vitliin the debris of the tissue elements. voided by the intestine, great quantities of typhoid bacilli ii all stages of development are found. (Loser/ch.) Albumen is always present in the urine; in severe cases of the disease large quantities are found. of a continuous fever for about a week or so, with a gradual decline. In such cases swelling of the spleen, roseolar eruption. diarrln ta, slight bronchial catarrli facilitate the diagnosis of the disease very much. In rare cases the mitigated form is marked by relatively low temperature; from the second to the eighth day only twice forty degrees cent., ordinarily thirty-eight degrees cent, or some fraction of a degree, higher. The third stage is characterized by sudden fluctuations of heat. Morning sub-normal. or even normal, in the evening forty degrees cent. in the higher grades of typhoid; in lighter forms a. barely perceptible rise and fall. with gradual return to the normal. The significance of the sudden rise and fall in the last stages of the graver forms is the great anatomical lesions which require time to be repaired by reactive processes of the bodv. In the mitigated forms the slight anatomical alterations require no such reactive measures and no sudden increase of temperr atures. That lighter forms may become, by imprndeiice. faulty (lict. irrational treatment, improper hygienic measures. exceedingly serious and often fatal ~ases, JtI/y/cnsrn, Z/cnistn,and [llt‘iltt'i'tttttltll have positively provcn. The spleen is found to be swollen and enlarged. Even in the lightest cases in about ninety-two per cent. 'mth iii the severest and in the lightest this .s/ttrntt/s may not be diagnosed. but cannot be necessarily considered as not existing. The distention of the jEttulugy of the Intestinal Diseases. The highly alterablc nature of the contents of the intestinal "anal. both its secretions and the substances purposely or accidentallv introduced into it. while it is eminently fit for carrying on the normal functions of digestion-that is. the proper change of all classes of food and secretions into absorbable cliyle-bccomes under untavorable circumstances a source of diseases of those organs and of danger to life. Normally the innumerable fcrments. both cor- puscular aiid chemical, ever present in the bowels, only favor physiological function by creating solvents,by assisting deconipoSition. and bringing forth new aflinities in the substances undergoing digestion. As long as the integrity of the mucous membrane. is maintained, as long as no adventitious agencies injuriously modify its nutrition, that long do these active agencies of decomposition and alteration not affect the organs. But when these. tissues become affected bv inflammatorv, mechanical. or toxic iIIJIII'lOS, either directlv or through the blood or nerve influence. then do these so usefiil forces become most detrimental and dangerous to the existence of the affected person. They become morliitie agencies. having a short activitv in acute diseases. and protracted action in the chronic. There is 2i class of exceedingly minute organisms, --althoiigli cognate with the harmless ones constantly present in intestines, and often of the abdomen, may sometimes displace the the intestine-iwhich. when introduced into the body, become a whole or a portion of the spleeii.and. of course. no splenic sound source of special morbid processes, with typical manilcstations all will be elicitcd by percussion. lioscolar eruptions usually exist I their own. and which make their appearance in epidemics hi) on |