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 scattered on tongue and cheeks. Epidemics have occurred in hospitals and orphanages. Mouth breathing is the cause of many ills. As a result of this, the mucous membrane of the tongue, &c., becomes dry, micro-organisms multiply and the mouth becomes foul. Also from disease of the nose, the upper jaw, palate and teeth do not make proper progress in development. There is overgrowth of tonsils, and adenoids, with resulting deafness, and the child’s mental development suffers. An ordinary “sore throat” usually signifies acute catarrh of the fauces, and is of purely organismal origin, “catching cold” being only a secondary and minor cause. In “relaxed throats” there is a chronic catarrhal state of the lining membrane, with some passive congestion. The tonsils are peculiarly liable to catarrhal attacks, as might a priori be expected by reason of their Cerberus-like function with regard to bacterial intruders. Still, acute attacks of tonsillitis appear on good evidence to be more common among individuals predisposed constitutionally to rheumatic manifestations. Cases of acute tonsillitis may or may not go on to suppuration or quinsy; in all there is great congestion of the glands, increased mucus secretion, and often secondary involvement of the lymphatic glands of the neck. Repeated acute attacks often lead to chronic inflammation, in which the glands are enlarged, and often hypertrophied in the true sense of the term. The oesophagus is the seat of inflammation but seldom. In infants and young children thrush due to Oidium albicans may spread from the mouth, and also a diphtheritic inflammation spreads from the fauces into the oesophagus. A catarrhal oesophagitis is rarely seen, but the commonest form is traumatic, due to the swallowing of boiling water, corrosive or irritant substances, &c. A non-malignant ulceration may result which later leads on to an oesophageal stricture. The physical changes presented by the coats of the stomach and the intestine, the subjects of catarrhal attacks, closely resemble one another, but differ symptomatically. Acute catarrh of the stomach is associated with intense hyperaemia of its lining coats, with visible engorgement and swelling of the mucous membrane, and an excessive secretion of mucus. The formation of active gastric juice is arrested, digestion ceases, peristaltic movements are sluggish or absent, unless so over-stimulated that they act in a direction the reverse of the normal, and induce expulsion of the gastric contents by vomiting. The gastric contents, in whatever degree of dilution or concentration they may have been ingested, when ejected are of porridge-thick consistency, and often but slightly digested. Such conditions may succeed a severe alcoholic bout, be caused by irritant substances taken in by the mouth or arise from fermentative processes in the stomach contents themselves. Should the irritating material succeed in passing from the stomach into the bowel, similar physical signs are present; but as the quickest path offered for the expulsion of the offending substances from the body is downwards, peristalsis is increased, the flow of fluid from the intestinal glands is larger in bulk, though of less potency as regards its normal actions, than in health, and diarrhoea, with removal of the irritant, follows. As a general rule, the more marked the involvement of the large bowel, the severer and more fluid is the resultant diarrhoea. Inflammation of the stomach may be due to mechanical injury, thermal or chemical irritants or invasion by micro-organisms. Also all the symptoms of gastric catarrh may be brought on by any acute emotion. The commonest mechanical injury is that due to an excess of food, especially when following on a fast; poisons act as irritants, and also the weevils of cheese and the larvae of insects.

Inflammatory affections of the caecum and its attached appendix vermiformis are very common, and give rise to several special symptoms and signs. Acute inflammatory appendicitis appears to be increasing in frequency, and is associated by many with the modern deterioration in the teeth. Constipation certainly predisposes to it, and it appears to be more prevalent among medical men, commercial travellers, or any engaged in arduous callings, subjected to irregular meals, fatigue and exposure. A foreign body is the exciting cause in many cases, though less commonly so than was formerly imagined. The inflammation in the appendix varies in intensity from a very slight catarrhal or simple form to an ulcerative variety, and much more rarely to the acute fulminating appendicitis in which necrosis of the appendix with abscess formation occurs. It is always accompanied by more or less peritonitis, which is protective in nature, shutting in the inflammatory process. Very similar symptomatically is the condition termed perityphlitis, doubtless in former days frequently due to the appendix, an acute or chronic inflammation of the walls of the caecum often leading to abscess formation outside the gut, with or without direct communication with the canal. The colon is subject to three main forms of inflammation. In simple colitis the mucous membrane of the colon is intensely injected, bright red in colour, and secreting a thick mucus, but there is no accompanying ulceration. It is often found in association with some constitutional disease, as Bright’s disease, and also with cancer of the bowel. But when it has no association with other trouble it is probably bacterial in origin, the Bacillus enteritidis spirogenes having been isolated in many cases. The motions always contain large quantities of mucus and more or less blood. A second very severe form of inflammation of the colon is known as “membranous colitis,” and this may be either dyspeptic, or secondary to other diseases. In this trouble membranes are passed per anum, accompanied by a pain so intense as often to cause fainting. In severe cases complete tubular casts of the intestine have been found. Often the motions contain very little faecal matter, but consist only of membranes, mucus and a little blood. A third form is that known as “ulcerative colitis.” Any part of the large intestine may be affected, and the ulceration shows no special distribution. In severe cases the muscular coat is exposed, and perforation may ensue. The number of ulcers varies from a few to many dozen, and in size from a pea to a five-shilling piece. Like all chronic intestinal ulcers they show a tendency to become transverse.

Chronic catarrhal affections of the stomach are very common, and often follow upon repeated acute attacks. In them the connective tissue increases at the expense of the glandular elements; the mucous membrane becomes thickened and less active in function. Should the muscular coat be involved, the elasticity and contractility of the organ suffer; peristaltic movement is weakened; expulsion of the contents through the pylorus hindered; and, aggravated by these effects, the condition becomes worse, atonic dyspepsia in its most pronounced form results, with or without dilatation. Chronic vascular congestion may occasion in process of time similar signs and symptoms.

Duodenal catarrh is constantly associated with jaundice, indeed is most probably the commonest cause of catarrhal jaundice; often it is accompanied by catarrh of the common bile-duct. Chronic inflammation of the small intestine gives rise to less prominent symptoms than in the stomach. It generally arises from more than one cause; or rather secondary causes rapidly become as important as the primary in its incidence. Chronic congestion and prolonged irritation lead to deficient secretion and sluggish peristalsis; these effects encourage intestinal putrefaction and auto-intoxication; and these latter, in turn, increase the local unrest.

The intestinal mucous membrane, the peritoneum and the mesenteric glands are the chief sites of tubercular infection in the digestive organs. Rarely met with in the gullet and stomach, and comparatively seldom in the mouth and lips, tubercular inflammation of the small intestine and peritoneum is common. Tubercular enteritis is a frequent accompaniment of phthisis, but may occur apart from tubercle of other organs. Children are especially subject to the primary form. Tubercular peritonitis often is present also. The inflammatory process readily tends towards ulcer formation, with haemorrhage and sometimes perforation. If in the large bowel, the symptoms are usually less acute than those characterizing tubercular inflammation of the small intestine. The appendix has been found to be the seat of tubercular processes; in the rectum they form the general cause of the fistulae and abscesses so commonly met with here. Tubercular peritonitis may be primary or secondary, acute or chronic; occasionally very acute cases are seen running a rapid course; the majority are chronic in type.