Page:EB1911 - Volume 08.djvu/282

 The tubercles spread over the surface of the serous membrane, and if small and not very numerous may give rise in chronic cases to few symptoms; if larger, and especially when they involve and obstruct the lymph- and blood-vessels, ascites follows. It is hardly possible that tubercular invasion of the mesenteric glands can ever occur unaccompanied by peritoneal infection; but when the infection of the glands constitutes the most prominent sign, the term tabes mesenterica is sometimes employed. Here the glands, enlarged, form a doughy mass in the abdomen, leading to marked protrusion of the abdominal walls, with wasting elsewhere and diarrhoea.

The liver is seldom attacked by tubercle, unless in cases of general miliary tuberculosis. Now and then it contains large caseous tubercular masses in its substance.

An important fact with regard to the tubercular processes in the digestive organs lies in the ready response to treatment shown by many cases of peritoneal or mesenteric invasion, particularly in the young.

The later sequelae of syphilis display a predilection for the rectum and the liver, usually leading to the development of a stricture in the former, to a diffuse hepatitis or the formation of gummata in the second. In inherited syphilis the temporary teeth usually appear early, are discoloured and soon crumble away. The permanent teeth may be sound and healthy, but are often—especially the upper incisors—notched and stunted, when they are known as “Hutchinson’s teeth.” As the result both of syphilis and of tubercle, the tissues of the liver and bowel may present a peculiar alteration; they become amyloid, or lardaceous, a condition in which they appear “waxy,” are coloured dark mahogany brown with dilute iodine solutions, and show degenerative changes in the connective tissue.

The Bacillus typhosus discovered by Eberth is the causal agent of typhoid fever, and has its chief seat of activity in the small intestine, more especially in the lower half of the ileum. Attacking the lymphoid follicles in the mucous membrane, it causes first inflammatory enlargement, then necrosis and ulceration. The adjacent portions of the mucous membrane show acute catarrhal changes. Diarrhoea, of a special “pea-soup” type, may or may not be present; while haemorrhage from the bowel, if ulcers have formed, is common. As the ulcers frequently extend down to the peritoneal coat of the bowel, perforation of this membrane and extravasation into the peritoneal cavity is easily induced by irritants introduced into or elaborated in the bowel, acting physically or by the excitation of hyper-peristalsis.

True Asiatic cholera is due to the comma-bacillus or spirillum of cholera, which is found in the rice-water evacuations, in the contents of the intestine after death, and in the mucous membrane of the intestine just beneath the epithelium. It has not been found in the blood. It produces an intense irritation of the bowel, seldom of the stomach, without giving rise locally to any marked physical change; it causes violent diarrhoea and copious discharges of “rice-water” stools, consisting largely of serum swarming with the organism.

Dysentery gives rise to an inflammation of the large intestine and sometimes of the lower part of the ileum, resulting in extensive ulceration and accompanied by faecal discharges of mucus, muco-pus or blood. In some forms a protozoan, the Amoeba dysenteriae, is found in the stools—this is the amoebic dysentery; in other cases a bacillus, Bacillus dysenteriae, is found—the bacillary dysentery.

Acute parotitis, or mumps, is an infectious disease of the parotid glands, chiefly interesting because of the association between it and the testes in males, inflammation of these glands occasionally following or replacing the affection of the parotids. The causal agent is probably organismal, but has as yet escaped detection.

The relative frequency with which malignant growths occur in the different organs of the digestive system may be gathered from the tabular analysis, on p. 266, of 1768 cases recorded in the books of the Edinburgh Royal Infirmary as having been treated in the medical and surgical wards between the years 1892 and 1899 inclusive. Of these, 1263, or 71·44%, were males; 505, or 28·56%, females. (See Table I. p. 266.)

If the figures there given be classified upon broader lines, the results are as given in Table II. p. 266, and speak for themselves.

The digestive organs are peculiarly subject to malignant disease, a result of the incessant changes from passive to active conditions, and vice versa, called for by repeated introduction of food; while the comparative frequency with which different parts are attacked depends, in part, upon the degree of irritation or changes of function imposed upon them. Scirrhous, encephaloid and colloid forms of carcinoma occur. In the stomach and oesophagus the scirrhous form is most common, the soft encephaloid form coming next. The most common situation for cancerous growth in the stomach is the pyloric region. Walsh out of 1300 cases found 60·8% near the pylorus, 11·4% over the lesser curvature, and 4·7% more or less over the whole organ. The small intestine is rarely attacked by cancer; the large intestine frequently. The rectum, sigmoid flexure, caecum and colon are affected, and in this order, the cylindrical-celled form being the most common. Carcinoma of the peritoneum is generally colloid in character, and is often secondary to growths in other organs. Cancer of the liver follows cancer of the stomach and rectum in frequency of occurrence, and is relatively more common in females than males. Secondary invasion of the liver is a frequent sequel to gastric cancer. The pancreas occasionally is the seat of cancerous growth.

Sarcomata are not so often met with in the digestive organs. When present, they generally involve the peritoneum or the mesenteric glands. The liver is sometimes attacked, the stomach rarely.

Benign tumours are not of common occurrence in the digestive organs. Simple growths of the salivary glands, cysts of the pancreas and polypoid tumours of the rectum are the most frequent.

The intestinal canal is the habitat of the majority of animal parasites found in man. Frequently their presence leads to no morbid symptoms, local or general; nor are the symptoms, when they do arise, always characteristic of the presence of parasites alone. Discovery of their bodies, or of their eggs, in the stools is in most instances the only satisfactory proof of their presence. The parasites found in the bowel belong principally to two natural groups, Protozoa and Metazoa. The great class of the Protozoa furnish amoebae, members of Sporozoa and Infusoria. The amoebae are almost invariably found in the large intestine; one species, indeed, is termed Amoeba coli. The frequently observed relation between attacks of dysentery and the presence of amoebae in the stools has led to the proposition that an Amoeba dysenterica exists, causing the disease—a theory supported by the detection of amoebae in the contents of dysenteric abscesses of the liver. No symptoms of injury to health appear to accompany the presence of Sporozoa in the bowel, while the species of Infusoria found in it, the Cercomonas, and Trichomonas intestinalis, and the Balantidium coli, may or may not be guilty of prolonging conditions within the bowel as have previously set up diarrhoea.

The Metazoa supply examples of intestinal parasites from the classes Annuloida and Nematoidea. To the former class belong the various tapeworms found in the small intestine of man. They, like other intestinal parasites, are destitute of any power of active digestion, simply absorbing the nutritious proceeds of the digestive processes of their hosts. Nematode worms infest both the small and large intestine; Ascaris lumbricoides, the common round worm, and the male Oxyuris vermicularis are found in the small bowel, the adult female Oxyuris vermicularis and the Tricocephalus dispar in the large.

The eggs of the Trichina spiralis, when introduced with the food, develop in the bowel into larval forms which invade the tissues of the body, to find in the muscles congenial spots wherein to reach maturity. Similarly, the eggs of the Echinococcus are hatched in the bowel, and the embryos proceed to take up their abode in the tissues of the body, developing into cysts capable of growth into mature worms after their ingestion by dogs. 