STOMACH AND INTESTINE. 



415 



membrane swollen, soft and relaxed ; 

 a change which is generally due to the in- 

 terstitial effusion of a large quantity of bloody 

 serum. A similar fluid is also poured out into 

 the interior of the organ in variable quantity ; 

 and its effusion is generally attended with the 

 detachment of the sloughs previously caused 

 by the direct action of the poison. The ex- 

 sudation also often distends the submucous 

 areolar tissue, so as to separate the muscular 

 and mucous tunics from each other. Some- 

 times the former of these two tunics is only 

 rendered paler and more yielding than na- 

 tural. But in other cases, the whole parietes 

 of the organ ultimately become converted 

 into a rotten, In-own, or reddish mass, in 

 which scarcely any structure is distinguish- 

 able. 



The details of those changes by which 

 the moderately inflamed gastric membrane 

 returns to a healthier state, are equally va- 

 riable with the preceding. The separation of 

 one or more flat sloughs lays bare what may 

 be regarded as an ulcerated surface. The 

 establishment of suppuration on this surface 

 precedes the formation of the reparative tissue. 

 When fully developed the latter substance 

 exhibits the ordinary fibrous structure of ci- 

 catrix. And since the process of exsudation 

 previously extended to some little distance 

 from the ulcer, the margin of the cica- 

 trix blends gradually with the surrounding 

 healthy mucous membrane ; while its base 

 generally exhibits similar gradations of 

 structure with the subjacent tissues. The 

 subsequent contraction of the new tissue may 

 materially alter the shape of the organ, and 

 diminish its size. Indeed, where there has 

 been much loss of substance at one point, it 

 may even cause a more or less complete ob- 

 struction or occlusion of its cavity. 



In dysentery, although the morbid changes 

 appear to begin in the follicles, and often 

 predominate here, still the relation of these 

 structures to the process is far less intimate and 

 specific than in typhoid fever. The dysenteric 

 state may rather be regarded as an intense in- 

 flammation of the whole of the mucous mem- 

 brane; which engages these closed sacs with 

 a rapidity and severity that seem to be not 

 more than proportionate to their vascularity, 

 and to the facilities which, as it were, their 

 very construction offers to the exsudative 

 process.* 



The morbid appearances chiefly affect the 

 large intestine; and generally exhibit an in- 

 crease in severity from the coecum towards 

 the anus. In a subordinate degree, however, 

 they not unfrequently involve the adjoining 

 segment of the ileum. 



The process begins as an enlargement of 

 the solitary follicles of particular parts of the 

 bowel, which is quickly followed by appear- 

 ances of inflammation in the adjacent mucous 

 membrane. Red, swollen, and injected streaks 

 are seen occupying the most projecting parts 

 of some of the transverse folds of the bowel. 



* See p. 357. et scq. 



And on examining these streaks, we find that 

 the epithelium is here and there raised from 

 the subjacent tissues; either as a grayish flake, 

 or as a semi-transparent vesication enclosing 

 serum. Beneath this cell-growth is the raw and 

 denuded mucous membrane; which is softened, 

 reddened, and infiltrated (especially in its sub- 

 mucous areolar tissue) with a bloody serum, 

 that easily exsudes on making pressure. 

 The above change soon extends, from these 

 isolated streaks, to larger portions of the mu- 

 cous surface ; so as to involve, not only the 

 projecting folds of the bowel, but also their 

 intervening depressions. The detached epi- 

 thelium, which has a dirty gray colour, be- 

 comes mixed with the subjacent reddish 

 exsudation. The latter is generally thick and 

 glutinous : but is sometimes of a denser and 

 more croupy consistence ; which permits it to 

 be detached and expelled as a more or less 

 perfect cast of the inflamed segment of the 

 bowel. The mucous membrane itself acquires 

 a pale, or dirty-red, or even somewhat yellow- 

 ish, colour; as well as an increased thickness, 

 and a pulpy gelatinous consistence. The sub- 

 mucous areolar tissue beneath it also becomes 

 infiltrated with an exsudation that has the 

 characters of bloody serum ; its enlarged fol- 

 licles ulcerate or rupture ; and its interstices 

 are here and there raised by effusion into 

 protuberances, which give a mammillated 

 aspect to the free inner surface of the intes- 

 tine. In extreme cases, these projections 

 multiply, enlarge, become confluent, and thus 

 proportionally thicken the whole texture. 



These changes are usually accompanied by 

 a more or less considerable dilatation of the 

 intestine; the cavity of which contains, in 

 addition to a large quantity of gases, a mixture 

 of fteces, blood, epithelium, and lymph, in va- 

 riable proportions. 



An increase in the intensity of the above ap- 

 pearances rapidly converts the inflamed mem- 

 brane into a sloughy or mortified mass. Prior 

 to this event, it becomes dark red, brown, or 

 almost black, from congestion and extravasa- 

 tion of blood. Where less ecchymosis is ori- 

 ginally present, and the blood poured out 

 undergoes alterations after its effusion, it fre- 

 quently offers a dirty gray or almost greenish 

 colour. Subsequently to the separation or 

 dissolution of the sloughy membrane, the de- 

 nuded submucous tissue may be seen occupied 

 by black masses of altered and coagulated blood, 

 and by more or fewer of the vascular trunks 

 formerly distributed to the destroyed tissues. 

 And at this stage of the process, if not pre- 

 viously, the adjacent muscular and peritoneal 

 coats exhibit every evidence of their sharing 

 in the disease. The former becomes infiltrated 

 with blood, or serum, and of a dark, gray, or 

 ash-coloured hue. While the peritoneum 

 loses its smooth and shining appearance, ac- 

 quires a dirty reddish colour and an injected 

 state of its vessels, and often has its surface 

 visibly occupied by a more or less purulent 

 or sero-purulent exsudation. In extreme cases, 

 these changes bring about an adhesion of the 

 diseased bowel to neighbouring segments of 



