STOMACH AND INTESTINE. 



413 



tents may be seen exchanged for a dark soft- 

 ened granular mass. Precisely similar changes 

 are often seen in the matrix of the tubes and 

 of the villi ; in which latter situation they are 

 generally accompanied by a loss of the in- 

 vesting epithelium. 



The closed follicles of the alimentary canal 

 are the seat of various changes : some of 

 which are obviously connected with an in- 

 flammatory state; while others probably have 

 an equally definite, though less direct, relation 

 to it. 



An unusual number of these follicles seems 

 to be one of their most frequent abnormal 

 conditions. In such cases we may often find 

 them strewn thickly through the submucous 

 areolar tissue of the stomach, the small in- 

 testine, the large intestine, or even the entire 

 alimentary canal. 



But not only may it be doubted whether 

 this increase in their number is due to an in- 

 flammatory process, but even whether it is a 

 real occurrence. For in many instances there 

 can be little question, that these follicles are 

 not so much really multiplied in number, as re- 

 vealed in increased numbers by their universal 

 and extreme distention. 



We have seen* that their apparent number 

 varies greatly in different individuals ; that, in 

 children, they are generally ver}' numerous and 

 distinct ; and that even that healthy afHux of 

 blood,which obtains during the act of digestion, 

 renders them unusually prominent and visible. 



Hence it is to the presence or absence of 

 other circumstances indicative of disease, that 

 we must look for evidence as to the really 

 morbid character of an increase in the num- 

 ber or size of these follicles. Wherever we 

 find these alterations associated with a gene- 

 ral dyscrasia, or with marks of congestion, hse- 

 raorrhage, or inflammation in the surrounding 

 tissues, or with a change in the character of 

 the contents of the follicle itself, there we are 

 entitled to regard them as indicative of a 

 morbid process. And conversely, where none 

 of these appearances are present, we must be 

 content to suspend our judgment on this 

 point. 



In typhoid fever, these follicles become 

 the seat of a definite morbid process ; which 

 not only constitutes a specific element of the 

 disease, but furnishes the pathognomonic lesion, 

 which seems to dictate many of the de- 

 tails that distinguish the typhoid from the 

 other varieties of fever. 



The typhoid process in the intestine is 

 almost limited to these follicles, of which it 

 engages both the agminate and solitary va- 

 rieties. Amongst the agminate follicles, those 

 are most affected which lie nearest to the ilio- 

 ccecal valve. The same rule applies to the 

 solitary follicles, both in the small and the 

 large intestine. In the latter segment of the 

 canal, the change rarely extends beyond the 

 follicles of the crecum and ascending colon. 



The process appears to commence by a stage 

 of congestion or hyperaemia. This is at first 



* See p. 360. 



general, and engages the whole mucous mem- 

 brane of the lower part of the ileum. It sub- 

 sequently increases in intensity, and at the 

 same time becomes limited to the neighbour- 

 hood of the affected follicles ; so that these 

 are surrounded with minute rings of injected 

 vessels, which are visible from the mucous sur- 

 face, or can be seen gleaming through the 

 transparent peritoneum as dark vascular points 

 or streaks. The microscope traces this conges- 

 tion into the small vessels (and especially the 

 veins) which intervene between the several 

 follicles. 



The latter phase of congestion marks the 

 access of the next stage : which corresponds 

 to the exsudation and deposit of a new sub- 

 stance within the follicles, and (to a lesser 

 extent) in the submucous tissue of their im- 

 mediate neighbourhood. The infiltration dis- 

 tends the several follicles with a mass, which 

 gives them a grayish, grayish red, or bluish- 

 red colour ; and a more or less firm or pulpy 

 consistence. They thus acquire a thickness 

 (1 2 lines) that raises them considerably 

 higher than the adjacent surface, and causes 

 them to stretch the mucous membrane above. 

 Below, they rest on the muscular tunic. Of 

 course the shape, extent, and situation of the 

 follicles thus brought into view, is that of the 

 original structures. Thus, in the case of the 

 agminate follicles, we see an oval or elliptical 

 patch that runs lengthwise along the free 

 margin of the bowel. While in the solitary 

 follicles, we find small round granules, of 

 about the size of a millet seed, or a very small 

 pea, irregularly scattered over the intestine. 



The mass itself exhibits under the mi- 

 croscope, the ordinary constituents of the 

 normal pulp of the follicle : mingled, however, 

 with a variable quantity of blood ; and with, 

 an amorphous granular substance in larger 

 quantity, and of a browner hue, than natural. 



The softening and breaking up of this pulpy 

 mass constitutes the next stage of the change. 

 In general, it occurs simultaneously over the 

 whole of the agminate follicle : and thus de- 

 taches from the subjacent muscular tunic, not 

 only the new deposit, but the follicles them- 

 selves; together with the areolar tissue by 

 which they are connected to each other, and 

 the tubes and villi of the mucous membrane by 

 which they are covered. In other instances, 

 the several follicles are softened and detached 

 separately, or in clusters of two or three only; 

 so as to leave some of the tubes and villi 

 which normally occupy their intervals. In 

 some cases, a portion of the patch undergoes a 

 modified process ; in which the contents of the 

 follicle seem to make their exit through small 

 openings at their projecting summit, with 

 little or no disturbance of the adjacent tissues. 

 Finally, in certain instances, more or fewer 

 of the follicles are said to undergo a retro- 

 grade change, in which their contents undergo 

 absorption, without either sloughing or de- 

 hiscence. 



The removal of the new deposit leaves the 

 characteristic typhoid ulcer ; the shape, size, 

 and situation of which are therefore precisely 



