416 



STOMACH AND INTESTINE. 



the large or small intestine. The lymphatic 

 glands connected with the diseased intestine 

 are also altered; becoming swelled, injected, 

 and of a red or bluish-red colour. These al- 

 terations seem chiefly due to their irritation. 



The changes by which the diseased portions 

 of intestine are restored to a healthier state, 

 of course vary with the intensity of the pro- 

 cess, and with the extent to which it has pro- 

 ceeded. Thus, in slighter cases, the process 

 is ,one of mere resolution. While, after the 

 occurrence of sloughing and loss of sub- 

 stance, the reparative act is much more imper- 

 fect. It is effected by the development of 

 a cicatrix ; which is gradually formed in the 

 suppurating ulcer that is left by the detach- 

 ment of the gangrenous portion of mem- 

 brane. 



This cicatrix, though similar in structure to 

 that noticed in the typhoid process, is very 

 different both in its amount and arrangement. 

 Its smooth (and apparently serous) surface 

 often has to fill up the intervals of the irregular 

 islands or isthmuses of mucous membrane which 

 are left by the process of sloughing ; and hence 

 the latter are often seen as thick projecting 

 nodules, surrounded by a basis of new tissue. 

 The base of the cicatrix extends to a va- 

 riable depth in the subjacent coats of the 

 bowel ; and, in chronic cases, often forms a 

 thickened base, that sustains an ulcer of long 

 standing and variable size. Finally, the great 

 loss of surface which the cicatrix replaces, 

 concurs with the two preceding circumstances 

 to render its subsequent contraction of great 

 influence on the shape and diameter of the 

 bowel. Thus the ordinary situation of the 

 sloughs in milder cases on the projecting 

 folds of the mucous membrane seems at 

 least a partial explanation of the frequency 

 with which the contracted cicatrix takes the 

 form of a cord or fold, itself more or less trans- 

 verse to the axis of the tube, and hence very 

 liable to cause obstruction of the canal. 



Ulceration constitutes a frequent termina- 

 tion of the various inflammations of the alimen- 

 tary canal. In this tube, as in most other 

 parts of the body, it is associated with inflam- 

 mation, chiefly as a secondary result ; which 

 is conditionated, not so much by mere inten- 

 sity of the process, as by a certain slow and 

 chronic rate of its progress. Thus in many 

 of the abnormal conditions already alluded to, 

 the sloughing occasioned by rapid and violent 

 inflammation is often replaced by this inter- 

 stitial mode of destruction, during the subsi- 

 dence of the earlier and more acute sym- 

 ptoms. While, in milder and more chronic 

 cases, it occurs independently of the gan- 

 grenous process. How far it is due to the 

 vascular disturbance which inflammation pro- 

 duces ; or to the direct effects of the ex- 

 sudation ; or finally, to a mere increase of the 

 ordinary destructive absorption, or a decrease 

 of assimilation ; it would be irrelevant to 

 this sketch to inquire. 



The specific ulceration of typhoid fever has 

 already been mentioned, as well as the secon- 

 dary ulceration to which it often gives rise. 



The ulceration of tubercle and of cancer of 

 the canal will be hereafter alluded to ; as 

 being essentially due to the metamorphosis of 

 certain deposits in the tissues of the organ, 

 and to the reaction excited in the latter by 

 their presence. Hence we need here only 

 enumerate one or two of the remaining forms 

 of ulceration most frequently seen in the 

 stomach and intestines. 



It is but rarely that we find ulcerations of 

 the tube which can be attributed to mecha- 

 nical causes. 



In certain instances, however, the mere pres- 

 sure of a neighbouring tumour, or of some 

 diseased viscus, results in this process. But 

 in such cases, the access of ulceration is 

 usually preceded by the occurrence of exsu- 

 dation and adhesion, which limit the amount 

 of original substance it removes, and thus 

 to some extent obviate the danger of its per- 

 forating the walls of the tube. 



The impaction of solid masses in the canal 

 more frequently leads to such a result. In 

 rare instances, these masses find their way 

 into the canal from neighbouring organs ; as 

 is the case with gall-stones. In still rarer 

 cases, they seem to be formed solely by the 

 concretion of the liquid contents of the canal ; 

 resulting in intestinal calculi. In most 

 instances, however, they are due to the in- 

 troduction, from without, of various foreign 

 bodies ; such as cherry-stones, pins, needles, 

 or nails. In all cases, the ulceration depends, 

 not only on the size, but also on the shape 

 and surface, of the mechanical irritant. The 

 most familiar examples of such ulceration are 

 seen in the vermiform appendix : where it is 

 not uncommon to find perforation produced 

 by an impacted mass ; which, on examination, 

 proves to be some one of the small solids just 

 alluded to, encrusted with rough calcareous 

 matter, that has been derived from the con- 

 tents of the canal. 



Ulcer of the stomach.-~~In the stomach and 

 the first portion of the duodenum, the ulcera- 

 tive process is often present in a peculiar 

 form : namely, that which is usually called 

 the simple or perforating ulcer. Of these 

 two epithets, the first refers to the slight ap- 

 pearances of inflammation often present in the 

 neighbourhood of such ulcers ; the last, to 

 the frequency with which they extend to such 

 a depth, as to perforate all the coats of the 

 organ. 



The size of these ulcers varies from that 

 of a fourpenny piece, to that of a crown 

 piece, or even larger. Their shape is usually 

 circular; sometimes elliptical: occasionally, 

 however, more irregular. In some instances, 

 this irregularity of outline is due to the fusion 

 of two or more neighbouring ulcers into one, 

 by an extension of their adjacent margins. 

 But in a majority of cases, only single ulcers 

 are present. 



The ulcer is generally situated, either in the 

 neighbourhood of the pylorus, or near the 

 lesser curvature of the organ : more rarely in 

 front than behind ; and least frequently of all, 

 in the cardiac sac. 



