Digestive Organs

Digestive Organs (Pathology). Several facts of importance have to be borne in mind for a proper appreciation of the pathology of the organs concerned in digestive processes (for the anatomy see Alimentary Canal and allied articles). In the first place, more than all other systems, the digestive comprises greater range of structure and exhibits wider diversity of function within its domain. Each separate structure and each different function presents special pathological signs and symptoms. Again, the duties imposed upon the system have to be performed notwithstanding constant variations in the work set them. The crude articles of diet offered them vary immensely in nature, bulk and utility, from which they must elaborate simple food-elements for absorption, incorporate them after absorption into complex organic substances properly designed to supply the constant needs of cellular activity, of growth and repair, and fitly harmonized to fulfil the many requirements of very divergent processes and functions. Any form of unphysiological diet, each failure to cater for the wants of any special tissue engaged in, or of any processes of, metabolism, carry with them pathological signs. Perhaps in greater degree than elsewhere are the individual sections of the digestive system dependent upon, and closely correlated with, one another. The lungs can only yield oxygen to the blood when the oxygen is uncombined; no compounds are of use. The digestive organs have to deal with an enormous variety of compound bodies, from which to obtain the elements necessary for protoplasmic upkeep and activity. Morbid lesions of the respiratory and circulatory systems are frequently capable of compensation through increased activity elsewhere, and the symptoms they give rise to follow chiefly along one line; diseases of the digestive organs are more liable to occasion disorders elsewhere than to excite compensatory actions. The digestive system includes every organ, function and process concerned with the utilization of food-stuffs, from the moment of their entrance into the mouth, their preparation in the canal, assimilation with the tissues, their employment therein, up to their excretion or expulsion in the form of waste. Each portion resembles a link of a continuous chain; each link depends upon the integrity of the others, the weakening or breaking of one straining or making impotent the chain as a whole.

The mucous membrane lining the alimentary tract is the part most subject to pathological alterations, and in this connexion it should be remembered that this membrane differs both in structure and functions throughout the tract. Chiefly protective from the mouth to the cardia, it is secretory and absorbent in the stomach and bowel; while the glandular cells forming part of it secrete both acid and alkaline fluids, several ferments or mucus. Over the dorsum of the tongue its modified cells subserve the sense of taste. Without, connected with it by the submucous connective tissue, is placed the muscular coat, and externally over the greater portion of its length the peritoneal serous membrane. All parts are supplied with blood-vessels, lymph-ducts and nerves, the last belonging either to local or to central circuits. Associated with the tract are the salivary glands, the liver and the pancreas; while, in addition, lymphoid tissue is met with diffusely scattered throughout the lining membranes in the tonsils, appendix, solitary glands and Peyer’s patches, and the mesenteric glands. The functions of the various parts of the system in whose lesions we are here interested are many in number, and can only be summarized here. (For the physiology of digestion see Nutrition.) Broadly, they maybe given as: (1) Ingestion and swallowing of food, transmission of it through the tract, and expulsion of the waste material; (2) secretion of acids and alkalis for the performance of digestive processes, aided by (3) elaboration and addition of complex bodies, termed enzymes or ferments; (4) secretion of mucus; (5) protection of the body against organismal infection, and against toxic products; (6) absorption of food elements and reconstitution of them into complex substances fitted for metabolic application; and (7) excretion of the waste products of protoplasmic action. These functions may be altered by disease, singly or in conjunction; it is rare, however, to find but one affected, while an apparently identical disturbance of function may often arise from totally different organic lesions. Another point of importance is seen in the close interdependence which exists between the secretions of acid and those of alkaline reaction. The difference in reaction seems to act mutatis mutandis as a stimulant in each instance.

General Diseases.

In all sections of the alimentary canal actively engaged in the digestion of food, a well-marked local engorgement of the blood-vessels supplying the walls occurs. The hyperaemia abates soon after completion of the special duties of the individual sections. Vascular lesions. This normal condition may be abnormally exaggerated by overstimulation from irritant poisons introduced into the canal; from too rich, too copious or indigestible articles of diet; or from too prolonged an experience of some unvaried kind of food-stuff, especially if large quantities of it are necessary for metabolic needs; entering into the first stage of inflammation, acute hyperaemia. More important, because productive of less tractable lesions, is passive congestion of the digestive organs. Whenever the flow of blood into the right side of the heart is hindered, whether it arise from disease of the heart itself, or of the lungs, or proceed from obstruction in some part of the portal system, the damming-back of the venous circulation speedily produces a more or less pronounced stasis of the blood in the walls of the alimentary canal and in the associated abdominal glands. The lack of a sufficiently vigorous flow of blood is followed by deficient secretion of digestive agents from the glandular elements involved, by decreased motility of the muscular coats of the stomach and bowel, and lessened adaptability throughout for dealing with even slight irregular demands on their powers. The mucous membrane of the stomach and bowel, less able to withstand the effects of irritation, even of a minor character, readily passes into a condition of chronic catarrh, while it frequently is the seat of small abrasions, haemorrhagic erosions, which may cause vomiting of blood and the appearance of blood in the stools. Obstruction to the flow of blood from the liver leads to dilatation of its blood-vessels, consequent pressure upon the hepatic cells adjoining them, and their gradual loss of function, or even atrophy and degeneration. In addition to the results of such passive congestion exhibited by the stomach and bowel as noted above, passive congestion of the liver is often accompanied by varicose enlargement of the abdominal veins, in particular of those which surround the lower end of the oesophagus, the lowest part of the rectum and anus. In the latter position these dilated veins constitute what are known as haemorrhoids or piles, internal or external as their site lies within or outside the anal aperture.

The mucous and serous membranes of the canal and the glandular elements of the associated organs are the parts most subject to inflammatory affections. Among the several sections of the digestive tract itself, the oesophagus and jejunum are singularly exempt from inflammatory processes; the fauces, stomach, caecum and appendix, ileum, mouth and duodenum (including the opening of the common bile-duct), are more commonly involved. Stomatitis, or inflammation of the mouth, Inflammatory lesions. has many predisposing factors, but it has now been definitely determined that its exciting cause is always some form of micro-organism. Any condition favouring oral sepsis, as carious teeth, pyorrhoea alveolaris (a discharge of pus due to inflamed granulations round carious teeth), granulations beneath thick crusts of tartar, or an irritating tooth plate, favours the growth of pyogenic organisms and hence of stomatitis. Many varieties of this disease have been described, but all are forms of “pyogenic” or “septic stomatitis.” This in its mildest form is catarrhal or erythematous, and is attended only by slight swelling tenderness and salivation. In its next stage of acuteness it is known as “membranous,” as a false membrane is produced somewhat resembling that due to diphtheria, though caused by a staphylococcus only. A still more acute form is “ulcerative,” which may go on to the formation of an abscess beneath the tongue. Scarlet fever usually gives rise to a slight inflammation of the mouth followed by desquamation, but more rarely it is accompanied by a most severe oedematous stomatitis with glossitis and tonsillitis. Erysipelas on the face may infect the mouth, and an acute stomatitis due to the diphtheria bacillus, Klebs-Loeffler bacillus, has been described. A distinct and very dangerous form of stomatitis in infants and young children is known as “aphthous stomatitis” or “thrush.” This is caused by the growth of Oidium albicans. It is always preceded by a gastro-enteritis and dry mouth, and if this is not attended to, soon attracts attention by the little white raised patches surrounded by a dusky red zone 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 Infective lesions. 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. 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 New growths. 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 Animal parasites. 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.

Numbers of bacterial forms habitually infest the alimentary canal. Many of them are non-pathogenic; some develop pathogenic characters only under provocation or when a suitable environment induces them to act in such a Vegetable parasites. manner; others may form the materies morbi of special lesions, or be casual visitors capable of originating disease if opportunity occurs. Apart from those organisms associated with acute infective diseases, disturbances of function and physical lesions may be the result of abnormal bacterial activity in the canal; and these disturbances may be both local and general. Many of the bacteria commonly present produce putrefactive changes in the contents of the tract by their metabolic processes. They render the medium they grow in alkaline, produce different gases and elaborate more or less virulent toxins. Other species set up an acid fermentation, seldom accompanied by gas or toxin formation. The products of either class are inimical to the free growth of members of the other. The species which produce acids are more resistant to the action of acids. Thus, when the contents of the stomach possess a normal or excessive proportion of free hydrochloric acid, a much larger number of putrefactive and pathogenic organisms in the food are destroyed or inhibited than of the bacteria of acid fermentation. Diminished gastric acidity allows of the entry of a greater number of putrefactive (and pathogenic) types, with, as a consequence, increased facilities for their growth and activity, and the appearance of intestinal derangements.

Table I.

Males.		Females.		Both Sexes.
Organ or Tissue in Order of Frequency.	Per- centage	Organ or Tissue in Order of Frequency.	Per- centage	Organ or Tissue in Order of Frequency.	Per- centage
1 Stomach	22.56	1 Stomach	22.37	1 Stomach	22.49
2 Lip	12.94	2 Rectum	17.24	2 Rectum	13.12
3 Rectum	11.57	3 Liver	15.50	3 Liver	10.02
4 Tongue	11.36	4 Peritoneum	7.86	4 Lip	9.89
5 Oesophagus	10.90	5 Oesophagus	5.33	5 Oesophagus	9.29
6 Liver	7.80	6 Sigmoid	4.53	6 Tongue	8.96
7 Jaw	6.38	7 Pancreas	3.52	7 Jaw	5.65
8 Mouth	2.88	8 Tongue	3.12	8 Peritoneum	2.94
9 Tonsils	2.09	9 Omentum	2.98	9 Sigmoid	2.56
10 Sigmoid flexure	1.77	10 Lip	2.57	10 Mouth	2.40
11 Parotid	1.10	11 Jaw	1.97	11 Pancreas	1.80
12 Pancreas	”	12 Colon	1.84	12 Tonsils	1.35
13 Caecum	0.94	13 Abdomen	”	13 Omentum	1.25
14 Peritoneum	”	14 Intestine	1.56	14 Parotid	1.12
15 Colon	0.89	15 Caecum	1.37	15 Colon	”
16 Pharynx	0.79	16 Mouth	1.18	16 Caecum	1.08
17 Intestine (site unknown)	”	17 Parotid	”	17 Intestine	1.00
18 Abdomen	0.71	18 Splenic flexure	0.98	18 Abdomen	”
19 Mesentery	0.55	19 Jejunum and ileum	0.78	19 Pharynx	0.62
20 Omentum	”	20 Tonsils	0.68	20 Mesentery	0.52
21 Hepatic flexure	0.39	21 Pharynx	0.40	21 Jejunum and ileum	0.44
22 Submaxillary gland	0.31	22 Hepatic flexure	”	22 Hepatic flexure	”
23 Jejunum and ileum	”	23 Mesentery	”	23 Splenic flexure	”
24 Duodenum	0.23	24 Submaxillary	0.20	24 Submaxillary	0.28
25 Splenic flexure	0.15	25 Duodenum	”	25 Duodenum	0.22
Note.—The figures where several organs are bracketed apply to each organ separately.

In a healthy new-born infant the mouth is free from micro-organisms, and very few are found in a breast-fed baby, but Bacillus lactis may be found where the child is bottle fed. If there is trouble with the first dentition and food is allowed to collect, staphylococci, streptococci, pneumococci and colon bacilli may be present. Even in healthy babies Oidium albicans may be present, and in older children the pseudo-diphtheria bacillus. From carious teeth may be isolated streptothrix, leptothrix, spirilla and fusiform bacilli. Under conditions of health these micro-organisms live in the mouth as saprophytes, and show no virulence when cultivated and injected into animals. The two common pyogenetic organisms, Staphylococcus albus and brevis, show no virulence. Also the pneumococcus, though often present, must be raised in virulence before it can produce untoward results. The foulness of the mouth is supposed to be due to the colon bacillus and its allies, but those obtained from the mouth are innocuous. Also to enable the Oidium albicans to attack the mucous membrane there must be some slight inflammation or injury. The micro-organisms found in the stomach gain access to that organ in the food or by regurgitation from the small intestine. Most are relatively inert, but some have a special fermentative action on the food (see Nutrition). Abelous isolated sixteen distinct species of organism from a healthy stomach, including Sarcinae, B. lactis, pyocyaneus, subtilis, lactis erythrogenes, amylobacter, megatherium, and Vibrio rugula.

Hare-lip, cleft palate, hernia and imperforate anus are physical abnormalities which are interesting to the surgeon rather than to the pathologist. The oesophagus may be the seat of a diverticulum, or blind pouch, usually situated in its lower half, which in Physical abnormalities most instances is probably partly acquired and partly congenital; a local weakness succumbing to pressure. Hypertrophy of the muscular coat of the pyloric region is an infrequent congenital gastric anomaly in infants, preventing the passage of food into the bowel, and causing death in a short time. Incomplete closure of the vitelline duct results in the presence of a diverticulum—Meckel’s—generally connected with the ileum, mainly important by reason of the readiness with which it occasions intestinal obstruction. Idiopathic congenital dilatation of the colon has been described.

Table II.

Males.	Per- centage.	Females.	Per- centage.	Total.	Per- centage.
1 Mouth and pharynx	37.85	1 Intestines	28.9	1 Oesophagus and stomach	31.78
2 Oesophagus and stomach	33.46	2 Oesophagus and stomach	27.7	2 Mouth and pharynx	30.27
3 Intestines	17.04	3 Liver	15.5	3 Intestines	20.42
4 Liver	7.8	4 Peritoneum	13.1	4 Liver	10.02
5 Peritoneum	2.75	5 Mouth and pharynx	11.3	5 Peritoneum	5.71
6 Pancreas	1.1	6 Pancreas	3.5	6 Pancreas	1.80

Traction diverticula of the oesophagus not uncommonly occur as sequels to suppurative inflammation of cervical lymphatic glands. More frequently dilatation of a section is met with, due as a rule to the presence of a stricture. The stomach often diverges from the normal in size, shape and position. Normally capable in the adult of containing from fifty to sixty ounces, either by reason of organic disease, or as the result of functional disturbance, its capacity may vary enormously. The writer has seen post mortem a stomach which held a gallon (160 ounces), and again one holding only two ounces. Cancer spread over a large area and cirrhosis of the stomach wall cause diminution in capacity; pyloric obstruction, weakness of the muscular coat, and nervous influences are associated with dilatation. A peculiar distortion of the shape of the stomach follows cicatrization of ulcers of greater or lesser curvature; the gastric cavity becomes “hour-glass” in shape. In addition, the stomach may be displaced downwards as a whole, a condition known as gastroptosis: if the pyloric portion only be displaced, the lesion is termed pyloroptosis. Ptoses of other abdominal organs are described; the liver, transverse colon, spleen and kidneys may be involved. Displacements downwards of the stomach and transverse colon, along with a movable right kidney and associated with dyspepsia and neurasthenia, form the malady termed by Glénard enteroptosis. A general visceroptosis often occurs in those patients who have some tuberculous lesion of the lungs or elsewhere, this disease causing a general weakening and subsequent stretching of all ligaments. Displacements of the abdominal viscera are almost invariably accompanied by symptoms of dyspepsia of a neurotic type. The rectum is liable to prolapse, consequent upon constipation and straining at stool, or following local injuries of the perineal floor.

Every pathological lesion shown by digestive organs is closely associated with the state of the nervous system, general or local; so stoppage of active gastric digestive processes after profound nervous shock, and occurrence of nervous Influence of the nervous system. diarrhoea from the same cause. Gastric dyspepsia of nervous origin presents most varied and contradictory symptoms: diminished acidity of the gastric juice, hyper-acidity, over-production, arrest of secretion, lessened or increased movements, greater sensitiveness to the presence of contents, dilatation or spasm. Often the nervous cause can be traced back farther,—in females, frequently to the pelvic organs; in both sexes, to the condition of the blood, the brain or the bowel. Unhealthy conditions related to evacuation of the bowel-contents commonly induce reflex nervous manifestations of abnormal character referred to the stomach and liver. Gastric disturbances similarly react upon the proper conduct of intestinal functions.

Local Diseases.

The Mouth.—The lining membrane of the cheeks inside the mouth, of the gums and the under-surface and edges of the tongue, is often the seat of small irritable ulcers, usually associated with some digestive derangement. A crop of minute vesicles known as Koplik’s spots over these parts has been lately stated by Koplik to be an early symptom of measles. Xerostomia, or dry mouth, is a rare condition, connected with lack of salivary secretion. Gangrenous stomatitis, cancrum oris, or noma, occasionally attacks debilitated children, or patients convalescing from acute fevers, more especially after measles. It commences in the gums or cheeks, and causes widespread sloughing of the adjacent soft parts—it may be of the bones.

The Stomach.—It were futile to attempt to enumerate all the protean manifestations of disturbance which proceed from a disordered stomach. The possible permutations and combinations of the causes of gastric vagaries almost reach infinity. Idiosyncrasy, past and present gastric education, penury or plethora, actual digestive power, motility, bodily requirements and conditions, environment, mental influences, local or adjacent organic lesions, and, not least, reflex impressions from other organs, all contribute to the variance.

Ulcer of the stomach, however—the perforating gastric ulcer—occupies a unique position among diseases of this organ. Gastric ulcers are circumscribed, punched out, rarely larger than a sixpenny-bit, funnel-shaped, the narrower end towards the peritoneal coat, and distributed in those regions of the stomach wall which are most exposed to the action of the gastric contents. They occur most frequently in females, especially if anaemic, and are usually accompanied by excess of acid, actual or relative to the state of the blood, in the stomach contents. Local pain, dorsal pain, generally to the left of the eighth or ninth dorsal spinous process, and haematernesis and melaena, are symptomatic of it. The amount of blood lost varies with the rapidity of ulcer formation and the size of vessel opened into. Fatal results arise from ulceration into large blood-vessels, followed by copious haemorrhage, or by perforation of the ulcer into the peritoneal cavity. Scars of such ulcers may be found post mortem, although no symptoms of gastric disease have been exhibited during life; gastric ulcers, therefore, may be latent.

Irritation of the sensory nerve-endings in the stomach wall from the presence of an increased proportion of acid, organic or mineral, in the stomach contents is accountable for the well known symptom heartburn. Water-brash is a term applied to eructation of a colourless, almost tasteless fluid, probably saliva, which has collected in the lower part of the oesophagus from failure of the cardiac sphincter of the stomach to relax; reversed oesophageal peristalsis causing regurgitation. A similar reversed action serves in merycism, or rumination, occasionally found in man, to raise part of the food, lately ingested, from the stomach to the mouth. Vomiting also is aided by reversed peristaltic action, both of the stomach and the oesophagus, with the help of the diaphragm and the muscles of the anterior abdominal wall. Emesis may be caused both by local nervous influence, and through the central nervous mechanism either reflexly or from the direct action of substances circulating in the blood. Further, the causal agent acting on the central nervous apparatus may be organic or functional, as well as medicinal. Vomiting without any apparent cause suggests nervous lesions, organic or reflex. The obstinate vomiting of pregnancy is a case in point. Here the primary cause proceeds reflexly from the pelvis. In females the pelvic organs are often the true source of emesis. Haematemesis accompanies gastric ulcer, cancer, chronic congestion with haemorrhagic erosion, congestion of the liver, or may follow violent acts of vomiting. In cases of ulcer the blood is usually bright and in considerable amount; in cancer, darker, like coffee-grounds; and in cases of erosion, in smaller quantity and of bright colour. The reaction of the stomach contents, if the cause be doubtful, yields valuable aid towards a diagnosis. Of increased acidity in gastric ulcer, normal in hepatic congestion, it is diminished in cancer; but as the acid present in cancer is largely lactic, analysis of the gastric contents must often be a sine qua non, because hyperacidity from lactic may obscure hypoacidity of hydrochloric acid.

Flatulence usually results from fermentative processes in the stomach and bowel, as the outcome of bacterial activity. A different form of flatulence is common in neurotic individuals: in such the gas evolved consists simply in carbonic acid liberated from the blood, and its evolution is generally characterized by rapid development and by lack of all fermentative signs.

The Liver.—The liver is an organ frequently libelled for the delinquencies of other organs, and regarded as a common source of ill. In catarrhal jaundice it is in most cases the bowel that is at fault, the liver acting properly, but unable to get rid of all the bile produced. The liver suffers, however, from several diseases of its own. Its fibrous or connective tissue is very apt to increase at the expense of the cellular elements, destroying their functions. This cirrhotic process usually follows long-continued irritation, such as is produced by too much alcohol absorbed from the bowel habitually, the organ gradually becoming harder in texture and smaller in bulk. Hypertrophic cirrhosis of the liver is not uncommonly met with, in which the liver is much increased in size, the “unilobular” form, also of alcoholic origin. In still-born children and in some infants a form of hypertrophic cirrhosis is occasionally seen, probably of hereditary syphilitic origin. Acute congestion of the liver forms an important symptom of malarial fever, and often leads in time to establishment of cirrhotic changes; here the liver is generally enlarged, but not invariably so, and the part played by alcohol in its causation has still to be investigated. Acute yellow atrophy of the liver is a disease sui generis. Of rare occurrence, possibly of toxic origin, it is marked by jaundice, at first of usual type, later becoming most intense; by vomiting; haemorrhages widely distributed; rapid diminution in the size of the liver; the appearance of leucin and tyrosin in the urine, with lessened urea; and in two or three days, death. The liver after death is soft, of a reddish colour dotted with yellow patches, and weighs only about a third part of the normal—about 1½ lb in place of 3¾ lb. A closely analogous affection of the liver, known as Weil’s disease, is of infectious type, and has been noted in epidemic form. In this the spleen and liver are commonly but not always swollen, and the liver is often tender on pressure. As a large proportion of the sufferers from this disease have been butchers, and the epidemics have occurred in the hot season of the year, it probably arises from contact with decomposing animal matter. Hepatic abscess may follow on an attack of amoebic dysentery, and is produced either by infection through the portal vein, or by direct infection from the adjacent colon. In general pyaemia multiple small abscesses may occur in the liver.

The Gall-Bladder.—The formation of biliary calculi in the gall-bladder is the chief point of interest here. At least 75% of such cases occur in women, especially in those who have borne children. Tight-lacing has been stated to act as an exciting cause, owing to the consequent retardation of the flow of bile. Gall-stones may number from one to many thousands. They are largely composed of cholesterin, combined with small amounts of bile-pigments and acids, lime and magnesium salts. Their presence may give rise to no symptoms, or may cause violent biliary colic, and, if the bile-stream be obstructed, to jaundice. Inflammatory processes may be initiated in the gall-bladder or the bile-ducts, catarrhal or suppurative in character.

The Pancreas.—Haemorrhages into the body of the pancreas, acute and chronic inflammation, calculi, cysts and tumours, among which cancer is by far the most common, are recognized as occurring in this organ; the point of greatest interest regarding them lies in the relations established between pancreatic disease and diabetes mellitus, affections of the gland frequently being complicated by, and probably causing, the appearance of sugar in the urine.

The Small Intestine.—Little remains to be added to the account of inflammatory lesions in connexion with the small intestine. It offers but few conditions peculiar to itself, save in typhoid fever, and the ease with which it contrives to become kinked, or intussuscepted, producing obstruction, or to take part in hernial protrusions. The first section, the duodenum, is subject to development of ulcers very similar to those of the gastric mucous membrane. For long duodenal ulceration has been regarded as a complication of extensive burns of the skin, but the relationship between them has not yet been quite satisfactorily explained. The condition of colic in the bowel usually arises from overdistension of some part of the small gut with gas, the frequent sharp turns of the gut facilitating temporary closure of its lumen by pressure of the dilated gut near a curve against the part beyond. In the large bowel accumulations of gas seldom cause such acute symptoms, having a readier exit.

The Large Intestine.—The colon, especially the ascending portion, may become immensely dilated, usually after prolonged constipation and paralysis of the gut; occasionally the condition is congenital. Straining efforts made in defaecation may often account for prolapse of the lower end of the rectum through the anus. Haemorrhage from the bowel is usually a sign of disease situated in the large intestine: if bright in colour, the source is probably low down; if dark, from the caecum or from above the ileo-caecal valve. Blood after a short stay in any section of the alimentary canal darkens, and eventually becomes almost black in colour.

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