In general, therefore, it can be stated that enterogenous infection, as far as conclusions can be drawn from clinical and pathologico-ana tomical findings, is exceedingly rare in childhood, and is insignificant in comparison to the usual mode of entrance, which is the mucous mem brane of the respiratory- organs, and the lymphatic glands connected with it. It can not be denied that such infection ean take place through the alimentary tract when it includes the cavity of the mouth and tonsils with their groups of lymph-glands, still there is need of more thorough proof founded on human material. Moreover, the view of Behring that the intestinal epithelium of young infants is permeable for bacteria, and that the invasion of the body with tubercle bacilli occurs in this manner, which, when a suitable opportunity presents itself, can be transported to distant organs, must be verified in human infants.
The pathologic-anatomic findings of this affection are manifold. Recent investigations have suggested that the tonsils and cervical lymph-nodes are often the seat of specific deposits; however, the tuberculous infection of these parts, or the presence in them of tubercle bacilli, is demonstrable only by means of animal experimentation. Tuberculous disease of the cesophagus is very rare, and the localization of the disease in the stomach is also uncommon either as a primary or secondaly infection.
Miliary tuberculosis, which is often present in young infants, can involve the intestine and produce an eruption of tubercles, lying, for the most part, in the serous coat ; but these may also be found in the mesenteric glands and peritoneum.
Chronic tuberculosis of the gastro-intestinal tract, whieh is of special interest, is generally loealized in the mueous membrane, where it produces erater-like undermined ulcerations, at the base and border of which eascous deposits of miliary tubercles ean be recognized (Figs. b and c on Plate .17). In addition there is also a decided swelling and partial caseation of the mesenteric lymph-glands. The localization of this ulcer is, for the most part, at the lowermost portion of the ileum and the region of the ileocecal valve; at those points, therefore, where the intestinal contents eontaining tubercle bacilli remains 'longest. The condition just described may- be developed on the basis of a chronic intestinal catarrh. In rare eases in children these ulcers are of consider able extent, become confluent and produce extensive loss of tissue which in certain situations leads to scar formation, which may involve the a-hole circumference of the intestine and so produce a stenosis in these situations.
Hypertrophie tuberculosis in the region of the cectun or of the colon, is very- unusual in children; on the other band, the appendix at this age is rather often the seat of specific inflammation, and appears, when so affected, either shriveled and hardened or swollen and lardaceous in appearance. In these cases the serosa contains caseous nodules, which are also present in the subserous tissue and in the surrounding per itoneum, while the neighboring glands undergo caseous degeneration.
The peritoneum is also aff ected in chronic tuberculosis of the intes tine; single intestinal loops may be found adherent to the anterior abdominal wall, and rupture of an ulcerated portion of the intestine or of the purulent caseous content of the abdominal cavity can result. This t,akes place usually in the region of the navel, but can lead to the formation of abscesses or fecal fistulm in other situations.
Isolated tuberculosis of the mesenteric lymph-nodes, without in volvement of the adjacent portion of the intestine, is very exceptional. On the other hand, chronic tuberculous infection of the peritoneum, without tuberculosis of the intestine and with the dis.semination of miliary tuberculosis, and the formation of extensive caseous deposits and masses, is of frequent occurrence.
Among the remaining abdominal organs, the liver participates in the process by a sclerotic thickening or fatty degeneration, and the spleen through chronic swelling. Other organs are seldom involved.
The symptomatology of this process is rather vague. Often the disease runs its course clinically under the picture of atrophy; its specific nature is guessed at from the lack of digestive indiscretions but is not definitely ascertained. Again, diarrhcea of a persistent character may set in without assignable cause, which resists all forms of medication and dietetic measures. The stools may contain bloody streaks or large quantities of blood, but in other respects exhibit no characteristic ap pearance. Examination of the dejecta for tubercle bacilli, which should never be omitted in suspected cases resistant to treatment, often gives the desired information.* The condition is more evident when in a child already suffering with tuberculosis of the lungs, and symptoms of col lapse, violent diarilima suddenly sets in; the stools then show as a rule rather a large number of bacilli.