Except in the cases already mentioned in which there are no macroscopic changes, the mucosa of the small intestine is traversed by tree-like branching wssels tilled with blood,* or else relaxed and (edematous; at times, especially on top of the fold it is hyperamfic; more rarely ha-morrhagic or eroded.
The peritoneum participates in these changes at most with a slight injection, which can spread entirely irregularly over the bowel, but which usually shows its greatest intensity in the lower part of the ileum, and in the ascending and transverse colon, and is sometimes widespread and sometimes confined to little areas. The follicles appear to be involved to a varying extent. Recently Ruf and Tugendreich have correctly pointed out, that the finding varies according to the stage of intestinal digestion at the time of death, and that vce are not famil iar enough with the normal condition of the follicles, such as would be found for example in healthy children suddenly dying from accident, to be able properly to call their swelling pathologic. The fact is, that at times the mucous membrane of the large intestine is found looking as if strewn with white sand, in other cases the prominent solitary follicles appear surrounded with a circle of vessels, or else involvement of the follicles in the changes of the mucous membrane may be entirely lacking. No regular rule, no relation to the clinical symptoms can be established. Often erosions or ulcerations of the solitary follicles are found, while Peyer's patches are hardly involved in the process, or at least show only slight swelling, which may perhaps be considered digestive.
Also the mesenteric lymph-nodes appear normal, or slightly enlarged and a little reddened on cross-section.
Changes are almost constantly found in the liver, varying from slight swelling and passive congestion to notable enlargement, with punctate or diffuse pallor, or with yellowish coloring. There may be in the latter case either increase in consistency, or friability with a fatty cut surface. Also here the findings show such an absence of regular rule, that they bear no relation to the clinical course (Terrien). They only permit one to say that there must have been a certain duration of illness, in order to produce such marked parenchymatous or fatty degeneration.
The condition of the spleen is also rather variable. Cases with rapid course and severe clinical symptoms show an acute infectious splenic tumor, eases in which the tissues have lost much water show a small spleen with wrinkling of the capsule, while the most common finding is an organ of normal size and consistency with marked passive congestion.
The kidneys are practically always involvecl. They are enlarged and pale with markedly injected glomeruli; the cortex appears streaked with red or entirely pale, and swollen on section; the pyramids are very hyperfemic; and the pelvis and calyces are usually injected and secrete a cloudy fluid. A not infrequent finding in severe cases is throm bosis of the renal VellIS With its resulting secondary appearances.
So much for the macroscopic findings in cases running an acute course with rapidly fatal ending. If the process becomes prolonged,
or passes over into a chronic stage, then the reaction of the mucous mem brane and organs is the more intense, and the more appreciable on post-mortem examination. Mentioning only essentials, we find on the one hand that the stomach is dilated, with its walls thinned, its greater curvature reaching down to the umbilicus or still lower, its mucous membrane much thinned as if macerated, and its cavity filled with grayish white fluid in which float large or small curds. (MI the other hand the organ may appear contracted, its mucous membrane feeling infiltrated and thickened, especially near the pylorus. The mucosa is also much wrinkled, and, 011 top of the folds, injected, with hadnor rhagic or brownish discoloration, at times even necrotic. The intestine, on opening the abdominal cavity, presents a degree of distention which varies with the period of time between death and the beginning of the autopsy. The large intestine, particularly its transverse portion and sigmoid flexure, fills most of the anterior abdomen, and appears slightly dilated, thin-walled, and much bent and twisted. The jejunum and ilium appear almost covered by the colon, and, assuming an early autopsy, show little distention, and in many parts even complete con traction. During my service as assistant in Munich, when I had frequent, opportunity both in the Children's Hospital itself, and in the different morgues of the eity to perform autopsies on children dying of chronic diseases of nutrition, especially such as result from too early admin istration of starchy food, I was frequently struck by the length of the vermiform appendix in these children and by the marked distention and lengthening of the large intestine. I induced Klaus, who was at that time in charge of the children's clinic, to undertake comparative measurements of the length and circumference of the bowel in naturally and artificially nourished children, because I knew that the frequency, of intussusception and volvulus among the Russian population is to be traced to an increased length of the bowel and mesentery caused by the preponderating vegetable diet of the poorer classes, and that therefore the influence of diet upon these conditions was already established. As Klaus left Munich shortly afterward, and as I returned a few weeks later to Prague, where I found no opportunity for rnaking measure ments, the que.stion remained unsolved. It was all thc more interesting to me, when a publication by Marfan appeared a few years later, in which these changes were emphasized, and in which in eases of this kind a very notable lengthening of the bowel was reported, as much as twelve times the body length, or double the normal. This lengthening affects both the small and large intestine, although it is more marked in the latter, and is usually accompanied by dilatation. It is well to establish these fact,s here, although they will be met with again in speaking of Eirschsprung's disease (megacolon eongcnitum).