The presence of Grain-staining and Gram-clecolorizing micro organisms in the mucous layer covering the mucosa and in exudate less rich in cells, is an almost regular finding. They are mainly in the supra epithelial layers, and not to he found either in the lumen of the crypts or in the deeper layers, or inside the lymphatics and blood vessels (Fig. k, Plate 47). But in certain eases, with carefully- obtained and preserved material, they can be found in the crypts, in the interstitial tissue, in the region of the follicles, in the blood vessels and lymphatics, and even as far as the serosa. Typical lesions of the tissue show that these organisms have entered these regions during life, and have left behind their traces. The. possibility of a general infection of the body originating there must be admitted, although I can give the assurance from iny own wide experience that such an oecurrenee is very rare.
I have repeatedly mentioned that in the severest disturbances of nutrition, those of chronic course resulting in atrophy, the intestinal canal shows very slight anatomic changes, and that, because of this almost negative histologic finding, a disturbance of the processes of assimilation has been assigned as the cause of this severe symptom complex. Baginsky alone expresses the opinion, based on his. micro scopic researches, that atrophy is due to a destruction of the absorb ing tissue elements over a wide stretch of intestine, and a resulting progressive cachexia from insufficient taking up of the food by- the tissue.
lieubner considers that Baginsky's findings are erroneous, and that they are to be explained through the investigation of much dilated parts of the bowel, in which the marked stretching apart of the villi and crypts gives a false impression of their disappearance. Gerlach, Habel, Kus kow, I3loch, and Tugendreicla, agree with Heubner. They made com parative preparations of adjacent contracted and dilated parts of the intestine, and demonstrated that in the former the structure of the intestinal wall was wholly intact. Bloch brought a new fact to light. He called attention to peculiar cells, situated in the fundus of some of the tubular glands, particularly in the region of the large intestine. These were fitst described by Paneth, and can be distinguished by proper staining methods from the adjacent cells, on account of their different nuclear content. Bloch noticed in cases of atrophy a marked diminu tion in their number, and through this he explains the deficient absorp tion in these conditions. This matter is still unsolved, and we must await a further confirmation of Bloch's conclusions. Tugendreicla failed to find any such confirmation in the cases lie studied. I for my part willingly admit the explanation for this condition in a stretched intes tine, as given by Heubner and the other writers named above, of the correctness of which one can easily convince himself (see Fig. V, a and b, Plate 46). I should like to raise the further question whether this very marked and extensive stretching of the bowel in atrophic children with pushing apart of the villi and glands, may not also in itself be of significance in absorption. We must take into consideration the
clinical experience which teaches us that the absorptive power of such patients frequently improves contemporaneously with diminution in the prominence of the abdomen, and that we see in this diminution a favorable prognostic sign. It would be too great a depreciation of the value of the anatomical finding, if we should have no faith in the significance of these effects of stretching.
W e will next take up briefly the histologic lesions in those organs which deserve our attention on account of their anatomic position and functional relation to the alitnentary canal. Little has been re ported on the macroscopic appearance of the mesenteric lymph-nodes. My own observation in cases in which one or more nodes happened to be in the plane of section, showed that they take part in tile inflam matory process through a marked proliferation of their lymphoid elements. The more acute the course of the disease, the more promi nent is the hyperfemia.
The pancreas, which certainly plays an important part in the pathology of intestinal infections, has up to the present been almost wholly neglected in anatomic research. I found in the literature only a reference by Nobecourt, to the effect that Arraga-Vinos was able to demonstrate in chronic cases a more or less pronounced sclerosis of this gland with .angtopancreatitis, the latter beginning around the duct. Also some of the gland cells appeared less clearly distinct and their nuclei less readily stained.
On the other hand we have a number of articles dealing with the investigation of the liver in acute and chronic diseases of nutrition, the results of which have been collected by Terrien and by Nobcieourt. They have a special importance because insufficiency of the oxidiz ing function of this organ has been repeatedly pointed out as an im portant factor in the origin especially of chronic disturbances of metab olism. Terrien, to whom we are indebted for the most thorough histologic studies, describes a.s follows the chronologic development of this process, of which the first stages belong to the acute, and the later stages to the chronic disorders of nutrition. It begins with capillary congestion, and intravaseular lettcocytosis. Then follows inflamma tion of the walls of the branches of the portal vein, which leads to swelling and casting off of epithelium, and a beginning parenchyma tous degeneration of the liver cells. The most advanced stages of this process are characterized by increase of the above-described lesions, round-celled infiltration of the hepatic tissue occurring in small areas, in places beginning sclerosis and new-growth of bile vessels and at the sante time very advanced degeneration of the hepatic cells. Similar observations have been reported by Leslie and :11 erklen. They give ground for suspicion that many cirrhoses of the liver in later childhood originated in processes of this kind.