ULCERATION OF THE BOWELS.
of ulceration of the intestinal mucous membrane must, neces sarily, be referred to in describing the various diseases in the course of which such ulcerations are liable to arise. Still, it seems desirable, in ad dition, to devote a special chapter to its consideration. It is not uncom mon to meet with ulceration of the bowels in children who have not re cently suffered from acute disease, and in whom no special cause for the intestinal lesion can be discovered. Such latent cases are not always easy of diagnosis, for ulceration of the bowels is not necessarily attended with diarrhoea. Purging, when it occurs, is dependent not upon the ulcerative process, but upon the intestinal catarrh which accompanies the breach of surface. When the catarrh is at an end the purging ceases, although the ulcers may be still unhealed. Typhoid fever in early life often runs its whole course without any looseness of the bowels, and this in instances where, from the length and severity of the attack, there can be little doubt that ulceration has been present. So, also, in cases of scrofulous or tuber cular ulceration of the intestinal mucous membrane, the occasional attacks of purging are often separated by considerable intervals during which the bowels are sluggish, although, on post-mortem examination of the body, extensive breaches of surface are discovered in the intestinal tract.
Ulceration of the bowels may be acute or chronic. The acute form is seen in cases of typhoid fever, dysentery, and inflammatory conditions of the bowel which give rise to lesions of the mucous membrane, either by the separation of superficial sloughs or by ulcerative inflammation of the glandular follicles. If life be prolonged the ulcerative process may pass, in certain cases, into a chronic stage, and lead to serious interference with the nutrition of the patient. The chronic form of the lesion will alone be considered in the present chapter. It occurs in two principal varieties in the child, viz.: the simple ulceration from prolonged intestinal catarrh, and the scrofulous or tubercular ulceration, which so often accompanies a sim ilar condition of the lungs.
Morbid .Anatomy.—Simple ulceration of the bowels is seen principally in infants and the younger children. The part of the bowel affected is the large intestine and lower part of the ilium. The ulcers are very shallow, and can best be detected by inspecting them sideways. They may be seat ed on the summit of the longitudinal folds of mucous membrane, and are then elongated or sinuous. Others are seen between the folds, and are small circular breaches of the surface, which can often only be detected by careful scrutiny, as their bases are of the same tint as that of the MUCOUS membrane surrounding them. The process by which they are formed appears to be as follows :—The follicles become enlarged and elevated above the surface like little pearly beads. Their contents then become
purulent, and the follicles still further increase in size. Lastly, the roof of the follicle is detached and the contents escape, leaving a clean-cut ulcer. Mixed up with the ulcers are other follicles—large, elevated, and semi transparent—the contents of which have not yet becoine purulent. The ulcers are roundish or irregular in shape, and vary considerably in size. Their edges are well defined and congested, their floor uneven, and of a reddish or grayish colour.
Tubercular or scrofulous ulceration of the bowels is more common in children of three or four years old and upwards than in infants. This form of lesion is usually associated with scrofulous or tubercular'disease of the lung, and almost invariably with caseous enlargement of the mesen teric glands. The ulceration appears to be chiefly of a scrofulous nature, the presence of the gray granulations being only an occasional and second ary consequence of the caseous degeneration of the follicular structures. The seat of the disease is usually the ilium, and the glands affected are the follicles of Peyer's patches and the solitary glands, especially those in the neighbourhood of the ilio-ctecal valve. Primarily, the destructive changes are limited to these parts. Thus, the follicles swell up from great multi plication of their corpuscular elements. They then undergo cheesy de generation, soften, and form a number of closely-set ulcers, which unite at their borders and give rise to more or less extensive areas of ulceration. Their edges are soft, red, and uneven, and their floor red or grayish in colour. The ulcerative process does not confine itself to the area of Pey er's patches, but extends laterally along the course of the smaller arteries and veins by a similar process of caseation and softening, so as often to encircle the gut completely. The infiltration advances into the neighbour ing tissues, and causes gradual disintegration and destruction. At the same time the ulcer deepens, but seldom passes beyond the muscular coat. As a secondary process gray granulations may appear, and miliary nodules are then seen in the tunica adventitia of the smaller vessels, especially the arteries and lymphatics. The serous surface at the site of the ulcer is opaque and reddened, and may also contain gray granulations. Some times adhesive peritonitis is set up, and neighbouring portions of intestine become glued firmly together. If in these cases rupture of the floor of the ulcer take place, the intestinal contents are extravasated, not into the gen eral peritoneal cavity, but into a limited pouch formed by the adherent bowels.