The colour of the mucous membrane varies. Its vascularity is not necessarily increased. Louis observed it of its natural paleness, or merely tinged with bile, in 17 out of 46 cases; and Jenner, in II out of 17 cases. In one-third of Louis' 46 cases, there was increased redness of the mucous membrane. This redness may be either uniform or in patches, and it is almost always most marked towards the lower extremity. When death does not occur until after the third or fourth week of the disease, the mucous membrane often presents a greyish or slate-coloured aspect. Chomel found the mucous membrane of the small intestine infiltrated with a bloody fluid, over a space varying from four inches to three feet, in 7 out of 42 cases. The membrane was much increased in thickness, and presented a gelatinous glistening aspect, and a rose or reddish-black colour. When squeezed, a bloody fluid oozed out, and the membrane regained its natural thickness. This appearance was uniform all round the bowel, and was not limited to the dependent portions of the coils. In most cases there had been intestinal hæmorrhage during life, or blood was found in the intestines after death. I have met with a similar condition in several cases. As to consistence, Louis found the mucous membrane softened in all except 9 of 42 cases. Chomel noted this condition in only 5 of 42 cases; and Jenner in 3 of 15 cases. Like the softening in the stomach, it is probably a post-mortem change, although Louis was inclined to think that in certain cases, where it was associated with redness and thickening, it was inflammatory. None of the above lesions are constant in, or peculiar to, enteric fever (see p. 251). The specific lesions, which are invariably present, and which consist in a disease of the agminated and solitary glands of the ileum, have now to be described. These lesions present different appearances according to the duration of the illness prior to death. They may be described as passing through four stages, although the disease is often arrested at the end of the first. The stages are:-1. The stage of enlargement of the intestinal glands. 2. The stage of softening and ulceration. 3. The stage of the genuine 'typhoid ulcer'; and 4. The stage of cicatrization. Two or more of these stages may often be traced in the same body; for the P See BUDD, Dis. of Stomach, 1855, p. 46. morbid process, as well as the process of reparation, always commences at the extremity of the ileum nearest the cæcum, and proceeds upwards. a. First Stage. This consists in the enlargement of the agminated and solitary glands. Rokitansky maintains that the enlargement of the glands is preceded by a congestive stage; and Trousseau states that enlargement does not commence before the fourth or fifth day of the disease, while Louis and Chomel held that it did not commence until the seventh or eighth day. But there is no evidence that the enlargement of the glands is preceded by increased vascularity; while there are facts to show that it commences with the disease, and continues to progress until about the ninth day. In no case, where death has occurred at an early stage of the disease, has there been increased vascularity without enlargement of the glands; and, indeed, in no instance has the latter appearance been wanting. In one case under my care, where death occurred on the sixth day, great enlargement had already taken place (see Case XLVII). Considerable deposition had also taken place in five cases recorded by S Fig. 16.-Lower two inches of ileum from a case of enteric fever fatal at the end of the second day. Bretonneau, Forget, Bristowe, and Hoffmann," which were fatal on the fifth day. In Case LVIII., p. 550, where death occurred at the end of the second day, there was also considerable enlargement of the solitary glands, as represented in the annexed woodcut. Lastly, in the cases which occurred at Clapham in 1829 (see p. 472) considerable enlargement was found at the end of the first day. Moreover, in cases fatal at a more advanced stage, it is not found that in the agminated glands at the uppermost limit of the disease there is increased TROUSSEAU, 1861, p. 139. BRETONNEAU, 1829, p. 70. vascularity without enlargement; while, on the other hand, slight enlargement, without any increase of vascularity, is not uncommon. At all events, mere increase of the vascularity Fig. 17.-Portion of the ileum, from a case of enteric fever fatal on the tenth lay showing the enlarged agminated and soli tary glands, not yet ulcerated. of the agminated and solitary glands, without any enlargement, will not justify the opinion that a patient has died of enteric fever, however short may have been the duration of the illness. An opportunity is rarely offered of examining the intestines before the eighth or tenth day of the disease. Peyer's patches are then found to be indurated and elevated from half-a-line to two lines above the surface of the bowel (Fig. 17). The membrane covering them is of a pinkish-grey or purplish colour, and is often softened; while that between the diseased patches may have its natural hue, or may present every grade of vascularity up to the most intense injection. The peritoneum corresponding to the patches is usually much injected, and of a bright-red or pale-purple colour. Two varieties of diseased patches have been described by most French writers since the time of Louis. These are the plaques molles and the plaques dures of Louis; or the plaques réticulées and plaques gauffrées of Chomel. In the former, the enlargement is comparatively slight, its consistence is soft, and the mucous membrane covering the patch is more or less red, and has a rugose or granular aspect. In the latter, the patch is more elevated, thicker, and harder, and the super-imposed mucous membrane is paler and presents a smoother and more uniform aspect. Louis was of opinion, that the plaques dures were less common than the plaques molles. He found them in only 13 of 46 fatal cases, and from the circumstance that they were most common in cases fatal before the fifteenth day he concluded that they constituted a more dangerous form of the disease than the other. The correctness of this opinion may be doubted. At an advanced stage of the disease, after the morbid material has sloughed out, it is impossible to say which of the two forms of the lesion has existed at first. From my own observations, I am inclined to think that in fatal cases the plaques dures constitute the more common form in adults. But after all, the differences between the two forms are differences merely of degree; the morbid process is the same in both. Gradations may be observed between them, and they constantly co-exist in the same intestine.▾ The solitary glands at the lower end of the ileum are often Dr. T. J. Maclagan thinks that there must be a reason why the morbid process should present two distinct forms in the same individual, and has endeavoured to show that the plaques molles are always excited by a secondary inoculation with poison thrown off by a plaque dure, or, in other words, that the plaques dures are primary, and the plaques molles secondary, lesions, and that a plaque molle can never be found prior to sloughing of at least one plaque dure. These secondary lesions he believes to run a more rapid course than the primary (so that at the end of the third week it is impossible to distinguish between the two), and to be the chief cause of hæmorrhage, perforation, and relapses. This view, in his opinion, is necessary to explain why the lesion is always so extensive at the lower end of the ileum (the ileo-colic valve like a sphincter detaining the poison from the primary lesions and so favouring secondary inoculation), why healthy Peyer's patches are not found below those that are diseased, and why the frequency of hæmorrhage, perforations, and relapses is in a direct ratio to a constipated state of the bowels, the retention of the poison given off by the primary lesions favouring the occurrence of those which are secondary but more dangerous. (See T. J. MACLAGAN, 1871 and 1873). In reference to these views I would observe:-1. Minute examination of the plaques dures and plaques molles shows that the former are merely a more severe form of inflammation of the glands than the latter. In the same bowel the two forms may be seen passing by insensible gradations into one another. 2. When death occurs before ulceration or sloughing, plaques molles may be seen interspersed among plaques dures, or even, as was long since shown by Louis, without any plaques dures. 3. After ulceration, the lesion highest in the bowel is not always, as in the one case examined by Dr. Maclagan, a plaque dure, but, according to my observation, is far oftener a plaque molle, the disease in fact becoming less intense as we proceed upwards. 4. The concentration of the lesion immediately above the valve is a feature of the disease from its commencement, before ulceration or sloughing, and is not the result of any secondary inoculation. 5. The lesion is not only most abundant, but most advanced, in the lower part of the ileum. I have repeatedly known extensive ulceration at the valve, and plaques molles not yet ulcerated several feet above it. The reason why healthy Peyer's patches are not found below those that are diseased is that the lesion advances from below upwards, and not from above downwards. 6. In two-thirds of the cases of enteric fever the glands of the colon escape. This exemption, according to Dr. Maclagan, may be due to dilution or neutralization of the poison by the acid secretion of the colon, but the explanation is unsatisfactory. It may be added that in my experience the colic glands have been as frequently affected in cases dying early, as in those dying late in the disease. 7. Although hemorrhage and perforation may occur in cases where there has been constipation, they are far more common where there has been diarrhoea (see pages 525 and 568). 8. In relapses which are fatal, the fresh lesions may be found higher up in the bowel than those of the primary attack (see pages 554 and 576). affected in a manner similar to Peyer's patches. Louis found them diseased in 12 out of 46 cases; and, in my experience, the proportion of cases in which they are implicated is even greater. They may be as large as a hemp-seed or a split-pea, or they may be larger; and their pale colour and flattened surface often impart to them an appearance not unlike the pustules of Variola. The diseased solitary glands are usually limited to the lower twelve inches of the ileum, but they may extend higher. In exceptional cases, of which I have seen two, the solitary glands are diseased, while Peyer's patches remain intact. Cruveilhier designated this variety 'forme pustuleuse.” The precise manner in which the intestinal glands are affected is a point of some interest, on which different opinions have been expressed. Boehm, in his admirable description of these glands," stated that in enteric fever the morbid material was deposited in the sub-mucous tissue external to the glandules, and this view has been commonly adopted. On the other hand, John Goodsir, from careful observations concluded that the morbid products were in the first place deposited in the interior of the glandules, which became much distended and ultimately burst, discharging their contents into the sub-mucous tissue. Goodsir's observations approach nearest to the truth, but modern means of research have shown that the glandules are not, as was imagined by most physiologists of his day, closed vesicles which periodically discharge their contents into the bowel, but that they are in reality small lymphatic glands. Each glandule is composed of a delicate fibrous reticulum, enclosing lymph-corpuscles in its meshes. In enteric fever the proper structure of the gland first becomes enlarged by a proliferation of its cellular elements, and as the process advances the surrounding connective tissue becomes implicated, until, at last, the whole patch becomes converted into a continuous mass of altered gland-tissue. This is what happens in the case of the plaques dures. In the plaques molles the morbid process stops short of this; the glandules become enlarged, but not to such an extent as to run into one another. The enlargement of the intestinal glands does not of necessity lead to ulceration. The morbid products to which the enlargement is due may be re-absorbed, absorption com "De Gland. Intestin. Berol. 1835. See for example, J. HARLEY, 1866, p. 575. GOODSIR, 1842. • STRICKER'S Man. of Histology, Syd. Soc. Ed. 1870, p. 567. On this subject see CHOMEL, 1834, Obs. 14 and 15; Louis, 1841, i. 181; BARTHEZ and RILLIET, 1853, ii. 667; LYONS, 1861, p. 243; TROUSSEAU, 1861, p. 139; AITKEN, Pract. of Med. 2nd ed., 1863, p. 396. |