appears thickened, and is often smooth, firm, and gray. Proliferating inflammation, such as has been described as occurring in the stomach, is less often found here, and then occurs principally in the colon (^colitis prolifera vel folypoBO) ; a circumscribed form is found more frequently in the small intestine also, around chronic ulcers, especially those of a tuberculous or dysenteric origin. Another rare form of chronic inflammation of the mucous membrane is met with, which, like the proliferating affection, attacks the large intestine chiefly, and occurs especially in chronic dysentery. The mucous membrane is decidedly thickened, and small mucous cysts are often formed in great quantity. These are produced by a swelling of the inter-tubular tissue, especially near the surface, so that the mouths of the tubular glands become constricted or completely closed ; a retention of the secretion follows, and finally, cystic dilatation of the deeper portions of the gland (^enteritis chronica cystica). The mucus may be easily pressed from those glands which are not completely closed, and the entrance to the little cavity may then be seen with the unaided eye. It is difficult to make a microscopic examination of this condition in fresh preparations, although the infiltration of the mucous membrane with small cells, and the displacement and dilatation of individual tubules may be seen in very thin sections made with the scissors or double knife.
<Callout type="important" title="Important">Chronic dysentery can lead to significant thickening of the intestinal walls.</Callout>
- Deep seated inflammation of the mucous and the sub-mucous coats (^enteritis phlegmonosa), is rare here as in the stomach, and is confined almost wholly to cases of an infectious nature. The affections (mucosis intestinalis) allied to malignant pustule also occur here, and more frequently than in the stomach. They are characterized by marked, circumscribed, phlegmonous swelling of the mucous membrane, (around the fungous growths), and by necrotic destruction of the surface and the formations of ulcers. The development of the typical bacteridia of malignant pustule (in the form of the previously described long threads), and also of micrococci, is not confined to the surface, but extends into the tissue, where masses of these organisms are sometimes very plainly seen in the vessels of the submucous layer.
<Callout type="risk" title="Risk">Infectious dysentery can lead to severe ulceration and perforation.</Callout>
- Enteritis follicularis. Inflammatory changes in the follicles, whether in the solitary, or agminated, or in both together, are associated with most inflammations of the mucous membrane. In many cases the follicles themselves are especially altered. They are swollen in simple inflammation, often from mere oedema, and are then translucent, like small pearls ; more often the swelling is due to an increase in their cells, when they are light gray and opaque. They present the frequently mentioned slate color in chronic catarrh. They become still more swollen in the higher degrees of acute inflammation, and are finally converted through suppuration into small abscesses (follicular abscesses). When the latter break into the intestine, the follicular ulcers are produced. These are evidently small (lenticular), and have sinuous edges which are elevated when water is poured into the cavity, owing to the fact that perforation takes place only at the top of the abscess, without destroying the whole covering.
<Callout type="tip" title="Tip">Follicular ulcers can be identified by their lenticular shape and sinuous edges.</Callout>
- Diphtheritic inflammation of the intestine. This occurs either alone or combined with the previous changes, and constitutes the second anatomical form, diphtheritic dysentery. It is also principally confined to the large intestine, although it may extend far into the ileum in extreme cases. The anatomical changes are such as have already been described in connection with the rectum, and generally diminish in intensity from below upwards. The inflammation begins as grayish bran-like spots on the surface of the mucous membrane, accompanied by marked swelling of the mucous and sub-mucous layers, owing to an acute (erysipelatous) oedema. These spots then become united, and the subjacent tissue becomes affected (infiltration of the mucous membrane) ; superficial necrosis and ulcers follow, and the base of the latter becomes in turn diphtheritic, so that by the constant extension of the necrosis, the ulcers increase both in size and depth, till, finally, in rare cases, the whole thickness of the walls is destroyed and perforation results. The gray color of the small deposits becomes yellow, or greenish-yellow as the infiltration advances, owing to the absorption of biliary coloring matter by the necrosed tissue. Gangrene of the mucous membrane may result (^gangrenous dysentery'), when the inflammation is very severe and extends rapidly. The localization of the diphtheritic process in the colon and ileum is more characteristic than even in the rectum. The diphtheritic infiltration is situated, almost without exception, on the projecting portions, as would be the case if a strong caustic had been rubbed over the intestinal surface. These portions are the three longitudinal bands (tesserae) of the large intestine, and the transverse folds which unite with them in forming the boundaries of the pouches ; in the small intestine, the parts affected are the transverse folds, and even the separate villi.
<Callout type="warning" title="Warning">Diphtheritic dysentery can lead to severe gangrene and perforation.</Callout>
- Scrofulous and tuberculous inflammation. These processes differ from the dysenteric, in being seated usually, and by preference, in the small intestine, though not to the exclusion of the large intestine. Besides the processes that are undoubtedly tuberculous, all those will be considered which lead to cheesy degeneration and ulceration of the follicles ; although the latter do not admit of being directly termed tuberculous, and are not considered as such by many authors, still they are very closely related to them. Such processes were formerly called scrofulous, as they occur especially in scrofulous individuals. The follicles, both solitary and those included in Peyer's patches, though not all of the latter, become swollen (attaining the size of a millet-grain or even that of a split pea), clouded, and gray, then perfectly opaque and yellowish in the centre, till finally the whole follicle is converted into a yellow, cheesy mass. When they are incised, pus does not appear, as in the case of suppurative follicles, but a crumbling, cheesy mass is brought to view, which presents, upon microscopic examination, the well-known appearances of cheesy material (shrivelled cells and fatty detritus). When the alterations are more advanced, the mucous membrane covering the follicles is destroyed, the cheesy material is discharged, and an ulcer results, which has a cheesy base, and projecting, cheesy edges (^the primary tubercular ulcer of Rokitansky). These may unite and form large, irregular, sinuous ulcerations (Rokitansky's secondary tubercular ulcer). When this stage is reached, unequivocal tuberculosis (secondary) appears, which is characterized by the development of small gray nodules in the base, upon the edges, and in the immediate neighbourhood of the ulcer. By the constant formation of such nodules and by cheesy degeneration of the older ones, the ulceration extends continuously, both in depth and surface. The shape of the ulcers at the outset is round, and is often maintained in those of a half-inch in diameter; still, as a rule, it becomes oblong, the long diameter being transverse to the axis of the intestine. This configuration is due to the fact that the development of the tubercles follows the course of the lymph-vessels, which extend from the side opposite the attachment of the mesentery, where the greater number of ulcers are situated, towards this structure. When the ulcer has reached its greatest development, it may completely encircle the intestine (annular ulcer). Both the base and edges are uneven, the latter appearing as if gnawed, and gray or yellow tubercles may be occasionally seen; they are also met with when the floor of the ulcer is formed by the muscular coat, the different layers of which may be recognized by the direction of their fibres, the innermost being transverse, the outer longitudinal. Recent tubercular nodules are situated on the peritoneum, which fact has been already fully considered. Hypersemia and also haemorrhages are of frequent occurrence, especially at the edges, and the mucous membrane in the vicinity is often hypertrophied. Large vessels are sometimes, though rarely, eaten into by the ulcer. Tubercular ulcers of large size may exceptionally lie parallel to the axis of the intestine instead of being transverse, thus involving a whole Peyer's patch, as is the case in typhoid fever.
<Callout type="important" title="Important">Tuberculosis can lead to extensive ulceration and perforation.</Callout>
- The principal changes in typhoid fever are seated in the ileum, hence the name 'ileo-typhus'; in certain cases the large intestine is also greatly involved ('colo-typhus'). The typhoid changes in the intestine are almost wholly limited to the follicles, especially to Peyer's patches, which are altered throughout their whole extent, and therein differ from the tuberculous affection. In recent cases of typhoid fever the changes consist in a marked swelling of the solitary follicles and Peyer's patches, which is most intense at the ileo-csecal valve, and gradually or quite suddenly diminishes from this point upwards, till it finally disappears altogether. The swelling is not confined to the follicles of the patches, but involves the interfollicular tissue also, so that the whole patch stands out like a flower-bed, often two to four millimeters high, while the edges are sometimes overhanging like those of a mushroom. The swollen solitary follicles may attain the size of a pea, from the associated changes in the surrounding tissue. The larger rounded swellings, which occur in various places upon the intestinal wall, at a greater or less distance from the attachment of the mesentery, do not arise from solitary follicles, but from small patches composed of three to five or more follicles. All the swollen portions are of a grayish-red color and soft consistency (medullary swelling). The rest of the intestine is, as a rule, of a dark red color, and in a state of catarrhal inflammation. The microscopic examination of teased preparations reveals large multinucleated cells in these swollen follicles similar to those occurring in the mesenteric glands. At a later stage, instead of the medullary swelling of the solitary follicles and patches, yellowish-gray or yellowish-brown (stained by biliary coloring matter) necrotic masses, sloughs (sphaceli), are seen; these do not necessarily exist throughout the patch, but are frequently confined to a small portion. When a section is made through the part, it may be seen that the sloughs
Key Takeaways
- Chronic dysentery can lead to significant thickening of the intestinal walls.
- Diphtheritic dysentery can result in severe gangrene and perforation.
- Tuberculosis causes extensive ulceration and can be identified by nodules and cheesy material.
- Typhoid fever primarily affects the ileum, causing swelling and necrotic masses in follicles.
- Follicular ulcers are characterized by their lenticular shape and sinuous edges.
Practical Tips
- Identify dysentery early to prevent severe complications such as ulceration and perforation.
- Look for signs of tuberculosis, including nodules and cheesy material in the intestinal walls.
- Monitor for typhoid fever by checking for swollen follicles and necrotic masses in the ileum.
- Use caution when handling samples from individuals with suspected dysentery to avoid spreading infection.
- Keep a clean environment to reduce the risk of infectious diseases like dysentery.
Warnings & Risks
- Be aware that diphtheritic dysentery can lead to severe gangrene and perforation, which are life-threatening conditions.
- Tuberculosis can cause extensive ulceration and perforation if left untreated, leading to serious complications.
- Typhoid fever can be highly contagious and requires immediate medical attention to prevent spread.
- Handling samples from individuals with suspected intestinal inflammation poses a risk of infection.
Modern Application
While the specific techniques described in this chapter are historical, the principles of recognizing and managing severe gastrointestinal infections remain crucial for modern survival preparedness. Understanding these conditions can help in early detection and appropriate response to prevent complications such as perforation and systemic spread of infection.
Frequently Asked Questions
Q: What is diphtheritic dysentery and how does it differ from other forms of dysentery?
Diphtheritic dysentery involves severe inflammation that leads to the formation of abscesses and ulcers, often in the large intestine. It differs from other forms by its characteristic grayish bran-like spots on the mucous membrane and the development of diphtheritic nodules.
Q: How can one identify follicular ulcers?
Follicular ulcers are identified by their lenticular shape and sinuous edges. They often form when abscesses break into the intestine, creating small, roundish ulcers with elevated edges that become more oblong as they grow.
Q: What are the key signs of tuberculosis in the intestines?
Tuberculosis in the intestines can be identified by the presence of nodules and cheesy material. The follicles may swell, turn yellowish, and eventually form ulcers with a base covered in cheese-like material.